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Julie Rovner
KHN

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Julie Rovner is chief Washington correspondent and host of KHN’s 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.

Medicare Advantage, the private-sector alternative to original Medicare, now enrolls nearly half of all Medicare beneficiaries. But it remains controversial because — while most of its subscribers like the extra benefits many plans provide — the program frequently costs the federal government more than if those seniors remained in the fully public program. That controversy is becoming political, as the Biden administration tries to rein in some of those payments without being accused of “cutting” Medicare.

Meanwhile, President Joe Biden has signed a bill to declassify U.S. intelligence about the possible origin of covid-19 in China. And new evidence has emerged potentially linking the virus to raccoon dogs at an animal market in Wuhan, where the virus reportedly first took hold.

This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories

Among the takeaways from this week’s episode:

• The Biden administration recently changed the formula used to calculate how much the federal government pays private Medicare Advantage plans to care for patients with serious conditions, amid allegations that many of the health plans overcharge or even defraud the government. Major insurers are making no secret about how lucrative the program can be: Humana recently said it would leave the commercial insurance market and focus on government-funded programs, like its booming Medicare Advantage plans.
• The formula change is intended to rein in excess spending on Medicare — a huge, costly program at risk of insolvency — yet it has triggered a lobbying blitz, including a vigorous letter-writing campaign in support of the popular Medicare Advantage program. On Capitol Hill, though, party leaders have not stepped up to defend private insurers as aggressively as they have in the past. But the 2024 campaign season could hear the parties trading accusations over whether Biden cut Medicare or, conversely, protected it.
• The latest maternal mortality rates released by the Centers for Disease Control and Prevention show the problem continued to worsen during the pandemic. Many states have extended Medicaid coverage for a full year after women give birth, in an effort to improve care during that higher-risk period. But other problems limit access to postpartum care. During the pandemic, some women did not get prenatal care. And after the fall of Roe v. Wade, some states are having trouble securing providers — including one rural Idaho hospital, which announced it will stop delivering babies.
• The federal government will soon declassify intelligence related to the origins of the covid pandemic. In the United States, the fight over what started the pandemic has largely morphed into an issue of political identity, with Republicans favoring the notion that a Chinese lab leak started the global health crisis that killed millions, while Democrats are more likely to believe it was animal transmission tied to a wet market.
• And in drug price news, Sanofi has become the third major insulin maker (of three) to announce it will reduce the price on some of its insulin products ahead of a U.S. government policy change next year that could have cost the company.

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

Julie Rovner: Vice News’ “Inside the Private Group Where Parents Give Ivermectin to Kids With Autism,” by David Gilbert

Jessie Hellmann: The Washington Post’s “Senior Care Is Crushingly Expensive. Boomers Aren’t Ready,” by Christopher Rowland

Joanne Kenen: The New Yorker’s “Will the Ozempic Era Change How We Think About Being Fat and Being Thin?” by Jia Tolentino

Margot Sanger-Katz: Slate’s “You Know What? I’m Not Doing This Anymore,” by Sophie Novack

Also mentioned on this week’s podcast:

• Coverage by KHN’s Fred Schulte on Medicare Advantage: https://khn.org/news/author/fred-schulte/
• The New York Times’ “Biden Plan to Cut Billions in Medicare Fraud Ignites Lobbying Frenzy,” by Reed Abelson and Margot Sanger-Katz
• The CDC’s “Maternal Mortality Rates in the United States, 2021,” by Donna L. Hoyert

Click to open the transcript

Transcript: The Policy, and Politics, of Medicare Advantage

KHN’s ‘What the Health?’Episode Title: The Policy, and Politics, of Medicare AdvantageEpisode Number: 290Published: March 23, 2023

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

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser 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 23, at 10:30 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Margot Sanger-Katz of The New York Times.

Margot Sanger-Katz: Good morning, everybody.

Rovner: Jessie Hellmann of CQ Roll Call.

Jessie Hellmann: Hello.

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

Joanne Kenen: Hi, everybody.

Rovner: So a happy 13th birthday to the Affordable Care Act, which President Obama signed just a couple of hundred feet from where I am sitting now. But there’s lots of other health news, so we’re going to dive right in. I want to start this week with Medicare Advantage, the private Medicare alternative that now enrolls more than half of all Medicare beneficiaries. If you watch cable TV or pretty much any TV at all, you have likely seen the dueling ads. They’re part of a multimillion-dollar lobbying campaign, like this ad from the Better Medicare Alliance, made up of mostly Medicare Advantage insurers.

Excerpt from ad set in a bowling alley:Bowler 1: They might cut Medicare Advantage.Bowler 2: C’mon!Bowler 1: They’re talking about it in Washington.Bowler 2: Cut Medicare Advantage? Higher premiums? With inflation already so high?Bowler 3: That’s nuts!

Rovner: Or this one from the consumer advocacy group Protect Our Care.

Excerpt from ad: Insurance companies are lying to America’s seniors about cuts to Medicare Advantage benefits. Experts agree what they are saying is just plain false. Health insurance companies are simply trying to stop cuts to their sky-high profits, CEO salaries, and bonuses.

Rovner: I swear, Margot, I pulled the clip from that first ad before you also used it in your excellent story published Wednesday. So — and I know this is a hugely complicated issue that we’re going to try to take apart at least a little bit — but, who’s right here? Those who are saying that Medicare Advantage is about to be cut or those who were saying not really.

Sanger-Katz: I think actually they are both a little bit right. The Biden administration has made a very technical change to the formula that pays these private plans extra money when they sign up patients who have serious medical diagnoses. And this is, of course, a response to an earlier problem. It used to be Medicare Advantage plans — those are the private plans that are an alternative to the government Medicare program. It used to be that they just got a flat fee for everyone that they signed up. That was about what it costs on average to take care of someone in Medicare. And what happened is that the plans then had a huge incentive to only sign up healthy people. And so that’s what they tried to do. And they marketed to healthy people by doing things like including gym benefits in the health insurance plan or this famous, and perhaps apocryphal, example of, you know, locating the enrollment office on the third story of a building with no elevators so only people who could get up the stairs would be able to sign up for the plan. And so, there was this policy response where it said, well, you know, sicker people are more expensive to take care of, and we want these plans to not just be cherry-picking all of the healthiest people. And so they created this system that basically pays extra to the plans. If you have congestive heart failure, if you have cancer, or if you have diabetes, then your health plan gets, like, a little bonus. But what we have seen over the course of the life of this program is that this has created enormous incentives for the plans to diagnose their customers with as many diseases as possible, regardless of the strength of the evidence that they have. And there is a whole industry of data-mining operations that go through people’s medical records, of home health agencies that go into people’s homes just to diagnose them with more illnesses. And there are just absolutely widespread — from, like, every possible authoritative source that you can think of — allegations of overcharging of the federal government through this program and also of fraud. Not every insurance plan in the country in this program has been accused of fraud, but quite a lot of them have, including most of the largest players. And they are facing lawsuits in federal court for basically scamming Medicare by saying that their people are too sick.

Rovner: So I want to go back to the beginning or, really, the middle. Medicare has offered beneficiaries the option of enrolling in a private managed-care plan instead of what’s known as traditional Medicare, where patients can go to just about any doctor or hospital, pretty much from the inception of the program and pretty broadly since the Reagan administration in the early 1980s. They were originally called Medicare risk plans. Health plans almost exclusively, HMOs, said they could provide the same care more efficiently by, quote, “managing care,” and could still make a profit even if the government paid them 5% less than the average patient in traditional Medicare in that area. So it was a good deal all around. The plans were making money. The government was saving money. Yeah, that was a very long time ago. Since then, Congress has significantly raised what it pays the plans with the stipulation that they use the excess funds to either reduce premiums or add benefits, mostly dental, vision, and hearing care. Still, however, a lot of insurers are, to use a technical term, raking it in. In fact, Humana last month announced that it was going to pull out of the commercial insurance market in order to concentrate on its much more lucrative Medicare Advantage business. So, how are these companies both providing more benefits and making big profits? I know that fraud is part of it. Jessie, where’s all this money coming from?

Hellmann: Like Margot said … I think a lot of it has to do with the upcoding that they do. They’re just able to find all of these diagnoses from their enrollees, either through chart reviews … some have done home health visits where they send in people to interview patients and ask about their health history without really providing any care. So that’s another way. And it’s just become, like, a really lucrative business practice for them. But like Margot said, they’ve just been facing more and more scrutiny and lawsuits over the way that they do this.

Rovner: They deny care, too, right? That has been a long-standing issue that people who go into these plans and then get sick sometimes have trouble getting the care that they need.

Hellmann: Medicare Advantage plans do something called prior authorization, where they require providers submit requests for something to be covered before they’ll pay for it. They do this with a lot of more costly things, like imaging or like nursing home stays, which are obviously very expensive. And so if they can deny these claims and maybe get a beneficiary to do something that is cheaper before moving onto these more costly things, then that obviously saves some money. But that’s something else that the Biden administration has been looking more closely at. They’ve proposed a few rules that would just say that Medicare Advantage plans have to cover things that are covered by Medicare. They can’t just deny care for something based on their own proprietary models of deciding whether something is medically necessary or not.

Kenen: It’s complicated because sometimes there are patients that ask for things that they actually don’t need. You know, something they have seen on TV or they heard their neighbor had or whatever, and that [there’s] actually something more conservative [that can be done]. Back surgery is the famous example. You know, sometimes physical therapy and other treatments will do better than an $80,000 back surgery. But there’s a difference between saying, “Let’s try something else first,” and times when somebody is really sick and needs an expensive drug, they may have already tried a cheaper drug in another health plan the year before. It’s very hard to untangle, you know, when “no” is appropriate because we have overtreatment in this country. But the problem here is that sometimes “no” it’s completely inappropriate, and the insurer is not paying for something that the patient expected to get when they signed up for a health plan to take care of their health.

Rovner: And we should point out this is true in all managed-care plans, not just in Medicare Advantage plans.

Kenen: Yes.

Rovner: So before we move on, I want to give a shoutout to my KHN colleague Fred Schulte, who has been on the Medicare Advantage fraud trail like a dog with a bone for more than a decade now. We will link to some of his award-winning work in our show notes. Anyway, now the Biden administration, Margot, as you said, is trying to crack down on the, if not outright fraud, at least the manipulation of payments, which will also, at the same time, save the Medicare trust fund a lot of money. In the past, though, even small changes to Medicare Advantage, because it is so popular, have been met with a lot of pushback from members of Congress in both parties. But that’s not really happening this time, is it?

Sanger-Katz: Yeah, This has, I think, been the biggest surprise and the most interesting part of reporting on this story. Historically, Medicare Advantage is about half of Medicare’s enrollment, as in these plans. If you survey seniors who have these plans, they tell you that they really love them. And notwithstanding all the stuff we just talked about, I think they are popular by most people who use them. In part, it’s because they get these extra benefits. They have lower premiums. You know, they get some goodies that they wouldn’t get with regular Medicare. And in Congress, the preponderance of members of Congress have signed letters indicating that they support, I think, what they call a stable policy-and-rate environment for the plan. So last year, 80% of members of the House of Representatives signed such a letter. That’s just, I mean, you don’t see 80% of members of the House of Representatives agreeing on practically anything — and a majority of senators as well. And I think everyone’s expectation, including me, is that when these people signed this letter and said, you know, this is important and my constituents care about it, that they would have the back of the plans and that it would be hard for regulators to be aggressive in trying to change anything about this program because there would be such a big political outcry. And, in fact, what’s happened is they have really started cracking down. They started with some of these smaller regulations. And then the one that they did, it was kind of hidden in a technical way, but it had a really big impact. They changed this whole formula and they basically said, hey, plans, like, you can no longer get these extra payments for a lot of the diseases that they were very commonly making money for diagnosing people for. And all of a sudden, you know, this support on the Hill just kind of dissolved. And that is very much in the face of this huge lobbying effort. You know, Julie, you mentioned the television commercials, but the plans also mobilize their customers to call their members of Congress to contact the White House. Something like 142,000 calls and letters have been submitted to members of Congress and the White House. The proposal itself, there’s the formal comment process — in a normal year [it] gets like a couple of hundred comments, mostly from various stakeholders in the Medicare system. This year there was an organized letter-writing campaign and 15,000 comments were submitted on this rate notice. So we just see this environment in which the public has been activated. Lobbyists are going crazy. The CEO of United[Healthcare], the largest health insurer in the country, was making the rounds on the Hill, talking to members of Congress. And yet … and yet there’s really no one in Congress who’s standing up and screaming and yelling about how terrible this is. I mean, I shouldn’t say no one. There are a few individual members of Congress, Republicans, who have been highly critical of this and who have pointed out that this move is potentially inconsistent with President [Joe] Biden’s promise to never cut Medicare, which is a key campaign message for him going into his reelection. But the leaders in Congress, the heads of committees, the really prominent members, and certainly leading Democrats have not said those kinds of things. There were letters that came out very late in the process, really in the last week or so, from Republicans in House and Senate committees of jurisdiction that you might have expected to be these angry, partisan, like, “how dare you do this to Medicare Advantage?” kind of letters. And they were not those kinds of letters. They weren’t critical, but they were very polite and they were very technical. They’re, like, could you please answer the following 10 very technical questions about this tiny little detail of the formula? So it’s clear … they are concerned and they are providing oversight. And I don’t think that they are enthusiastically embracing these changes. But at the same time, I think they are not carrying water for the insurance industry and making it very politically difficult for the Biden administration to make these changes.

Rovner: I feel like the Humana announcement actually sent quite a message that says, wow, we can make a lot more money from Medicare than we can make from the commercial market.

Kenen: Well, I think that’s true. I mean, one reason so many seniors are in Medicare Advantage, and do like it, is that they get an incredible deluge of marketing. I mean, the companies went in here, they saw that it was a business opportunity. They have marketed themselves very aggressively. People get dozens and dozens of letters saying, “Apply for this plan” or “We’ll give you this. We’ll give you that.” So the market is there. But I also think there’s a political dynamic that’s bubbled up recently that’s different. There’s been a fight every year about Medicare Advantage payments. It hasn’t been as grassroots; it hasn’t gotten as much attention. But there’s been a fight. I mean, every year the administration puts out their formula. Every year the industry fights it back. You know, there’s some kind of compromise. The industry doesn’t get hit as much as it would have. It’s part of the game, right? I mean, that’s how payment rules are made in Washington. But something has changed here that Biden quite successfully, at the State of the Union, really put the Republicans on the hot seat in terms of protecting Medicare and Social Security. And they’ve flipped it. Because the Republicans are better at language. You know, if this was a Republican rule, they would be calling it the “Protect America’s Seniors From Fraudulent Insurers” rule. You know … the Democrats just don’t do that.

Rovner: We should point out that it was the Republicans who named it Medicare Advantage — renamed the whole Medicare private plan program.

Kenen: Right. But just as … Biden’s politically great moment at the State of the Union making the Republicans promise not to touch Medicare, the Republicans have flipped it, because now they’re accusing Biden of attacking Medicare in a different way. And, you know, Medicare was this hot political issue in campaigns in the late Nineties and the early 2000s. It was replaced by a 10- to 15-year fight about what became the Affordable Care Act and repealing it and all that. And then there was this political vacuum in 2022, and in 2020, after the Republicans failed to repeal the ACA, we sort of had a — not health slogan-free, but it was on the back burner and …

Rovner: We had a reset. Well, we did have a pandemic.

Kenen: We had the pandemic, but — and that was politicized — but the traditional health care fight is reemerging. The traditional partisan health care fight is … both sides have accused the other over the year of “Mediscare.” This is the platform for that fight that I think we will continue to see going into 2024. I mean, it will evolve. I mean, this particular rule will get settled. But, you know, you’re sort of seeing who is the champion of Medicare, which Republicans, years ago, when Paul Ryan, when he was the budget chair of the House and the speaker of the House, he really wanted to significantly transform Medicare in ways that made it very different than the Medicare as it existed for them, Republicans, who are “saving Medicare.” For the Democrats, it was “Republicans are privatizing and destroying Medicare.” This is just Chapter 9,000. It’ll morph again between now and November 2024, but it’s begun.

Sanger-Katz: I think the politics of this are interesting and I think kind of unsettled. I’m very curious to see how this plays out in the campaigns. I do think that there is an available argument for Republicans to make that this change, which does take money out of the pockets of these plans and which potentially could mean that beneficiaries are going to end up with a little bit less generosity, because when those plans make less money, maybe they’re not going to give you as many extra goodies or lower your premium by as much. We don’t know that, but it’s certainly possible.

Rovner: In 1997, they cut payments for what was then Medicare Plus Choice, I think, Medicare Part C. And that’s exactly what happened. They cut all the extra benefits and people threw a fit, and they ended up having to put a lot of the money back.

Sanger-Katz: But in the Affordable Care Act, they cut a lot of the money and the benefits just kept growing. So we don’t know how the plans are going to absorb this change. But anyway, I think there is this available attack line for Republicans. Biden said he’s not going to cut Medicare. Look what he did. He’s cut Medicare. He’s taken all this money out of Medicare and it’s causing your premiums to go up. On the other hand, I do think there is this opportunity for Biden to say, “We reduced fraud; we improved the health of the Medicare trust fund.” And I think a lot of Republicans are actually committed to both of those things. I think they care about program integrity. They care about the fiscal future of the program. And so it’s all just a little bit scrambled. This almost feels more like something you might see in a Republican administration than a Democratic one.

Rovner: I was just saying, Jessie, is there any inclination on the Hill to do anything about this, or do you think they’re just going to either talk about it or not talk about it, as it were?

Hellmann: I haven’t heard anything about any potential action on the Hill. There’s just been letters sent asking questions, or some Republicans have sent letters saying, “We don’t like this.” But I don’t know that there’s enough support in both the Senate and the House to override this. And they are talking more about, like, the health of the Medicare trust fund. And some of the rules proposed by the administration could help strengthen that a little bit. It’s not going to solve all of its problems. But to go in and meddle with what the administration is doing to help the trust fund a little bit, while Congress is having more and more debates about helping the trust fund, I don’t know if that would be a good look.

Kenen: You could still have a policy compromise on, like, anti-fraud policy and still have a political fight. “We saved it!” “No, we saved it!” Oh, they … it’s way too soon to know what issues are going to dominate 2024 and what issues attract sustained attention from a public that doesn’t sustain attention to much of anything anymore. But right now, this is certainly a trial balloon for 2024. And I can see it. I can see that. I can see working out some kind of compromise on the actual technical issues and still having a political fight.

Rovner: Well, we’re going to move on because we’re clearly not gonna settle this today. But I hope people at least got a flavor for really how complicated this is, both, you know, technically and politically. I want to turn to something else that’s complicated: That’s reproductive health. And by that I mean much more than abortion and birth control. A new study from the Centers for Disease Control and Prevention finds that maternal mortality, the death rate for people when they are giving birth or in the weeks immediately after, rose by more than a third in 2021 compared to 2020. And African American women, even those with higher incomes, were 2½ times more likely to die during or just after childbirth than white women. Certainly, the pandemic had something to do with this. It disrupted medical care for just about everybody, and pregnant women who got covid had a higher risk of severe illness or death. But this is really just a continuation of a trend that’s been troubling health experts for several years now. Joanne, you’re our public health expert here. Why has this been so difficult to address?

Kenen: I mean, I think some of it is the two things that Julie said for 2020. I mean, you know, there was all this fear that the vaccines could hurt pregnant women. Actually, it was covid that hurt pregnant women and their babies. So, hopefully, we’re over the worst of that. And people weren’t going in for good prenatal care. So that was a factor. But this is a really sustained problem, and we’ve begun to take some steps. Most states are now extending Medicaid coverage postpartum for six months or a year under Medicaid. I think that when many of us, including me, when I first heard about these problems with maternal mortality, I was thinking about giving birth. I was thinking about hemorrhage and things that happen in the delivery room or right after, when, in fact, it’s really the full year after. There is high risk for everything. And that’s where a lot of the disparities in our system … the states that don’t have Medicaid, the states that  …

Rovner: Didn’t expand Medicaid.

Kenen: … didn’t extend Medicaid, you know, or there aren’t … most of them are now expanding it for women in this category, or beginning to. So that might help. I mean, the disparities throughout the health care system, this is not just an income thing. In all economic strata, the racial disparities in maternal mortality exist. And then I just found out something recently that really shocked me. I’ve done some work over the past six months writing about domestic violence as a public health problem, and I’ve moderated two panels, just like in the last 10 days on it. And most states do not count homicide, suicide, and overdose as part of the maternal mortality figures. So if you think these figures are bad, it’s way worse, because pregnancy and postpartum are all so high risk for all of those things. But since the OB-GYNs actually review these maternal mortality cases, they’re not reviewing those other three categories. So as bad as it is, it shocked me to realize what we’re looking at and being horrified by isn’t even the full picture.

Rovner: Wow. So, well, here’s where reproductive health writ large and abortion policy cross in ways that may be unexpected to lawmakers who voted for their states’ bans, but not to anybody who’s studied health policy. In Idaho, a rural hospital has announced it will no longer deliver babies, forcing women seeking labor and delivery care to travel nearly 50 miles. Why? Because the hospital, Bonner General Health in Sandpoint, says it cannot keep enough health professionals, both OB-GYNs and pediatricians, to safely run a maternity ward. Why not? Well, Idaho’s, quote, “legal and political climate,” says the hospital from its press release, quote: “The Idaho legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.” Margot, your extra credit this week is about something similar, but in Texas. So why don’t you do it now?

Sanger-Katz: Yes, I wanted to recommend this article from Sophie Novak in Slate called “You Know What? I’m Not Doing This Anymore.” And her piece profiles a whole bunch of nurses and doctors who work in OB-GYN care in Texas who are quitting or leaving or who are considering not taking jobs that they might otherwise have taken. And I think we don’t have real data on these trends, and I’m always a little bit worried about these kinds of stories that, you know, you can always find five or six or seven or 10 doctors who are unhappy or who say that they might quit. There was a lot of those stories, like, when Obamacare passed, all these doctors are going to retire early because they don’t like the rules. I think that turned out to be more marginal than we might have expected based on that coverage. But I still think that this story is telling these stories of these providers, and I think it’s pointing to something that is a real risk and is potentially a real trend, which is if you are someone who is in the business of caring for women through pregnancy and childbirth, and you feel like you cannot do the things that you were trained to do, that there is potential criminal liability for you in providing the care that your patients need, if you’re having to watch your patients suffer through needless harm or medical risk because you can’t provide an abortion when one is medically indicated without facing that kind of legal risk. I do think that there is a real risk that these people are not going to want to practice in those states. They would rather go to a place where they have a little bit more autonomy and a little bit less concern about prosecution. And what that means is that the women left behind in these states, however you feel about abortion, may not have access to as many health care providers, and they are going to continue to have pregnancies and births and need that kind of support. And I think that is a very interesting and troubling dynamic that I think could have very large reverberations and could, of course, make the trends that Joanne was just talking about, you know, even more concerning and lead to even more disparities. Because, of course, it is a lot of the states that are banning abortion are states that have these kind of poor, minority communities who are already facing a lot of the maternal mortality. We see in the existing data it’s increasing in a kind of across-the-board way, but there are some places where it’s worse than other places. And a lot of the worst places for maternal and fetal mortality are these same places that are banning abortion and where they may be at risk of losing some of the providers that can help ameliorate the problem.

Rovner: And it’s not just losing the providers, it’s replacing the providers who do get old enough and retire or who leave, because we’re seeing medical students, fourth-year medical students, say they’re loath to apply for residencies in some of these states, partly because they’re worried about their training, but partly because, you know, if they’re women, they may need this care at some point or they may have family members who will come with them who need this care at some point. And because, for the most part, where you do your residency tends to be where you end up practicing. So, I mean, we didn’t see it so much in this year’s match, but I’m wondering whether this is going to be an issue, too. There’s some big, important academic training centers in some of these states with bans. I’m thinking, you know, Vanderbilt comes to mind immediately in Tennessee. I think this is another thing that was perhaps unexpected, although if you thought about it hard, you could have predicted it.

Kenen: I mean, pregnancy is complicated. A century ago, women commonly died in pregnancy. And we live in an era where it’s safer than it had been, but we forget it can still be risky. And wanted pregnancies, very much wanted pregnancies, can go wrong. And I’ve experienced … I mean, I have two kids, but I experienced that, and I needed emergency medical care and I was able to get it. I needed emergency medical care more than once, and I was able to get it.

Rovner: And I remember visiting you when you were on bed rest.

Kenen: Right? It was one of my few fun nights on bed rest, when Julie and Joanne Silberner brought me dinner. We had a picnic, right? In bed, right? But, you know, I never had to deal with anything except the grief of losing a pregnancy. So, you know, it was a very much wanted pregnancy, and I didn’t have to worry about anything being withheld from me. I had a lot of things go wrong a lot of times. But, you know, I was really lucky to end up with the family I have. When I read these stories, and I go back and think, what if I had to deal with infection? What if I couldn’t get that care? And we’re just not thinking this assumption, by mostly male lawmakers, that it’s not a huge medical thing. Pregnancy changes your body, everything about your body, it’s not just cosmetic. There are lots and lots of risk factors, before and after. That [has] sort of just been glossed over as, oh, it’s not a problem. And it is a problem. And one reason we’re going to see this shift in medical practice is because they understand it’s a problem. I mean, you read these stories about these doctors, and we’ve talked about them every week, and our listeners have heard them and read them, about doctors who are watching a patient with a serious infection, until she is getting close enough to die that they can treat her, but not so close to dying that they lose her. And you hear the anguish.

Rovner: That’s why I was so taken by that line in the press release from the hospital in Idaho, which is that doctors don’t want to possibly be criminalized for what is considered the standard of care. They’re being asked to basically choose between perhaps getting sued or put in jail and what they vowed to do to care for their patients. And it’s really hard. It’s not really that much of a surprise that people are going to leave or not go there. All right. Well, we will definitely come back to this, too. I want to talk about covid briefly. Jessie, the president signed the bill passed by Congress to declassify intelligence on the origin of covid. Do we have any idea when that’s going to happen? How soon? And do we get to see this, too? Or just the members of Congress?

Hellmann: The director of national intelligence is supposed to declassify this information 90 days after the law is passed. After that, I’m not entirely sure if it’s just for Congress or it’s for the public, to be honest.

Rovner: We will see. I was amused that, right after this happened — because now we have all this talk that, you know, “Oh, absolutely” or not, absolutely it was a lab leak, but “more likely it was a lab leak.” Now we have new evidence suggesting that it may, in fact, have started in the Wuhan wet market, after all, jumping from something called raccoon dogs? Now, I consider myself something of an animal expert here. I have never heard of a raccoon dog.

Sanger-Katz: They’re really cute. I was enjoying looking at all the photographs of them.

Rovner: Are we going to now go back to the “OK, maybe it really did come from the market”? I-I-I …

Kenen: What I’m about to say is an oversimplification, but if you’re a Republican, you think it’s a lab leak. And if you’re a Democrat, you think it’s a raccoon dog. And that is an oversimplification. And one of the things that drives me crazy is that the potential for lab leaks exists and lab safety is an issue that should be bipartisan. There have been lab leaks in the U.S., there have been lab leaks elsewhere in the world. And that doesn’t mean this came from a lab leak, but lab leaks are a thing. And we want to make them not a thing. But again, there are many lessons we should be able to take from the pandemic; that’s one of them. Like, OK, maybe this wasn’t a lab leak, maybe this was the Wuhan animal market, but let’s take this as a moment to think about how we can protect ourselves from a future lab leak. You know, we may never conclusively know. Even the raccoon dog thing is still a theory. I mean, there’s evidence behind that theory, but the scientific establishment has not said, OK, this is it. There’s still debate. The science world tends to think it’s zoonotic, that it’s from an animal, but it’s not over yet. And again, the politicization is preventing good public policy.

Rovner: If only someone could turn that fight into something. And as I quoted Michael Osterholm last week as saying, “It doesn’t matter which one it was, because we have to be ready for both of them in a future pandemic.”

Kenen: Exactly. And we’ll probably have both. I mean, we may not have a pandemic from a lab leak, but is it possible that somebody, somewhere, or some community will be hurt from a lab leak? Yes, it is. And we need to mitigate that. Is it possible we have another zoonotic infection? I mean, there’s two Marburg outbreaks in Africa right now. I mean, that’s from animals. And there’s two of them going on. It’s an obscure disease. It’s worse than Ebola. It doesn’t spread as fast, but we have zoonotic infections way more often than the average American realizes.

Sanger-Katz: And also just one more thing, which is we still had and have a global pandemic that has caused enormous suffering and death and fear around the world. And in some ways, I feel like this obsession with like whose fault it is is a distraction from what can we do to prevent such a thing from happening in the future and really looking at, like, what was done appropriately and inappropriately in terms of the covid response? Pinning this down seems … it seems academically interesting to me. It seems useful to know. I think, as you guys have said, you’ve got to be ready for both things anyway. But it also feels like a little bit of a sideshow sometimes when the reality is: Covid came for us. It wasn’t a near-miss where looking at the origin is the whole story. It’s also everything that came afterwards is really important, too.

Rovner: Yes, absolutely. Well, finally this week, one more update. On last week’s podcast,while we were discussing Novo Nordisk following Eli Lilly’s lead in announcing insulin price cuts, I wondered aloud how long it would be before the third company in the triumvirate that controls most of the diabetes drug market, Sanofi, would follow suit. As it turned out, the answer was a couple of hours. In a press release that came out Thursday afternoon, Sanofi said it would cut the price of its most popular insulin product by 78% and ensure that people with health insurance pay no more than $35 a month for their insulin. But I’m thinking this fight is not completely over; now that the three big companies have voluntarily said we’ll lower our prices on some of our insulins, Congress is still going to want to do something about this, right?

Hellmann: Yeah. Sen. [Chuck] Schumer said last week that he still wants Congress to address this issue. He still wants to cap the cost of insulin because, like you said, there are still insulin products that some of these companies offer that don’t fall under these announcements.

Rovner: Drug prices will continue to be a top-of-mind issue, I suspect. All right. Well, that’s as much news as we have time for this week. Now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Margot, you’ve already done yours. Joanne, why don’t you go next?

Kenen: It’s a piece in The New Yorker, and I’m not sure how she pronounces her name. I think it’s Jia Tolentino. If any of you know, please correct me. But the story is called “Will the Ozempic Era Change How We Think About Being Fat and Being Thin?” I mean, this is a diabetes drug that is being used off-label for weight loss, quite widely to the point that there’s a shortage for people who have diabetes; they are having trouble getting it. It does help people lose weight and it’s become very much in demand because it does help you lose weight. And there are a few others in this class. So, the question she poses: This is a metabolic disorder, it’s not just a willpower issue, and will this help us get to that point? … It was a really good, interesting article, and I still ended up with a lot of questions about long-term safety, about do you have to take it forever and how much, and what happens if you don’t? It’s treating obesity rather than thinking about how to prevent obesity, which is a better — you know, too late for some millions of Americans, but there is generations to come. So but it was an interesting, provocative landscape piece.

Hellmann: My story is from The Washington Post. It’s called “Senior Care Is Crushingly Expensive. Boomers Aren’t Ready.” It’s just a story about how expensive long-term care could be, especially if you need really specialized care. One of the people interviewed for this story would have to pay about $72,000 a year to stay in an assisted-living facility. This person has Alzheimer’s and so they just need a little more help than someone else might. And they talk a lot about how Medicaid will cover some of this care, but only if you spend all of your life savings. And obviously, Medicare doesn’t really cover stays in assisted-living facilities either. I know we talked in email about how perennial this issue is. It’s something that was an issue 20 years ago. People are warning: We need to fix this problem.

Rovner: More than that. When I first joined CQ in 1986, it was the first big story I wrote, about what are we going to do about long-term care for the baby boomers? Here we are almost 40 years later, still talking about the same thing.

Hellmann: Yeah, I guess the answer is nothing.

Rovner: Not much has happened.

Kenen: Yeah, what’s happened is we’ve shifted more and more of it onto families.

Rovner: Yeah, that’s true.

Kenen: More complicated care for longer.

Rovner: My extra credit this week is a truly terrifying piece from Vice News called “Inside the Private Group Where Parents Give Ivermectin to Kids With Autism,” by David Gilbert. And the headline says most of it. What it doesn’t say is that when you give horse wormer to kids — and this group actually advises the use of the paste that’s given to horses — they’re going to have adverse reactions. The kids, not the horses, including headaches, stomachaches, blurry vision, and more. But the administrators of this group insist that the side effects aren’t because the children are being administered something that can kill people in the wrong dosages, but because the medication is, quote, “working.” They also say it can cure a whole host of other disorders from Down syndrome to alopecia. It is quite the story. You really do need to read it.

OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always to our ever-patient producer, Francis Ying. As always, you can email us your comments or questions. We’re at whatthehealth — all one word — at kff.org. Or you can tweet me. I am @jrovner. Margot?

Sanger-Katz: @sangerkatz

Rovner: Jessie.

Hellmann: @jessiehellmann

Rovner: Joanne.

Kenen: @JoanneKenen

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

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

This week, the eyes of the nation are on Texas, where a federal judge who formerly worked for a conservative Christian advocacy group is set to decide whether the abortion pill mifepristone can stay on the market. Mifepristone is half of a two-pill regimen that now accounts for more than half of the abortions in the United States.

Meanwhile, Novo Nordisk, another of the three large drug companies that dominate the market for diabetes treatments, has announced it will cut the price of many of its insulin products. Eli Lilly announced its cuts early this month. But the push for more affordable insulin from activists and members of Congress is not the only reason for the change: Because of quirks in the way the drug market works, cutting prices could actually save the companies money in the long run.

This week’s panelists are Julie Rovner of KHN, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.

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Sarah Karlin-Smith
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Alice Miranda Ollstein
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Among the takeaways from this week’s episode:

• The federal judge examining the decades-old approval of mifepristone could issue a decision at any time after a hearing largely behind closed doors, during which he appeared open to restricting access to the drug.
• Democratic governors seek to counter the chill of Republican states’ warnings to pharmacies about distributing mifepristone, and a separate lawsuit in Texas seeks to set a precedent for punishing people who aren’t medical providers for assisting someone in obtaining an abortion.
• In pandemic news, Congress is moving forward with legislation that would force the Biden administration to declassify intelligence related to the origins of covid-19, while the editor of Cochrane Reviews posted a clarification of its recently published masking study, noting it is “inaccurate” to say it found that masks are not effective.
• Top federal health officials sent an unusual letter to Florida’s surgeon general, warning that his embrace of vaccination misinformation is harmful, even deadly, to Americans. While covid vaccines come with some risk of negative health effects, contracting covid carries a higher risk of poor outcomes.
• Novo Nordisk’s announcement that it will cut insulin prices puts pressure on Sanofi, the remaining insulin maker that has yet to adjust its prices.
• The Veterans Health Administration will cover Leqembi, a new Alzheimer’s drug. The decision comes as Medicare considers whether it will also cover the drug. Experts caution that new drugs shaking up the weight-loss market could prove costly for Medicare.
• Washington is eyeing changes to federal rules that would affect the practice of medicine. One change would force health plans to speed up “prior authorization” decisions by health insurers and increase transparency around denials, which supporters say would help patients better access needed care. Another proposal would ban noncompete clauses in contracts, including in health care. Arguments for and against the change both cite the issue of physician burnout — though they disagree on whether the ban would make the problem better or worse.

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

Julie Rovner: “Tradeoffs” podcast’s “The Conservative Clash Over Abortion Bans,” by Alice Miranda Ollstein and Dan Gorenstein

Alice Miranda Ollstein: Politico’s “Sharpton Dodges the Spotlight on Latest Push to Ban Menthol Cigarettes,” by Julia Marsh

Sarah Karlin-Smith: Allure’s “With New Legislation, You Can Expect More Recalls to Hit the Beauty Industry,” by Elizabeth Siegel and Deanna Pai

Jessie Hellmann: The New York Times’ “Opioid Settlement Hinders Patients’ Access to a Wide Array of Drugs,” by Christina Jewett and Ellen Gabler

Also mentioned in this week’s podcast:

• CQ Roll Call’s “Noncompete Rule Puts Doctors, Hospitals at Odds,” by Jessie Hellmann
• Cochrane’s “Statement on ‘Physical Interventions to Interrupt or Reduce the Spread of Respiratory Viruses’ Review,” by Karla Soares-Weiser, editor-in-chief
• The “Osterholm Update” podcast’s “Truth in the Midst of Political Theater,” by Michael Osterholm and Chris Dall
• Stat’s “Denied by AI: How Medicare Advantage Plans Use Algorithms to Cut Off Care for Seniors in Need,” by Casey Ross and Bob Herman

click to open the transcript

Transcript: Judging the Abortion Pill

KHN’s ‘What the Health?’Episode Title: Judging the Abortion PillEpisode Number: 289Published: March 16, 2023

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

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser 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 16, 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: Good morning.

Rovner: Jessie Hellmann of CQ Roll Call.

Jessie Hellmann: Hello.

Rovner: And Sarah Karlin-Smith the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

Rovner: So, we have more than enough news. Let us get right to it. We will start this week with abortion. And, of course, that means we will start in Texas. On Wednesday, federal District Judge Matthew Kacsmaryk held a four-hour hearing in Amarillo on a lawsuit charging that the FDA wrongly approved the abortion pill mifepristone back in the year 2000 and that he, Judge Kacsmaryk, should substitute his legal judgment for the FDA’s medical judgment and order the FDA to take it off the market. What was said at the hearing? Well, we don’t really know because only 18 reporters were allowed in. They weren’t allowed to take any electronic devices in with them. And there’s no audio and no transcript. But, Alice, I know you’ve been trying to follow this from afar, like I have. What do we know about what happened and when might we expect a ruling?

Ollstein: So we can expect a ruling literally at any time. Hopefully not while we are taping right now. The judge did say that he would rule as soon as possible, although with four hours of oral arguments to sift through, that could take a bit of time. I always bank on a Friday evening news dump, because that’s when it tends to happen.

Rovner: I keep reminding people that’s when the ACA [Affordable Care Act] ruling came down.

Ollstein: Exactly.

Rovner: Came down on the Friday before Christmas at 7:30 at night.

Ollstein: Exactly. Thankfully, some great reporters were able to make it and provided us with some updates about this. It was really fascinating. The judge definitely, as we anticipated from his record of working for conservative, explicitly anti-abortion organizations before he was confirmed to this judgeship, he did seem open to taking the steps that the challengers were asking for in restricting access to this medication. I think the question really is whether he is going to go for a full ban or — what a lot of the questions during oral arguments centered around — was around rolling back more recent FDA rules that allowed people to get the pills by telemedicine, by mail delivery. And so there is some question as to … if going all the way back to a 20-year-old FDA approval and overturning it is a bridge too far. Maybe these more recent agency rules are sort of more justifiable in having the court go after them. So, we’re all just on high, high alert, refreshing pages over here.

Rovner: Yeah. Once again, remind us of why this could have national impact, this one judge in Amarillo, Texas?

Ollstein: Yeah. So these anti-abortion medical groups incorporated in Amarillo specifically so that they could get in front of this judge who has a record of being an abortion opponent. And so this is an example of “judge shopping,” which is an increasingly common practice. So this could have national implications because it’s going after the federal regulations around these pills. Really, this will mainly impact blue and purple states, where the pills are still legal and still used today. A bunch of states have already banned them and put restrictions on all forms of abortion or just the pills. And so this really will squeeze states where their use is protected.

Rovner: And I think abortion rights organizations are freaked out because everybody thinks, well, it’s just one judge. You’ll go up to the next level and you’ll get it, you know, you’ll get it stayed. Except in this case, the next level is the 5th Circuit Court of Appeals, which is just as conservative. And we seem to do a lot of anti-abortion rulings. And then if you go above the 5th Circuit Court of Appeals, you’re at the Supreme Court, which just overturned Roe v. Wade. So if this judge rules for the plaintiffs in this case, there’s not a lot of hope, I guess, from the abortion rights side that anything could be overturned, right?

Ollstein: It also gets into really interesting stuff about what is on the labels of these different drugs. Pro-abortion rights and other medical groups have been pushing the FDA to officially add miscarriage management to the label of mifepristone, so that if it is banned in this case, people can still access it for that. That has not happened. It is used for miscarriage management off-label. That is the real risk of people losing access; they’re not just for abortion. Again, there are two pills that have been used for abortions together for the past 20 years, and the other one, misoprostol, there could be restrictions put on it through this case, but because it officially is labeled and marketed for non-abortion purposes, it’s harder to ban.

Rovner: It’s a stomach ulcer drug.

Ollstein: Exactly.

Rovner: All right. Well, assuming that the pill is not pulled from the market, the squabble over whether pharmacies will stock it continues. As we discussed at some length last week, Walgreens caved to threats of prosecution from Republican attorneys general and waffled on whether they’ll sell the pills, even in some states where abortion remains legal. Now, a group of Democratic governors are not so subtly urging seven other national pharmacy chains to pay no attention to those Republican attorneys general threats. Have we heard from any of the other pharmacy chains about whether they will or won’t sell mifepristone in the wake of Walgreens getting raked over the coals by both sides?

Ollstein: Total radio silence. And I think that the backlash to Walgreens is the reason for that. I think they saw what happened. They saw Walgreens getting really slammed from both sides. You know, you have anti-abortion folks slamming Walgreens for saying they’ll sell the pills anywhere in the country. And you have pro-abortion rights people mad at Walgreens for saying that they won’t sell them in some places. So it’s kind of a no-win situation. And the other pharmacies, I’m sure, are looking at that and saying, why would we stick our necks out getting certification from the drugmakers to sell the pills in the first place? It’s going to still take a while and who knows what could happen by the? And so why would we prematurely come out and say what we’re doing when we have no idea?

Rovner: Yeah, and I remind people for the millionth time that it’s not that Walgreens was going to stop selling them. None of the pharmacies have started selling them yet because it was only in January that FDA said for the first time that they could, which, as Alice points out, may be one of the things that this judge in Texas rolls back, if he doesn’t try to roll back the entire approval of the pill. One more on abortion: Also in Texas, the ex-husband of a woman who got an abortion last summer is suing three of her friends for, quote, “wrongful death” for allegedly helping her obtain abortion medication. His evidence largely comes from screenshots from a group chat, raising more calls for better privacy protections for electronic information. Meanwhile, it’s not even totally clear that the abortion was illegal last July, because there was some legal back and forth about whether Texas’ trigger law abortion ban was actually triggered when Roe was overturned the month before. If the ex-husband wins this suit, though, I’m wondering how much of a reaction there is going to be to nonmedical providers being found liable for damages. He’s suing them for $1,000,000. We keep hearing about this, but to my knowledge, it hasn’t actually happened yet, that nobody’s been convicted, I don’t think anywhere of, you know, abetting someone having an abortion, particularly a nonmedical provider.

Karlin-Smith: And then I mean, it seems like, again, it’s designed to have these chilling effects on people and get people to think twice before they do things they otherwise would. And I know this story raises the issue of whether there’ll be more pressure on tech companies to encrypt all data and messages, which would be interesting to see, you know, how companies react going forward. But we already know that …

Rovner: How the tech companies react.

Karlin-Smith: Right. I think we already have seen that doctors who take oaths and hold certain ethical standards to protect people’s health and life have felt like they’ve been put in very challenging situations between the law and what the best care they normally provide for their patients with abortion. So if doctors feel this way, if regular people feel like they’re also going to be on the hook for something, I would be more concerned, in the sense that regular people would feel even less protected. The medical providers, which tend to work for companies that have, you know, lawyers to help them guide them through their decision-making. And, you know, they have various types of insurance as well to help them through this stuff. So it does seem like it could have a big chilling effect if this ex-husband wins in any way.

Rovner: Yes. I mean, the point here is to just further isolate women who are pregnant and don’t want to be, for whatever reason, from reaching out, not just to medical providers, but to their friends, or at least, I guess, reaching out in some way other than in person. We will see how this one plays out. All right. Well, let’s talk about covid, which we haven’t done for a while. First, the reignited fight over the lab leak versus wet-market-origin theory. I have studiously tried to steer away from this because the one thing just about every expert agrees on is that we will probably never know for sure where covid-19 came from. And to quote Michael Osterholm, the esteemed epidemiologist at the University of Minnesota, we have to be prepared for the future for both events: another spillover event and for the lab leak. Still, the House moved forward with a bill this week, already passed by the Senate the week before, to require the declassification of some intelligence related to covid’s origins. Jessie, you covered it. What would the bill do? And is … do we think the president is going to sign this?

Hellmann: So the president hasn’t said yet if he will veto it, but if he does, it would be his first time vetoing something, if I’m not mistaken. So it could be a bad look if he does decide to make that decision. It passed the House 419 to 0. There were 16 non-voting members. It passed the Senate unanimously a few weeks ago, so I can’t imagine that he would veto it. And, basically, what the bill does, it would require the director of national intelligence to declassify information on covid-19 origins within 90 days and send the declassified report to Congress. It’s not clear how much that will illuminate. There’s so many questions about this. The intelligence community is still pretty divided on this issue, despite the Department of Energy, intelligence community saying a few weeks ago that they think it could have arose from a lab leak, though they said that with low confidence. So, it’s not really clear what information we’ll get from this.

Rovner: And this is just basically Congress saying, well, we don’t know, but we want to know what you know.

Hellmann: Yeah.

Rovner: Is that basically where we are?

Hellmann: Exactly. And there’s also, like, a lot of hearings going on right now in Congress where they’re starting to bring people and talk about this. And I think last week, or was it this week, a select committee had a closed meeting with the Department of Energy about their report. So there’s definitely a lot of interest in this.

Rovner: We will definitely see how this plays out. Well, another thing, we are still fighting about, three years in, the efficacy of masks. A couple of weeks ago, the gold-standard scientific organization, the Cochrane Review[s], put out a meta-analysis of mask studies conducted over the years that concluded there was not sufficient evidence to demonstrate that masks help stop the spread of respiratory illnesses. Well, as so often happens with conditional findings like those, mask opponents immediately trumpeted that the study shows that masks don’t work, which is not what the study showed. Now, in a fairly rare step, the editor of the Cochrane Review herself has posted a clarification of the summary of the study, which we will post in the show notes, but I will quote from it: “Commentators have claimed that a recently updated Cochrane Review shows that, quote, ‘Masks don’t work,’ quote, which is an inaccurate and misleading interpretation.” So what’s that line again? A lie travels around the world before the truth can even get out of bed. Is that where we are with masks now? We’ve gotten to the point where there’s this huge belief that masks don’t work. And the fact is, like the origin of covid, we don’t actually know.

Karlin-Smith: I think that the “don’t actually know” is maybe not the best way to put it. There are things we do know, and that’s some of what, you know, has tried to be clarified in the past week or so from this, although there is that ultimate question of: Is it too little, too late, and are people already sort of set in their views? And that’s the sort of thing for different types of researchers to figure out in terms of how you convince people of various evidence and stuff. But, you know, I think one line that stuck out to me is, in The New York Times piece, trying to dissect the nuance of this review. And it is really nuanced and you really have to appreciate those nuances. You know, they say is what we learn from the Cochrane Review is that particularly before the pandemic, distributing masks didn’t lead people to wear them. And thus, if a mask is going to work, but you don’t wear it, it’s not going to work. And you know, people who have been sort of anti-mask to some degree have said, well, but that does show masks don’t work, because if we can’t get people to wear masks, what does it matter? Of course, for people that want to wear a mask or, you know, are comfortable wearing a mask, there’s also plenty of evidence that shows well-fitting, quality masks will block covid. So you shouldn’t think on an individual level, “Let me throw away my N95. It’s not doing me any good.” It certainly is doing you good. And we have, you know, laboratory research and other research to prove that. So, you know, The New York Times did a really good job of dissecting what was really studied, how much was studied, pre-covid, post-covid, what they looked at, and to try and help people understand where we’re at, which is definitely, again, that there can be benefits to wearing masks. There are differences in population benefits versus individual benefits. And when you think about the population benefits, too, sometimes I think you also have to think about even small, subtle benefits on a population level can make a big difference. So even if mask-wearing isn’t the be-all and end-all some people maybe want you to think about, but it helps lower transmission and lowers cases on a population level, you know, that can translate to hundreds of thousands or even millions less cases, which can then lead, you know, to whatever corresponding number of deaths. So I think it’s also thinking about that, you know, something doesn’t have to be 100% effective in stopping transmission to be really valuable on a societal level.

Rovner: They could have summarized it as “Masks don’t work if people don’t wear them, and it’s hard to get people to wear them.” That would have been accurate. Right?

Karlin-Smith: But the other question is: How do we figure out how to get people to wear them if they do work?

Rovner: Well, but that’s not what this study was about.

Karlin-Smith: Right.

Ollstein: I found this whole reaction really depressing. And it’s been huge on Capitol Hill. It’s been coming up at all of these hearings with Republican members citing this and flatly declaring that it shows that masks don’t work, using it to go after officials like CDC Director [Rochelle] Walensky and excoriate her for recommending masks. And it just feels like we’ve learned nothing. Like Sarah was saying, we have not learned the difference between individual and population-level benefits. Everything is so black and white. Either something is completely effective or completely ineffective. There’s no nuance around reducing risk, and everyone keeps talking about how the next pandemic is inevitable. And it just feels like we absolutely have not learned anything from this one.

Rovner: Yeah, if you’d asked me three years ago where we would be in three years, this is not the place I would have predicted. Speaking of covid misinformation, this week the directors of the Food and Drug Administration and the Centers for Disease Control and Prevention took the rare step of writing a joint letter to Florida Surgeon General Joseph Ladapo — I assume that’s how he pronounces his name — warning that his claims that the covid vaccine is causing an upswing in adverse events are, quote, “incorrect, misleading and could be harmful to the American public.” Sarah, I’ve never seen a joint letter from the FDA and the CDC, certainly not to a state official. I mean, they must have been very unhappy about this.

Karlin-Smith: Yeah, I think it was a unique step. But also, Robert Califf at the FDA has made going after what he calls, you know, scientific misinformation, a key part of his commissionership. He often makes the claim that he feels like misinformation is what is killing so many Americans. So it wasn’t surprising in the sense that he felt the need to publicly respond in this way, particularly when you have an individual of such high stature in the state making claims that he feels are potentially dangerous to people. And a lot of what the Florida surgeon general said, again, has a little nugget of truth, but has largely been debunked in the way he’s framing it. So, yes, we do know there is some risk of these myocarditis, these negative heart effects from these covid mRNA vaccines. But we also know that getting covid actually poses a higher risk of these heart events. So it’s a trade-off that most people argue you would prefer to go with the vaccine than that. And so, the fact that, you know, you have such a high-level health official in a state perpetuating anti-vaccine sentiments, I think is why you see Califf and Walensky really feeling like they had to respond, though I’m a little bit perplexed as to why they decided to do it at this particular moment. But I think it’s because he actually addressed them first with a letter. But, you know, this surgeon general has been doing this for a while now.

Rovner: He’s been the surgeon general for a while, and he’s been saying things outside the mainstream, shall we say, for a while. Well, I want to turn to drug prices because there’s a lot of news there, too. Another one of the big three diabetes drugmakers, Novo Nordisk, has followed Eli Lilly’s lead in announcing it will slash the cost of many of its insulin products by up to 75%. First question, how much pressure will this put on Sanofi, the last of the drug companies that dominate the diabetes drug market? Are they almost inevitably going to follow?

Karlin-Smith: I think most people think it is inevitable, although maybe not for the reasons we’re all thinking. Some of it is just that peer pressure. But a big thing that sort of comes out in this: Sean Dickson, to give him credit, at West Health was sort of the first person I saw point this out. There’s changes in the law related to Medicaid rebates and what these companies will essentially, you know, the discounts they have to give Medicaid coming up, that when you raise your prices faster than inflation, because these insulin products have had their prices raised so much over the years, they were going to have to start owing the government money soon for their drugs instead of the government reimbursing them. So that’s seen as really probably one of the key reasons why these changes are happening when they’re happening, which is not to, like, take any credit away from all the advocates who have pushed for lower insulin prices over the years. Certainly, this law and regulation that was passed was designed, in fact, to motivate companies to do this. So, you know, there’s a cynical way of looking at it, and there’s another way of working at it. But, you know, I do think most people expect Sanofi to follow through, particularly if they think it’s going to impact their formulary placement, in terms of how they compete with these products. But then also just, you know, from a PR perspective, it’s not going to look good for them to be that last holdout.

Rovner: But this sort of leads to my next question. I haven’t seen anybody mention this yet, but I can’t help but think that particularly Lilly and Novo Nordisk are happy to cut the prices on insulin and get lots of good press, as you point out, because both of them are sitting on giant blockbuster drugs to treat obesity. Novo already has FDA approval for Wegovy, which is the same drug as its diabetes drug Ozempic, just in a larger dose. While Lilly already has the diabetes drug Mounjaro, whose clinical trials for obesity have shown it may be even more effective than Wegovy in helping people lose weight. Am I missing something here, or are these companies about to make a killing on other drugs?

Karlin-Smith: No, I mean, that’s one point. And I think, you know, Novo Nordisk is more reliant on insulin and diabetes products in general than Eli Lilly and Sanofi, which have broader profiles. But one thing to note is most of the insulin drugs that are getting list price cuts are older insulin. So, you know, Novo Nordisk notably did not cut the price of one of their newer insulins … in their announcement this week. So again, you have to look at which particular products they’re cutting and why. But there’s big concern about how the use of some of these diabetes medicines to treat obesity will impact budgets because such a large percentage of the U.S. population is overweight.

Rovner: You’re just getting to my next question.

Karlin-Smith: That’s what … I assumed you were thinking of this Medicare issue. Right now Medicare does not cover drugs for weight loss, but the thought process is, if they change that, because these drugs are much more effective than prior weight loss drugs have been, you know how will Medicare pay for these? So that’s another big drug pricing debate coming down the pike.

Rovner: I was just going to say, I mean, this is the thing that I’ve been thinking about, you know, and I guess the complication with Medicare … there’s a piece in the New England Journal of Medicine this week by a bunch of drug price researchers that said, well, maybe the cost-benefit for Medicare wouldn’t be quite as good as it would be for the younger population, because obesity is not such a factor for shortening your life if you’re over 65 than if you’re under 65. But as others point out, it’s unlikely that private insurers are going to start covering this medication if Medicare doesn’t. So you’ve got this sort of place where you’ve got these very promising drugs that are currently very expensive, many in the neighborhood of $1,300 a month, which is not what most people can afford, if insurance isn’t covering it. But the promise of working … and you’ve got all these rich people buying it from heaven-knows-what doctor. So there is actually a shortage. But this is expensive enough that if they can’t push the price down, it has the potential to really impact the entire cost of the health care system. Right?

Karlin-Smith: Right. I’ve seen people writing about this the way we were talking about the Alzheimer’s drugs if Medicare was decided to cover it for all patients who qualify for Alzheimer’s, some of the drugs that came out, how they would essentially have to raise premiums and the implications there. They remind me also of, a number of years ago now, when some new cholesterol-lowering medicines came out that were really pricey. And what would happen to Medicare if they got prescribed and used widely? That, of course, didn’t happen. In part, perhaps, because payers curtail these to some degree. This is going to become a really interesting public discussion because the costs issue, but it’s also sort of about how we think about obesity and weight loss. And for a long time, there’s been sort of a stigma attached to weight loss and weight loss products and people not thinking about it as a medical condition, something where you really need to try other things before you get a medicine or get a medical procedure. It’s sort of a personal failure, a cosmetic issue, issues of self-control … and the fact that these drugs are much more successful than previous weight loss medicines, which tended to not help people lose very much weight and had a lot more side effects, some of them were fairly dangerous.

Rovner: And got pulled off the market.

Karlin-Smith: Right.

Ollstein: For killing people.

Karlin-Smith: You’re going to confront a lot of issues head-on in figuring out how to deal with this, because it’s not just about price. It’s sort of thinking about what we consider a disease and what we’re willing to treat as a medical condition.

Rovner: Yeah, I think this is going to be a really big debate going forward. Well, you mentioned Alzheimer’s. And speaking of Alzheimer’s, the Veterans [Health] Administration has announced that it will offer patients with Alzheimer’s disease, that newest Alzheimer’s drug, Leqembi, is that how you pronounce it? It received accelerated approval from the FDA in January. That means more evidence needs to be presented to assure its safety and efficacy. Sarah, is this drug really better/safer than Aduhelm, which it’s a chemical cousin of, right? And that’s the one that we had all the fighting over last year. So what do we think Medicare is going to do with this drug?

Karlin-Smith: So we do have some evidence that this drug does seem to be an improvement over Aduhelm, even though Leqembi only got an accelerated approval so far from the FDA. FDA is already evaluating the drug for full approval because in that interim between when they filed the accelerated approval, they actually pretty much wrapped up a Phase 3 clinical trial that looked at outcomes and did show some benefit on cognition and so forth. There’s certainly a debate out there as to how meaningful that benefit was, but they have shown a hard clinical benefit in trials, not just changed a laboratory marker that is predictive of Alzheimer’s. So that is significant for the company. But it’s just that FDA and then I think CMS hasn’t really considered that further data yet. And so I think there is a good chance that if FDA grants the drug full approval, which I think is pretty likely, will reconsider it, and they maybe were just sort of buying them some time because, again, it is going to be a bit of a challenge to figure out how to operationalize this. The VA, if you compare to Medicare, I was looking yesterday, you know, the VA probably has a few hundred thousand people that might qualify for this drug versus Medicare potentially has upwards of 6 million or so forth. So the different budget process and the VA also has more ability to negotiate drug prices with the company than Medicare does right now for this particular product.

Rovner: So very first-world problems. We finally have drugs to treat things that we’ve been trying to treat effectively for a long time, except that we can’t afford them. So we’re going to … I imagine this debate is going to also continue. Well, finally this week, I wanted to talk briefly about the practice of medicine and the role of the federal government, even though that’s sort of what we’ve been talking about this entire time. Jessie, you wrote about the Biden administration’s rules barring noncompete clauses in employment this week. Obviously, this is something that transcends health care. Apparently, even Starbucks doesn’t want its trained baristas going to work for local competitors. But how does this affect health care?

Hellmann: Yeah, so from what I’ve heard, noncompetes are really rampant in the health care. Especially between physicians and group practices in hospitals. So I’ve seen a lot of doctors submitting comments to the FTC telling them, and some of these is begging them to finalize this rule. There have been … the American Academy of Family Physicians has come out really strongly in favor of the rule. Basically, the argument is that it contributes to burnout, when doctors can’t leave jobs they’re unhappy in. And it also contributes to workforce shortages. If you’re in a noncompete agreement saying that you can’t work at a competitor within a 10- or 20-mile radius and you’re really unhappy in your job, but you might feel compelled to just go work somewhere else. On the other side, you have the American Hospital Association coming out really forcefully against this rule, which is not a good sign and, obviously, very powerful in Washington. And they’re kind of using the covid pandemic as the impetus to try to block this, arguing that providers are really burned out right now. People are leaving the workforce. We really can’t afford to lose people at this time to competitors, and this will make it harder for us to retain and recruit workers. Both sides are making the same arguments in different ways.

Rovner: We’ll wait on these rules. Well, the other big intra-health care dispute that federal officials are being asked to weigh in on is prior authorization. That’s when insurers make it cumbersome for patients to get care their doctors want them to have. The idea is to prevent doctors from providing unnecessary or unnecessarily expensive care. But doctors say it just throws up barriers that make it harder even to get fairly typical care and puts patients at risk by delaying their treatment. I honestly thought this got taken care of in the Affordable Care Act, which incorporated the provisions of the patients’ bill of rights that Congress had been arguing about for the entire decade leading up to the ACA. But now the Biden administration has proposed rules that would require insurers to at least respond faster to prior authorization requests, although that wouldn’t start until 2026. This is actually one of the American Medical Association’s top issues. Is this just another example of people who are not doctors trying to practice medicine, i.e., the insurance companies, and does the federal government really have a role in all of this?

Karlin-Smith: I think this is a tough issue because usually the insurance companies do have doctors that are trying to make these decisions. What you see are doctors actually in medical practice, not an insurance company, complaining about as they’re often not the peers that they say they are. So, you know, you might have a cardiologist making a decision regarding a prior authorization that relates to something in the orthopedic field. So there’s questions about whether the people that really have enough knowledge are making the calls.

Rovner: Or, God forbid, they have nurses making these calls, too.

Karlin-Smith: But it’s one of these issues that’s really tough because there is a sort of in some cases, I think, a need and a reason to have prior authorization. And it can be useful because not all doctors are willing to, you know, maybe try the cheapest alternative for patients when one does exist. There are some, you know, to use the term, sort of, “quacks” out there that sometimes recommend things that the medical establishment overall would agree you shouldn’t be using on patients. But it’s just that the way this is, like, in the real world, it’s sort of gotten out of control, I guess, in some ways. The best way … where legitimate medical care is being denied, patients are going through prior authorization for refills of prescription drugs they clearly have benefited from and have been on for years. So it’s a tricky situation because there is certainly, for the government, an economic reason to have some degree of prior authorization. It’s just figuring out how to get the good out of it, where it actually can benefit and help, even both protect patients financially and medically without hurting patients, and particularly patients that don’t understand how to navigate the system and push back against bad decisions on prior auth.

Hellmann: There is also a really interesting story in Stat this week about the role of artificial intelligence and algorithms in making some of these decisions. So I do have questions about that. It does seem like I have been hearing more and more from doctors lately about how burdensome prior auth has been. I did a story a few months ago about prior authorization requirements for opioid treatment programs, and providers are saying it takes a long time to get approval. Sometimes you get denials for seemingly no reason, like people who need opioid treatment. Some of these people are really vulnerable, and once you decide you need care, you kind of want to get them at that moment. And they might not want to go through an appeals process. And that’s something that the administration has acknowledged is an issue, too. They say that they’re going to look at it.

Rovner: I remember when most of the health beat was actually refereeing these disputes between pieces of the medical establishment, so … there are other things that the administration is busy with in the health care realm. Well, that is the news for this week. Now it is time for our extra-credit segment — that’s where 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 khn.org and in our show notes on your phone or other mobile device. Sarah, why don’t you go first this week?

Karlin-Smith: I took a look at a story in Allure magazine: “With New Legislation, You Can Expect More Recalls to Hit the Beauty Industry.” And it’s a good explainer on modernizations to FDA’s regulations of cosmetics that passed in the end of the year in Congress. It’s the first overhaul since World War II. They say it gives the FDA some pretty big new authorities, like they can mandate the recall of a beauty product if it’s contaminated. Before they basically just had to beg companies to voluntarily do that, which in many cases companies don’t want products that might harm people to be on the market. But sometimes for whatever reason, they might not move as you want. And so it’s important for FDA to have that authority. You know, it also will do things like disclose common allergens to protect people, gives FDA a lot of new funding to help implement this. You know, I think it’s a pretty big consumer bill and it was kind of like an interesting thing to look at a different part of health policy we don’t often talk about. One thing that the story brings up that’ll be interesting to see and I know has been sort of a tension with leading up to whether this law would ever get passed, was how small companies will be able to handle this, and will it put basically small beauty out of business over big companies that know how to handle FDA and its regulations? So we’ll look to see what happens to your smaller cosmetic brands moving forward.

Rovner: Indeed. Jessie.

Hellmann: My extra credit is a story from The New York Times called “Opioid Settlement Hinders Patients’ Access to a Wide Array of Drugs.” And this is an angle I hadn’t really thought about: That $21 billion opioid settlement came with an agreement that distributors place stricter limits on drug suppliers to individual pharmacies and scrutinized their dispensing activity. But it doesn’t just apply to opioids. It applies to all controlled substances. So we’re seeing medications like Xanax and Adderall get caught up in this. And pharmacies are saying, like, it’s making it hard for them to fill prescriptions for patients and some of whom have had them for a really long time. And I don’t know, like, if anyone else has heard about the Adderall shortage — I don’t know if you would classify this as a shortage — but it’s an angle that I hadn’t really thought of. Like, it might not just be supply-chain issues.

Rovner: Yeah, I’ve heard about the Adderall shortage. I mean, I think there’s been a lot of coverage of that. So, yeah, I thought that was a really interesting story, too. Alice.

Ollstein: Yes. I chose a story by my colleagues up in New York, my colleague Julia Marsh, which is about the debate in New York over a flavored-cigarette ban and how it is dividing the civil rights community. And so, you have some civil rights leaders saying that we should ban menthol cigarettes because they have caused a lot of health harms to the Black community. They have long been marketed in ways that target the Black community. They’re in some ways more addictive than non-flavored tobacco. So they’re in support of this ban. And then you have Al Sharpton and some other civil rights leaders on the other side warning that such a ban and the enforcement of such a ban will lead to more police interaction with the Black community, more targeting, and potentially more deaths, which is what we’ve seen in the past. And so a fascinating piece about some …

Rovner: Deaths from law enforcement. Not from cigarettes.

Ollstein: Exactly. Well, yes, it’s kind of “damned if you do, damned if you don’t” on this issue. But a fascinating look at this and what could be a preview as the debates around this at the national level ramp up. So we’ve already seen this happen in California and some other states. Now, the debate is really hot in New York, but it could indicate some of the arguments we might hear if it really moves forward at the national level.

Rovner: Well, my extra credit this week is the latest episode of our competitor podcast “Tradeoffs,” which you really should also listen to regularly, by the way. It’s called “The Conservative Clash Over Abortion Bans,” and it’s actually by Alice here. And it’s a really close look at those exceptions to abortion bans, like for life or health. That’s something that we’ve talked about quite a bit here, except this looks at it from the viewpoint of how it’s dividing the anti-abortion community, which is really interesting. So, super helpful. Everybody listen to it. Thank you, Alice. OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. As always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Alice?

Ollstein: @AliceOllstein

Rovner: Sarah?

Karlin-Smith: @SarahKarlin

Rovner: Jessie.

Hellmann: @jessiehellmann

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

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Companies who raised drug prices higher than the rate of inflation must rebate the difference to Medicare, according to a provision of the Inflation Reduction Act. The highest-profile product on the list might be AbbVie’s blockbuster immunology drug Humira.

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

President Joe Biden’s fiscal 2024 budget proposal includes new policies and funding boosts for many of the Democratic Party’s important constituencies, including advocates for people with disabilities and reproductive rights. It also proposes ways to shore up Medicare’s dwindling Hospital Insurance Trust Fund without cutting benefits, basically daring Republicans to match him on the politically potent issue.

Meanwhile, five women in Texas who were denied abortions when their pregnancies threatened their lives or the viability of the fetuses they were carrying are suing the state. They charge that the language of Texas’ abortion ban makes it impossible for doctors to provide needed care without fear of enormous fines or prison sentences.

This week’s panelists are Julie Rovner of KHN, Shefali Luthra of The 19th, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times.

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Victoria Knight
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Shefali Luthra
The 19th

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Read Shefali's stories

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories

Among the takeaways from this week’s episode:

• Biden’s budget manages to toe the line between preserving Medicare and keeping the Medicare trust fund solvent while advancing progressive policies. Republicans have yet to propose a budget, but it seems likely any GOP plan would lean heavily on cuts to Medicaid and subsidies provided under the Affordable Care Act. Democrats will fight both of those.
• Even though the president’s budget includes something of a Democratic “wish list” of social policy priorities, the proposals are less sweeping than those made last year. Rather, many — such as extending to private insurance the $35 monthly Medicare cost cap for insulin — build on achievements already realized. That puts new focus on things the president has accomplished.
• Walgreens, the nation’s second-largest pharmacy chain, is caught up in the abortion wars. In January, the chain said it would apply for certification from the FDA to sell the abortion pill mifepristone in states where abortion is legal. However, last week, under threats from Republican attorneys general in states where abortion is still legal, the chain wavered on whether it would seek to sell the pill there or not, which caused a backlash from both abortion rights proponents and opponents.
• The five women suing Texas after being denied abortions amid dangerous pregnancy complications are not asking for the state’s ban to be lifted. Rather, they’re seeking clarification about who qualifies for exceptions to the ban, so doctors and hospitals can provide needed care without fear of prosecution.
• Although anti-abortion groups have for decades insisted that those who have abortions should not be prosecuted, bills introduced in several state legislatures would do exactly that. In South Carolina, those who have abortions could even be subject to the death penalty. So far none of these bills have passed, but the wave of measures could herald a major policy change.

Also this week, Rovner interviews Harris Meyer, who reported and wrote the two latest KHN-NPR “Bill of the Month” features. Both were about families facing unexpected bills after childbirth. If you have an outrageous or exorbitant medical bill you want to share with us, you can do that here.

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

Julie Rovner: KHN’s “Girls in Texas Could Get Birth Control at Federal Clinics, Until a Christian Father Objected,” by Sarah Varney

Shefali Luthra: The 19th’s “Language for Treating Childhood Obesity Carries Its Own Health Risks to Kids, Experts Say,” by Jennifer Gerson

Victoria Knight: KHN’s “After People on Medicaid Die, Some States Aggressively Seek Repayment From Their Estates,” by Tony Leys

Margot Sanger-Katz: ProPublica’s “How Obamacare Enabled a Multibillion-Dollar Christian Health Care Cash Grab,” by J. David McSwane and Ryan Gabrielson

Also mentioned in this week’s podcast:

• The New York Times’ “The Programs You’d Have to Cut to Balance the Budget,” by Alicia Parlapiano, Margot Sanger-Katz, and Josh Katz

Click to open the transcript

Transcript: Biden Budget Touches All the Bases

KHN’s “What the Health?”Episode Title: Biden Budget Touches All the BasesEpisode Number: 288Published: March 10, 2023

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

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We are taping this week on Friday, March 10, 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 Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: Victoria Knight of Axios News.

Victoria Knight: Hi. Good morning.

Rovner: And Margot Sanger Katz of The New York Times.

Margot Sanger Katz: Hello, everybody.

Rovner: Later in this episode we’ll have my “Bill of the Month” interview with Harris Meyer. It’s a twofer this time: two successive bills from two different families related to having a baby. But first, this week’s news. We are taping on Friday this week because President [Joe] Biden released his budget Thursday afternoon, and it felt weird to have a news podcast without talking about the budget. And yes, like most presidential budgets since the 1980s, this one is, quote-unquote, “dead on arrival” on Capitol Hill. But one thing the president’s budget does is provide a pretty-detailed look at the administration’s priorities and policy initiatives. Which health program stuck out to you as getting a publicity, if not an actual funding, boost in this document? Victoria, you were looking at the budget.

Knight: Yeah. My colleagues at Axios and I spent several hours yesterday morning going through the budget. I think it was really interesting because I think he was trying to toe the line between “we want to save Medicare, make sure it stays solvent,” but also “we want to push some more progressive ideas as well.” So there’s kind of both things in there. Some obvious things: He wants to permanently extend the enhanced tax credits for the ACA [Affordable Care Act] — so, make permanent those subsidies. Those expire, currently, at the end of 2025. He also wanted to do something called Medicaid-like coverage for eligible people in states that haven’t expanded Medicaid. And then he also wants to expand the number of drugs to be negotiated under the IRA [Inflation Reduction Act] and also move up the timeline a little bit. So, just an example: It’s supposed to be 10 drugs to be negotiated in 2026. And now he wants to do 20. Something also really interesting: [He] wants to do like a Netflix-like subscription service for hepatitis C to basically eradicate hepatitis C within the U.S.

Rovner: I thought that was maybe the most interesting thing in this budget because it’s something that we just hadn’t heard of before.

Knight: Yeah.

Rovner: That, basically, I mean, these hepatitis C drugs were really expensive when they first came out and there was concern that Medicaid programs, in particular, were going to have trouble paying for them because many of the people who have hepatitis C are intravenous drug users, and they’re more likely to get hepatitis C — or people in prison. Lots of people on Medicaid who have hepatitis C. And this would basically be a way to pay in advance for the drugs. Is that essentially what they would do?

Knight: Yeah. And I think it’s also interesting that it at least has one Republican senator — Bill Cassidy is super into this idea. He did something similar in Louisiana. I’m not sure there’s other Republicans that are on board for that, but I thought that was really interesting. You know, of course, he was talking about extending the $35 insulin cap to the commercial market. There’s some other stuff about behavioral health, pandemic preparedness. One other thing Shefali will appreciate also, he proposed increasing Title X family planning funding by almost 80% from 2023 levels, which I think — Shefali, maybe you know — [is] one of the highest increases they’ve ever proposed, in a while at least.

Luthra: Yeah, the family planning clinics, interest groups, etc., were very, very happy about this proposal, even if they know it will not become reality. I think their sense was this was a commitment that would be really transformative for them, especially now, when they are so tightly funded.

Rovner: I did notice that for a president who has not technically said that he’s running again, some of these targeted increases were for some of the very important interest groups who have been kind of, I won’t say whining, but complaining. You know, Title X had not gotten big increases since Biden became president. There’s an initiative for more money for home- and community-based care in Medicaid, which is something, again, there’s an active constituency for in the Democratic Party; the “Cancer Moonshot,” you know, which has obviously been something near and dear to President Biden’s heart; also more money … also, the [American] Cancer Society sent out a lot of emails yesterday saying, yay, thanks for proposing this big budget increase. So there does certainly seem to be a lot of touching of the important constituencies, perhaps in anticipation of reelection campaign?

[Three panelists chime in at once.]

Luthra: Julie, you forgot …

Sanger-Katz: I would say …

Knight: And I think he did … Go, Margot!

Rovner: One at a time! [laughing all around] Margot, you go first.

Sanger-Katz: I would say so. And I would also just point out that the Medicare policies in the bill were previewed by the White House a couple of days before the budget release, and they were, like, the main thing. This is what they were leading with. The president had an op-ed in The New York Times describing his Medicare policies, and they put out a fact sheet with a lot of the Medicare policies. And I think it really reflects this notion that improving the solvency of Medicare and also committing to not really cutting the core services of Medicare, that this is a very key political message that the president cares about, that the president wants to run on, and that he thinks is a very useful contrast with what some Republicans have proposed in the past and what he imagines they might want to propose as House Republicans get ready to release their own budget, which faces some difficult constraints because Speaker [Kevin] McCarthy has promised certain members that the budget that they will pass will be a balanced budget. And that’s quite hard to do without touching the big health care programs.

Rovner: Yeah. Republicans have not promised not to touch Medicaid, which now the president has been very careful to say, “It’s not just Medicare and Social Security. I’m not going to let you cut Medicare, the Affordable Care Act either.” All right, Victoria, you wanted to say something?

Knight: I think — it was also interesting that, I do think, the president did want to push forward some of the more progressive policies that … the progressive base care about, such as doing more negotiating of drugs; something Sen. Bernie Sanders (I-Vt.) has talked a lot about is the community health centers program; expanding Medicaid, home- and community-based services; … and the insulin price cap — things that I think the progressive base cares about as well. So I feel like, as you’re saying, that interest groups, but also the different bases and also the groups that care about reproductive health care, they want him to do something after Roe v. Wade. So it definitely was, like, this huge list of trying to cater to everyone.

Rovner: It’s kind of a Democratic wish list.

Sanger-Katz: At the same time, though, I think he did leave out some of the things that were part of the Build Back Better package. In the previous budgets, the president had gone even bigger on things that the progressive base wanted. And you can see a lot of things in this budget where he’s ticking those boxes, as you say. And I think a lot of policies that he has proposed in the past that he wasn’t able to get through the last Congress — but not all. It does seem like this budget is a little more focused on being able to reduce the deficit a little bit less on this very expansive notion of a robust federal government that is spending money to improve people’s lives in quite as many ways as the message that he has been proposing in his previous budgets. You can see, again, I think this is a pivot towards campaign mode, towards his assessment of the current political moment, growing concerns about the deficit and about inflation.

Rovner: But also, as you mentioned, Margot, they put out the Medicare part of this in advance, mainly because I feel like the Medicare part of the budget is not so much a part of, you know, the statement of the budget as it is a negotiating position for this whole fight we’re going to have over the debt ceiling in a couple of months, where the Republicans are going to want to demand cuts to programs basically in exchange for not letting the U.S. default on its debts. And what the president has managed to do here is say, “We’re going to lower the price of prescription drugs more, we’re going to tax the rich more. And those two things are going to a) reduce the deficit some and b) shore up the Medicare trust fund. So you can’t accuse me of not dealing with the impending problem of Medicare.” How much of a box does that actually put Republicans in when we start to get to these negotiations?

Sanger-Katz: I don’t know how much of a box it really puts them in for a couple of reasons. One is that some of what he’s proposing is really kind of an accounting gimmick. He’s taking money that is already flowing into the federal budget, that is already part of the dollars and cents of our deficit, and he’s just redirecting them from the general fund into the Medicare trust fund. So it is true that these proposals would extend the solvency of the Medicare Hospital Insurance Trust Fund, which is projected to run into some financial trouble in the coming decade. But it is not true that, like, all of the things that he’s proposing are actually new money. Some of it just comes out of other parts of the budget. It doesn’t change the deficit.

Rovner: So I will point out that that is a time honored way of extending the solvency of trusts.

Sanger-Katz: Oh, sure. I’m not saying that Biden is alone in doing that. But I just think there’s kind of three things he’s doing in this proposal. One of them is not deficit reduction. It’s just kind of moving money around. One is this drug price reduction proposal where he’s trying to get more savings by going more aggressively after more drugs. I think that is a place where he can put Republicans in a box a little bit. They’ve come out in opposition to the drug price negotiation provisions that were part of the Inflation Reduction Act that they passed last year. But those policies are super popular. The public really supports them. They feel like the pharmaceutical companies make too much money. They think that Medicare should be able to negotiate. So I think that’s a very politically shrewd decision that I think does demand potentially a response from Republicans as a possibility for deficit reduction. But then the third thing that he did is he really just raised taxes. You know, these are taxes on the rich; as Biden has been promising all along, he’s not going to raise taxes for people earning under $400,000 a year. So they’ve increased these payroll taxes, they’ve increased some investment taxes. There was kind of a loophole, a category of businesses that were not subject to that tax in the past. And, you know, I think those are basically nonstarters with Republicans. And when Republicans talk about deficit reduction, they often are very, very focused on cutting spending that the federal government does. They are much less interested in increasing taxes. And I do think that the fact that Biden led with this proposal, that he’s so comfortable talking about raising taxes as a core part of his platform, is a sign that the politics of tax cuts have changed a little bit, that that is … if you’re just taxing the rich, it seems like the public will accept that. Democrats seem actually excited about that in certain cases. But I still think tax increases are a hard political row to hoe. I think that it is not something that probably appeals to many Republican politicians. And I also think it’s probably not something that appeals to many Republican voters, either. So I don’t know that it really puts Republicans in a box in a meaningful way because they don’t feel any tension where their supporters will want them to do this thing.

Rovner: Obviously, this is a big fight yet to come. Victoria, you wanted to say something.

Knight: Yeah. I just want to add one thing. We did have, like, the first indicator: The House Freedom Caucus had a press conference this morning, and they didn’t give a lot of details, but they did say they want to restore Clinton-era work requirements for welfare programs. So they didn’t specify Medicaid, but it seems pretty likely that’s probably what they’re talking about. My colleagues and I did talk to some Republicans last week that were indicating they did want work requirements for Medicaid. So I think that seems like the very first. There’s going to be three different groups within the House Republican caucus that are going to release budgets: the Budget Committee, the House Freedom Caucus, the Republican Study Committee. So I think we are going to start seeing the outlines of what they want to do very soon. But that was kind of the first one coming out this morning, so …

Rovner: Yes, underscoring the fact that the Republicans don’t agree on what they want to do …

Knight: No.

Rovner: … which is why we haven’t seen their budget yet.

Knight: Exactly.

Rovner: Although I will point out President Biden’s budget was a month late, too.

Sanger-Katz: Can I just say one thing about the Republican budget? Because I actually spent a lot of time looking at various budget proposals and trying to examine this goal that the Republicans have of balancing the budget. Just like: How hard is it to balance the budget? And it turns out that it’s extremely hard. It’s sort of hard in a normal year. But in this post-covid era, when spending has been so elevated for so long, balancing the budget within a decade is just really, really, really hard. If you do it without raising taxes, which Republicans say they don’t want to raise taxes; if you do it without cutting defense spending, which Republicans say they don’t want to cut defense spending; if you do it without cutting Medicare or Social Security, which recently McCarthy has said he does not want to do — you end up just … this is just the basic math … having to cut everything else by 70%. That’s 7-0%. That is not the kind of cut that you can achieve even by imposing a work requirement on Medicaid, a work requirement on food stamps, and other kinds of policies that Republicans have proposed in the past. That is like deeply, deeply reducing the role of the federal government, you know, cutting Medicaid in more than half. Larry Levitt [KFF’s executive vice president for health policy] pointed out earlier this week reducing Medicaid spending by 70% probably means 50 million fewer people would have Medicaid coverage. And that’s just Medicaid. You’re talking about basically everything that the government does — environmental protection, law enforcement, military pensions, just about any program that you can think about in the government that’s not Medicare, Social Security, or direct defense spending. Seventy percent cut is quite hard to do. And so I am very curious to see what these budgets look like. I can tell you, having looked at some of the previous Republican proposals, that those all relied on some reductions to Medicare and Social Security because those programs represent such a large percentage of federal spending that if you don’t cut those at all, there’s just not a lot of dollars left. And in my reporting on this question, it does seem like one thing that the Republican Budget Committee is very likely to do is to use very aggressive assumptions about the economic growth that their policies will unleash. And so the idea is that if the economy grows by so much, then tax revenue, what increase all by itself, because people will be earning more money, and so that will enable them to balance the budget in 10 years without having to actually reduce the deficit by as much as independent scorekeepers like the Congressional Budget Office think would be necessary.

Rovner: Although I would point out that every time we’ve had one of these big tax cuts that Republicans say it’s going to grow the economy enough to pay for it, it has not grown the economy enough to pay for it.

Sanger-Katz: Indeed! You know, cutting everything that the government does by 70% probably actually would have a negative impact on the economy. People would be losing money. They would be losing their government jobs. These would be very large economic impacts that probably most economists do not think would lead to economic growth.

Rovner: Yeah, well, we will see. I will put, Margot, the nice story you did with your colleagues demonstrating all of this in chart form in the show notes. OK. Let us turn to abortion. We will start with Walgreens, poor Walgreens, caught in the maw of the abortion wars. In January, the FDA said that brick-and-mortar pharmacies for the first time could start dispensing the abortion pill, mifepristone, whose distribution had been tightly regulated since it was first approved more than 20 years ago. Almost immediately, both CVS and Walgreens, the country’s largest and second-largest pharmacy chains, announced they would apply for FDA certification to distribute the pills in states where abortion is still legal. Then, last month, 20 Republican state attorneys general, including at least four in states where abortion is still legal, warned CVS and Walgreens that if they send the pills by mail, they could be in violation of the 1873 Comstock Act, which we have talked about here before, which prohibited the mailing of items considered, air quotes, “obscene,” which at the time included information about birth control. Cut to last week when Walgreens appeared to cave to the pressure and the threat of legal action, saying it would not sell the pill in states where it’s illegal, not actually naming those states. Then, after a huge backlash, it tried to walk back its position a little, mostly leaving lots of questions. Shefali, what is your take on what Walgreens is and isn’t going to do now vis-a-vis mifepristone? They’ve kind of said both things.

Luthra: I think there’s a lot of layers here, but I want to go back to January for a moment, when we got that news from Walgreens and CVS so quickly that they would participate in providing mifepristone. Frankly, a lot of these folks that I spoke to were very surprised that [the pharmacies] reacted so quickly because carrying mifepristone in stock opens you up to really intense harassment, boycotts, protests from the anti-abortion movement. And we did see right away many of the premier anti-abortion movements calling for boycotts of Walgreens and CVS, for protests, etc. They have been organizing protests outside pharmacies right now. And there has been pressure from the beginning from governors like [Florida] Gov. Ron DeSantis instructing pharmacies not to stock the press down. The fact that Walgreens ultimately has caved in these states with hostile governments wasn’t surprising. If anything, it was surprising that it took quite so long. I am incredibly curious to see what happens with CVS and Rite Aid, the other two pharmacies that are now getting caught in the crosshairs, facing really intense pressure from lawmakers and politicians who support abortion access and also those who don’t. We saw in New York this week, the governor and the attorney general called on pharmacies to continue carrying mifepristone. Frankly, I’m skeptical that that really matters because there is no reason not to carry mifepristone in New York, a state where the government is very friendly to abortion.

Rovner: And we should point out, because this is my biggest frustration: Nobody’s actually doing it yet because nobody’s gotten certified yet.

Luthra: Correct.

Rovner: They’re not — all these headlines that said, “Walgreens is going to stop doing this.” It’s like, no, they’re going to not start doing this. Sorry.

Luthra: And we have no idea when they will get certified how long it would take. We have no idea, frankly, if mifepristone will still be able to be distributed in the country at that point, because we are still waiting on the ruling from this judge in Texas. We simply have so many open questions. And at this point, this really is more of an avenue for people to make statements about how they feel about abortion access, than it is actually affecting people’s ability to get care. The other statement grandstanding that I have been really struck by is what we’ve seen from the California governor, Gavin Newsom, who really does love to talk a lot about his pro-abortion rights bona fides, even if those statements don’t translate much into actual impact or policy. And what we saw this week was his promise that California wouldn’t do business with Walgreens if they wouldn’t stock mifepristone.

Rovner: And this is not just an idle threat in California, right? There’s a huge contract that he now says he’s not going to renew.

Luthra: So there is a contract. But friend of the podcast and former KHNer Sydney Lumpkin found the contract that Newsom was referring to. You would think it would be a significant amount of money, given how much attention it has gotten. It is a $54 million contract over five years. When you look at the overall market cap of Walgreens, a $30 billion company, it’s not clear exactly how meaningful that actually is compared to the pressure they are facing from lawsuits and the very powerful anti-abortion movement.

Rovner: So, and what … I mean, you referred to this, but what are we thinking that CVS and Rite Aid are going to do — having seen Walgreens literally put through the wringer here on this issue?

Luthra: I think that’s a really good question. I — I mean, coming into this week — had assumed that they would follow the path of Walgreens and do the exact same thing, right? Stock mifepristone, provide it with a doctor’s prescription in states where they are protected and face no legal risks, but perhaps not do so in those states where a) mifepristone is banned, as they have said they would not do. And also in states where, like Kansas, for instance, abortion is legal, but you have a very anti-abortion attorney general. It is quite interesting that they have not said either way what they will do beyond just, well we won’t do it in states where it’s illegal.

Rovner: Yeah, if I was advising CVS at this point, I would tell them to not say a word to anybody until some of this shakes out.

Luthra: Exactly.

Rovner: All right. Well, let us move on to Texas, where there is always abortion news. As Shefali mentioned, we have not had the decision yet on that abortion pill case out of Amarillo, but both sides are still going at it on other issues. Remember all those stories we’ve been chronicling about women with wanted pregnancies gone wrong who couldn’t get medical care until they were literally at death’s door or they went to another state? Well, five of them are suing the state of Texas, saying they should have been allowed to terminate their pregnancies under existing exceptions to the abortion bans, except that doctors and hospitals have been unwilling to risk giant fines and even jail time. The five women — some of whom are still pregnant, some of whom are not — want the state, whose officials continue to claim that these women were eligible for abortions in Texas if their lives were truly at risk, they want the state to clarify those exceptions even more. Is there any chance this happens? They’re not asking for the bans to be lifted. I mean, this is a kind of a unique lawsuit that we’ve not seen before because we’ve not seen that many women in this situation before.

Luthra: I think this is a pretty smart approach. I wouldn’t be surprised if it has better odds of success than, as you mentioned, a request to fully overturn Texas’ abortion bans because the exceptions are really unclear. Doctors do not feel safe talking about abortion, even in cases where it is likely that it would be very beneficial for the pregnant person, for a fetus that has really minimal chance of survival upon birth. One thing that Nancy Northup, the head of CRR [the Center for Reproductive Rights], said to me when I asked her is, depending on how this case goes, it is not at all unlikely that we see similar lawsuits filed in other states with abortion bans with similarly vague “life of the parent” exceptions that are, in reality, impossible to enforce. I think this is going to be the beginning of a very robust series of legal challenges to state abortion bans. And we’ll see better success for abortion rights lawyers in some states than in others — really depending on the makeup of these different states’ supreme courts.

Rovner: Yeah, I mean, it’s funny because over the years I’ve heard obviously lots of warning about this possibility, both from the Center for Reproductive Rights, which, as you say, is pushing this case, and other groups. But nobody could sue because nobody had standing, because it hadn’t happened. It was all theoretical. Well, now it’s happened and we have people to whom it is not theoretical, who are able to go to court and say, hey, this happened to us and it violated our rights and you need to do something about it.

Luthra: And I do want to add just one thing. I mean, it’s — I think we can’t understate just what these people have been through, the women who are suing Texas. I was just really struck by one woman who flew from Texas to Colorado for an abortion that she couldn’t get in state, paid extra for a seat by the airplane in case she went into labor on the flight, and said that she still has PTSD to this day from having to travel while afraid that she might go into labor and could die from it. Like, what these people are going through right now is just … it’s really difficult for us to imagine. And I think we’re just going to hear so many more stories that are really troubling about people whose lives have been so deeply put at risk, and they’re unable to get the care their doctors want to provide.

Rovner: Right. And I say for the 11th time, these are not women who got pregnant by accident and don’t wish to be pregnant. Many of these are women who’ve been through infertility treatment and were desperately anxious to be pregnant, were thrilled when they got pregnant, but whose pregnancy took a bad turn either for the fetus or, in some cases, one of the fetuses of twins, or in some cases the pregnant person themselves. Well, meanwhile, the Texas Republican legislature has been busy proposing even more abortion restrictions. Last week, we talked about a bill that would ban websites that include information about how to get abortion pills and punish internet providers who don’t block those sites. This week, we have a bill giving state officials the upper hand in prosecuting abortion cases in parts of the state where local Democratic prosecutors have suggested they don’t plan to zealously pursue such cases. Another bill would create a special prosecutor whose job would be, among other things, to pursue violations of the state’s abortion bans. Why is Texas such a hotbed of this?

Luthra: It’s always Texas. Texas is the biggest state in the country to have banned abortion, right? Most of the people who are traveling out of state — well, maybe not most, but the plurality — are Texans, because just so many people live there. And if we think about it, Roe v. Wade, as a case, it came from Texas. SB 8, the first law that allowed a state to circumvent Roe and ban abortions [at] anything after six weeks, that was a Texas law. This is a place where lawmakers really believe that they can be a fertile testing ground for the future of abortion restrictions. Between them and Missouri, I think, that is where we will see the bulk of innovative new ways to further restrict access.

Rovner: Well, speaking of big states that are banning or thinking about banning abortion, you wrote about Florida this week, which already has a ban on abortions after 15 weeks [and is] now considering a ban after six weeks. Florida is kind of a pivotal state in all this, right?

Luthra: Florida, third-biggest state in the country. And if we look at the map of the U.S. South and particularly the Southeast, Florida is just critical. Between Florida and North Carolina, that is where people across the region are going for abortions. And Florida has more than 60 clinics compared to, you know, around a dozen in North Carolina. If abortion there is banned after six weeks, there will be thousands of people who are displaced. They will probably have to go to North Carolina, while abortion is legal there, to Virginia and then to Illinois. And that is just really too far for so many people to travel. There just aren’t realistic options once you take Florida off the map.

Rovner: Well, finally, a bill has been introduced in the South Carolina legislature that could potentially subject patients who get abortions to the death penalty. Now, I am old enough to remember last year, when anti-abortion groups insisted they didn’t want to punish women who had abortions, just those who provide or facilitate them. I guess that’s not the case anymore.

Luthra: And I think we need to see where this bill goes. It is not the only state, either, where we are seeing legislation proposed that would treat abortion as murder or as homicide. There was a bill in Louisiana just last summer that failed on that front. But we have seen bills introduced in Tennessee, in Georgia, in so many others that I cannot remember now. But it’s a long list. I think what’s interesting is, so far, none of these bills have actually moved forward. And it’s still obviously early in the session. But what I’m curious about is, is this chipping away at the resistance toward these kinds of really strict abortion bans? And is this the first step in a multiyear effort to redirect who is punished for getting an abortion to switch from the doctors, the health care providers, to the pregnant people themselves, which has always been sort of this Rubicon the movement has been afraid to cross.

Rovner: Yeah, I remember in 2016 Chris Matthews was interviewing then-candidate Donald Trump and sort of got Donald Trump to say, you know, yes, the woman should be punished. And the anti-abortion movement came at him, like, no, no, no, that’s not what we say. That’s not what we want. And now it’s, you know, seven, eight years later and that’s not necessarily what people are saying. So, we will see how that goes. OK. That’s the news for this week. Now, we will play my “Bill of the Month” interview with Harris Meyer and then we’ll come back and do her extra credits.

We are pleased to welcome to the podcast Harris Meyer, who reported and wrote the last two KHN-NPR “Bill of the Month” stories, which are kind of related. Harris, welcome to “What the Health?”

Harris Meyer: Thanks very much, Julie.

Rovner: So, both of these bills have to do with something very common and very treacherous to your financial health: having a baby. Let’s start with baby No. 1, a now-3-year-old named Joey Trumble. Where is she from? Why was she in the hospital for 36 days?

Meyer: Joey was born prematurely in December 2019. Her mother, Brenna Kearney, is a writer in Chicago, and she was diagnosed with preeclampsia, and her doctors ordered her hospitalized at Northwestern. And then she developed a worse form of preeclampsia called HELLP syndrome. But anyway, the baby was born healthy but premature. And the baby, Joey, was treated at Northwestern Prentice, but without the knowledge of the parents the doctors who were treating her came over from next door from Lurie Children’s, and her hospital, Northwestern, was in network for her health plan. But Lurie Children’s doctors were out of network. They did not know that. So after her baby was sent home — it had about a month, 36 days, of hospitalization — the family got a bill of about $12,000, which was unexpected.

Rovner: That’s right. And we should point out that the baby was covered, right, under the mother’s health insurance.

Meyer: Correct.

Rovner: And yet they still got a bill for $12,000.

Meyer: That’s right. The hospitalization was covered. And, to their surprise, the doctors, the neonatologist from Lurie who treated the baby, were not covered in network. And so Brenna spent the next year contesting these charges. And they were never told that the doctors were out of the network. But she had found out that there was a 2011 Illinois law, which was in effect, which prohibited this kind of out-of-network billing for neonatology services.

Rovner: That’s right. And we should point out that this was before the federal No Surprises Act took effect, because this was late 2019.

Meyer: Correct.

Rovner: But there was a state law that should have applied.

Meyer: There was a state law. Illinois was a pioneer in this. So she cited that law to Blue Cross Blue Shield Illinois and to Lurie Children’s, and they said they knew nothing about it. So the bill was sent to collections about a year later, and she was able to get Blue Cross, finally, and, a year after the birth, to cover the Lurie doctor charges fully. However, in December, three years after she gave birth, she finds out she’s being billed again, after she thought the whole ordeal was over — many years after. And she finds out that Blue Cross of Illinois had taken the money back and now Lurie was coming after her and her husband again for the out-of-network charges. And that’s when she came to Kaiser Health News, and I made calls to Lurie, to Blue Cross of Illinois, and to Northwestern. And after my calls, Lurie agreed to drop the charges. But now a state senator, the Illinois Department of Insurance, and the Illinois attorney general are looking into this to see if there was a long pattern of violations by Lurie of this 2011 state law. And Brenna actually has been contacted now by three other women who experienced similar out-of-network bills from Lurie. So we’ll see what happens with that.

Rovner: So sort of a happy ending to that one. Let’s move to baby No. 2, or, more accurately, his mother. Who is she and what happened to her?

Meyer: OK. This was last June. Danielle Laskey is a school nurse, an RN, in Seattle. She was on vacation with the family. And at 26 weeks pregnant she felt that her water broke. Her doctors in Seattle ordered her to come back and said, you’d better come in. And her doctors were at Swedish Maternal & Fetal Specialty Center in Seattle, which was in network for her Blue Shield health plan. And when she got there, they said, yes, your water broke. You were at risk for the same complication from your first pregnancy three years ago. We want you to go to Swedish Medical Center across the street immediately, and we want you to stay there until you give birth, and we’ll monitor you. So she was in the hospital for seven weeks until she gave birth in August of last year.

Rovner: Oh, so just for context, Swedish is one of the big hospitals in Seattle, right?

Meyer: Yes, absolutely. And it’s one of the specialty facilities for this particular uncommon complication, which is called placenta accreta. Anyway, she was there for seven weeks. And again, she and her husband were not told that the hospital was out of network. But it turns out that Swedish, even though her doctors were — her Swedish doctors were in network for her health plan, it turns out that Swedish Medical Center was out of network, and she found out. Then the baby was born. The baby was in the hospital, the baby boy, for about a month. And then, meanwhile, after the baby was born, she experienced symptoms again, and she was rehospitalized for a day to have this placenta condition treated. Both those hospitalizations — you know, she and her husband, who’s a psychiatrist, thought they were emergencies. The doctors regarded them as emergencies. But yet afterward, the Regence Blue Shield and Swedish decided they were not emergencies. And so, guess what? The family was hit with over $100,000 in out-of-network bills for the two Swedish hospitalizations.

Rovner: And this was after the federal law took effect, right? This was last year.

Meyer: The federal law and a Washington state law were both in effect at that point, which say that you cannot apply out-of-network charges in an emergency situation. So, at first, Blue Shield said that it was not an emergency and it didn’t come under the law. And Swedish Medical Center was going to take the family to collections. The family appealed to Regence Blue Shield. Regence in January granted the appeal for the first hospitalization, erasing $100,000 or so of the charges. But the second hospitalization, $15,000 bill, was still in effect. And then they contacted Kaiser Health News. I contacted Regence Blue Shield and Swedish, and then the charges were dropped for the second hospitalization.

Rovner: Amazing how that happens.

Meyer: Yeah, well, it’s not a solution. So the twist on this one is that Regence Blue Shield said we decided it was an emergency and that it wasn’t proper that the doctors were in network but the hospital wasn’t, so we’re going to consider this an in network and erase the charges. But they said Regence Blue Shield had a contract with Swedish, which made Swedish a quote-unquote “participating provider”; therefore, the federal and state laws do not apply to that situation, and the hospital was allowed to charge the out-of-network charge. We’re going to erase it for this case, but the law does not apply to that situation.

Rovner: I confess, if I’m in a hospital and they say they’re a participating provider, I’m going to assume that means they’re in network. And in this case, it doesn’t, right?

Meyer: Right. It’s a very strange twist that my experts had never encountered before. I took the issue to the federal agency CMS, which administers the No Surprises Act, and they said that they’re going to look into this and HHS, Treasury Department, and Department of Labor are all going to have to look into this to see if this could be fixed through an agency guidance or whether this would require a congressional action to fix this apparent loophole in the law.

Rovner: Creativity. So what’s the takeaway here for both women and particularly for pregnant women who know at some point they’re likely to be in the hospital? You can’t ask every single person who touches you whether they’re in your network. And isn’t that what state and the federal law are supposed to guard against? These are the exact things that we assumed would be taken care of. Right?

Meyer: Right. Well, first of all, the family, the patient, and their loved ones need to ask the hospital and the insurer to tell them their rights under the No Surprises Act and make sure that both the insurer and the provider are following the letter of those federal and state laws. Second, if they do get, God forbid, a out-of-network bill, they need to immediately appeal that to the insurance company, and there’s a two-level appeal process. The second level, they get an independent review. And then, at the same time, they need to file a report or a complaint with the state attorney general’s office, the state department of insurance, and maybe even contact state legislators. There also are private agencies or private companies with nurses and lawyers, etc., that will help families, for a fee, address issues like this. Hopefully it shouldn’t require that, but sometimes it may. And of course, then there’s Kaiser Health News. You can file your “Bill of the Month” complaint through the portal, which we can’t deal with hundreds of thousands of cases, obviously.

Rovner: But we can help at least a few. And Harris Meyer, you helped two. So thank you very much. And thank you for joining us.

Meyer: Thank you, Julie.

Rovner: OK, we’re back. And now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week? You got one of my favorites.

Knight: My extra credit is called “They Could Lose the House — to Medicaid,” by Tony Leys, and it is published on NPR but is a KHN story. It’s about a family in Iowa who found out, after the mother in the family died, that they could lose their house because she was getting services through Medicaid. She had dementia, and so she needed really intensive at-home family care. Then after she died, they got a letter from the Iowa Department of Human Services — just a month after she died, so not long after — saying that the state was trying to recoup the money that they had spent on her care. So it was almost over $200,000 that they were asking for. And what was really upsetting is this family home was going to be the inheritance for the daughter. And so now they’re kind of like, what are we going to do? Thankfully, they don’t have to do anything with the house until something happens to the father. So it’s not gone immediately. But this is basically something that some states do. It’s called estate recovery programs. And if people use Medicaid in those states, the states have the ability to come back later … whether it’s, like, a house or they can ask for funds that these families used for Medicaid. So it’s really illuminating. I had no idea this was something that happened, and it varies by state to state. But in Iowa, this is something that they kind of pursue very aggressively.

Rovner: I remember when Congress made this a possibility, I think it was back in 1995. It’s been around, the possibility of states recouping Medicaid money for a long time. But as you point out, not all states do it. And it’s usually a surprise when states do do it. People still really don’t know about it. Shefali.

Luthra: So my story is from my 19th colleague, Jennifer Gerson. The headline is “Language for Treating Childhood Obesity Carries Its Own Health Risks to Kids, Experts Say.” And what Jen did, which I think is really smart and important, is she looked at the new clinical guidelines we got from the American Academy of Pediatrics. And those were meant to improve how we evaluate and treat obesity in children. And what she gets into is that there are a lot of children’s health experts, especially mental health experts, who are deeply concerned about what the impacts of these new guidelines could be, how they might exacerbate weight stigma, and how the long-term ramifications of some of the treatment guidelines could actually have worse outcomes for young people as a result, by building on weight stigma, which could lead to different kinds of unhealthy behaviors, could lead to mental health harms that could have much longer term repercussions, possibly more, in fact, dangerous than the actual problems that these guidelines are trying to treat. And one thing that Jen notes I think is really important is that the implications of weight stigma, in particular, are especially harmful for young girls who, as we know, are already facing so many mental health crises in general right now. I thought this was a really important look at a potentially really troubling unintended consequence, and I’m really glad Jen wrote about it.

Rovner: Yeah, I had no idea. It was a very counterintuitive but really interesting piece. Margot, what do you have this week?

Sanger-Katz: I wanted to suggest an article in ProPublica called “How Obamacare Enabled a Multibillion-Dollar Christian Health Care Cash Grab,” by J. David McSwane and Ryan Gabrielson which is just this wonderful historic dive into how the Affordable Care Act ended up allowing something called Christian health ministries to provide an alternative to health insurance. As we all know, the Affordable Care Act basically said, if you’re going to offer health insurance, it has to meet certain minimum guidelines in terms of what it covers and how it works. And these Christian health sharing ministries are just this huge, huge exception where basically it’s just, you know, groups of religiously affiliated people can get together and just pay for each other’s health care or not, depending on what they want to do. There has been a lot of reporting over the years about the degree to which these plans are kind of scammy or poorly run or are not paying for needed health care for their members who think that they are an alternative to insurance. And so this piece is just fun because it looked at the lobbying that generated this strange policy.

Rovner: Yeah. You know, I remember when they got the Christian sharing ministries exception into the ACA and not really knowing where it came from. Well, this story explains exactly where it came from. So it is quite an eye-popping read. Mine is from my KHN colleague Sarah Varney, and it’s called “Girls in Texas Could Get Birth Control at Federal Clinics, Until a Christian Father Objected. Now, for decades, underage girls have been able to get contraception from federally funded Title X family planning clinics without parental permission. An effort by the Reagan administration in the early 1980s, dubbed the “Squeal Rule,” which would have required that parents be notified after the fact, was struck down in federal court and the Reagan administration did not appeal it. And no, I was not there to cover that at that time. I did look it up. A couple of months ago, Judge Matthew Kacsmaryk — yes, that Judge Kacsmaryk, who will any day now rule on whether the FDA approval of the abortion pill should be revoked — ruled in favor of a father in Texas, not a father whose daughters did or said they wanted to obtain contraception from a Title X clinic. But the father complained that the very possibility that his daughters could get birth control without his consent rendered that portion of the law — which has been in effect since Title X, was signed by Richard Nixon in 1970 — unconstitutional. And of course, the judge agreed with him. So for now, the ruling only applies in Texas. But lest you think they’re not coming for your birth control, think again.

OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Shefali?

Luthra: I’m @shefalil

Rovner: Victoria.

Knight: @victoriaregisk

Rovner: Margot.

Sanger-Katz: @sangerkatz

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

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

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Less than two years after opening a state-of-the-art $26 million hospital in Leadville, Colorado, St. Vincent Health nearly ran out of money.

Hospital officials said in early December that without a cash infusion they would be unable to pay their bills or meet payroll by the end of the week.

The eight-bed rural hospital had turned a $2.2 million profit in 2021, but the windfall was largely a mirage. Pandemic relief payments masked problems in the way the hospital billed for services and collected payments.

In 2022, St. Vincent lost nearly $2.3 million. It was at risk of closing and leaving the 7,400 residents of Lake County without a hospital or immediate emergency care. A $480,000 bailout from the county and an advance of more than $1 million from the state kept the doors open and the lights on.

Since 2010, 145 rural hospitals across the U.S. have closed, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. But covid-19 relief measures slowed that trend. Only 10 rural hospitals shut down in 2021 and 2022 combined, after a record 19 in 2020. Two rural hospitals have closed already this year.

Now that those covid funds are gone, many challenges that threatened rural hospitals before the pandemic have resurfaced. Industry analysts warn that rural facilities, like St. Vincent Health, are once again on shaky ground.

Jeffrey Johnson, a partner with the consulting firm Wipfli, said he has been warning hospital boards during audits not to overestimate their financial position coming out of the pandemic.

He said the influx of cash aid gave rural hospital operators a “false sense of reality.”

No rural hospitals have closed in Colorado in the past decade, but 16 are operating in the red, according to Michelle Mills, CEO of the nonprofit Colorado Rural Health Center, the State Office of Rural Health. Last year, Delta County voters saved a rural hospital owned by Delta Health by passing a sales tax ballot measure to help support the facility. And state legislators are fast-tracking a $5 million payment to stabilize Denver Health, an urban safety-net hospital.

John Gardner took over as interim CEO of St. Vincent after the previous CEO resigned last year. He said the hospital’s cash crunch stemmed from decisions to spend covid funds on equipment instead of operating costs.

St. Vincent is classified by Medicare as a critical access hospital, so the federal program reimburses it based on its costs. Medicare advanced payments to hospitals in 2020, but then recouped the money by reducing payments in 2022. St. Vincent had to repay $1.2 million at the same time the hospital faced higher spending, a growing accounts-payable obligation, and falling revenue. The hospital, Gardner said, had mismanaged its billing process, hadn’t updated its prices since 2018, and failed to credential new clinicians with insurance plans.

Meanwhile, the hospital began adding services, including behavioral health, home health and hospice, and genetic testing, which came with high startup costs and additional employees.

“Some businesses the hospital was looking at getting into were beyond the normal menu of critical access hospitals,” Gardner said. “I think they lost their focus. There were just some bad decisions made.”

Once the hospital’s upside-down finances became clear, those services were dropped, and the hospital reduced staffing from 145 employees to 98.

Additionally, St. Vincent had purchased an accounting system designed for hospitals but had trouble getting it to work.

The accounting problems meant the hospital was late completing its 2021 audit and hadn’t provided its board with monthly financial updates. Gardner said the hospital believes it may have underreported its costs to Medicare, and so it is updating its reports in hopes of securing additional revenue.

The hospital also ran into difficulty with equipment it purchased to perform colonoscopies. St. Vincent is believed to be the highest-elevation hospital in the U.S., at more than 10,150 feet, and the equipment used to verify that the scopes weren’t leaking did not work at that altitude.

“We’re peeling the onion, trying to find out what are the things that went wrong and then fixing them, so it’s hopefully a ship that’s running fairly smoothly,” Gardner said.

Soon Gardner will hand off operations to a management company charged with getting the hospital back on track and hiring new leadership. But officials expect it could take two to three years to get the hospital on solid ground.

Some of those challenges are unique to St. Vincent, but many are not. According to the Chartis Center for Rural Health, a consulting and research firm, the average rural hospital operates with a razor-thin 1.8% margin, leaving little room for error.

Rural hospitals operating in states that have expanded Medicaid under the Affordable Care Act, as Colorado did, average a 2.6% margin, but rural hospitals in the 12 non-expansion states have a margin of minus 0.5%.

Chartis calculated that 43% of rural hospitals are operating in the red, down slightly from 45% last year. Michael Topchik, who heads the Chartis Center for Rural Health, said the rate was only 33% 10 years ago.

A hospital should be able to sustain operations with the income from patient care, he said. Additional payments — such as provider relief funds, revenues from tax levies, or other state or federal funds — should be set aside for the capital expenditures needed to keep hospitals up to date.

“That’s not what we see,” Topchik said, adding that hospitals use that supplemental income to pay salaries and keep the lights on.

Bob Morasko, CEO of Heart of the Rockies Regional Medical Center in Salida, said a change in the way Colorado’s Medicaid program pays hospitals has hurt rural facilities.

Several years ago, the program shifted from a cost-based approach, similar to Medicare’s, to one that pays per patient visit. He said a rural hospital has to staff its ER every night with at least a doctor, a nurse, and X-ray and laboratory technicians.

“If you’re paid on an encounter and you have very low volumes, you can’t cover your costs,” he said. “Some nights, you might get only one or two patients.”

Hospitals also struggle to recruit staff to rural areas and often have to pay higher salaries than they can afford. When they can’t recruit, they must pay even higher wages for temporary travel nurses or doctors. And the shift to an encounter-based system, Morasko said, also complicated coding for billing , leading to difficulties in hiring competent billing staff.

On top of that, inflation has meant hospitals pay more for goods and services, said Mills, from the state’s rural health center.

“Critical access hospitals and rural health clinics were established to provide care, not to be a moneymaker in the community,” she said.

Even if rural hospitals manage to stay open, their financial weakness can affect patients in other ways. Chartis found the number of rural hospitals eliminating obstetrics rose from 198 in 2019 to 217 last year, and the number no longer offering chemotherapy grew from 311 to 353.

“These were two we were able to track with large data sets, but it’s across the board,” Topchik said. “You don’t have to close to be weak.”

Back in Leadville, Gardner said financial lifelines thrown to the hospital have stabilized its financial situation for now, and he doesn’t anticipate needing to ask the county or state for more money.

“It gives us the cushion that we need to fix all the other things,” he said. “It’s not perfect, but I see light at the end of the tunnel.”

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

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Julie Rovner is chief Washington correspondent and host of KHN’s 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.

With Medicare and Social Security apparently off the table for federal budget cuts, the focus has turned to Medicaid, the federal-state health program for those with low incomes. President Joe Biden has made it clear he wants to protect the program, along with the Affordable Care Act, but Republicans will likely propose cuts to both when they present a proposed budget in the next several weeks.

Meanwhile, confusion over abortion restrictions continues, particularly at the FDA. One lawsuit in Texas calls for a federal judge to temporarily halt distribution of the abortion pill mifepristone. A separate suit, though, asks a different federal judge to temporarily make the drug easier to get, by removing some of the FDA’s safety restrictions.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Rachel Cohrs of STAT News, and Lauren Weber of The Washington Post.

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Rachel Cohrs
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Alice Miranda Ollstein
Politico

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Lauren Weber
The Washington Post

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Read Lauren's stories

Among the takeaways from this week’s episode:

• States are working to review Medicaid eligibility for millions of people as pandemic-era coverage rules lapse at the end of March, amid fears that many Americans kicked off Medicaid who are eligible for free or near-free coverage under the ACA won’t know their options and will go uninsured.
• Biden promised this week to stop Republicans from “gutting” Medicaid and the ACA. But not all Republicans are on board with cuts to Medicaid. Between the party’s narrow majority in the House and the fact that Medicaid pays for nursing homes for many seniors, cutting the program is a politically dicey move.
• A national group that pushed the use of ivermectin to treat covid-19 is now hyping the drug as a treatment for flu and RSV — despite a lack of clinical evidence to support their claims that it is effective against any of those illnesses. Nonetheless, there is a movement of people, many of them doctors, who believe ivermectin works.
• In reproductive health news, a federal judge recently ruled that a Texas law cannot be used to prosecute groups that help women travel out of state to obtain abortions. And the abortion issue has highlighted the role of attorneys general around the country — politicizing a formerly nonpartisan state post. –And Eli Lilly announced plans to cut the price of some insulin products and cap out-of-pocket costs, though their reasons may not be completely altruistic: An expert pointed out that a change to Medicaid rebates next year means drugmakers soon will have to pay the government every time a patient fills a prescription for insulin, meaning Eli Lilly’s plan could save the company money.

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’ “A Drug Company Exploited a Safety Requirement to Make Money,” by Rebecca Robbins.

Alice Miranda Ollstein: The New York Times’ “Alone and Exploited, Migrant Children Work Brutal Jobs Across the U.S.,” by Hannah Dreier.

Rachel Cohrs: STAT News’ “Nonprofit Hospitals Are Failing Americans. Their Boards May Be a Reason Why,” by Sanjay Kishore and Suhas Gondi.

Lauren Weber: KHN and CBS News’ “This Dental Device Was Sold to Fix Patients’ Jaws. Lawsuits Claim It Wrecked Their Teeth,” by Brett Kelman and Anna Werner.

Also mentioned in this week’s podcast:

• Politico’s “Why One State’s Plan to Unwind a Covid-Era Medicaid Rule Is Raising Red Flags,” by Megan Messerly.
• The Washington Post’s “Doctors Who Touted Ivermectin as Covid Fix Now Pushing It for Flu, RSV,” by Lauren Weber.
• NPR’s “To Safeguard Healthy Twins in Utero, She Had to ‘Escape’ Texas for Abortion Procedure,” by Selena Simmons-Duffin.
• The Daily Beast’s “Tennessee Abortion Ban a ‘Nightmare’ for Woman With Doomed Pregnancy,” by Michael Daly.

click to open the transcript

Transcript: March Medicaid Madness

KHN’s ‘What the Health?’Episode Title: Medicaid March MadnessEpisode Number: 287Published: March 2, 2023

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We are taping this week on Thursday, March 2, 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: Good morning.

Rovner: Rachel Cohrs of Stat News.

Rachel Cohrs: Hi, everybody.

Rovner: And we officially welcome to the podcast panel this week Lauren Weber, ex of KHN and now at The Washington Post covering a cool new beat on health and science disinformation. Lauren, welcome back to the podcast.

Lauren Weber: Thanks for having me.

Rovner: So we’re going to get right to this week’s news. We’ve talked a lot about the political fight swirling around Medicare the past couple of weeks. So this week, I want to talk more about Medicaid. Our regular listeners will know, or should know, that states are beginning to re-determine eligibility for people who got on Medicaid during the covid pandemic and were allowed to stay on until now. In fact, Arkansas is vowing to re-determine eligibility for half a million people over the next six months. Alice, the last time Arkansas tried to do something bureaucratically complicated with Medicaid, it didn’t turn out so well, did it?

Ollstein: No. It was so much of a cautionary tale that no other state until now has gone down that path, although now at least a couple are attempting to. So Arkansas was the only state to actually move forward under the Trump administration with implementing Medicaid work requirements. And we covered it at the time, and just thousands and thousands of people lost coverage who should have qualified. They were working. They just couldn’t navigate the reporting system. Part of the problem was that you had to report your working hours online and a lot of people who are poor don’t have access to the internet. And, you know, the system was buggy and clunky and it was just a huge mess. But that is not stopping the state from trying again on several fronts. One, they want to do Medicaid work requirements again. The governor, Sarah Huckabee Sanders, has said that they plan to do that and also they plan to do their redeterminations for the end of the public health emergency in half the time the federal government would like states to take to do it. The federal government has incentives for states to go slow and take a full year to make sure people know how to prove whether or not they qualify for Medicaid and to learn what other insurance coverage options might be available to them. For instance, you know, Obamacare plans that are free or almost free.

Rovner: Yeah. Presumably most of the people who are no longer eligible for Medicaid but are still low-income will be eligible for Obamacare with hefty subsidies.

Ollstein: That’s right. So the fear is that history will repeat itself. A lot of people who should be covered will be dropped from coverage and won’t even know it because the state didn’t take the time to contact people and seek them out.

Rovner: This is something that we will certainly follow as it plays out over the next year. More broadly, though, there have been whispers — well, more than whispers, whines — over the past couple of weeks that President [Joe] Biden’s challenge to Republicans not to cut Social Security and Medicare, and Republicans’ apparent acceptance of that challenge, specifically leaves out Medicaid. Now, I never thought that was true, at least for the Democrats. But earlier this week, President Biden extended his promises to Medicaid and the Affordable Care Act. How much of a threat is there really to Medicaid in the coming budget battles? Rachel, you wrote about that today.

Cohrs: There is a lot of anxiety swirling around this on the Hill. I know there’s a former Trump White House official who’s circulated some documents that are making people a little bit nervous about Republicans’ position. But it is useful to look at existing documents out there. It is not reflective necessarily of the consensus Republican position. And it’s a very diverse party right now in the House. They have an incredibly narrow majority and Kevin McCarthy is really going to have to walk a tightrope here. And I think it is important to remember that when Medicaid has come up on steep ballot initiatives in red states, so many times it has passed overwhelmingly. So I think there is an argument to be made that Medicaid enjoys more political support among the GOP voting populace than maybe it does among members of Congress. So I think I am viewing it with caution. You know, obviously, it’s something that we’re going to have to be tracking and watching as these negotiations develop. But Democrats still hold the Senate and they still hold the presidency. So Republicans have more leverage than they did last Congress, but they’re still … Democrats still have a lot of sway here.

Rovner: Although I’ll just point out, as I think I pointed out before, that in 2017, when the Republicans tried to repeal the Affordable Care Act, one of the things they discovered is that Medicaid is actually kind of popular. I think … much to their surprise, they discovered that Medicaid is also kind of popular, maybe not as much as Medicare, but more than I think they thought. So I guess the budget wars really get started next week: We get President Biden’s budget, right?

Ollstein: And House Republicans are allegedly working on something. We don’t know when it will come or how much detail it will have, but it will be some sort of counter to Biden’s budget. But, you know, the real work will come later, in hashing it out in negotiations. And, really, a small number of people will be involved in that. And so just like Rachel said, you know, you’re going to see a lot of proposals thrown out over the next several months. Not all of them should necessarily be taken seriously or taken as determinative. Just one last interesting thing: This has been a really interesting education time, both for lawmakers and the public on just who is covered under these programs. I mean, the idea is that Medicare is so untouchable, is this third rail, because it is primarily seniors, and seniors vote. And seniors are more politically important to conservatives and Republicans. But people forget a lot of seniors are also on Medicaid. They get their nursing home coverage through there. And so I’ve heard a lot of Democratic lawmakers really hammering that argument lately and saying, look, you know, the stereotype for Medicaid is that it’s just poor adults, but …

Rovner: Yeah, moms and kids. That was how it started out.

Ollstein: Exactly.

Rovner: It was poor moms and kids.

Ollstein: Exactly. But it’s a lot more than that now. And it is more politically dicey to go after it than maybe people think.

Rovner: Yeah, I think Nancy Pelosi … in 2017 when, you know, if the threat with Medicare is throwing Granny off the cliff in her wheelchair, the threat of Medicaid is throwing Granny out of her nursing home, both of which have their political perils. All right. Well, we’ll definitely see this one play out for a while. I want to move to the public health beat. Lauren, you had a really cool story on the front page of The Washington Post this week about how the promise of ivermectin to treat infectious diseases in humans. And for those who forget, ivermectin is an anti-wormer drug that I give to my horse and both of my dogs. But the idea of using it for various infectious diseases just won’t die. What is the latest ivermectin craze?

Weber: Yes, and to be clear, there is an ivermectin that is a pill that can be given to humans, which is what these folks are talking about. But there’s this group called the Front Line COVID-19 Critical Care Alliance that really pushed ivermectin in the height of covid. As we all know on this podcast, scientific study after scientific study after clinical trial has disproved that there is any efficacy for that. But this group has continued to push it. And I discovered, looking at their website back this winter, that they’re now pushing it for the flu and RSV. And as I asked the CDC [Centers for Disease Control and Prevention] and medical experts, there’s no clinical data to support pushing that for the flu or RSV. And, you know, as one scientist said to me, they had data that … had antiviral properties in a test tube. But as one scientist said to me, well, if you put Coca-Cola in a test tube, it would show it had antiviral properties as well. So there’s a lot of pushback to these folks. But, that said, they told me that they have had their protocols downloaded over a million times. You know, they’re … absolutely have some prominence and have, you know, converted a share of the American population to the belief that this is a useful medical treatment for them. And one of the doctors that has left their group over their support of ivermectin said to me, “Look, I’m not surprised that they’re continuing to push this for something else. This is what they do now. They push this for other things.” And so it’s quite interesting to see this continue to play out as we continue into covid, to see them kind of expand, as these folks said to me, into other diseases.

Rovner: I know I mean, usually when we see these kinds of things, it’s because the people who are pushing them are also selling them and making money off of them. And I know that’s the case in some of this, but a lot of these are just doctors who are writing prescriptions for ivermectin. Right? I mean, this is an actual belief that they have.

Weber: Yeah, some of them do make money off of telehealth appointments. They can charge up to a couple hundred dollars for telehealth appointments. And one of the couple of co-founders had a lucrative Substack and book deal that talks about ivermectin and do get paid by this alliance. One of them made almost a quarter of a million dollars in salary from the alliance. But yeah, I mean, the average doctor that’s prescribing ivermectin, I mean — there were over 400,000 ivermectin prescriptions in, I think, it was August of 2021. So that’s a lot of prescriptions.

Rovner: They’re not all making money off of it.

Weber: They’re not all making money. And I mean, what’s wild to me is Merck has come out and said, which, in a very rare statement for a pharmaceutical company, you know, don’t prescribe our drug for this. And when I asked them about RSV and the flu, they said, yeah, our statement would still stand on that. So it’s a movement, to some extent. And the folks I talked to about it, they really believe …

Rovner: And I will say, for a while in 2021, you couldn’t get horse wormer, which is a very nasty-tasting paste, even the horses don’t really like it. Because it was hard to get ivermectin at all. So we’ll see where this goes next. Here’s one of those “in case you missed It” stories. The Tulsa World this week has an interview with former Republican Sen. James Inhofe, who said, in his blunt Inhofe way, that he retired last year not only because he’s 88, but because he’s still suffering the effects of long covid. And he’s not the only one — quote, “five or six others have [long covid], but I’m the only one who admits it,” he told the paper, referring to other members of the Senate, presumably other Republican members of the Senate. Now, mind you, the very conservative Inhofe voted against just about every covid funding bill. And my impression from not going to the Hill regularly in 2021 and 2022 is that while covid seemed to be floating around in the air, lots of people were getting it, very few people seemed to be getting very sick. But now we’re thinking that’s not really the case, right?

Ollstein: When I saw this, I immediately went back to a story I wrote about a year ago on Tim Kaine’s long covid diagnosis and his attempts to convince his colleagues to put more research funding or treatment funding, more basic covid prevention funding … you know, fewer people will get long covid if fewer people get covid in the first place. And there was just zero appetite on the Republican side for that. And that’s why a lot of it didn’t end up passing. Inhofe was one of the Republicans I talked to, and I said, you know, do you think you should do more about long covid? What do you think about this? And this is what he told me: “I have other priorities. We’re handling all we can right now.” And then he added that long covid is not that well defined. And he argued there’s no way to determine how many people are affected. Well.

Rovner: OK.

Ollstein: So that … in “Quotes That Aged Poorly Hall of Fame.”

Rovner: You know, obviously Tim Kaine came forward and talked about it. But now I’m wondering if there are people who are slowing down or looking like they’re not well, maybe they have long covid and don’t want to say.

Ollstein: Well, I mean, something that Tim Kaine’s case shows is that there’s no one thing it can look like and somebody can look completely healthy and normal on the outside and be suffering symptoms. And Tim Kaine has also said that members of Congress have quietly disclosed to him and thanked him for speaking up, but said they weren’t willing to do it themselves. And he, Tim Kaine, told me that he felt more comfortable speaking up because the kind of symptoms he had were less stigmatized. They weren’t anything in terms of impeding his mental capacity and function. And there’s just a lot of stigma and fear of people coming forward and admitting they’re having a problem.

Rovner: I find it kind of ironic that last week we talked about how, you know, members of Congress and politicians with mental health, you know, normally stigmatizing problems are more willing to talk about it. And yet here are people with long covid not willing to talk about it. So maybe we’ll see a little bit more after this or maybe not. I want to talk a little bit about artificial intelligence and health care. I’ve been wanting to talk about this for a while, but this week seems to be everyone is talking about AI. There have been a spate of stories about how different types of artificial intelligence are aiding in medical care, but also some cautionary tales, particularly about chat engines. They get all their information from the internet, good or bad. Now, we already have robots that do intricate surgeries and lots and lots of treatment algorithms. On the other hand, the little bit of AI that I already have that’s medical-oriented, my Fitbit, that sometimes accurately tracks my exercise and sometimes doesn’t, and the chat bot from my favorite chain drugstore that honestly cannot keep my medication straight. None of that makes me terribly optimistic about launching into health AI. Is this, like most tech, going to roll out a little before it’s ready and then we’ll work the bugs out? Or maybe are we going to be a little bit more careful with some of this stuff?

Cohrs: I think we’ve already seen some examples of things rolling out before they’re exactly ready. And I just thought of my colleague Casey Ross’ reporting on Epic’s algorithm that was supposed to help …

Rovner: Epic, the electronic medical records company.

Cohrs: Yes, yes. They had this algorithm that was supposed to help doctors treat sepsis patients, and it didn’t work. The problem with using AI in health care is that there are life-and-death consequences for some of these things. If you’re misdiagnosing someone, if you’re giving them medicine they don’t need, there are, like, those big consequences. But there are also the smaller ones too. And my colleague Brittany Trang wrote about how with doctor’s notes or transcripts of conversations between a physician and a patient sometimes AI has difficulty differentiating between an “mm-hm” or an “uh-huh” and telling whether that’s a yes or a no. And so I think that there’s just all of these really fascinating issues that we’re going to have to work through. And I think there is enormous potential, certainly, and I think there’s getting more experimentation. But like you said, I think in health care it’s just a very different beast when you’re rolling things out and making sure that they work.

Weber: Yeah, I wanted to add, I mean, one of the things that I found really interesting is that doctors’ offices are using some of it to reduce some of the administrative burden. As we all know, prior authorizations suck up a lot of time for doctors’ offices. And it seems like this has actually been really helpful for them. That said, I mean, that comes with the caveat of — my colleagues and I and much reporting has shown that — sometimes these things just make up references for studies. They just make it up. That level of “Is this just a made-up study that supports what I’m saying?” I think is really jarring. This isn’t quite like using Google. It cannot be trusted to the level … and I think people do have caution with it and they will have to continue to have caution with it. But I think we’re really only at the forefront of figuring out how this all plays out.

Rovner: I was talking before we started taping about how I got a text from my favorite chain drugstore saying that I was out of refills and that they would call my doctor, which is fine. And then they said, “Text ‘Yes’ if you would like us to call” … some other doctor. I’m like, “Who the heck is this other doctor?” And then I realize he’s the doctor I saw at urgent care last September when I burned myself. I’m like, “Why on earth would you even have him in your system?” So, you know, that’s the sort of thing … it’s like, we’re going to be really helpful and do something really stupid. I worry that Congress, in trying to regulate tech, and failing so far — I mean, we’ve seen how much they do and don’t know about, you know, Facebook and Instagram and the hand-wringing over TikTok because it’s owned by the Chinese — I can’t imagine any kind of serious, thoughtful regulation on this. We’re going to have to basically rely on the medical industry to decide how to roll this out, right? Or might somebody step in?

Ollstein: I mean, there could be agency, you know, rulemaking, potentially. But, yes, it’s the classic conundrum of technology evolving way faster than government can act to regulate it. I mean, we see that on so many fronts. I mean, look how long has gone without any kind of update. And, you know, the kinds of ways health information is shared are completely different from when that law was written, so …

Rovner: Indeed.

Weber: And as Rachel said, I mean, this is life-or-death consequences in some places. So the slowness with which the government regulates things could really have a problem here, because this is not something that is just little …

Rovner: Of the things that keep me awake at night, this is one of the things that keeps me awake at night. All right. Well, one of these weeks, we will not have a ton of reproductive health news. But this week isn’t it. As of this taping, we still have not gotten a decision in that Texas case challenging the FDA approval of the abortion pill, mifepristone, back in the year 2000. But there’s plenty of other abortion news happening in the Lone Star State. First, a federal judge in Texas who was not handpicked by the anti-abortion groups ruled that Texas officials cannot enforce the state’s abortion ban against groups who help women get abortion out of state, including abortion funds that help women get the money to go out of state to get an abortion. The judge also questioned whether the state’s pre-Roe ban is even in effect or has actually been repealed, although there are overlapping bans in the state that … so that wouldn’t make abortion legal. But still, this is a win for the abortion rights side, right, Alice?

Ollstein: Yeah, I think the right knows that there are two main ways that people are still getting abortions who live in ban states. They’re traveling out of state or they are ordering pills in the mail. And so they are moving to try to cut off both of those avenues. And, you know, running into some difficulty in doing so, both in the courts and just practically in terms of enforcing. This is part of that bigger battle to try to cut off, you know, people’s remaining avenues to access the procedure.

Rovner: Well, speaking exactly of that, Texas being Texas, this week, we saw a bill introduced in the state legislature that would ban the websites that include information about how to get abortion pills and would punish internet providers that fail to block those sites. It would also overturn the court ruling we just talked about by allowing criminal prosecution of anyone who helps someone get an abortion. Even a year ago, I would have said this is an obvious legislative overreach, but this is Texas. So now maybe not so much.

Ollstein: I mean, I think lots of states are just throwing things at the wall to see what sticks and to see what gets through the courts. You had states test the waters on banning certain kinds of out-of-state travel, and that hasn’t gone anywhere yet. But even things that don’t end up passing and being implemented can have a chilling effect. You have a lot of confusion right now. You have a lot of people not sure what’s legal, what’s not. And if you create this atmosphere of fear where people might be afraid to go out of state, might be afraid to ask for funding to go out of state, afraid to Google around and see what their options are that serves the intended impacts of these proposals, in terms of preventing people from exploring their options and seeing what they can do to terminate a pregnancy.

Rovner: Yeah. Well, meanwhile, a dozen states that are not named Texas are suing the FDA, trying to get it to roll back some of the prescribing requirements around the abortion pill. The states are arguing that not only are the risk-mitigation rules unnecessary, given the proven safety of mifepristone, but that some of the certification requirements could invade the privacy of patients and prescribers and subject them to harassment or worse. They’re asking the judge to halt enforcement of the restrictions while the case is being litigated. That could run right into [U.S. District] Judge [Matthew] Kacsmaryk’s possible injunction in Texas banning mifepristone nationwide. Then what happens? If you’ve got one judge saying, “OK, you can’t sell this nationwide,” and another judge saying … “Of course you can sell it, and you can’t use these safety restrictions that the FDA has put around it.” Then the FDA has two conflicting decisions in front of it.

Weber: Yeah, and I find the battles of the AGs and the abortion wars are really fascinating because, I mean, this is a lawsuit brought by states, which is attorneys general, Democratic attorneys general. And you’re seeing that play out. I mean, you see that in Texas, too, with [Ken] Paxton. You see it in Michigan with [Dana] Nessel. I mean, I would argue one of the things that attorney generals have been the most prominent on in the last several decades of American history and have actually had immediate effects on due to the fall of Roe v. Wade. So we’ll see what happens. But it is fascinating to see in real time this proxy battle, so to speak, between the two sides play out across the states and across the country.

Rovner: No, it’s funny. State AGs did do the tobacco settlement.

Weber: Yes.

Rovner: I mean, that would not have happened. But what was interesting about that is that it was very bipartisan.

Weber: Well, they were on the same side.

Rovner: And this is not.

Weber: Yeah, I mean, yeah, they were on the same side. This is a different deal. And I think to some extent, and I did some reporting on this last year, it speaks to the politicization of that office and what that office has become and how it’s become, frankly, a huge launching pad for people’s political careers. And the rhetoric there often is really notched up to the highest levels on both sides. So, you know, as we continue to see that play out, I think a lot of these folks will end up being folks you see on the national stage for quite some time.

Ollstein: I’ve been really interested in the states where the attorney general has clashed with other parts of their own state government. And so in North Carolina, for example, right now you have the current Democratic attorney general who is planning to run for governor. And he said, I’m not going to defend our state restrictions on abortion pills in court because I agree with the people challenging them. And then you have the Republican state legislatures saying, well, if he’s not going to defend these laws, we will. So that kind of clash has happened in Kentucky and other states where the attorney general is not always on the same side with other state officials.

Rovner: If that’s not confusing enough, we have a story out of Mississippi this week, one of the few states where voters technically have the ability to put a question on the ballot, except that process has been blocked for the moment by a technicality. Now, Republican legislators are proposing to restart the ballot initiative process. They would fix the technicality, but not for abortion questions. Reading from the AP story here, quote, “If the proposed new initiative process is adopted, state legislators would be the only people in Mississippi with the power to change abortion laws.” Really? I mean, it’s hard to conceive that they could say you can have a ballot question, but not on this.

Ollstein: This is, again, part of a national trend. There are several Republican-controlled states that are moving right now to attempt to limit the ability of people to put a measure on the ballot. And this, you know, comes as a direct result of last year. Six states had abortion-related referendums on their ballot. And in all six, the pro-abortion rights side won. Each one was a little different. We don’t need to get into it, but that’s the important thing. And so people voted pretty overwhelmingly, even in really red states like Kentucky and Montana. And so other states that fear that could happen there are now moving to make that process harder in different ways. You have Mississippi trying to do, like, a carve-out where nothing on abortion can make it through. Other states are just trying to raise, like, the signature threshold or the vote threshold people need to get these passed. There are a lot of different ways they’re going about it.

Rovner: I covered the Mississippi “personhood” amendment back in 2011. It was the first statewide vote on, you know, granting personhood to fetuses. And everybody assumed it was going to win, and it didn’t, even in Mississippi. So I think there’s reason for the legislators who are trying to re-stand up this ballot initiative process to worry about what might come up and how the voters might vote on it. Well, because I continue to hear people say that women trying to have babies are not being affected by state abortion bans and restrictions, this week we have not one but two stories of pregnant women who were very much impacted by abortion bans. One from NPR is the story of a Texas woman pregnant with twins — except one twin had genetic defects not only incompatible with life, but that threatened the life of both the other twin and the pregnant woman. She not only had to leave the state for a procedure to preserve her own life and that of the surviving twin, but doctors in Texas couldn’t even tell her explicitly what was going on for fear of being brought up on charges of violating the state’s ban. I think, Alice, you were the one talking about how, you know, women are afraid to Google. Doctors are afraid to say anything.

Ollstein: Yeah, absolutely. I mean, it’s a really chilling and litigious environment right now. And I think, as more and more of these stories start to come forward, I think that is spurring the debates you’re seeing in a lot of states right now about adding or clarifying or expanding the kind of exceptions that exist on these bans. So you have very heated debates going on right now in Utah and Tennessee and in several states around, you know, should we add more exceptions because there are some Republican lawmakers who are looking at these really tragic stories that are trickling out and saying, “This isn’t what we intended when we voted for this ban. Let’s go back and revisit.” Whether exceptions even work when they are on the books is another question that we can discuss. I mean, we have seen them not be effective in other states and people not able to navigate them.

Rovner: We’ve seen a lot of these stories about women whose water broke early and at what point is it threatening her life? How close to death does she have to be before doctors can step in? I mean, we’ve seen four or five of these. It’s not like they’re one-offs. The other story this week is from the Daily Beast. It’s about a 28-year-old Tennessee woman whose fetus had anomalies with its heart, brain, and kidneys. That woman also had to leave the state at her own expense to protect her own health. Is there a point where anti-abortion forces might realize they are actually deterring women who want babies from getting pregnant for fear of complications that they won’t be able to get treated?

Ollstein: Most of the pushback I’ve seen from anti-abortion groups, they claim that the state laws are fine and that doctors are misinterpreting them. And there is a semantic tug of war going on right now where anti-abortion groups are trying to argue that intervening in a medical emergency shouldn’t even count as an abortion. Doctors argue, no, it is an abortion. It’s the same procedure medically, and thus we are afraid to do it under the current law. And the anti-abortion groups are saying, “Oh, no, you’re saying that in bad faith; that doesn’t count as an abortion. An abortion is when it’s intended to kill the fetus.” So you’re having this challenging tug of war, and it’s not really clear what states are going to do. There’s a lot of state bills on this making their way through legislatures right now.

Rovner: And doctors and patients are caught in the middle. Well, finally this week, Eli Lilly announced it would lower, in some cases dramatically, the list prices for some of its insulin products. You may remember that, last year, Democrats in Congress passed a $35-per-month cap for Medicare beneficiaries but couldn’t get those last few votes to apply the cap to the rest of the population. Lilly is getting very good press. Its stock price went up, even though it’s not really capping all the out-of-pocket costs for insulin for everybody. But I’m guessing they’re not doing this out of the goodness of their drugmaking heart, right, Rachel?

Cohrs: Probably not. Even though there’s a quote from their CEO that implied that that was the case. I think there was one drug pricing expert at West Health Policy Center, Sean Dickson, who is very sharp on these issues, knows the programs well. And he pointed out that there’s a new policy going into effect in Medicaid next year, and it’s really, really wonky and complicated. But I’ll do my best to try to explain that, generally, in the Medicare program, rebates are capped, or they have been historically, at the price of the drug. So you can’t charge a drugmaker a rebate that’s higher than the cost. But …

Rovner: That would make sense.

Cohrs: Right. But that math can get kind of wonky when there are really high drug price increases and then that math gets really messed up. But Congress, I want to say it was in 2021, tweaked this policy to discourage those big price increases. And they said, you know what? We’re going to raise the rebate cap in Medicaid, which means that, drugmakers, if you are taking really big price increases, you may have to pay us every time someone on Medicaid fills those prescriptions. And I think people thought about insulin right away as a drug that has these really high rebates already and could be a candidate disproportionately impacted by this policy. So I thought that was an interesting point that Sean made about the timing of this. That change is supposed to go into effect early next year. So this could, in theory, save Lilly a lot of money in the Medicaid program because we don’t know exactly what their net prices were before.

Rovner: But this is very convenient.

Cohrs: It’s convenient. And there’s a chance that they’re not really losing any money right now, depending on how their contracts work with insurers. So I think, yeah, there is definitely a possibility for some ulterior motives here.

Rovner: And plus, the thing that I learned this week that I hadn’t known before is that there are starting to be some generic competition. The three big insulin makers, which are Lilly, Sanofi, and Novo Nordisk, may actually not become the, almost, the only insulin maker. So it’s probably in Lilly’s interest to step forward now. And, you know, they’re reducing the prices on their most popular insulins, but not necessarily their most expensive insulin. So I think there’s still money to be made in this segment. But they sure did get, you know, I watched all the stories come across. It’s, like, it’s all, oh, look at this great thing that Lilly has done and that everything’s going to be cheap. And it’s, like, not quite. But …

Cohrs: But it is different. It’s a big step. And I think …

Rovner: It is. It is.

Cohrs: Somebody has to go first in breaking this cycle. And I think it will be interesting to see how that plays out for them and whether the other two companies do follow suit. Sen. Bernie Sanders asked them to and said, you know, why don’t you just all do the same thing and lower prices on more products? So, yeah, we’ll see how it plays out.

Weber: Day to day, I mean, that’s a huge difference for people. I mean, that is a lot of money. That is a big deal. So, I mean, you know, no matter what the motivation, at the end of the day, I think the American public will be much happier with having to pay a lot less for insulin.

Rovner: Yeah, I’m just saying that not everybody who takes insulin is going to pay a lot less for insulin.

Weber: Right. Which is very fair, very fair.

Rovner: But many more people than before, which is, I think, why it got lauded by everybody. Although I will … I wrote in my notes, please, someone mention Josh Hawley taking credit and calling for legislation. Sen. Hawley from Missouri, who voted against extending the $35 cap, as all Republicans did, to the rest of the population, put out a tweet yesterday that was, like, this is a great thing and now we should have, you know, legislation to follow up. And I’m like: OK.

Cohrs: You’ll have to check on that. I actually think Hawley may have voted for it.

Rovner: Oh, a-ha. All right.

Cohrs: There were a few Republicans.

Rovner: Thank you.

Cohrs: It’s not enough, though.

Rovner: Yeah, I remember that they couldn’t get those last few votes. Yes, I think [Sen. Joe] Manchin voted against. He was the one, the last Democrat they couldn’t get right. That’s why they ended up dropping …

Cohrs: Uh, it had to be a 60-vote threshold, so …

Rovner: Oh, that’s right.

Cohrs: Yeah.

Rovner: All right. Good. Thank you. Good point, Rachel. All right. Well, that is the news for this week. Now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?

Ollstein: Yeah. So I did the incredible New York Times investigation by Hannah Dreier on child labor. This is about undocumented, unaccompanied migrant children who are coming to the U.S. And the reason I’m bringing it up on our podcast is there is a health angle. So HHS [the Department of Health and Human Services], their Office of Refugee Resettlement has jurisdiction over these kids’ welfare and making sure they are safe. And that is not happening right now. The system is so overwhelmed that they have been cutting corners in how they vet the sponsors that they release the kids to. Of course, we remember that there were tons of problems with these kids being detained and kept for way too long and that being a huge threat to their physical and mental health. But this is sort of the pendulum has swung too far in the opposite direction, and they’re being released to people who in some cases straight up trafficking them and in other cases just forcing them to work and drop out of school, even if it’s not a trafficking situation. And so this reporting has already had an impact. The HHS has announced all these new initiatives to try to stop this. So we’ll see if they are effective. But really moving, incredible reporting.

Rovner: Yeah, it was an incredible story. Lauren.

Weber: I’m going to shout out my former KHN colleague Brett Kelman. I loved his piece on, I guess you can’t call it a medical device because it wasn’t approved by the FDA, which is the point of the story. But this device that was supposed to fix your jaw so you didn’t have to have expensive jaw surgery. Well, what it ended up doing is it messed up all these people’s teeth and totally destroyed their mouths and left them with a bunch more medical and dental bills. And, you know, what I find interesting about the story, what I find interesting about the trend in general is the problem is, they never applied for anything with the FDA. So people were using this device, but they didn’t check, they didn’t know. And I think that speaks to the American public’s perception that devices and medical devices and things like this are safe to use. But a lot of times the FDA regulations are outdated or are not on top of this or the agency is so understaffed and not investigating that things like this slipped through the cracks. And then you have people — and it’s 10,000 patients, I believe, that have used this tool — that did not do what it is supposed to do and, in fact, injured them along the way. And I think that the FDA piece of that is really interesting. It’s something I’ve run into before looking at air cleaners and how they fit the gaps of that. And I think it’s something we’re going to continue to see as we examine how these agencies are really stacking up to the evolution of technology today.

Rovner: Yeah, capitalism is going to push everything. Rachel.

Cohrs: So my extra credit this week is actually an opinion piece, in Stat, and the headline is “Nonprofit Hospitals Are Failing Americans. Their Boards May Be a Reason Why.” It was written by Sanjay Kishore and Suhas Gondi. I think the part that really stood out to me is they analyzed the backgrounds and makeups of hospital boards, especially nonprofit hospitals. I think they analyzed like 20 large facilities. And the statistic that really surprised me was that, I think, 44% of those board members came from the financial sector representing investment funds, real estate, and other entities. Less than 15% were health care workers, 13% were physicians, and less than 1% were nurses. And, you know, I’ve spent a lot of time and we’ve spent a lot of time thinking about just how nonprofit hospitals are operating as businesses. And I think a lot of other publications have done great work as well making that point. But I think this is just a stark statistic that shows these boards that are supposed to be holding these organizations accountable are thinking about the bottom line, because that’s what the financial services sector is all about, and that there’s so much disproportionately less clinical representation. So obviously hospitals need admin sides to run, and they are businesses, and a lot of them don’t have very large margins. But the statistics just really surprised me as to the balance there.

Rovner: Yeah, I felt like this is one, you know, we’ve all been sort of enmeshed in this, you know, what are we going to do about the nonprofit hospitals that are not actually acting as charitable institutions? But I think the boards had been something that I had not seen anybody else look at until now. So it’s a really interesting piece. All right. Well, my story this week is the other big investigation from The New York Times. It’s called “A Drug Company Exploited a Safety Requirement to Make Money,” by Rebecca Robbins. And it’s about those same risk-mitigation rules from the FDA that are at the heart of those abortion drug lawsuits we talked about a few minutes ago. Except in this case, the drug company in question, Jazz Pharmaceuticals, somehow patented its risk-mitigation strategy as the distribution center — it’s actually called the REMS [Risk Evaluation and Mitigation Strategies] — which is managed to fend off generic competition for the company’s narcolepsy drug. It had also had a response already. It has produced a bipartisan bill in the Senate to close the loophole — but [I’ll] never underestimate the creativity of drugmakers when it comes to protecting their profit. It’s quite a story. OK. 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 us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — at kff.org. Or you can tweet me. I’m @jrovner. Alice?

Ollstein: @AliceOllstein

Rovner: Rachel.

Cohrs: @rachelcohrs

Rovner: Lauren.

Weber: @LaurenWeberHP

Rovner: We will be back in your feed next week. In the meantime, be healthy.

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Julie Rovner is chief Washington correspondent and host of KHN’s 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.

Both Republicans and Democrats in Congress reacted with compassion to the news that Sen. John Fetterman (D-Pa.) has checked himself into Walter Reed National Military Medical Center for treatment of clinical depression. The reaction is a far cry from what it would have been 20 or even 10 years ago, as more politicians from both parties are willing to admit they are humans with human frailties.

Meanwhile, former South Carolina governor and GOP presidential candidate Nikki Haley is pushing “competency” tests for politicians over age 75. She has not specified, however, who would determine what the test should include and who would decide if politicians pass or fail.

This week’s panelists are Julie Rovner of KHN, Sarah Karlin-Smith of the Pink Sheet, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachel Roubein of The Washington Post.

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Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

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Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories

Among the takeaways from this week’s episode:

• Acknowledging a mental health disorder could spell doom for a politician’s career in the past, but rather than raising questions about his fitness to serve, Sen. John Fetterman’s decision to make his depression diagnosis and treatment public raises the possibility that personal experiences with the health system could make lawmakers better representatives.
• In Medicare news, Sen. Rick Scott (R-Fla.) dropped Medicare and Social Security from his proposal to require that every federal program be specifically renewed every five years. Scott’s plan has been hammered by Democrats after President Joe Biden criticized it this month in his State of the Union address.
• Medicare is not politically “untouchable,” though. Two Biden administration proposals seek to rein in the high cost of the popular Medicare Advantage program. Those are already proving controversial as well, particularly among Medicare beneficiaries who like the additional benefits that often come with the private-sector plans.
• New studies on the effectiveness of ivermectin and mask use are drawing attention to pandemic preparedness. The study of ivermectin revealed that the drug is not effective against the covid-19 virus even in higher doses, raising the question about how far researchers must go to convince skeptics fed misinformation about using the drug to treat covid. Also, a new analysis of studies on mask use leaned on pre-pandemic studies, potentially undermining mask recommendations for future health crises.
• On the abortion front, abortion rights supporters in Ohio are pushing for a ballot measure enshrining access to the procedure in its state constitution, while a lawyer in Florida is making an unusual “personhood” argument to advocate for a pregnant woman to be released from jail.

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

Julie Rovner: Stat’s “Current Treatments for Cramps Aren’t Cutting It. Why Aren’t There Better Options?” by Calli McMurray

Joanne Kenen: The Atlantic’s “Eagles Are Falling, Bears Are Going Blind,” by Katherine J. Wu

Rachel Roubein: The Washington Post’s “Her Baby Has a Deadly Diagnosis. Her Florida Doctors Refused an Abortion,” by Frances Stead Sellers

Sarah Karlin-Smith: DCist’s “Locals Who Don’t Speak English Need Medical Translators, but Some Say They Don’t Always Get the Service,” by Amanda Michelle Gomez and Hector Alejandro Arzate

Also mentioned in this week’s podcast:

• The Hill’s “Nikki Haley: Bernie Sanders Is ‘Exactly the Reason’ Mental Competency Tests Are Needed,” by Niall Stanage
• USA Today’s “Idaho Bill Would Criminalize Giving mRNA Vaccines — The Tech Used in Popular COVID Vaccines,” by Thao Nguyen
• The Washington Post’s “Twenty Governors Are Forming a New Coalition to Support Abortion Rights,” by Rachel Roubein with McKenzie Beard
• The Washington Post’s “Fla. Lawyer Argues Pregnant Inmate’s Fetus Is Being Illegally Detained,” by Kyle Melnick

click to open the transcript

Transcript: Senators Have Mental Health Crises, Too

KHN’s ‘What the Health?’Episode Title: Senators Have Mental Crises, TooEpisode Number: 286Published: Feb. 23, 2023

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 23, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Rachel Roubein of The Washington Post.

Rachel Roubein: Hi. Thanks for having me.

Rovner: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

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

Joanne Kenen: Hi, everybody.

Rovner: So, no interview this week, but lots of interesting news, even with Congress in recess and the president out of the country. So we will get right to it. We’re going to start this week with mental health. No, not the mental health of the population, although that remains a very large problem, but specifically the mental health of politicians. I am old enough to remember when a politician admitting to having been treated for any mental health problem basically disqualified them from holding higher office. You young people go Google Tom Eagleton. Now we have Sen. John Fetterman [D-Pa.], who made headlines while campaigning during his stroke recovery, checking himself into Walter Reed for major depression treatment. And the reaction from his colleagues on both sides of the aisle has been unusually compassionate for political Washington. Have we turned a corner here on admitting to having problems not meaning incapable of serving or working?

Karlin-Smith: It’s obviously getting better, but I think as we saw with Fetterman’s coverage during the campaign, it was far from perfect. And I think there was some dissatisfaction that his coverage was in many … sometimes unfair in how his stroke and his stroke recovery and his needs for accommodations were presented in the media. But I do think we are shifting at least somewhat from thinking about, Does this situation make a person fit to serve? to thinking about, OK, what does this person’s experience navigating the health care system perhaps provide that might actually make them a better representative, or understand their constituents’ needs in navigating the health care system, which is a big part of our political agenda?

Kenen: There are very few times when Congress makes nice. I think on rare occasions mental health has done it. I can think of the fight for mental parity. It was a bipartisan pair: Sen. Pete Domenici [R-N.M.] had a daughter with schizophrenia, and Sen. Paul Wellstone [D-Minn.] had … what, was it … a brother?

Rovner: I think it was a sibling, yeah.

Kenen: … with a severe mental illness. I no longer remember whether it was schizophrenia or another severe mental illness. And they teamed up to get mental health parity, which they didn’t get all the way. And there are still gaps, but they got the first, and it took years.

Rovner: And they were a very unlike pair, Domenici was …

Kenen: They were a very unlikely couple.

Rovner: a very conservative Republican. Wellstone was a very liberal Democrat.

Kenen: And their personalities were completely like, you know, one was a kind but grumpy person and one was the teddy bear. And they were a very odd couple in every possible way. And it didn’t make lawmakers talk about themselves at that point, but they did get more open about their family. About 10 or 15 years later, there was a senator’s son died by suicide and he was very open about it. It was really one of the most remarkable moments I’ve ever seen on the Hill, because other people started getting up and talking about loved ones who had died by suicide, including [Sen.] Don Nickles [R-Okla.], who was very conservative, who had never spoken about it before. And it was Sen. Gordon Smith [R-Ore.] whose son had died at the time. And he tried to put it to use and got mental health legislation for college. So these were like, you know, 10 or 15 years apart. But Congress, they don’t treat each other very well. It’s not just politics. They’re often quite nasty across party lines. So this was sort of like the third moment I’ve seen where a little bit of compassion and identification came out. Is it a kumbaya turnaround? No, but it’s good to see kindness, not “he should resign this moment.” I mean, the response was pretty human and humane.

Rovner: And we also had the unique moment with Patrick Kennedy, who was then in the House, son of Sen. Ted Kennedy, who was still in the Senate. And Patrick Kennedy, of course, had had substance abuse issues in addition to his mental health issues. And he actually championed through what turned into the final realization of the mental health parity that Domenici and Wellstone had started. So, I mean, to Sarah’s point, I think, sometimes if the person experiences it themselves, they may be even more able to navigate through to help other people, so …

Kenen: You’re not immune from mental illness if you’re a lawmaker and neither is your family. And there are a number of very sad stories and there are other lawmakers who have lost relatives to suicide. So there’s this additional connection between stroke and depression that I think got a little bit of attention here, because that’s also a thing.

Rovner: Well, all right, then again, it is not all sunshine and roses on the political mental health front. Former South Carolina Republican Gov. Nikki Haley, who’s now running for president, is proposing a mental competency test for politicians over the age of 75. That would, of course, include both Donald Trump and Joe Biden. But this week, Haley extended her proposed mental competency test to the Senate, where there are dozens of members over the age of 75. She specifically called out 81-year-old Bernie Sanders after he called her proposal ageism. Now, it’s pretty clear that Haley is using this to keep herself in the news, and it’s working. But could we actually see mental competency tests rolled out at some point? And who would decide what constitutes competency in someone who’s getting older?

Kenen: Or younger.

Rovner: Or younger, yeah.

Karlin-Smith: Wait, has Joanne solved the aging [mystery]? I think … what Julie said, in terms of who would decide, I think that’s where it gets really dicey. I think, first of all, if you’re going to deal with this, there seems no way you can make it based on age, right? Because competency is not necessarily tied with age. But I think, ethically, I’m not sure our society has any fair way to really determine … and it would just become such a political football that I don’t think anybody wants to deal with figuring out how to do that. Obviously, you don’t want somebody, probably, in office who is not capable of doing the job to a point where they really can’t be productive. But again, as we’ve seen with these other health issues, you also don’t want to exclude people because they are not perfectly in some sort of heightened state of being that, you know, all people are not perfect in capacity at every single moment and deal with struggles. So there’s this fine line, I think, that would be too difficult to sort of figure out how to do that.

Kenen: And you could be fine one day and not fine the next. If you have a disease [of] cognitive decline that’s gradual, you know, when do you pick it up? When do you define it? And then you can have something very sudden like a car crash, a stroke and any number of things that can cause cognitive damage immediately.

Rovner: Now, we didn’t know then, but we know now that Ronald Reagan had the first stages of dementia towards the end of his second term. Sorry, Rachel, you wanted to say something?

Roubein: We’ve seen careful reporting around — I think, about like the San Francisco Chronicle story last year — about [Sen.] Dianne Feinstein [D-Calif.], which essentially looked at this. There were some questions around [Sen.] Thad Cochran [R-Miss.], as well. And it’s something journalists have looked at pretty carefully by talking to other senators and those who know the lawmakers well to see how they are essentially.

Kenen: And Strom Thurmond, who was, to a layperson, like all the reporters covering the Hill, it was clear that … he served until he was, what, 98 or something? You know, it was very clear that half the time he was having struggles.

Rovner: And I remember so many times that there would be the very old senators on the floor who would basically be napping on the floor of the Senate.

Kenen: That might be a sign of mental health.

Rovner: Yeah, that’s true. But napping because they couldn’t stay awake, not just curling up for a nap. But, I mean, it’s an interesting discussion. You know, as I say, I’m pretty sure that Nikki Haley is doing it to try and poke at both Biden and Trump and keep herself in the news. And, as I say, it’s working.

Kenen: But I think there’s a question of fitness that I think has come up over and over again. I mean, Paul Tsongas was running for president, what, the Nineties and said he was over his lymphoma or luekemia.

Rovner: I think he had lymphoma. Yeah.

Kenen: He said he was fine, and it turns out he wasn’t. And he actually died quite young, quite soon after not getting the nomination. So there are legitimate issues of fitness, mental and physical, for the presidency. I would think that there’s a different standard for senators just because you’re one out of 100 instead of one out of one. I think there is a tradition, which Trump didn’t really follow. There is a tradition of disclosure, but it’s not foolproof. And Trump certainly just had — remember, he had that letter from his doctor who also didn’t live much longer after that, saying he was the most fit president in history, Like, just don’t get me started, but basically said he was a greek god. So there are legitimate concerns about fitness, but it’s hard to figure out. I mean, it was really hard to figure out in Congress how to do that.

Rovner: Yeah, I think the “who decides” what will be the most difficult part of that, which is probably why they haven’t done it yet. All right. Well, turning to policy, two weeks ago, we talked about the coming Medicare wars with President Biden taking aim at Republicans in his State of the Union speech, and particularly, although he didn’t name him, with Florida Sen. Rick Scott, who last year as head of the Republican Senate Campaign Committee, released a plan that would have sunset every federal program, including Medicare and Social Security, every five years. And they would cease to be unless Congress re-approved them. We know how much trouble Congress has doing anything. This horrified a whole lot of Republicans, who not only have been on the wrong end politically of threatening Medicare — and paid a price for it at the ballot box — but who themselves have used it as a weapon on Democrats. See my column from last week, which I will put in the show notes. So now, kind of predictably, Sen. Scott has succumbed and proposed a new plan that would sunset every federal program except Medicare and Social Security. But I imagine that’s not going to end this particular political fight, right? The Democrats seem to have become a dog with a bone on this.

Roubein: Yeah. And it’s known as “Mediscare” for a reason, right? It’s something both political parties use and try and weaponize. I mean, I think one of the really big questions for me when I kept on hearing this, like what? Cuts to Medicare, what does that actually mean in practice? Some experts said that it might simply mean slowing the rate of growth in the program compared to what it would have been, which doesn’t necessarily impact people’s benefits. It can; it depends how it’s done. But I mean, we’ve seen this political fight before. It happened during the Affordable Care Act and afterwards, the effect of cutting Medicare Advantage plan payments, etc., didn’t really make plans less generous. They continued to be more generous. So it’s something that we’ll continue to see Biden talk about because the administration thinks that it plays well among seniors.

Rovner: But even as Bernie Sanders pointed out this week, we’re going to have to deal with Medicare and Social Security eventually. They can’t continue on their current path because they will both run out of money at some point unless something gets changed. But right now, it seems that both sides are much happier to use it as a cudgel than to actually sit down and figure out how to fix it.

Kenen: But one thing that’s interesting is that it wasn’t a big issue in the November elections. The Democrats late in the game tried to draw attention to the Rick Scott proposal. I almost wrote a piece how there was no discussion of Medicare for the first time in years. And just as I was starting to write it, they began talking about it a little bit. So I didn’t write it. But it never stuck. It wasn’t a major issue. And the one race where it really could have been would have been Wisconsin, because that was a tight Senate race — the Democrats really wanted to defeat Ron Johnson, who is to the right of Rick Scott on phasing out Medicare. He’s the only one who endorsed Scott and actually wanted to go further, and it didn’t even really stick there. So it’s sort of interesting that it’s now bubbling up. I mean, yes, we’re into 2024, but we’re not into 2024 the way we’re going to be into 2024. It’s sort of interesting to see that the Democrats are hitting this so far.

Rovner: No, I think that’s because of the debt ceiling.

Kenen: Right. But it’s supposedly off the table for the debt ceiling, which doesn’t mean, as Rachel just said, there are legitimate fiscal issues that Democrats and Republicans both acknowledge. They’re, crudely speaking, Democrats want to raise more money for them, and Republicans want to slow spending. That’s a that’s an oversimplification. But the rhetoric is always throwing Grandma off the cliff. Never Grandpa, always Grandma.

Rovner: Always Grandma.

Kenen: You know, actually, you can do things over a 20-year period. That’s what we did with Social Security. We did raise the age in a bipartisan fashion on Social Security 20 years … took like 20 years to phase it.

Rovner: And I would point out that the only person who really reacted to Rick Scott’s plan when it came out last February was, I think, a year ago this week, was Mitch McConnell.

Kenen: Yeah, he blew a gasket.

Rovner: But he immediately disavowed it. So Mitch McConnell knew what a problem it could turn into and kind of has now. So we have kind of the reverse sides in Medicare Advantage of the fight. That’s the private alternative to traditional Medicare. It’s the darling of Republicans, who touched off the current popularity of the program when they dramatically increased payments for it in 2003, which led to increased benefits and increased profits for insurance companies. They split those — that extra money between themselves and the beneficiaries. And, not surprisingly, increased popularity to the point where a majority of beneficiaries right now are in Medicare Advantage plans rather than traditional Medicare. On the other hand, these plans, which were originally supposed to cut overall Medicare costs, are instead proving more expensive than traditional Medicare. And Democrats would like to claw some of those profits back. But that looks about as likely as Republicans sunsetting Medicare, right? There’s just too many people who are too happy with their extra benefits.

Roubein: I guess we’ve seen two proposals from the administration this year which would change Medicare benefits. Then Republicans are trying to paint this as a cut but are saying it wouldn’t change benefits. But to change Medicare Advantage, one way …

Rovner: To change payments for Medicare Advantage.

Roubein: Yes, exactly. One which essentially would increase the government’s ability to audit plans and recover past overpayments and one which is the annual rate proposal. And there’s some aspects in there that Medicare Advantage plans are on a full-court lobbying press to say these are cuts which the administration is pushing back on really, really hard. So this is another microcosm of this Medicare scare tactics.

Rovner: And they’re all over TV already, commercials that probably don’t mean much to anybody if you’re not completely up on this fight of, like, “Congress is thinking about cutting Medicare Advantage.” No, really? I do laugh every time I see that ad.

Kenen: But, you know, Julie, you’re right that this began as a Republican cause, I mean, they had a similar program in the late ’90s that flopped and they revived it as Medicare Advantage. But it didn’t stay a Republican pet project for long. I mean, Democrats, starting with those in states with a lot of retirees — I’m thinking in Florida, who had Democratic senators at the time. I mean, they jumped on board, too, because people like … there are people who want to stay in traditional Medicare and there are people who jumped on to Medicare Advantage, which has certain advantages. It is less partisan than it began. It has always been more expensive than it was touted to be. And it’s now, we’re heading into 20 years since the legislation was passed, and nothing has really been done to change that trajectory, nothing significant. And I don’t think you’re going to see a major overhaul of it. There may be things that you can do [on] a bipartisan basis that nip. But if you’re nipping at that many billions of dollars, a nip as can be a lot of money.

Rovner: Yeah, that’s the thing about Medicare. Although I would point out also that the reason it flopped in the late 1990s is because Congress whacked the payments for it as part of the Balanced Budget Act. And as they gave the money back, it got more popular again because, lo and behold, extra money means extra benefits and people liked it. So its popularity has been definitely tied to how much the payments are that Congress has been willing to provide for it.

Kenen: And how they market and who they market to.

Rovner: Absolutely, which is a whole ’nother issue. But I want to do a covid check-in this week because it’s been a while. First, we have a study from Duke University published in this week’s Journal of the American Medical Association showing that using the deworming drug ivermectin, even at a higher dose and for a longer time, still doesn’t work against covid. This was a decent-sized, double-blind, randomized, controlled trial over nine months. Why is this such a persistent desire of so many people and even doctors to use this drug that clearly doesn’t work?

Karlin-Smith: You know, there’s been a lot of misinformation out there, particularly spread by the right and people that have not just, in general, trusted the government during covid and felt like this drug worked. And for whatever reason, they were being convinced that there was a government effort to kind of repress that. What’s interesting to point out, you know, you mentioned the trial being run at Duke. This was actually a part of a big NIH [National Institutes of Health] study to study various drugs for covid. So even NIH has been willing to actually do the research and to prove whether the drug does or doesn’t work. One of the issues this raises is this was one of many studies at this point that has shown the drug doesn’t work. In this one they even were willing to test, OK, a lower dose didn’t work. Let’s test a higher dose. Again, it fails. And the question becomes is, is there any amount of data or trials that can convince people who have, again, gone through this process where they’ve been convinced by this misinformation to believe it works and that the government is lying to them? Is there any way to convince them, with this type of evidence, it doesn’t work? And then what are the ethics of doing this research on people? Because you’re wasting government resources. You’re wasting resources in general. You’re wasting time, money. You’re giving people a drug in the trial when they could be getting another drug and that might actually work. So it’s really complicated because, again, I’m not sure you can convince the true ivermectin fans. I’m not sure there’s any amount of this type of scientific evidence that’s going to convince them that it doesn’t work for covid.

Rovner: But while we are talking about scientific studies about covid, a controversial meta-analysis from the esteemed Cochrane Review found basically no evidence that masks have done anything to prevent the spread of covid. But this is another study that seems to have been wildly misinterpreted. It didn’t find … what it looked like was not necessarily what we think. A lot of it turned out to be studies that were seeing whether flu, whether masks prevented against flu, rather than against covid. I mean, have we ended the whole idea of mask wearing and maybe not correctly?

Kenen: This was a meta-analysis for Cochrane, which is really basically … I mean, I think Sarah probably knows more about Cochrane than the rest of us, but their reviews are meaningful and taken seriously and they’re usually well done. The studies that they use in this meta-analysis didn’t ask the question that the headlines said it asked. And also, I mean, I don’t totally understand why they did it, because a) as Julie just pointed out, there was something like 78 studies, 76 of which were done before covid. So, you know, a) that’s a problem. And b), it didn’t actually measure who was wearing a mask. It was like, OK, you’re told to wear a mask or maybe you’re required to wear a mask if you’re working in a hospital while you’re in the hospital. But then you go out to a bar that night and you’re not wearing … I mean, it didn’t really look at the totality of whether people were actually wearing masks properly, consistently. And therefore, why use this flu data to answer questions about masking? And secondly, I also think it always is worth reminding people that, you know, no one ever said masks were the be-all and end-all. It was a component — you know, masking, handwashing, vaccination, distancing, testing, all the things that we didn’t do right. Ventilation … I mean, all that. There’s a long list of things we didn’t do right; masking was one of many. This is not going to help if we ever need masks for any disease again in the future. It did not advance this public health strategy — they call it, like, they like to talk about Swiss cheese, that any one step has holes in it. So you use a whole lot of steps and you don’t have any more holes in your Swiss cheese. It’s going to make it harder if we ever need them.

Rovner: Yeah. Well, notwithstanding scientific evidence now, we have two Republican state lawmakers in Idaho who have introduced a bill that would make any mRNA vaccines illegal to administer in the state, not just to people, but to, quote, “any mammal” with violators subject to jail time. And if I may read the subhead of the story about this … at the science website Ars Technica, quote, “It’s not clear if the two lawmakers know what messenger RNA is exactly.” In a normal world, I would say this is just silly and it couldn’t pass. But we’re not in a normal world anymore, right? I mean, we could actually see Idaho ban mRNA technology, which is used, going to be used for a lot more than covid.

Karlin-Smith: So I think the thing that really interests me about reading about this, and I’d be interested to hear what legal scholars think about this, but I was wondering if there’s a parallel here between this and what’s going on with the abortion pill in Republican states and what the courts may do with that, because it seems to me like there’s probably should be some kind of federal preemption that would kick in here, which is that vaccines are regulated, approved by this technology, by the federal government. Yes, there’s some practice of medicine where states have control from the federal government. But this seems like a case where, and in the past, when states have tried to get into banning FDA-approved products in this way, courts … have pushed back and said, you can’t do this. And I would say, I don’t think this Idaho law would hold up if it gets passed. But now we have this issue going on with the abortion pill, and it seems like there could be this major challenge by the courts to FDA’s authority. So you do sort of wonder, is this another example of what could happen if this authority gets challenged by the states? And, like you said, we are in this different world where maybe three years ago I would say, well, you know, even if Idaho can pass this, of course, this isn’t going to come to practice. But I do wonder, as we’re watching some of these other legal challenges to FDA-approved technologies, what it could mean down the line.

Kenen: I mean, remember, it also … with ivermectin, there are state legislatures that have actually protected patients’ rights to get ivermectin.

Rovner: And doctors’ rights to provide it.

Kenen: Right. And I know more than half the states had legislation. I don’t know how many actually passed it. I don’t remember. But I mean, it was a significant number of states. So these are … all these things that we’re talking about are related — you know, who gets to decide based on what evidence or lack thereof.

Rovner: So if there’s a reason that I brought these three things up, because after all this, a federal judge in California has temporarily blocked enforcement of a new state law that would allow the state medical board to sanction doctors who spread false or misleading information about covid vaccines and treatments. One of the plaintiffs told The New York Times that the law is too vague, quote “Today’s quote-unquote, ‘misinformation’ is tomorrow’s standard of care, he said.” Which is absolutely true. So how should we go about combating medical misinformation? I mean, you know, sometimes people who sound wacky end up having the answer. You know, you don’t want to stop them, but you also don’t want people peddling stuff that clearly doesn’t work.

Kenen: In addition to state boards, there are large medical societies that are — I don’t know how far they’ve gone, but they have said that they will take action. I’m sure that any action they take either will or has already ended up in court. So there are multiple ways of getting at misinformation. But, you know, like Sarah said it really well, there are people who’ve made up their mind and nothing you do is going to stop them from believing that. And some of them have died because they believe the wrong people. So I don’t think we’re going to solve the misinformation problem on this podcast. Or even off — I don’t think the four of us …

Rovner: If only we could.

Kenen: Even if we were off the podcast! But it’s very complicated. I — a lot of my work right now is centered on that. The idea that courts and states are coming down on the wrong side, in terms of where the science stands right now, understanding that science can change and does change. I mean, whether another version of that law could get through the California courts, I mean, there are apparently some broad drafting problems with that law.

Rovner: It hasn’t been struck down yet. It’s just been temporarily blocked while the court process continues. We’ll see. All right. Well, let’s move on to abortion since we’ve been kind of nibbling around the edges. Rachel, you wrote about a group of abortion rights-supporting Democratic governors organizing to coordinate state responses to anti-abortion efforts. What could that do?

Roubein: Yeah, so it’s news this week. It’s called the Reproductive Freedom Alliance. And essentially the idea is so governors can have a forum to more rapidly collaborate, compare notes on things like executive orders that are aimed at expanding and protecting abortion bills, moving through the legislature, budgetary techniques. And as we’re talking about lawsuits, I mean, talk to some governors and you know that the Texas lawsuit from conservative groups seeking to revoke the FDA’s approval of a key abortion pill is top of mind in this new alliance. Kind of the idea is to be able to rapidly come together and have some sort of response if the outcome of that case doesn’t go their way or other major looming decisions. I think it’s interesting. They are billing themselves as nonpartisan. But, you know, only Democratic governors have signed up here.

Rovner: Well, we could have had Larry Hogan and the few moderate Republicans that are left.

Roubein: Yes, Charlie Baker.

Rovner: If they were still … Charlie Baker.

Roubein: Sununu.

Rovner: If they were still there, which they’re not.

Roubein: I mean, I think the other interesting thing about this is if … you looked at 2024, and if a Republican’s in the White House in 2025, they might try and roll back actions Biden has done. So I could foresee a Democratic governors alliance trying to attempt to counteract that in a way that states can.

Rovner: Well, also, on the abortion rights front, supporters in Ohio are trying to get a measure on the ballot that would write abortion rights into the state constitution. This has worked in other red and purple states like Kansas and Michigan. But Ohio? A state that’s been trending redder and redder. It was the home of the first introduced six-week abortion ban five or six years ago. How big a message would that send if Ohio actually voted to protect abortion rights in its constitution? And does anybody think there’s any chance that they would?

Roubein: I think it’s interesting when you look at Kentucky and Kansas, which their ballot measures were different. It was for the state constitution to say that there was no right to an abortion, but abortion rights …

Rovner: There was a negative they defeated saying there was no right.

Roubein: Yeah. I mean, abortion groups really think the public is on their side here. And anti-abortion leaders do think that ballot measures aren’t … like, fighting ballot measures isn’t their best position either. So I think it’ll be interesting to see. Something that caught my eye with this is that the groups are trying to get it on the 2023 general election ballot. And right now what some Republican lawmakers are trying to do to counteract not just abortion ballot measures, but more progressive ballot measures, which is to try and increase the threshold of passage for a ballot measure. And there’s a bill in the Ohio legislature that would increase passage for enshrining anything into the state constitution to 60% support. But that would have to go to the people, too. So essentially, the timing here could counteract to that. So.

Rovner: Yeah, and as we saw in Kansas, if you have this question at a normally … off time for a big turnout, you can turn out your own people. So I assume they’re doing that very much on purpose. They don’t want it to be on the 2024 ballot with the president and Senate race in Ohio and everything else. All right. Well, one more on the abortion issue. Moving to the other side. A Florida lawyer is petitioning to have a pregnant woman who’s been accused, although not convicted, of second-degree murder released from jail because her fetus is being held illegally. Now, it’s not entirely clear if the lawyer is actually in favor of so-called personhood or it’s just trying to get his client, the pregnant woman, out of jail. But these kinds of cases can eventually have pretty significant ramifications, right? If a judge were to say, I’m going to release this woman because the fetus hasn’t done anything wrong.

Kenen: Well, there’s going to be an amendment to the personhood amendment saying, except when we don’t like the mother, right? I mean, she’s already almost at her due date. So it probably is going to be moot. There’s an underlying question in this case about whether she’s been getting good prenatal care, and that’s a separate issue than personhood. I mean, if the allegations are correct and she has not gotten the necessary prenatal care, then she certainly should be getting the necessary prenatal care. I don’t think this is going to be ruled on in time — I think she’s already in her final month of pregnancy. So I don’t think we’re going to see a ruling that’s going to create personhood for fetal inmates.

Rovner: She’ll have the baby before she gets let out of jail.

Kenen: I think other lawyers might try this. I mean, I think it’s legal chutzpah, I guess. If one lawyer came up with it, I don’t see why other lawyers won’t try it for other incarcerated pregnant women.

Rovner: Yeah. And you could see it feeding into the whole personhood issue of, you know, [does] the fetus have its own set of individual rights, you know, apart from the pregnant woman who’s carrying it? And it’s obviously something that’s that we’re going to continue to grapple with, I think, as this debate continues. All right. That is the news for this week. Now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week 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 khn.org and in our show notes on your phone or other mobile device. Sarah, why don’t you go first this week?

Karlin-Smith: I took a look at a story in the DCist. It’s called “Locals Who Don’t Speak English Need Medical Translators, but Some Say They Don’t Always Get the Service.” It was by Amanda Michelle Gomez and Hector Alejandro Arzate, and it basically takes a look at a lack of medical translators who can help patients who don’t speak English in the D.C. area and the harm that can be caused when patients don’t have that support, whether they’re in the hospital or at medical appointment, focusing on a woman who basically said she wasn’t getting food for three days and actually left the hospital to provide her food and she was undergoing … cancer treatment and in there for an emergency situation. It also highlights a federally funded facility in D.C. that is trying to support patients in the area with translators, but some of the health policy challenges they face, such as, you know, there’s reimbursement for basically accompanying a patient to an appointment, but there’s out-of-appointment care that patients need. Like if you’re sent home with instructions in English and there’s difficulty funding that care. And I mean, I just think the issue is important and fascinating because people who cover health policy, I think, tend to realize sometimes, even if you have an M.D. and a Ph.D. in various aspects of this system, it can be very hard to navigate your care in the U.S., even if you are best positioned. So to add in not speaking a language and, in this case, having had experience trying to help somebody who spoke a language much less more commonly spoken in the U.S. You know, I was thinking, well, she spoke Spanish, you know, how bad could it be? A lot of people in the U.S. often are bilingual and Spanish is a common language that you might expect lots of people in a medical facility to know. So I think, you know, again, it just shows the complexities here of even when you’re best positioned to succeed, you often have trouble succeeding as a patient. And when you add in other factors, we really set people up for pretty difficult situations.

Rovner: Yeah, it was kind of eye-opening. Rachel.

Roubein: My extra credit is titled “Her Baby Has a Deadly Diagnosis. Her Florida Doctors Refused an Abortion,” and it’s by Frances Stead Sellers from The Washington Post. I chose the story because it gives this rare window into how an abortion ban can play on the ground when a fetus is diagnosed with a fatal abnormality. So Frances basically chronicles how one woman in Florida, Deborah Dorbert, and her husband, Lee, were told by a specialist when she was roughly 24 weeks pregnant that the fetus had a condition incompatible with life, and the couple decided to terminate the pregnancy. But they say they were ultimately told by doctors that they couldn’t due to a law passed last year in Florida that banned most abortions after 15 weeks. And so that new law does have exceptions, including allowing later termination if two physicians certify in writing that the fetus has a fatal fetal abnormality. So it’s not clear exactly how or why the Dorberts’ doctors said that they couldn’t or how they applied the law in this situation.

Rovner: Yeah, I feel like this is maybe the 10th one of these that I’ve read of women who have wanted pregnancies and wanted babies and something goes wrong with the pregnancy, and an abortion ban has prevented them from actually getting the care that they need. And I just wonder if the anti-abortion forces have really thought this through, because if they want to encourage women to get pregnant, I know a lot of women who want babies, who want to get pregnant, want to have a baby, but they’re worried that if something goes wrong, that they won’t be able to get care. You know, this question of how close to death does the pregnant woman have to be for the abortion to, quote-unquote, “save her life”? We keep seeing it now in different states and in different iterations. Sorry, it’s my little two cents. Joanne.

Kenen: My extra credit is from The Atlantic’s Katherine J. Wu. And the headline is “Eagles Are Falling, Bears Are Going Blind.” It’s about bird flu or avian flu. It does not say it couldn’t jump to humans. It does say it’s not likely to jump to humans, but that we have to be better prepared, and we have to watch it. But it really made the interesting point that it is much more pervasive among not just birds, but other animals than prior, what we and laypeople call “bird flu.” And it’s going to have — 60, something like 60 million U.S. birds have died. It is affecting Peruvian sea lions, grizzly bears, bald eagles, all sorts of other species, mostly birds, but some mammals. And it’s going to have a huge impact on wildlife for many years to come. And, you know, the ecological environment, our wildlife enviornments. And it’s a really interesting piece. I hadn’t seen that aspect of it described. And if you think — and eggs are going to stay expensive.

Karlin-Smith: I was going to say this morning, I actually saw that in Cambodia reported one of the first deaths in this recent wave, of a person with this bird flu. So the question, I guess, is in the past, it hasn’t easily spread from person to person. And so that would be like the big concern where you’d worry about really large outbreaks.

Rovner: Yeah, because we don’t have enough to worry about right now.

Kenen: We should be watching this one. I mean, this is a different manifestation of it. But we do know there have been isolated cases like the one Sarah just described where, you know, people have gotten it and a few people have died, but it has not easily adapted. And of course, if it does adapt, that’s a different story. And then … in what form does it adapt? Is it more like the flu we know, or, I mean, there are all sorts of unanswered questions. Yes, we need to watch it. But this story was actually just so interesting because it was about what it’s doing to animals.

Rovner: Yeah, it is. The ecosystem is more than just us. Well, my story is from Stat News by Calli McMurray, and it’s highly relevant for our podcast. It’s called “Current Treatments for Cramps Aren’t Cutting It. Why Aren’t There Better Options?” And yes, it’s about menstrual cramps, which affect as many as 91% of all women of reproductive age. Nearly a third of them severely. Yet there’s very little research on the actual cause of cramps and current treatments, mostly nonsteroidal anti-inflammatory drugs or birth control pills, don’t work for a lot of people. As someone who spent at least a day a month of her 20s and 30s in bed with a heating pad, I can’t tell you how angry it makes me that this is still a thing with all the other things that we have managed to cure in medicine.

OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Joanne?

Kenen: @JoanneKenen

Rovner: Rachel.

Roubein: @rachel_roubein

Rovner: Sarah.

Karlin-Smith: @SarahKarlin

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

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Julie Rovner is chief Washington correspondent and host of KHN’s 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.

Health care was a recurring theme throughout President Joe Biden’s 2023 State of the Union address on Capitol Hill this week. He took a victory lap on recent accomplishments like capping prescription drug costs for seniors on Medicare. He urged Congress to do more, including making permanent the boosted insurance premium subsidies added to the Affordable Care Act during the pandemic. And he sparred with Republicans in the audience — who jeered and called him a liar — over GOP proposals that would cut Medicare and Social Security.

Meanwhile, abortion rights advocates and opponents are anxiously awaiting a federal court decision out of Texas that could result in a nationwide ban on mifepristone, one of two drugs used in medication abortion.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sarah Karlin-Smith of the Pink Sheet.

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Alice Miranda Ollstein
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Among the takeaways from this week’s episode:

• President Joe Biden’s State of the Union address emphasized recent victories against high health care costs, like Medicare coverage caps on insulin and out-of-pocket caps on prescription drug spending. Biden’s lively, informal exchange with lawmakers over potential cuts to Medicare and Social Security seemed to steal the show, though the political fight over cutting costs in those entitlement programs is rooted in a key question: What constitutes a “cut”?
• Biden’s calls for bipartisanship to extend health programs like pandemic-era subsidies for Affordable Care Act health plans are expected to clash with conservative demands to slash federal government spending. And last year’s Senate fights demonstrate that sometimes the opposition comes from within the Democratic Party.
• While some abortion advocates praised Biden for vowing to veto a federal abortion ban, others felt he did not talk enough about the looming challenges to abortion access in the courts. A decision is expected soon in a Texas court case challenging the future use of mifepristone. The Trump-appointed judge’s decision could ban the drug nationwide, meaning it would be barred even in states where abortion continues to be legal.
• The FDA is at the center of the abortion pill case, which challenges its approval of the drug decades ago and could set a precedent for legal challenges to the approval of other drugs. In other FDA news, the agency recently changed policy to allow gay men to donate blood; announced new food safety leadership in response to the baby formula crisis; and kicked back to Congress a question of how to regulate CBD, or cannabidiol, products.
• In drug pricing, the top-selling pharmaceutical, Humira, will soon reach the end of its patent, which will offer a telling look at how competition influences the price of biosimilars — and the problems that remain for lawmakers to resolve.

Also this week, Rovner interviews Kate Baicker of the University of Chicago about a new paper providing a possible middle ground in the effort to establish universal health insurance coverage in the U.S.

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

Julie Rovner: The New York Times’ “Don’t Let Republican ‘Judge Shoppers’ Thwart the Will of Voters,” by Stephen I. Vladeck

Alice Miranda Ollstein: Politico’s “Mpox Is Simmering South of the Border, Threatening a Resurgence,” by Carmen Paun

Sarah Karlin-Smith: KHN’s “Decisions by CVS and Optum Panicked Thousands of Their Sickest Patients,” by Arthur Allen

Rachel Cohrs: ProPublica’s “UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings,” by David Armstrong, Patrick Rucker, and Maya Miller

Also mentioned in this week’s podcast:

• The Associated Press’ “20 Attorneys General Warn Walgreens, CVS Over Abortion Pills,” by Jim Salter
• NPR’s “A Trump-Appointed Texas Judge Could Force a Major Abortion Pill off the Market,” by Sarah McCammon
• Politico’s “Federal Judge Says Constitutional Right to Abortion May Still Exist, Despite Dobbs,” by Kyle Cheney and Josh Gerstein
• The Becker Friedman Institute’s “Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Floor?” by Katherine Baicker, Amitabh Chandra, and Mark Shepard

click to open the transcript

Transcript: A Health-Heavy State of the Union

KHN’s ‘What the Health?’Episode Title: A Health-Heavy State of the UnionEpisode Number: 284Published: Feb. 9, 2023

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 9, 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: Good morning.

Rovner: Rachel Cohrs of Stat News.

Rachel Cohrs: Hi, everybody.

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

Sarah Karlin-Smith: Hi, Julie.

Rovner: Later in this episode, we’ll play my interview with Kate Baicker of the University of Chicago. She’s one of the authors of a new paper outlining a new proposal for the U.S. to achieve universal health insurance coverage, something every other developing nation already has, but we have not yet been able to achieve. But first, this week’s health news. We’re going to start, of course, with the State of the Union, which was livelier than usual, with way more back and forth than I’ve ever seen at one of these, and also more health-heavy than usual. I’m going to start with entitlements, notably the president threatening Republican proposals to hold the debt ceiling hostage for cuts in Social Security and Medicare. I’m still trying to decide whether this was intended or not, but Biden nevertheless ended up getting Republicans to vow not to demand cuts in Social Security and Medicare in exchange for raising the debt ceiling later this year. Here is the tape.

President Joe Biden: So, folks, as we all apparently agree, Social Security and Medicare is off the books now, right? And they’re not going to strike … [prolonged applause] All right. We got unanimity!

Rovner: So was this very clever or very lucky or both?

Ollstein: Well, it’s a little not quite what it seems. Republicans have been swearing up and down more recently that they never intended to cut Medicare and Social Security. But when they say “We want to reform it, we want to shore it up,” they’re talking about things that could limit benefits for beneficiaries. So it’s a semantics game, in part. I also want to point out that neither Republicans nor Biden have yet said that they consider Medicaid in that same untouchable category. So that really jumped out at me in the speech as well.

Rovner: Yeah, I mean, if you don’t touch Social Security or Medicare — and the Republicans are trying to say that because this has been used as a weapon for so many years — then basically that leaves Medicaid. And as we discovered in 2017, when they were trying to repeal the Affordable Care Act, Medicaid is actually pretty popular, too, because it takes care of a lot of people’s grandparents in nursing homes. I’m wondering when somebody is going to bring that up. Obviously, over the years, many, quote-unquote, “cuts” have been made to both Social Security and Medicare, mainly to slow the growth of the programs so that we can continue to afford them. Many more, quote-unquote, “cuts” will have to be made going forward. Every time you reduce payment to a drugmaker or a hospital or any other health care provider, that’s a cut, but it helps beneficiaries. So, you know, you say “cuts,” [and] beneficiaries say “they’re going to cut our benefits.” Not necessarily. They may just be making the program more affordable, including for the beneficiaries. I mean, this is just the continuous back and forth of each side, weaponizing Medicare in particular, right?

Ollstein: Well, and until we see actual proposals on paper, like you’re indicating, it is a semantics game — what some people consider a cut might not be what other people consider a cut. And there’s going to be all sorts of rhetorical games over the next several months along these lines. So, I’m waiting till we see an actual black-and-white proposal that we can all pick at and analyze together.

Rovner: Well, as we have seen, there’s danger in putting things on paper, as Rick Scott discovered this week. For those who don’t remember, it was his rather infamous proposal — was it last summer, I think? It was before the election — suggesting that all federal programs be sunsetted every five years and then have to be reauthorized, which would include Social Security and Medicare and Medicaid. And that’s not playing well at this point, as I think was predicted at the time, including by us. So moving on, I was also impressed at how the speechwriters managed to combine the, quote, “victory lap” stuff, record Affordable Care [Act] enrollment, Medicare drug price changes, limits on insulin, and surprise bills with the agenda ahead: expanding insulin price caps to the non-Medicare population, Medicaid expansion in the states that haven’t done it, making the Affordable Care Act subsidies expansions permanent. But none of these things — popular, though they may be — are likely to happen in this Congress, are they? … These are the things that fell out of the bill that passed last year.

Cohrs: Right. A lot of those cost money, which is going to cause even more problems this Congress than it did in the last one. And I thought it was pretty informative that the chair of the Energy and Commerce Committee in the House threw cold water on the insulin price-cap idea because it did gain some Republican support in the Senate when it came up for a vote. That was complicated. We won’t go into it. But yeah, it wasn’t a straight up-and-down vote on that policy, really. So I think there was some hope that maybe Republicans could get on board with it. But I think, because it applies to private market insurers, [it was called] a socialist policy, like, they just don’t want government in private plans, even though it’s a wildly popular policy. So, yeah, I think that doesn’t seem like a good signal for that policy in particular and for Medicaid expansion and a lot of these things. Democrats couldn’t even do it when they all agreed or had power in both the House and the Senate. So it’s definitely not a good indication for a lot of these things.

Ollstein: Let’s not forget that [Sen. Joe] Manchin [D-W.Va.] was the one who put the kibosh on the federal Medicaid expansion. He thought it wasn’t fair to states like his that expanded a long time ago and have been paying in a little bit. He thought it wasn’t right that states that were holdouts get a free ride. And the other Democrats argued back that it’s not fair for the residents in those states to be left out in the cold uninsured either. So this will continue. But like Rachel said, not going anywhere soon.

Rovner: So the things that in theory could happen, and these didn’t mostly come up in the speech or didn’t come up very much. But earlier in the day, Biden officials were floating a quote-unquote, “unity agenda” that included a long list of potentially bipartisan health issues, starting with the “cancer moonshot,” mental health and opioid treatment, strengthening the mental health parity rules. Some of these things actually could happen, right?

Cohrs: Yeah, I think especially on the mental health package, I think there was some unfinished business from last Congress, from the Senate Finance Committee. I think that all of these are issues that have been talked about this Congress already. And the leaders have signaled that they might be interested in. But I think there is some daylight here, and we’re still in very much the agenda-setting, throwing ideas out there that are a very vague part of this Congress. And I think actually getting things down on paper and going through hearings and that kind of thing will signal which areas there might actually be some agreement on. But again, spending is going to be a big challenge and there’s just not going to be time to get to everything.

Rovner: I think one of my frustrations is that normally the State of the Union comes right before the president’s budget comes out, usually within a week or two. And this year, the president’s budget isn’t coming out until March 9. So we have this, you know, talk about agenda-setting. We’re going to have a lot of time for people to just yap at each other without any specifics. But speaking of things that didn’t and aren’t likely to happen, the president didn’t talk very much about abortion. And what he did say — like threatening to veto any abortion ban Congress might pass, which won’t happen either with Democrats in charge of the Senate — that disappointed abortion rights supporters. They’re not happy, right, Alice?

Ollstein: Some were not. To be fair, some praised the speech, praised the president for saying the word “abortion.” This was a big thing over much of his career, including the beginning of his presidency. He would talk around it and not actually say the word “abortion,” which the groups felt contributed to stigma around it. And so the big mainstream groups, Planned Parenthood, NARAL, put out statements praising the speech, praising him for saying he would veto a ban, although, again, like you said, that’s a hypothetical. It’s not going to happen. But some other groups were critical that, one, he didn’t talk about some of the very looming direct threats to abortion access in the courts that we’re probably going to get to later.

Rovner: In a minute.

Ollstein: Just in a minute! But they were frustrated that he didn’t lay out more specifics that his administration will actually do to respond to the current loss of access in a lot of the country. They felt that we’re in a crisis moment and he spent less of the speech on abortion than he did on resort fees. That was a sore point for some advocates who I talked to.

Rovner: There was a lot of emphasis on junk fees. And I get why: These are the things that drive people crazy, and, particularly, in times of high inflation. But yes, abortion came very late in the speech — almost after a lot of people had tuned out and stopped paying attention, which I think also made some people unhappy. Well, speaking of abortion, here we are waiting for another make-or-break court decision out of Texas. Alice, this time it’s the future of the “abortion pill,” not just in Texas, but around the nation that’s at stake. How did we get here? And could we really see the abortion pill banned nationwide?

Ollstein: We really could. People have really been sleeping on this case, including some elected officials who were slow to realize the impact it could have. And mainly what people don’t understand is a bunch of states already ban all methods of abortion, including the pill, and then some additional states besides that have restrictions just on the pill. So this will mainly hit blue states and states where abortion access still exists. And so it could really have a huge impact because those states are now serving more than just their own populations. And in a lot of places, losing access to medication abortion means losing access to all abortion because there aren’t clinical services available. And so my colleague and I did some reporting on how the Biden administration is preparing or not for this ruling. They rebuffed calls from activists to declare a public health emergency for abortion. They said they don’t think that would help. While they do plan to appeal the ruling should the FDA lose, the upheaval that could happen in the meantime can’t really be overstated. And not to mention that an appeal would go to the 5th Circuit, which is very conservative, and then to the Supreme Court, which just overturned Roe v. Wade. And so while most experts we’ve talked to don’t think the legal arguments are that sound, you just can’t really …

Rovner: And remind us, this is the lawsuit that’s challenging the 22-year-old approval of the drug in the first place.

Ollstein: Exactly. And so health care legal experts also say that besides the absolute upheaval in the abortion space that this could cause, this would just completely destroy any certainty around drug approvals for the FDA. If anybody could come back decades later and challenge the approval of a drug, how can drugmakers feel comfortable developing and submitting things for approval and making their plans around that? It’s very chaotic.

Rovner: Sarah, is the FDA worried about this case? Has it not been on their radar either?

Karlin-Smith: I mean, they’re involved in the defense.

Rovner: They’re being sued.

Karlin-Smith: Right. I think it is a concern if this is used, right? If the folks who want this drug pulled would win, does it become precedent-setting in a way that you can get other products pulled? Perhaps. Again, the sentiments would not be there for a lot of other products in the way to use it. But it is a bit concerning when you think about judges having this power to overrule the scientific decisions we’ve left to civil servants, not politicians or judges, because they have expertise in science and medicine and clinical trial design and all these things we just would not expect judges to be able to rule on.

Rovner: Well, speaking of more politics, this week — actually, last week — a group of 20 state attorneys general from states with abortion restrictions wrote to CVS and Walgreens, which had already announced that they would apply to become providers of the abortion pill, warning them not to rely on the Justice Department’s interpretation of a 19th-century law that banned the use of the U.S. mail to send abortifacients. The letter doesn’t outright threaten the companies. It merely says that, quote, “We offer you these thoughts on the current legal landscape.” Has anybody sued over this yet? And what do we expect to happen here? I mean, are CVS and Walgreens going to back off their plans to become providers?

Ollstein: Well, the anti-abortion elected officials and advocacy groups are hoping that’s the case. But I think this could play out in so many ways. I mean, one, we have this national ruling that could come down, but we also have a few state rulings that could flip things the other way and force states that have put restrictions on the abortion pill to lift those restrictions and allow it. So now we have cases pending in North Carolina and West Virginia. One of them is by the manufacturer of the abortion pill, saying that states don’t have the right to put the FDA’s hat on their own heads and make those decisions. And the other is by an abortion provider, a doctor who says that these state restrictions hurt her ability to practice and hurt her patients. And so it’s just wild that we can swing anywhere from a national ban to forcing states with bans to lift those bans. I mean, it’s just all up in the air right now. I wanted to quickly point out two other things. A lot of activist groups say they are not counting on the Biden administration to adequately respond to this crisis. And so they’re doing a couple things. One, they’re encouraging people to do something known as “advance provision,” which is order abortion pills before they’re pregnant, before you need them, and just have them on hand just in case. And so they’re advising people do that in advance of the ruling. Interestingly, the FDA does not support that practice, but activist groups are encouraging it anyways. And then the other thing is the abortion pill regimen is actually two pills. And the big FDA lawsuit only goes after the first one. And so people are saying, you know, you can terminate a pregnancy just by taking a few of the second pill, even though that has a higher rate of not working and needing a follow-up procedure. And so …

Rovner: Although it’s still like, 95%, right?

Ollstein: It’s still very effective, but not quite as effective as using the two pills together.

Rovner: And I think it used to be when people would go to Mexico, that’s what they would get. They would get misoprostol, not mifepristone, which is what we think of as “the abortion pill” — and also methotrexate, which we talked about in the context of people with diseases for which methotrexate is indicated not being able to get it because it can cause abortions. But that’s another option there, right? And … it would be hard for FDA to pull those drugs because those drugs do have a lot of uses for other diseases.

Karlin-Smith: Or FDA could, I guess, be forced to take off the formal indication for use for abortion, but the drug would be out there and then could be subject to off-label prescribing, which then could potentially, I guess, impact insurance coverage if you’re using it for abortion. Pivot to if you had to go back to this one-drug regimen while, yes, it would still exist and be possible, I think a lot of providers are worried about the added burden that would create on folks that help people obtain abortion. And this system is just not set up to have enough workers to deal with that more complicated regimen. And it seems like it could end up leading to more need for surgical abortions, depending on how well it works and so forth. So I think logistically it creates a lot more challenges.

Rovner: Yeah, it’s a mess. Well, meanwhile, last issue here, we have a curious story out of a lawsuit in federal district court here in Washington, D.C., in which a judge proffered the notion that while the Supreme Court may have found no right to abortion in the 14th Amendment, that doesn’t mean there isn’t a federal right under the 13th Amendment. That’s the one barring slavery, specifically the restriction on the pregnant person’s personal liberty. As the judge correctly pointed out, the majority in last year’s Dobbs [v. Jackson Women’s Health Organization] ruling may well believe there’s no right to abortion anywhere in the Constitution. But that’s not the question that they litigated. Is this potentially an avenue that abortion rights advocates are going to explore?

Ollstein: I am not hearing a lot of hope being placed on this. If it goes anywhere, it would go back to the same Supreme Court that just ruled last year. And so abortion rights advocates are not optimistic about this strategy, but I think it’s a good indication of really both sides right now just trying to get as creative as possible and explore every legal avenue in the U.S. Constitution, in state constitutions, things where it never says the word abortion, but you could interpret it a certain way. I think that’s what we’re seeing right now. And so it’s really interesting to see where it goes.

Rovner: We are literally at the point where everybody is throwing whatever they can against the wall and seeing what sticks. All right. Well, let us turn to the federal research establishment. Late last month, a panel of advisers recommended a set of policies to strengthen oversight of so-called gain-of-function research that could inadvertently cause new pandemics. This was also one of the subjects of the first House hearing that called leading federal public health officials up on the carpet. What do we learn from the hearing? And has the federal government actually been funding gain-of-function research, or do we even know for sure?

Cohrs: So there has been a moratorium on this sort of research. And the interim director of the NIH [National Institutes of Health] quibbled over the term “gain-of-function research.” And he said we’re talking about a very select part of all of the research that could technically fall under that umbrella term. But he did say that there is a moratorium on funding that right now; there’s not current funding because they are reviewing their practices. And an advisory board did pass proposals and he laid out the process forward for that. So once those are finalized, he’ll write a memo to [Department of Health and Human Services] HHS Secretary Xavier Becerra, then it will get to the White House. So there is this bureaucratic progression that these new guidelines are going to go under, and it’s been pretty transparent and public so far. But we’ll see how things ultimately turn out. But I think they are very sensitive to this politically and they are trying to create guidelines that offer some lessons learned from some of the criticism they’ve gotten recently.

Rovner: And I think, I mean, this has become one of the major lines of argument about Republicans trying to figure out where covid came from. Perhaps it came from U.S.-funded gain-of-function research in China, which we don’t know, I don’t think. But there’s been a lot of “Yes, you did”-“No, you didn’t” going on. I mean, Sarah, does this go back to the, you know, politicians playing scientists?

Karlin-Smith: A little bit. And I think at the hearing, a lot of the Republicans who are pressuring NIH in particular on this are not super interested in listening to the subtleties and nuance of the argument. They just really want to make the point and bring up in people’s minds the possibility of, you know, covid being a lab leak, which I think … which hasn’t 100% been ruled out, but it’s kind of on the 98%, probably 99% ruled out by a lot of scientists. And so it was very hard for NIH and those lawmakers to have a reasonable discussion about the nuances and where this research might possibly benefit us in future pandemic prep. What type of precautions do need to be put in place? And I think NIH was trying to strive to communicate that actually a lot of what was recommended in this oversight report is things they’ve been working on and have put in place. But the hearing was designed by Republicans more to land those political punches and sound bites and not really delve into “Are there policy improvements that could be made here?”

Rovner: Well, speaking of civil servants trying to do their science policy jobs, the FDA’s been busy the last couple of weeks, including lifting a ban on men who have sex with other men donating blood. That’s a ban that’s been in effect in one way or another since the 1980s, when AIDS was first discovered. And in the wake of baby formula shortages, there’s now going to be a new deputy commissioner for food. And finally, the agency is asking Congress for new authority to regulate CBD [cannabidiol] products, particularly as more states legalize marijuana in all forms for recreational use. Sarah, this is an awful lot of stuff at once. Big policy changes where they try to hide some of them, or did they just all show up at once because that’s when they got finished?

Karlin-Smith: The food changes were sort of driven by events not quite within their control, and the blood policy, the CBD stuff were things in the works for some number of years now. So FDA is busy, and these are different divisions operating under it. I think the CBD stuff is drawing a lot of frustration because FDA had been working on considering how to regulate this aspect of hemp for a while now. And instead of coming up with a policy and taking action, they’ve rewound the circle; we’re back to square one and putting it on Congress’ issues. So that’s like one area where there’s a lot of frustration versus, I think, people are generally happier that the blood donation process was finally gone through and changed.

Rovner: Yes, the wheels of the federal regulatory process move slowly, as we know. All right. Finally this week, drug prices. Humira — which is a biological that treats rheumatoid arthritis and many other serious ailments, and for which you have undoubtedly seen TV commercials if you have ever turned on your television, because it’s the top-selling pharmaceutical in the world — is reaching the end of its patent life. That will soon provide the first real test of where the Affordable Care Act’s pathway to allow biosimilar competitors — effectively biologics version of generic drugs — whether that will actually bring down prices. Because there’s a chance here that there’s going to be a bunch of competitors to Humira and the price isn’t going to come down, right?

Karlin-Smith: Yeah, I mean, that’s a major concern for a number of reasons that get us back to the broader U.S. drug pricing debate and — including the role of pharmacy benefit managers in figuring out how people get coverage of their drugs. So Humira is one of the first biologics to lose patent protection, where patients actually fill the prescriptions themselves and give themselves the medicine, which is a very different payment system than if you’re getting a biologic medicine at a doctor’s office or a hospital. And so the way that most of the insurers are covering the drug for this year, they’re actually going to charge patients the same out-of-pocket cost in most instances, as if you’ve got the brand drug or the biosimilar. And because, unlike traditional generic medicines, a lot of these, at least initially, they’re not what is called auto-substitutable. So if your doctor writes you Humira, the pharmacist doesn’t automatically give you that generic. So you’d actually have to request a new prescription from your doctor, and they’d have to write it. And if you’re not going to pay less, why are you motivated to do that?

Rovner: When you’re not even positive how much whether the drug works the same way, whether the biosimilar works the same way.

Karlin-Smith: Right. And they think people are a little bit more hesitant. They don’t understand how biosimilars work compared to generic drugs, where it took — again, when the generic drug industry first started, it took people a while to get comfortable. So there are those issues. So, basically, what has happened is AbbVie has given insurance plans and payers’ discounts on their brand drug to keep it in a good place on their formularies. So there will be savings to the broader health system, for sure. The problem is if that doesn’t get passed on to the patients, and AbbVie can continue their market monopoly, my worry is, down the line, what happens to this biosimilar industry overall? Humira is not the only top-selling, big-selling biologic medicine where we want to bring down the cost. So if these biosimilar competitors don’t eventually gain market share and make money off of doing this, why are they going to go back and develop a biosimilar and try and lower the cost of the next big drug? And that’s what people are watching. I think there’s cautious optimism that, as more biosimilars for Humira launch, there will be some pressure for insurance companies to cut deals and lower prices and not just rely on making money off high rebates. But we don’t really know how it’s going to play out. And AbbVie was pretty creative over the years. In some ways that helped patients and others questionable — how much of … like, you know, there’s high concentration of the drug, low concentration. There is citrate-free, non-citrate-free. And that means that not all the competitors are going to be exactly the same in a way that creates as much competition as it seems at first. So yeah, it’s going to be messy.

Rovner: This is the famous evergreening that we saw with drugs. I mean, where they would change something small and get a whole new patent life.

Karlin-Smith: Right. So usually with generic research, you need three direct competitors to help bring the price down a lot. But in the case of Humira, while there’s going to be, probably at least six competitors this summer, maybe more, they’re not all direct competitors for the same version of Humira. So it sort of bifurcates the space a bit more and makes it harder to, you know, figure out the economics of all of that.

Rovner: Well, if you thought that drug pricing was confusing, now we’re adding a whole new level to it. So, I’m sure we will be talking about this more as we go forward. OK. That’s the news for this week. Now, we will play my interview with Kate Baicker of the University of Chicago. Then we will come back and do our extra credits.

I am excited to welcome to the podcast Katherine Baicker, currently the dean of the University of Chicago Harris School of Public Policy and soon to be provost of the university. Congratulations.

Katherine Baicker: Thank you so much.

Rovner: So, Kate is a health economist who is well known to health policy students for a lot of things, but most notably as the co-lead author of the Oregon Medicaid health experiment, which was able to follow a randomized population of people who got Medicaid coverage and a population that didn’t to help determine the actual impact of having Medicaid health insurance. Today, she’s here as lead author of a paper with a new way to possibly provide health coverage to all Americans. Kate, thank you so much for joining us.

Baicker: It’s a pleasure.

Rovner: So your new paper is called “Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Safety Net.” And in that single sentence, you’ve pretty much summed up the entire health insurance debate for, like, the last half-century. For those who don’t know, why is it that the U.S. doesn’t have universal insurance when literally all of our economic competitors do?

Baicker: Well, like so many things about our health care system, it goes back to the history of how it evolved, as well as some things that are different about the U.S. from other countries. If you look at how big the U.S. is geographically, how diverse our country is, how heterogeneous the health needs are. A lot of the solutions you see in other countries might not work so well in the U.S.

Rovner: So … and we’ve basically just not ever gotten over the hump here.

Baicker: Well, I also think we haven’t been asking the right questions necessarily. There is a real debate about whether health care is a “right” or not. And, of course, your listeners can’t see my “air quotes,” but I put that in air quotes because I think that’s the wrong question. Health care is not just one thing. Health care is a continuum of things. And if we just boil it down to should people have access to care or not, that doesn’t let us engage with the hard question of how much care we want to provide to everyone and how we’re going to pay for it.

Rovner: So I know a lot of people assume that the Affordable Care Act would — I’ll use my air quotes — “fix” the U.S. health insurance problem. And it has gone a long way to cover a lot of previously uninsured people. But who are the rest of the uninsured and why don’t they have coverage? It’s not necessarily who you think, right?

Baicker: That’s right. And, you know, the ACA, or Obamacare, actually made a lot of headway in covering big swaths of the uninsured population. There was a lot of discussion about health insurance exchanges, but actually more people were covered by Medicaid expansions than by health insurance exchanges. But both of those, as well as letting young people up to age 26 get on their parents’ policies. All of this chipped away at the ranks of the uninsured, but it left, for example, undocumented immigrants uninsured and also the vast majority of the uninsured people in the U.S. are already eligible for either a public program or heavily subsidized private insurance. And we have a problem of takeup and availability, not just affordability.

Rovner: So let’s get to your proposal. It’s not really that different from things that either we’ve tried in some parts of our health insurance ecosystem or what other countries do. What would it actually look like if we were to do it?

Baicker: Well, if you go back to what I think is the right question of how much health care do we want to make sure that everyone has access to and how are we going to get them enrolled in those programs? I think one key feature is having that coverage be as low-hassle as possible, automatic if possible, because we know that nonfinancial barriers to insurance are responsible for a lot of the uninsured population we still see today.

Rovner: We’ve seen that with pension plans, right? That automatically enrolling people get more people to actually put money away?

Baicker: That’s right. That’s one of the takeaways from behavioral economics is that defaults matter. Meaning what the baseline is and letting you opt in and out makes a big difference because people tend to stick with where they are. There’s a lot of inertia in saving for retirement, in enrolling in health insurance, in lots of different things. And being sophisticated in how we design the mechanics of those programs is important, as well as making sure that they’re financially affordable to people. So one step is making sure that whatever is available to people is as easy as possible for them to take advantage of. But the other is having a much harder discussion about what we want that basic package to be. And when you say “I want everybody to have all of the care that might possibly be available, no matter what price and no matter how much it impacts their health,” that’s more than 100% of GDP. We just can’t do that and still have any money for anything like food and housing and education and roads and all of the things that we also care about. So if we had that tough discussion as a nation, as a body politic, to say, here is the care that we think is really high-value that we think is a right for everyone and that we want to make sure is available to everyone, then people could be automatically enrolled in that default package and have the option to get more care that is more expensive and maybe a little less effective, but still worth it to them that they purchase on their own. And that opens up a whole host of other questions and ethical dilemmas that I’m sure you’re going to want to ask about.

Rovner: But it also — as a lot of people are concerned, that something like “Medicare for All” would eliminate the incentive to innovate new kinds of care. I mean, obviously, there’s this race to figure out, you know, a drug to treat Alzheimer’s and that if the federal government were to basically set prices for everything, that there would be no more innovation incentive. You actually address that here, right?

Baicker: Yes. And I’m so glad you raised that concern, because there are many challenges to having a monolithic one-size-fits-all Medicare for All type plan. One of them is, you know, affordability for the system and accessibility. But another is the dulled incentive for innovation and the dulled drive towards having new medicines and new treatments available. Medicare is very slow to innovate. It took 40-plus years for Medicare to include prescription drugs at all. And that was because when Medicare was formed in the Sixties, prescription medicine wasn’t a very important part of health care. It wasn’t a very expensive part of health care, there just weren’t that many drugs to treat people. Well, now those medicines are crucial to health and well-being. And Medicare finally added a prescription drug benefit in 2005. But that was a long lag, and that’s just one example. So I think having some fundamental access to care that we know is of high value for everyone could be coupled with having the option to purchase more generous insurance that covers more things. And that private insurance layered on top would really provide the financial incentives for continued innovation. It acknowledges the reality that in a world of scarce resources, higher-income people are going to have more health care than lower-income people. And that is an ugly reality and one that we ought to grapple with ethically, and as a matter of public policy priorities. I would argue we’re already rationing care. It is not possible for public programs to pay for all care for all people, no matter what the price, no matter what the health benefit, and being intentional about defining what it is we’re going to cover with public dollars and then letting people buy more care with private dollars is a way perhaps to make a financially sustainable system that also promotes innovation.

Rovner: And this isn’t really new. I mean, lots of other countries do this. I was in Switzerland a decade ago, and I remember that they … their extra-benefit package includes things like single rooms in hospitals and homeopathic medicine and things that I’m not sure we would end up putting into our top-up plans, but it’s something that’s important to them.

Baicker: Yes. And when people point to our European counterparts and say, look, they all have single-payer. In fact, a lot of them have a hybrid system like the one that we’re describing. And it’s important to differentiate: We’re talking about a basic plan that’s available for everyone. That doesn’t mean that it only covers cheap things. It should only cover high-value things. But some cheap things are incredibly ineffective and low-value, and some expensive things are really important for health and very high-value. So it’s about the value of the dollar spent in terms of producing health, not whether it’s expensive or cheap. And so when you think about having a top-up plan, it shouldn’t be about billing cost sharing that, you know, lower-income people are exposed to in the basic plan. It should be about adding services that are of less health importance but still valuable to the people purchasing them.

Rovner: Obviously, the biggest issue here is going to be who’s going to make that determination? I’m old enough to remember fights over the ACA, death panels, and the independent Medicare advisory board that never happened. In fact, there were a lot of these, you know, we’re going to appoint experts. And it never happened because none of the experts ever wanted to be on these panels. How do you overcome that hurdle of actually grappling with the decision of what should be covered?

Baicker: Yes, the devil is always in the details for these things, and you put your finger on a really important one where we haven’t provided a robust answer, and our analysis is meant to highlight the importance of making these hard decisions and the value of this framework. But we don’t have a magic bullet for this. I would argue that having Congress make this decision every year is a recipe for lobbying and decision-making that doesn’t actually line up with value. There’s an opportunity perhaps to have a panel of experts who, as you note, is just a hop, skip and a jump from being called a “death panel.” But I think we can rely on some clinical guidelines as guardrails on this. And we do have some examples of experimentation in this direction in the U.S. In fact, more than experimentation — if you look at Medicare Advantage, this used to be a small part of the Medicare program. These are private plans for Medicare beneficiaries that are now, I think, pretty soon going to be the majority of plans that people have. And it’s a mechanism for people to choose among plans that have some things that have to be covered, but can then add additional benefits for enrollees, and it can be a little more tailored to what people value in their plans. So I don’t think that’s the answer either. But it’s a proof of concept that we can do something like this in the U.S.

Rovner: So in some ways this would bridge the gap between Republican marketplace ideas and Democratic Medicare for All ideas. But it feels like, since the fight over the Affordable Care Act, Republicans have moved more to the right on health care and Democrats have moved more to the left on health care. You are no stranger to partisan politics nor the ways of Washington, D.C. How could everybody be brought back to what I daresay looks like a political compromise?

Baicker: Well, I’m an economist, as you noted, and that’s notoriously bad at understanding actual human beings. I don’t have any idea for the path forward through the political thicket that we’re in. In some ways, it is a little disheartening to see how difficult it is to do some basic commonsense things. In any complicated system like the U.S. health care system, there are always small technical fixes that need to be made that are just commonsense, that ought not to be political. And it’s hard to do those.

Rovner: We’re lacking in common sense right now in Washington.

Baicker: Yeah. So I can’t say that I’m hugely optimistic about a big change happening right away. On the other hand, I think covid really highlighted to people across the political spectrum how important it is to have continuity of coverage, how disparate our current system is in terms of access to care, how problematic it is to have your main avenue of health insurance be through your employer when a pandemic is coupled with a recession. So I think the challenges and the vast inequities of our health care system were laid bare during covid. So it is perhaps salient enough that people might be willing to consider alternative structures. But I can’t say I’m holding my breath.

Rovner: Well, Kate Baicker, thank you very much for, if anything, a great thought experiment. It’s really wonderful to look your way through … it’s like, oh, we could get there, maybe in another half a century.

Baicker: I hope sooner than that.

Rovner: I do, too. Thank you so much.

Baicker: My pleasure.

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

Cohrs: My extra credit is headlined “UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings,” in ProPublica by David Armstrong, Patrick Rucker, and Maya Miller. And I thought this story was just such a good illustration of the jargon that we use in D.C., of, like, utilization management and prior authorization. And sometimes these terms just feel so impersonal. But I feel like this story did such a good job walking through one patient’s struggle to find something that worked and then just the arbitrary choices that insurers were making, looking at their bottom line to try to prevent him from getting a very expensive treatment that actually did increase his quality of life significantly. So I would definitely recommend, as we’re thinking about insurers’ role in this whole health care cost debate as well.

Rovner: Yeah, it does bring home how the patient is always in the middle of this. Alice.

Ollstein: I chose a piece by my colleague Carmen Paun called “Mpox Is Simmering South of the Border, Threatening a Resurgence,” and it’s about how the U.S. was extremely successful in vaccinating high-risk people against mpox, which for folks who still remember the artist formerly known as monkeypox, the name was changed to reduce stigma and be more accurate. The U.S. vaccination campaign and messaging campaign to the most high-risk populations was really successful and did the trick. But as we learned from covid and every other infectious disease, if you don’t take care of other parts of the world, it could eventually come back. We’re not an island, and even islands aren’t safe. But, you know, this is about a bunch of countries, including Mexico, that really have made no mass vaccination effort at all. You know, some civil society groups are trying on their own, but they just don’t have official government backing. And that’s really dangerous. And it meant that cases are surging in parts of Latin America and parts of Africa. And as we saw from covid, that leads to the development of new variants and things traveling back to the U.S. and other places around the world. So, certainly, something to pay attention to.

Rovner: Public health is important. World public health is important. Sarah.

Karlin-Smith: I looked at a piece called “Decisions by CVS and Optum Panicked Thousands of Their Sickest Patients,” by Arthur Allen for Kaiser Health News. It’s a deep dive into CVS and Optum moving out of, to some degree, business places where they provide home infusion services of perinatal nutrition to people that essentially cannot eat or drink in most cases. And they basically decided that it’s not a great business opportunity for them in many cases. But these are people that really depend on these services to live and survive, and they’re very complex medicines and essential nutrition to get and deliver. And at the same time, I think what really fascinated me about this story is it talks about this dynamic of while companies are getting out of the space where you’re providing this service to people that need these IV treatments to survive and live, there also has been development of these medical spas, as they’re called, where people that actually do not need IV hydration or IV nutrition are essentially being given it for nonmedical purposes. And there’s a lot of money being made there. And it just shows you how some of the profit incentives in our system don’t necessarily align with treating the people that actually need the health care first.

Rovner: Yeah, it’s like the people with diabetes not being able to get their drugs because people in Hollywood want to lose 10 pounds fast. But this obviously is, you know, another life-or-death issue. Well, I chose an op-ed this week in The New York Times by the University of Texas law professor Steven I. Vladeck called “Don’t Let Republican ‘Judge Shoppers’ Thwart the Will of Voters.” And it answered a lot of questions for me. First, how is it that so many suits end up in front of the same judges who the plaintiffs know are likely to rule in their favor, and all in Texas? So it turns out that Texas has distributed its federal judges in a way that in nine districts there is only one judge. And in 10 more, there are only two judges. Obviously, there’s no random draw in those districts where there’s only one judge. That’s what you’re going to get. So we keep seeing some of the same Texas judges, first Judge Reed O’Connor in Fort Worth, and now Matthew Kacsmaryk, a former advocate for a conservative think tank and the only federal judge in Amarillo. Judge O’Connor had the big ACA case, now has a big preventive care case. Judge Kacsmaryk has the abortion pill case that we’ve been talking about. It’s a really interesting piece about how that could really twist justice. But it also includes several ways to fix it. We’ll have to see if any of them actually get taken up.

OK. That is our show for this week. As always, if you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me as long as Twitter is still up. I’m @jrovner. Alice?

Ollstein: @AliceOllstein

Rovner: Rachel

Cohrs: @rachelcohrs

Rovner: Sarah.

Karlin-Smith: @SarahKarlin

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

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Julie Rovner is chief Washington correspondent and host of KHN’s 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 public health emergency in effect since the start of the covid-19 pandemic will end on May 11, the Biden administration announced this week. The end of the so-called PHE will bring about a raft of policy changes affecting patients, health care providers, and states. But Republicans in Congress, along with some Democrats, have been agitating for an end to the “emergency” designation for months.

Meanwhile, despite Republicans’ less-than-stellar showing in the 2022 midterm elections and broad public support for preserving abortion access, anti-abortion groups are pushing for even stronger restrictions on the procedure, arguing that Republicans did poorly because they were not strident enough on abortion issues.

This week’s panelists are Julie Rovner of KHN, Victoria Knight of Axios, Rachel Roubein of The Washington Post, and Margot Sanger-Katz of The New York Times.

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Victoria Knight
Axios

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Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories

Among the takeaways from this week’s episode:

• This week the Biden administration announced the covid public health emergency will end in May, terminating many flexibilities the government afforded health care providers during the pandemic to ease the challenges of caring for patients.
• Some of the biggest covid-era changes, like the expansion of telehealth and Medicare coverage for the antiviral medication Paxlovid, have already been extended by Congress. Lawmakers have also set a separate timetable for the end of the Medicaid coverage requirement. Meanwhile, the White House is pushing back on reports that the end of the public health emergency will also mean the end of free vaccines, testing, and treatments.
• A new KFF poll shows widespread public confusion over medication abortion, with many respondents saying they are unsure whether the abortion pill is legal in their state and how to access it. Advocates say medication abortion, which accounts for about half of abortions nationwide, is the procedure’s future, and state laws regarding its use are changing often.
• On abortion politics, the Republican National Committee passed a resolution urging candidates to “go on the offense” in 2024 and push stricter abortion laws. Abortion opponents were unhappy that Republican congressional leaders did not push through a federal gestational limit on abortion last year, and the party is signaling a desire to appeal to its conservative base in the presidential election year.
• This week, the federal government announced it will audit Medicare Advantage plans for overbilling. But according to a KHN scoop, the government will limit its clawbacks to recent years, allowing many plans to keep the money it overpaid them. Medicare Advantage is poised to enroll the majority of seniors this year.

Also this week, Rovner interviews Hannah Wesolowski of the National Alliance on Mental Illness about how the rollout of the new 988 suicide prevention hotline is going.

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

Julie Rovner: Axios’ “Republicans Break With Another Historical Ally: Doctors,” by Caitlin Owens and Victoria Knight

Margot Sanger-Katz: The New York Times’ “Most Abortion Bans Include Exceptions. In Practice, Few Are Granted,” by Amy Schoenfeld Walker

Rachel Roubein: The Washington Post’s “I Wrote About High-Priced Drugs for Years. Then My Toddler Needed One,” by Carolyn Y. Johnson

Victoria Knight: The New York Times’ “Emailing Your Doctor May Carry a Fee,” by Benjamin Ryan

Also mentioned in this week’s podcast:

• KFF’s “KFF Health Tracking Poll: Early 2023 Update on Public Awareness on Abortion and Emergency Contraception,” by Grace Sparks, Shannon Schumacher, Marley Presiado, Ashley Kirzinger, and Mollyann Brodie
• USA Today’s “Biden Seeks to Bolster the Affordable Care Act’s No-Cost Contraception Rule,” by Ken Alltucker
• The National Review’s “To Reduce Abortions, Should Giving Birth Be Free?” by Wesley J. Smith
• The New York Times’ “New Medicare Rule Aims to Take Back $4.7 Billion From Insurers,” by Reed Abelson and Margot Sanger-Katz
• KHN’s “Government Lets Health Plans That Ripped Off Medicare Keep the Money,” by Fred Schulte

Click to open the transcript

Transcript: Au Revoir, Public Health Emergency

KHN’s ‘What the Health?’Episode Title: Au Revoir, Public Health EmergencyEpisode Number: 283Published: Feb. 2, 2023

Tamar Haspel: A lot of us want to eat better for the planet, but we’re not always sure how to do it. I’m Tamar Haspel.

Michael Grunwald: And I’m Michael Grunwald. And this is “Climavores,” a show about eating on a changing planet.

Haspel: We’re here to answer all kinds of questions. Questions like: Is fake meat really a good alternative to beef? Does local food actually matter?

Grunwald: You can follow us or subscribe on Stitcher, Apple Podcasts, Spotify, or wherever you listen.

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 2, 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 Margot Sanger-Katz of The New York Times.

Margot Sanger-Katz: Good morning, everybody.

Rovner: Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, good morning.

Rovner: And Victoria Knight of Axios.

Victoria Knight: Hi! Good morning.

Rovner: Later in this episode we’ll play my interview with Hannah Wesolowski of the National Alliance on Mental Illness. She’s going to update us on the rollout of 988, the new national suicide prevention hotline. And because it’s February, we’re asking for your best health policy valentines. You can write a poem or haiku and tweet it, tagging @KHNews, and use the hashtag #healthpolicyvalentines, all one word. We’ll choose some of our favorites for that week’s podcast and the winner will be featured on Valentine’s Day on khn.org with its own illustration. But first, this week’s news. So we’re going to start with covid, which we actually haven’t talked about very much for a couple of weeks. But this week there’s some real actual news, which is that President [Joe] Biden has announced he will be ending the public health emergency, as well as the national covid emergency, which is a different thing, on May 11. Depending on who you believe, the president’s hand was forced by the Republican House this week voting on a bunch of bills that would immediately end the emergencies — or that May had always been the administration’s plan. I’m guessing it’s probably a bit of both. But let’s start with what’s going to happen in May, because it’s a bit confusing. We’ve talked at some length over the months about the Medicaid “unwinding.” So let’s start with that. How is that going to roll out, as we will?

Sanger-Katz: So that is actually not going to be affected at all by this change. When Congress passed the CARES Act, it tied a lot of these pandemic programs to the public health emergency. And I think what Congress has been doing in recent months is trying to untie some of those policies from the public health emergency, because I think it has identified that some of them are worth keeping and some of them are worth eliminating, and that it ought to make up its own mind about the right timeline and process for that — instead of just leaving it in the hands of the president to end the public health emergency when he sees fit. So what happened in the omnibus legislation, the big spending bill that passed at the end of the year, is that Congress said, OK, there has been this provision in the CARES Act that said that states need to keep everyone who is enrolled in Medicaid continuously enrolled in Medicaid until the end of the public health emergency, or they risk losing this extra Medicaid funding that they have been getting — and that, I think, has been beneficial to state budgets. And what Congress did is they said, OK, we’re going to create a date certain, starting in April, [that] this policy is going to go away, but we’re going to do it sort of incrementally. So the money’s not going to go away all at once. It’s going to go away in a couple of stages to make it a little easier on states. And they also created a lot of procedures and what they call guardrails to prevent states from just dumping everyone out of Medicaid all at once. So they’re requiring them to do various things to make sure they have the right address and that they’ve contacted people in Medicaid. They will punish them. There’s new penalties that the secretary can use to punish them if it seems like they’re doing things too arbitrarily, and there are other provisions. So as a result, the public health emergency doesn’t have any effect on this. But this policy and Medicaid is going to start unwinding right around the same time. In April and May we’re going to start seeing states probably phasing down their enrollment of some Medicaid beneficiaries as this extra funding that is tied to that goes away.

Rovner: And just a reminder, I mean, there’s now more than close to 90 million people on Medicaid, many of whom are probably no longer still eligible. So the concern is that states are going to have to basically reevaluate the eligibility of all of those people to see who’s still eligible and who’s not and who may be eligible for other government programs. And it’s just going to be a very long process. And I know health advocates are really worried about people falling through the cracks and losing their health insurance entirely.

Sanger-Katz: I think it’s still a huge risk and there still are a lot of people who are likely to lose their insurance as a result of this transition. But it was a weird situation that we were in, where you kind of went from all or nothing, just by the president deciding that the public health emergency was over. And I do understand why Congress decided, OK, look, why don’t we take some leadership over how this policy is going to phase down instead of just leaving it as this looming cliff that we don’t know exactly when it will come and where we don’t have control over the procedure for it.

Rovner: And Margot, you also mentioned things that Congress thought they might want to keep. And I guess a big one of those is telehealth, right? Because that was also in the end-of-year omnibus bill.

Sanger-Katz: Yeah, that’s proved to be really popular, because of the pandemic, because it was dangerous for people to get into doctors’ offices and hospitals early in the pandemic. Medicare loosened some rules and then Congress kind of cemented that. That allowed people to get doctors’ visits using video conferencing, telephone, other kinds of remote technologies, and Medicare paid for that. And that’s been super popular. It has a lot of bipartisan support. And now Congress has extended that benefit for longer. So I think we’re going to see telehealth become a more permanent part of how Medicare benefits are delivered.

Rovner: But not permanent yet. I think there’s still some concern that if it …

Sanger-Katz: Just for two years right now.

Rovner: Well, if it gets too popular, it could get really expensive. I think there’s a worry about …

Sanger-Katz: I do think that the two years will create some infrastructure — I think even just the temporary provision. A lot of doctors and hospitals … I was talking to folks that worked in medicine, they just weren’t set up for it at all. And they had to figure out, how are we going to do it? How are we going to build for it? What systems are we going to use? How are we going to make it secure? So some of that has already happened. But I also think two years is a long-enough runway that you start to imagine that there will be more start-ups, more health care providers that are really orienting their practice around this method of delivering care because they have some sense of permanence now.

Rovner: And I can’t imagine that this won’t become one of those, quote-unquote, “extenders” that Congress renews whenever it expires, which they do now. Rachel, you wanted to say something?

Roubein: Oh, yeah. To your point, I just think once there’s infrastructure built, it’s really hard to take things away. But I guess while we’re on the train of things that aren’t impacting, Congress also in their big government spending bill made a change to Paxlovid, allowing Medicare to continue to cover it under emergency use authorization. So that also won’t be impacted by an end to the public health emergency.

Rovner: So what are the things that will be impacted by the end of the public health emergency?

Knight: Really the biggest thing — and my colleague Maya [Goldman] has been pioneering at writing about this — is that it’s really CMS [the Centers for Medicare & Medicaid Services gave providers a lot of flexibilities that were tied to the PHE [public health emergency]. So it’s a bunch of different small things. It’s, like, reporting requirements, physical environment standards, even things like where radiologists can read X-rays. It’s small stuff like that that a lot of providers have kind of gotten used to and relied on during covid. And so those may go away. It’s possible also that HHS [the Department of Health and Human Services] could allow some of those to remain in place. When I talked to congressman Brett Guthrie, who is the one who introduced the bill to end the PHE, he said he wants to talk to HHS and figure out what are some things that he knows providers enjoy on these flexibilities. There was something about nurses’ training that he wants to keep in place. So they’re making it sound like it’s the end of the world end to this. I’m not sure that that’s actually true.

Rovner: Yeah, and I know the administration’s been pushing back on some of the stories that said that this will be an end to free vaccines and the actual covid testing. But that’s not even really true, right?

Roubein: I think one of my colleagues had talked a little bit about this to Jen Kates from the Kaiser Family Foundation, and that was a concern of hers. So I think some of it is dependent on what policies … and see what the next few months …

Rovner: My impression is that federal government has purchased all of these things. So it’s not … so much the end of the public health emergency. It’s when they run out of supply that they have now. So it’s not so much linked to a date. It’s linked to the supply, because I guess at the end of the public health emergency, they won’t be buying anymore. If nobody wants to answer this question, please don’t. But I’m confused about how this all affects the controversial Title 42, which is a public health requirement that was put in by the Trump administration that limited how many people could come across the border because of covid. I’m still confused about who’s for ending it and who’s not for ending it, and whether ending the emergency ends it or whether it’s in court. And if nobody knows, that’s fine because it’s not totally a health issue. But if anybody does, I’m dying to know.

Sanger-Katz: So my understanding on this one — which I also want to say I’m not like 1,000% sure, but this is what I’ve been told — is that it is related to public health authority and assessment that there is a health emergency, but that it is not part of that CARES framework where … when the public health emergency ends, it ends. It is a separate declaration by the CDC [and Health and Human Services] secretary. And so what I have been told is that it is not directly linked to this, but obviously it is the policy of the Biden administration that we are no longer experiencing a public health emergency. Then I do think the continued use of that policy starts to come under question because the justification for it is quite similar, even if the mechanism is different.

Knight: And I have to tell you, Julie, some of my immigration reporter friends on the Hill were also confused. I think everyone was a little confused because the Biden administration was saying this will lift Title 42 immediately, and Republicans were saying, no, it doesn’t. Brett Guthrie literally came to me and was like, “It is not ending yet.” So I think …

Rovner: I’m not the only one confused?

Knight: Yeah, you’re not the only one confused. And people were calling lawyers, being like, what does this mean when that was going on this week? So, yeah.

Roubein: I think it’s going to be a continuation of this big political fight that we’ve seen over Title 42. An administration official argued to my White House colleague Tyler Pager that essentially because Title 42 is a public health order, the CDC is determining that [there] would no longer be a need for the measure once the coronavirus no longer presents a public health emergency. So we’ll see wrangling over this.

Rovner: Yes, this will go on.

Sanger-Katz: I mean, it’s the same administration, you would think that they would be making a similar judgment about these different things. But the politics around this immigration policy are quite fraught. And it’s possible that they will be de-linked in some way. We’ll see.

Rovner: We will see.

Roubein: And the fight over this held up millions of dollars of covid aid last year. So it’s just been really political.

Rovner: That’s right. Well, moving along and speaking of the Republican-led House, they have, shall we say, refocused the special committee on covid that was set up in the last Congress. Rather than looking at how the nation flubbed preparedness in the early response to the pandemic. The Republican panel is now expected to concentrate on complaining about mask and vaccine mandates, trying to figure out the virus’s origins, and, at least so they’ve said, roasting scientists and public health leaders like the now-retired Anthony Fauci. Among the new Republican members appointed to the panel are the outspoken Marjorie Taylor Greene and former Trump White House doctor, now congressman, Ronny Jackson of Texas. I imagine, if nothing else, these hearings will be very lively to watch, right?

Knight: They definitely are going to be lively to watch. We did just find out yesterday that congressman Raul Ruiz is going to be the Democratic ranking member [of the Select Subcommittee on the Coronavirus Pandemic]. He’s also a doctor. Congressman Brad Wenstrup [R-Ohio] is the chairman of the committee. He’s also a doctor. So it is not only some members who have pushed forward misinformation about covid; there are also members that agree with vaccines and things like that. So I think it’ll be interesting to see how they play this out. I’ve been talking to a lot of them on what they’re going to focus on the committee, what the goal is. So it may not be as wild as we’re anticipating. There may be some members that want it to be, but I think that they want to look at covid origins for sure and the Biden administration’s rollout of vaccines and mandates and things like that. But there’s also Democrats on the committee. So we’ll see how it goes.

Rovner: I will point out, though, when you point out how many doctors are there that Andy Harris of Maryland, who’s also a doctor, a Johns Hopkins anesthesiologist, came under fire for prescribing ivermectin. So we’ve got doctors and we’ve got doctors in the House.

Knight: But I listened to the covid origins hearing yesterday — they did the first one, the Energy and Commerce [ Committee], and I covered it — and I was expecting it to be, like, very intense. And it actually was pretty measured and nothing too wild happened, so …

Rovner: But we shall see. All right. Well, let’s move on to abortion. This is where I get to say that if you didn’t listen to last week’s two-parter on the state of the abortion debate and you’re at all interested in this subject, you should definitely go back and do that. But, obviously, I wish more people would listen to it because a new poll this week from my colleagues over the firewall at KFF finds that a large portion of the public is still confused over whether medication abortion is legal in their state, about whether it requires a prescription (it does), and about how it works compared to emergency contraception. The first one can terminate an early pregnancy. The second one can only prevent pregnancy. Given how fast things are changing in various states, I suppose this confusion is predictable. But is there any way to make this even a little bit clearer? I mean, we have a public that honestly is getting ready to throw its hands up because they can’t figure out what’s what.

Sanger-Katz: I think there’s a good role for journalism here. The abortion pill is a very mature technology. It’s been around for a very long time. It’s become the means for more than half of abortions in America. But I still think, you know, a lot of people don’t know about it. I think when they think about abortion, a lot of Americans are thinking about a surgical procedure that happens in a clinic. Advocates on both sides of the abortion debate are very clear that medication abortion is likely the future of abortion for a lot of Americans because it is easily transportable, because it is able to be prescribed through telemedicine, because it is less expensive than clinic abortion. But I do think just a lot of Americans just don’t have a lot of familiarity with this. And so I think we just have to keep telling them about it, explaining how it works, what the safety profile of it is, how you can get it, what the laws are around it. And, you know, this is a bit of a shifting ground beneath our feet because states are actively regulating and restricting this technology. And I have a team of colleagues at The New York Times in the graphics department who are amazing, who are just like every day updating a page on our website about what is the state of laws surrounding abortion in this country? And it’s really remarkable how often the laws, particularly about abortion pills, are changing. You know, several times a week they are updating that page. So I think all of us just have to keep educating the public about this.

Rovner: And my required reminder that the “morning-after pill” is not the same as the abortion pill. The morning-after pill is now available over the counter. And we now know — thank you, FDA, for changing the label — that it cannot actually interrupt an existing pregnancy. It can only prevent pregnancy. So that’s my little PSA. Meanwhile, we have talked a lot about how anti-abortion forces are pushing harder than ever for a national abortion ban. The Republican National Committee passed a resolution last week, pushed by some of the more strident anti-abortion groups, calling for Republicans to, quote, “go on the offense” in 2024 to work for the most restrictive abortion laws possible. Given that polling still shows a majority of Americans and even a majority of swing voters still think abortion should be legal, are the Republicans driving themselves politically off a cliff here, or do they really think that revving up their base will help them win elections?

Roubein: I think that this is notable from the RNC because, as you mentioned, anti-abortion advocates were really, really mad at people like Senate Majority Leader Mitch McConnell, other Republicans who were saying that it was a state issue and had been pushing for them to paint Democrats as extreme, pushing a very different message. So this is ahead of 2024. Obviously, anti-abortion advocates are, when they’re looking at who they’re going to endorse in the presidential race, are going to be looking for candidates that support some kind of federal gestational limit on abortion.

Knight: I know Alice [Miranda Ollstein], who has been on here a lot, she was reporting that these anti-abortion groups are also pushing Republicans to put bills on the House floor to vote on restricting abortion. So there’s a six-week bill that’s already been introduced, maybe some other weeks. And so I think depending on if they actually do floor votes on this, that’s going to be something Democrats will use to attack them, I’m sure, in the upcoming election and maybe also something Republicans want to promote. So I think that it’s definitely notable, and we’re going to have to see if it’s the same as it was in the midterms when it didn’t seem to be a winning message for Republicans. But the anti-abortion groups are saying double down more. So we’ll see.

Rovner: Well, speaking of anti-abortion groups, they’ve been quietly pushing something new: a campaign to, as they call it, quote, “make birth free.” The idea is that a pregnant woman shouldn’t be swayed to have an abortion because she thinks she can’t afford to give birth. It’s been quite a few years since the anti-abortion side tried to advocate for benefits for pregnant women. I remember in the mid-1980s, congressman Henry Hyde — yes, he of the Hyde Amendment — joined with one of the most liberal members of the House, former California Democrat Henry Waxman, to sponsor a bill to reduce infant mortality. It turned out to be the beginning of Medicaid’s benefit for pregnant women, for prenatal delivery and postnatal care, something that’s now extremely popular. Do we expect to see more for this, more of this, or for this to catch on? … I’ve seen the group asking for this. I haven’t really seen any lawmakers suggesting this. It would be pretty expensive to basically pay for every birth in the country. We have a lot of shaking heads.

Knight: I had not heard any lawmakers talking about that. I don’t know if others have. I know there has been some push from some Republicans to put more safeguards in place for women who give birth, like just more supportive programs, but like, I haven’t heard like making birth completely free. And I know also that’s not maybe a widely held view within — I know there are some Republicans pushing for it. There’s a really good Washington Post article about this recently, about paid leave also. But they seem to be in the minority. And so there’s not enough movement to, like, make the party actually do anything on that.

Roubein: I think it’s sort of the beginning. Like Americans United for Life, a big anti-abortion group that’s written a lot, a lot of model laws that states have adopted. They had released a white paper about this. I think that’s sort of the beginning of the push and that’s what we tend to see with the anti-abortion movement is, you know, sometimes we see these policies come out from different groups and then they advocate and then potentially it goes to legislation and they try and find different lawmakers’ ears. So I think it’s a little bit TBD at this point.

Sanger-Katz: I also think it highlights how there’s a growing movement in the Republican Party — and I would say this is not a majority of Republicans yet — but we do see a significant minority that really are pursuing these pro-family policies, policies that we often think about as being pursued by Democrats. Family leave is an example of that, interest in day care, the child tax credit. There are a number of Republicans that were really champions of that policy in the last few years. And I think this feels like it’s a piece with that, that a lot of Republicans, they want to encourage people to have families, to have children, to be able to care for their children. And they understand that it’s hard and it’s expensive. But I do think that those ideas tend to bump up against the more libertarian elements in the Republican Party that are opposed to a lot of government spending, a lot of government intervention in people’s family lives and just concerned about the deficit and debt as well. And so this continues to be an interesting development. My colleague Claire Cain Miller at The Upshot has written a lot about this debate within the Republican Party as it relates to some of these other policies. And I wonder if this idea of making birth free could start to become part of that package of policies that you see some Republicans really interested in, even though you might think of the issue as being something that is more classically a Democratic issue.

Rovner: Although I’m wondering if the Democrats are going to pick up on this and try to hold the Republicans’ feet to the fire on it. It’s like, see, your base would like to make this free. Don’t you want to join them? I could see that happening although hard to know. All right. Well, finally this week on the reproductive health agenda, the Biden administration undid another Trump regulation, this one to eliminate employers with, quote-unquote, “moral objections to birth control” from having to offer it under the Affordable Care Act. Those with religious objections would still have a workaround to ensure that their employees get the coverage, according to the Department of Health and Human Services. Actually, only a handful of employers have used the moral exception. Actually, I think the more important part of this regulation would create a new pathway for employees of religiously objecting employers, like religious schools and colleges, to get coverage without involving the employer at all, nor making the employer pay for it. This has been a big sticking point and created a giant backlash early on in the Affordable Care Act’s rollout — and two separate Supreme Court cases — because the employers didn’t want to be seen to be facilitating people getting birth control that they didn’t believe in. Now that they’re going to totally separate this from the employer, might this put that little fight to rest? Not a little — a big fight to rest? [pause] We have no predictions?

Sanger-Katz: This feels like one of those policies that is just going to flip-flop back and forth when we have different presidents. The Trump administration, you know, went really far. This idea of a moral objection, I think doesn’t have a particularly strong basis in law or at least didn’t historically. But the Supreme Court said that they had the authority to do it. And so I think that then creates a precedent that future administrations can do it. I do think that there is a concern from the religious community that this requirement imposes too much of a moral stricture on them. And so they are always pushing for more and wider exceptions to this contraceptive coverage policy. To me, the big surprise in this is just that it took so long. The Trump administration rolled out this particular policy almost immediately upon taking office. And now we’re more than two years into the Biden administration and they have finally rolled it back.

Rovner: Yes. And I am keeping track. And I will update my little infographic about how long it’s taking the Biden administration to change some of these policies. Well, finally, this week, Medicare Advantage, as we’ve mentioned before, private Medicare plans have become very popular, particularly because they often offer extra benefits, mostly because they’re being paid extra by the federal government. But it seems some of these companies have also figured out how to game the system. Surprise. So this week, the federal government announced a crackdown by way of new audits that’s predicted to recoup nearly $5 billion. Medicare’s always … things with lots of zeros. Margot, you wrote about this this week. What are they going to do?

Sanger-Katz: So just a little bit of background. Medicare pays Medicare Advantage plans a set amount per person to take care of them. And the idea is the insurance company can try to do a better job and provide less medical care and keep people healthier and save the remainder as profits. And when Medicare Advantage started, there was this problem where the plans had this huge incentive to just pick all the healthy seniors, because if you pick all the healthy people, they don’t need a lot of medical care and then you get to keep a lot of that payment as profits. And so Congress came up with a new system where if you take care of someone who is sick, who has diabetes, who has substance abuse problems, who has COPD [chronic obstructive pulmonary disease], you get a little bonus payment so that the insurer has an incentive to cover that person. They have a little bit of extra money to take care of their health needs. And what we’ve seen over the years that the Medicare Advantage program has become mature, is that the plans have gotten extremely good at finding every single possible thing that is wrong with every single possible person that they enroll. And in some cases, they just kind of make things up that don’t seem to be justified by that person’s medical records. And so the amount that the Medicare system is paying to these plans has just gone up and up and up. And there are all kinds of estimates of how much they’ve been overpaid that are kind of eye-popping. And there are quite a lot of serious fraud lawsuits that are making their way through the federal courts. There have been some settlements, but basically every major insurer in this program is facing some kind of legal scrutiny for the way that they are diagnosing their patients to get these payments. And you know, what’s interesting to me about it is there’s been quite a lot of good journalism about this problem. Julie, your colleague Fred Schulte, I think, has been a real leader on this and had actually a big, big scoop recently. And the GAO has written about it. The HHS inspector general has done audits and written about it. There have been these lawsuits. This is not really a secret, but there has been very little action by CMS over the last decade on this problem. And I think there are a few reasons for that. One, I think it’s hard to fix. I will give them some credit. The policy levers are complicated, but I also think there is just a big political disincentive to do anything about this. Medicare Advantage has become more and more popular over the years. It is poised to enroll a majority of seniors, of Medicare beneficiaries, this year, and those people are very diffuse across the country. It’s not the case that there’s just Medicare Advantage in one or two markets where you have a couple members of Congress who care about it. They’re kind of everywhere. And they’re not just in Republican districts. Even though Republicans created this program, there are a lot of them in Democratic districts, too. And people like these plans. They have some downsides, which we could talk about another time. But they tend to have lower premiums for seniors. They tend to cover benefits like hearing, vision, and dental benefits that the traditional Medicare program does not cover. And so people really like these plans. And the more the plans are paid, the more they can afford to give all these goodies to their beneficiaries. And so I think there has been a lot of political pressure on CMS to not aggressively regulate the plans. And that’s part of why what they did this week is actually pretty striking. They did something pretty aggressive. They have been conducting these audits where they take 200 patients — which is a very, very small fraction of the total number of patients in any one plan — and they look at the diagnoses and they compare them to the medical records for those patients and they say, hey, wait a minute, I don’t think that this patient really has lung cancer. I think this patient doesn’t have that. So you shouldn’t have gotten that payment. And so that has been the system for some time where they look at a couple of records and they go back to the plans and they say, hey, pay us back this lung cancer payment. You can’t justify this based on the medical record.

Rovner: And they extrapolate from that, right? And it’s not …

Sanger-Katz: No. So what this new rule says is it says, you know, if in your 200 people that we look at, we find that you have an error rate of whatever, 5%, we are now going to ask you to pay back the money across your whole book of business, that you can’t just pay us back for the five people that we found, you have to pay back for everyone because we assume that whatever kinds of mistakes or sketchy things that you’ve done to create these errors in this small sample, probably you’ve done them to other patients, too. So that’s like the big thing that the rule does. It says “Pay back more money.” And then the other thing that it says is it says we’re going to reach back in time and you’re got to pay back all the extra money you got in 2018, in 2019, in 2020, and in 2021. So it’s not just forward-looking, but it’s also backward-looking, trying to recover some of what CMS believes are excessive payments that the plans received.

Rovner: Although, as my colleague Fred Schulte points out, they don’t go back in time as far as they could. So they’re basically leaving a fair bit of money on the table for … I guess that’s part of the balancing that they’re trying to do with being aggressive in recouping some of this money and noting that this is a very popular program that has a lot of bipartisan support.

Sanger-Katz: Yeah, it’s been interesting. The market reaction was very muted. So this suggests to me that the plans, even though it is aggressive relative to what we have seen in the past, that it was not as aggressive as what the plans and their shareholders were worried about.

Rovner: Exactly. All right. Well, that is as much time as we have for the news this week. Now, we will play my interview with Hannah Wesolowski of NAMI. Then we will come back and do our extra credits.

I am pleased to welcome back to the podcast Hannah Wesolowski of the National Alliance on Mental Illness. You may remember we spoke to Hannah last February in anticipation of the launch of the new three-digit national suicide hotline, 988. Hannah, welcome back.

Hannah Wesolowski: Thanks, Julie. It’s great to be here.

Rovner: So the 988 hotline officially launched last July. It’s been up and running now for just about seven months. How’s it going?

Wesolowski: Largely, it’s going great. We’re really excited to see that not only are more people reaching out for help — overall, there’s about a 30% to 40% increase, year over year, when we look at every month of the helpline — but they’re talking to people quickly. They’re getting that help. They’re getting connected to crisis counselors in their state. And that really displays the tremendous work that’s happened across the country to build up capacity in anticipation of the lifeline.

Rovner: Is there anything that surprised you about the rollout, something that was unexpected — or that you expected that didn’t happen?

Wesolowski: I had a few sleepless nights there, worried about: Would people be able to get through? What would demand look like? And would call centers have that capacity? This was a quick turnaround. Congress passed this in late 2020, and it went live in mid-2022. That’s not a lot of time in the real world to actually stand up call centers that have a 24/7 capacity to answer calls, texts, and chats. And yet, when we look at the numbers, they’re amazing. The number of texts alone has grown exponentially, when we look at people who were texting the lifeline previously and are now texting 988. They’re getting through. They’re talking to people quickly, and there’s tens of thousands of them that are doing it every month.

Rovner: And I imagine, particularly, younger people might well prefer to text than to actually talk to someone on the phone.

Wesolowski: Exactly. This is about making sure this resource is accessible to anyone and makes it as easy for them to get the help they need in the way that they prefer to get it. It is hard to get a young person to pick up the phone. So texting is absolutely critical to reach a population that is in crisis. There’s a youth mental health crisis in this country. And so making sure that we are responsive to the needs of youth and young adults is absolutely critical.

Rovner: So I see that mental health, in general, and the 988 program, in particular, got big funding boosts in the most recent omnibus spending bill. Republicans in the House, however, say they want to roll back funding for all of these domestic discretionary programs to fiscal 2022 levels. What would that mean for this program and for mental health in general?

Wesolowski: You’re right. 988 got [an] exponential increase in funding in the omnibus. It grew from $101.6 million in fiscal year 2022 to $501.6 million in fiscal year 2023. So nearly five times the funding. And it’s still not everything we estimated that is needed out there. Just to fund the local call centers alone, it would probably be more than $560 million. That doesn’t include the cost of operating the national network, the data integrity, the technical platforms, the backup networks, you know, all the resources that are needed to do this, plus public awareness. There still hasn’t been a widespread public awareness campaign of 988. So while $501.6 million is amazing, it’s still only a fraction of what we ultimately need. So thinking about future cuts to this … this is something that saves lives. There’s very clear data that lifelines save lives, and we’re telling people that this resource is there; to cut funding would mean that people [who need] help wouldn’t be able to connect to somebody when they need it most.

Rovner: So I know there’s been some resistance to using 988. Some folks, particularly on social media, warn that callers could be subject to police involvement or involuntary treatment or confinement. Tell us how it really works when someone calls. And are some of those concerns well placed or not?

Wesolowski: Every concern that is made about this system comes from a real place of people who have been in crisis and gotten a horrific and traumatic response. With 988, the thing that is important for people to understand is there is no way to know your location. There is no tracking of your information. This is 100% anonymous. In fact, right now we have the challenge of calls being routed based on area code and not somebody’s general geographic location. So, for example, I have a New Hampshire area code, love the great state of New Hampshire, but live in Virginia and have for many years — I would get routed to New Hampshire. I’m still talking to a crisis counselor. That’s wonderful. But we want to be connected locally. So there is no way that police can be dispatched or somebody can be taken to a hospital. Now, there are situations where the crisis counselor determines a person may be at imminent risk. They may be having thoughts of suicide, and the counselors are trained to look for that, in which case they’ll initiate emergency protocol to try to get the individual to share their location. And it’s less than 2% of contacts that an individual is at imminent risk. And many of those voluntarily share their location. So it’s a lengthy process when they don’t. And that means many minutes where we could lose a life. So it’s a challenging situation, but we know that that location is not available when somebody calls 988. And the intention is very much for this to be an anonymous resource that provides the least invasive intervention.

Rovner: So I’ve also seen concerns about just the lack of resources to back up the call centers, particularly in rural areas. What’s being done to build up the capacity?

Wesolowski: That’s one of the biggest challenges with this. 988 should be the entry point to a crisis continuum of care. When you call 911, you are connected to existing services: law enforcement, fire, EMS. 988 — we’re trying to build that system at the same time this resource is available. Many states already have robust mobile crisis response, which is a behavioral health-based response, rather than relying on law enforcement, which is unfortunately often the response that people see in their communities.

Rovner: And often doesn’t end well.

Wesolowski: Right. Often very tragic and traumatic circumstances — and it doesn’t get people the mental health care that they need. Unfortunately, [in] many communities, that’s still the main option. But more and more communities are getting mobile crisis response online, social workers, peer support specialists, nurses, EMTs, psychologists who staff those and provide a mental health-based response. But it’s much harder in rural areas. It takes longer to get to people. You’re covering a much bigger geographic area. And so that still is a challenge. You know, communities are looking at innovative ways that they can leverage existing emergency response to connect to behavioral health providers, like having law enforcement with iPads so they can leverage telehealth if somebody is in a crisis. But certainly, it’s a challenge and a solution that has to be very localized to the needs of that community.

Rovner: So what still is most needed? I know the law that created 988 also allows states to assess a fee on cellphones to help pay to boost mental health services. Are any states doing that yet?

Wesolowski: We have five states that have passed laws since 2020 to assess a monthly fee on all phone bills. That’s similar to how we fund 911. Everyone across the country already pays a 911 fee. Virginia, Colorado, Nevada, California, and Washington state all currently have legislation that has implemented a small fee on phone bills. It ranges from $0.12 to $0.40 per phone line per month. And that really is helping build out not just the 988 call centers, but that range of crisis services that can respond when somebody needs more help; it can be provided over the phone.

Rovner: Well, it sounds like it’s off to a good start. Hannah Wesolowski, thank you for coming back to update us, and I’m sure we’ll have you back again.

Wesolowski: Thank you so much, Julie. Always a pleasure.

Rovner: OK, we’re back and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it; we will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Victoria, why don’t you kick us off this week?

Knight: My extra credit is “Emailing Your Doctor May Carry a Fee.” That’s the name of the article by Benjamin Ryan in The New York Times. So it basically was documenting how doctors practices are starting to charge for sending an email correspondence with a patient. I think we’ve all probably done that, especially during covid. It can be really helpful sometimes when you’re not feeling well and you don’t want to go into the office. But these doctors practices are starting to sometimes charge up to $30, $50 for this, and it’s going to become a new revenue stream for some clinics. And the example they gave in the story was the Cleveland Clinic that was doing this for some people.

Rovner: And the Cleveland Clinic, for people who don’t know, has a lot of patients. It’s a very large organization.

Knight: Yes. Yes, absolutely. So clinics are saying their doctors are spending time on this and so they need to be reimbursed for it. But the critics of this are saying it could discourage people from getting care when they need it. It also could contribute to health inequities, and also can contribute to doctor burnout, because they’re having to now really do these emails to contribute to the revenue stream. So anyway, super interesting, hasn’t happened to me yet, but I hope it doesn’t.

Rovner: The continued tension over doctors getting paid and patients having to pay and insurers having to pay. Rachel.

Roubein: My extra credit, it’s by my colleague, she’s a health and science reporter, Carolyn Y. Johnson, and it’s titled “I Wrote About High-Priced Drugs for Years. Then My Toddler Needed One.” And in her story, she describes her effort of essentially getting lost in the health care system and having to deal with a really complex system to get a pricey medication for her 3-year-old son. So her 3-year-old son was diagnosed with a rare type of childhood arthritis, which can cause young kids to suffer from daily spiking fevers, a fleeting rash, and arthritis. And doctors had recommended a really pricey drug, which required approval from her insurer. Aetna denied the request. In September, doctors wrote another test, which the insurer wanted. The denial was upheld again. She was able to get the medication through a free program offered by the drugmaker, but she was really worried because she was close to using up the last dose. She was calling it the insurer, etc., just really, really often. And, ultimately, the resolution was she was able to get a different high-cost drug that worked in a similar way approved because the request was subject to different rules. And the big-picture point that she makes is that this isn’t a unique story. It’s something that a lot of Americans deal with, a really frustrating, routine process known as prior authorization and step therapy, etc., trying to get coverage of medication that doctors think are needed.

Rovner: And boy, if it takes a professional health reporter that much time and effort to get this, just imagine what people who know less about the system have to go through. It was a really hard piece to read, but very good. Margot.

Sanger-Katz: I wanted to recommend an article from my colleague Amy Schoenfeld Walker called “Most Abortion Bans Include Exceptions. In Practice, Few Are Granted.” And I know that this connects with the abortion discussion that you guys had in the last episode, but I thought what she did was really remarkable. You know, we talk a lot in the political debate about abortion, about exceptions to protect the health of the mother, exceptions for fetuses that cannot survive outside the womb. And, of course, these very politically heated discussions about exceptions for rape and incest. And her article actually looked at the numbers of abortions that are being granted due to these exceptions and states that have them on the books and found that, you know, it’s so minimal that it’s almost not happening at all. If you are a woman who has been raped, if you are a woman who has a really serious health complication in a state where abortion has been banned, you almost always have to travel out of state, despite the existence of these exceptions. And I think this is not a huge surprise. It makes sense that medical providers are scared of getting in trouble when the sanction for being wrong is so high. And also that there aren’t a lot of abortion providers available in states that have banned abortion because there’s no place for them to practice. But I thought she did a really nice job of really putting numbers to this intuition that we all had about what was going to happen and showing how limited access is, and how meaningless in some ways these talking points are that, you know, legislators say that they are providing exceptions, but they’re not actually providing any infrastructure to provide care for the people who qualify.

Rovner: And yet we’re seeing these huge political fights in a lot of states about these exceptions, which, as we now know, don’t actually result in that much in actual practice. Well, my story this week is from Axios by former podcast panelist Caitlin Owens and Victoria here. It’s called “Republicans Break With Another Historical Ally: Doctors,” and it’s about the growing discord between the American Medical Association, long the bastion of male white Republican M.D.s, and Republicans in Congress, particularly Republican M.D.s themselves. The AMA has been moving, I won’t say left, but at least towards the center in recent years, reflecting in large part the changing demographics of the medical profession itself. And if you go back to our podcast of July 21 of last year, you can hear the “not that AMA-like” list of priorities from Jack Resnick, who’s the AMA’s current president. Well, the very conservative Republicans in Congress aren’t too thrilled and are describing the AMA as, quote, “woke” and prioritizing things that lawmakers don’t support, like the right to practice reproductive health according to their medical expertise and to treat teens with gender issues. I never thought I would say it, but it seems the Republicans in the AMA might actually be heading for a divorce. It’s a really great story. You really should read it.

OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Margot?

Sanger-Katz: @sangerkatz

Rovner: Victoria?

Knight: @victoriaregisk

Rovner: Rachel.

Roubein: @rachel_roubein

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

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Julie Rovner is chief Washington correspondent and host of KHN’s 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.

While repealing the Affordable Care Act seems to have fallen off congressional Republicans’ to-do list for 2023, plans to cut Medicare and Medicaid are back. The GOP wants Democrats to agree to cut spending on both programs in exchange for a vote to prevent the government from defaulting on its debts.

Meanwhile, the nation’s health care workers — from nurses to doctors to pharmacists — are feeling the strain of caring not just for the rising number of insured patients seeking care, but also more seriously ill patients who are difficult and sometimes even violent.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Tami Luhby of CNN, and Victoria Knight of Axios.

Panelists

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Tami Luhby
CNN

@luhby

Read Tami's stories

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories

Among the takeaways from this week’s episode:

• Conservative House Republicans are hoping to capitalize on their new legislative clout to slash government spending, as the fight over raising the debt ceiling offers a preview of possible debates this year over costly federal entitlement programs like Medicare.
• House Speaker Kevin McCarthy said Republicans will protect Medicare and Social Security, but the elevation of conservative firebrands — like the new chair of the powerful House Ways and Means Committee — raises questions about what “protecting” those programs means to Republicans.
• Record numbers of Americans enrolled for insurance coverage this year under the Affordable Care Act. Years after congressional Republicans last attempted to repeal it, the once highly controversial program also known as Obamacare appears to be following the trajectory of other established federal entitlement programs: evolving, growing, and becoming less controversial over time.
• Recent reports show that while Americans had less trouble paying for health care last year, many still delayed care due to costs. The findings highlight that being insured is not enough to keep care affordable for many Americans.
• Health care workers are growing louder in their calls for better staffing, with a nursing strike in New York City and recent reports about pharmacist burnout providing some of the latest arguments for how widespread staffing issues may be harming patient care. There is bipartisan agreement in Congress for addressing the nursing shortage, but what they would do is another question.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week that they think you should read, too:

Julie Rovner: Roll Call’s “NIH Missing Top Leadership at Start of a Divided Congress,” by Ariel Cohen

Tami Luhby: CNN’s “ER on the Field: An Inside Look at How NFL Medical Teams Prepare for a Game Day Emergency,” by Nadia Kounang and Amanda Sealy

Joanne Kenen: The Atlantic’s “Don’t Fear the Handshake,” by Katherine J. Wu

Victoria Knight: The Washington Post’s “‘The Last of Us’ Zombie Fungus Is Real, and It’s Found in Health Supplements,” by Mike Hume

Also mentioned in this week’s podcast:

The New York Times’ “As France Moves to Delay Retirement, Older Workers Are in a Quandary,” by Liz Alderman

Stat’s “Congressional Medicare Advisers Warn of Higher Drug Prices, Despite New Price Negotiation,” by John Wilkerson

Click to Expand

Episode 280 Transcript

KHN’s ‘What the Health?’Episode Title: As US Bumps Against Debt Ceiling, Medicare Becomes a Bargaining ChipEpisode Number: 280Published: Dec. 19, 2023

Tamar Haspel: A lot of us want to eat better for the planet, but we’re not always sure how to do it. I’m Tamar Haspel.

Michael Grunwald: And I’m Michael Grunwald. And this is “Climavores,” a show about eating on a changing planet.

Haspel: We’re here to answer all kinds of questions. Questions like: Is fake meat really a good alternative to beef? Does local food actually matter?

Grunwald: You can follow us or subscribe on Stitcher, Apple Podcasts, Spotify, or wherever you listen.

Julie Rovner: Hello! Welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 19, 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 Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Good morning, everybody.

Rovner: Tami Luhby of CNN.

Tami Luhby: Good morning.

Rovner: And Victoria Knight of Axios.

Victoria Knight: Good morning.

Rovner: So Congress is in recess this week, but there is still plenty of news, so we’ll get right to it. The new Congress is taking a breather for the MLK holiday, having worked very hard the first two weeks of the session. But there’s still plenty going on on Capitol Hill. Late last week, House Republicans leaked to The Washington Post a plan to pay only some of the nation’s bills if the standoff over raising the debt ceiling later this year results in the U.S. actually defaulting. Republicans say they won’t agree to raise the debt ceiling, something that’s been done every couple of years for decades, unless Democrats agree to deep spending cuts, including for entitlement programs like Social Security, Medicare, and Medicaid — why we are talking about this. Democrats say that a default, even a partial one, could trigger not just a crisis in U.S. financial markets, but possibly a worldwide recession. It’s worth remembering that the last time the U.S. neared a default but didn’t actually get there, in 2011, the U.S. still got its credit rating downgraded. So who blinks in this standoff? And, Tami, what happens if nobody does?

Luhby: That’s going to be a major problem for a lot of people. I mean, the U.S. economy, potentially the global economy, global financial markets, but also practical things like Social Security recipients getting their payments and federal employees in the military getting paid, and Treasury bond holders getting their interest payments. So it would be a giant mess. [Treasury Secretary Janet] Yellen last week in her letter to [House Speaker Kevin] McCarthy, signaling that we were going to hit the debt ceiling, likely today, urged Congress to act quickly. But instead, of course, what just happened was they dug their heels in on either side. So, you know, we have the Republicans saying that we can’t keep spending like we are. We don’t have just an unlimited credit card. We have to change our behavior to save the country in the future. And the White House and Senate Democrats saying this is not a negotiable subject. You know, we’ve been here before. We haven’t actually crossed the line before. So we’ll see what happens. But one of the differences is, this year, that McCarthy has a very narrow margin in the House. Any one of his members — this is among the negotiations that he did not want to agree to but had to after 15 rounds of voting for his job — any member can make a motion to vacate the speaker’s chair. And if that happens, then we don’t have to worry about the debt ceiling because we have to worry more about who’s going to be leading the House, because we can’t deal with the debt ceiling until we actually have someone leading the House. So this is going to be even more complicated than in the past.

Rovner: Just to be clear, even if we hit the debt ceiling today, that doesn’t mean we’re going to default, right? I mean, that’s not coming for several months.

Luhby: Right. So Social Security, seniors and people with disabilities, and the military and federal employees don’t have to yet worry about their payments. They’re going to be paid. The Treasury secretary and Treasury Department will take what’s called “extraordinary measures.” They’re mainly just behind-the-scenes accounting maneuvers. They won’t actually hurt anybody. Yellen had said that she expects these extraordinary measures in cash to last at least until early June, although she did warn that the forecast has considerable uncertainty, as does everything around the debt ceiling.

Rovner: So, Victoria, obviously, the sides are shaping up. Is this going to be the big major health fight this year?

Knight: I think it’s going to be one of the big topics that we’re definitely talking about this year in Congress. I think it’s going to be a dramatic year, as we’ve already seen in these first two weeks. My colleagues at Axios, we talked to some Republicans last week, asking them about: Do you actually think they will make cuts to entitlement programs, to Medicare, Medicaid? Is that realistic? It’s kind of a mixed bag. Some are like, yeah, we should look at this, and some are like, we don’t really want to touch it. I think they know it’s really a touchy subject. There are a lot of Medicare beneficiaries that don’t want the age increase. You know, there’s some talk of increasing the age to 67 rather than 65. They know that is a touchy subject. Last week in a press conference, McCarthy said, “We’re Republicans; we’ll protect Medicare and Social Security,” so they know people are talking about this. They know people are looking at it. So I think in a divided government, obviously, the Senate is in Democratic control. I think it seems pretty unlikely, but I think they’re going to talk about it. And we have a new Ways and Means chairman, Jason Smith from Missouri. He’s kind of a firebrand. He’s talked about wanting to do reform on the U.S. spending. So I think it’s something they’re going to be talking about. But I don’t know if that much will actually happen. So we’ll see. I have been talking to Republicans on what else they want to work on this year in Congress. I think a big thing will be PBM [pharmacy benefit managers] reform. It’s a big topic that’s actually bipartisan. So I think that’s something that we’ll see. These are the middlemen in regards to between pharmacies and insurers. And they’re negotiating drug prices. And we know there are going to be hearings on that. I think health care costs. There’s some talk about fentanyl, scheduling. But I think in regards to big health care reform, there probably isn’t going to be a lot, because we are in a divided government now.

Kenen: Just one thing about how people talk about protecting Medicare and Social Security, it doesn’t mean they don’t want to make changes to it. We’ve been through this before. Entitlement reform was the driving force for Republicans for quite a few years under … when Paul Ryan was both, I guess it was budget chair before he was speaker. I mean, that was the thing, right? And he wanted to make very dramatic changes to Medicare, but he called it protecting Medicare. So there’s no one like Ryan with a policy really driving what it should look like. I mean, he had a plan, yet the plan never got through anywhere. It died, but it was an animating force for many years. It went away for a minute in the face of the last 10 years that were about the Affordable Care Act. So I don’t think they’re clear on what they want to do. But we do know some conservative Republicans want to make some kind of changes to Medicare. TBD.

Rovner: And Tami, we know the debt ceiling isn’t the only place where House Republicans are setting themselves up for deep cuts that they might not be able to make while still giving themselves the ability to cut taxes. They finessed some of this in their rules package, didn’t they?

Luhby: Yes, they did. And they made it very clear that they, in the rules, they made it harder to raise taxes. They increased it to a supermajority, 3/5 of the House. They made it easier to cut spending in the debt ceiling and elsewhere. And, you know, the debt ceiling isn’t our only issue that we have coming up. It’s going to be right around the same time, generally, maybe, as the fiscal 2024 budget, which will necessitate discussion on spending cuts and may result in spending cuts and changes possibly to some of our favorite health programs. So we will see. But also just getting back to what we were talking about with Medicare. Remember, the trustees estimate that the trust fund is going to run out of money by 2028. So we’ll see in a couple of months what the latest forecast is. But, you know, something needs to be done relatively soon. I mean … the years keep inching out slowly. So we keep being able to put this off. But at some point …

Rovner: Yeah, we keep getting to this sort of brinksmanship, but nobody, as Joanne points out, ever really has a plan because it would be unpopular. Speaking of which, while cutting entitlement programs here is still just a talking point, we have kind of a real-life cautionary tale out of France, where the retirement age may be raised from 62 to 64, which is still younger than the 67, the U.S. retirement age is marching toward. It seems that an unintended consequence of what’s going on in France is that employers don’t want to hire older workers. So now they can’t get retirement and they can’t find a job. And currently, only half of the French population is still employed by age 62, which is way lower than other members of the European Union. France is looking at protests and strikes over this. Could the same thing happen here, if we might get to that point? It’s been a while since we’ve seen the silver-haired set out on the street with picket signs.

Knight: I think it would be pretty contentious, I think, if they decide to actually raise the age. It’ll be interesting to see [if] there are actual protests, but I think people will be very upset, for sure, especially people reaching retirement age having counted on this. So …

Kenen: They probably wouldn’t do it like … if you’re 62, you wouldn’t [go] to 67. When they’ve talked about these kinds of changes in the past, they’ve talked about phasing it in over a number of years or starting it in the …

Rovner: Right, affecting people in the future.

Kenen: Right.

Rovner: But I’m thinking not just raising the retirement age. I’m thinking of making actual big changes to Medicare or even Medicaid.

Kenen: Well, there’s two things since the last debate about this. Well, first of all, Social Security was raised and it didn’t cause … it was raised slowly, a couple of months at a time over, what, a 20-year period. Is that right? Am I remembering that right, Julie?

Rovner: Yeah, my retirement age is 66 and eight months.

Kenen: Right. So … it used to be 65. And they’ve been going, like, 65 and one month, 65 and two months. It’s crept up. And that was done on a bipartisan basis, which, of course, not a whole lot is looking very bipartisan right now. But I mean, that’s the other pathway we could get. We could get a commission. We could move toward some kind of changes after … last time there was a commission that failed, but the Social Security commission did work. The last Medicare commission did not. The two sides are so intractable and so far apart on debt right now that there’s probably going to have to be some kind of saving grace down the road for somebody. So it could be yet another commission. And also in 2011, 2012, which was the last time there was the big debate over Medicare age, was pre-ACA [Affordable Care Act] implementation. And, you know, if you’re 65 and you’re not working, if they do change the Medicare in the out years, it’s complicated what it would do to the risk pools and premiums and all that. But you do have an option. I mean, the Affordable Care Act would … right now you only get it to Medicare. That would have to be changed. So it’s not totally the same … I’m not advocating for this. I’m just saying it is a slightly different world of options and the chessboard’s a little different.

Rovner: Well, clearly, we are not there yet, although we may be there in the next couple of months. Finally, on the new Congress front. Last week, we talked about some of the new committee chairs in the House and Senate. This week, House Republicans are filling out some of those critical subcommittee chairs. Rep. Andy Harris, a Republican from Maryland who’s also an anesthesiologist who bragged about prescribing ivermectin for covid, will chair the Appropriations subcommittee responsible for the FDA’s budget [the Agriculture, Rural Development, Food and Drug Administration subcommittee]. Things could get kind of interesting there, right?

Knight: Yeah. And there is talk that he wanted to chair the Labor [Health and Human Services, Education] subcommittee, which would have been really interesting. He’s not.

Rovner: Which would’ve been the rest of HHS. We should point out that in the world of appropriations, FDA is with Agriculture for reasons I once tried to figure out, but they go back to the late 1940s. But the rest of HHS is the Labor HHS Appropriations subcommittee, which he won’t chair.

Knight: Right, he is not. Rep. Robert Aderholt is chairing Labor HHS. But this is, as we were talking about, they’re going to have to fund the government. Republicans are talking about wanting to pass 12 appropriations bills. If they actually want to try to do that, they’re going to have to do a lot of negotiations on what goes into the Labor HHS bill, what goes into the AG bill with FDA, with these chairs over the subcommittees, they’re going to want certain things in there. They’re going to maybe want oversight of these agencies, especially in regards to what’s happening with covid, what’s going on with the abortion pills. So I think it’ll be really interesting to see what happens. It seems unlikely they’re actually going to be able to pass 12 appropriations bills, but it’s just another thing to watch.

Rovner: I would point out that every single Congress, Republican and Democrat, comes in saying, we’re going to go back to regular order. We’re going to pass the appropriations bills separately, which is what we were supposed to do. I believe the last time that they passed separately, and that wasn’t even all of them, was the year 2000; it was the last year of President [Bill], it might have been. It was definitely right around then. When I started covering Congress, they always did it all separately, but no more.

Luhby: And they want to pass the debt ceiling vote separately.

Rovner: Right, exactly. Not that much going on this year. All right. Well, last week we talked about health insurance coverage. Now it is official. Obamacare enrollment has never been higher and there are still several weeks to go to sign up in some states, even though enrollment through the federal marketplace ended for the year on Sunday. Tami, have we finally gotten to the point that this program is too big to fail or is it always going to hang by a political thread?

Luhby: Well, I think the fact that we’re all not reporting on the weekly or biweekly enrollment numbers, saying “It’s popular, people are still signing up!” or under the Trump years, “Fewer people are signing up and it’s lost interest.” I think that in and of itself is very indicative of the fact that it is becoming part of our health care system. And I mean, I guess one day I’m not going to write the story that says enrollment opens on Nov. 1, then another one that says it’s ending on Jan. 15.

Rovner: I think we’ll always do that because we’re still doing it with Medicare.

Luhby: Well, but I’m not. So … it’s possible, although now with Medicare Advantage, I think it is actually worth a story. So that’s a separate issue.

Rovner: Yes, that is a separate issue.

Luhby: But yeah, no, I mean, you know, I think it’s here to stay. We’ll see what [District Judge Reed] O’Connor does in Texas with the preventive treatment, but …

Rovner: Yes, there will always be another lawsuit.

Luhby: There will be chips around the edges.

Kenen: I mean, this court has done … we all thought that litigation was over, like we thought, OK, it’s done. They’ve … upheld it, you know, however many times, move on. But this Supreme Court has done some pretty dramatic rulings and not just Roe [v. Wade], on many public health measures, about gun control and the environment and vaccine mandates. And, of course, you know, obviously, Roe. Do I think that there’s going to be another huge existential threat to the ACA arising out of this preventive care thing? No, but we didn’t think a lot of the things that the Supreme Court would do. There’s a real ideological shift in how they approach these issues. So politically, no, we’re not going to see more repeal votes. In the wings could there be more legal issues to bite us? I don’t think it’s likely, but I wouldn’t say never.

Rovner: In other words, just because congressional Republicans aren’t still harping on this, it doesn’t mean that nobody is.

Kenen: Right. But it’s also, I mean, I agree with Tami … I wrote a similar story a year ago on the 10th anniversary: It’s here. They spent a lot of political capital trying to repeal it and they could not. People do rely on it and more … Biden has made improvements to it. It’s like every other American entitlement: It evolves over time. It gets bigger over time. And it gets less controversial over time.

Rovner: Well, we still have problems with health care costs. And this week we have two sort of contradictory studies about health care costs. One from the Centers for Disease Control and Prevention found a three-percentage-point decline in the number of Americans who had trouble paying medical bills in 2021 compared to the pre-pandemic year of 2019. That’s likely a result of extra pandemic payments and more people with health insurance. But in 2022, according to a survey by Gallup, the 38% of patients reported they delayed care because of cost. That was the biggest increase ever since Gallup has been keeping track over the past two decades, up 12 percentage points from 2020 and 2021. This has me scratching my head a little bit. Is it maybe because even though more people have insurance, which we saw from the previous year. Also more have high-deductible health plans. So perhaps they don’t want to go out and spend money or they don’t have the money to spend initially on their health care. Anybody got another theory? Victoria, I see you sort of nodding.

Knight: I mean, that’s kind of my theory is, like, I think they just have high-deductible plans, so they’re still having to pay a lot out-of-pocket. And I know my brother had to get an ACA plan because he is interning for an electrician and — so he doesn’t have insurance on his own, and I know that, like, it’s still pretty high and he just has to pay a lot out-of-pocket. He’s had medical debt before. So even though more people have health insurance, it’s still a huge issue, it doesn’t make that go away.

Rovner: And speaking of high medical prices, we are going to talk about prescription drugs because you can’t really talk about high prices without talking about drugs. Stat News reports this week that some of the members of the Medicare Payment Advisory Committee, or MedPAC, are warning that even with the changes to Medicare that are designed to save money on drugs for both the government and patients — those are ones taking effect this year — we should still expect very high prices on new drugs. Partly that’s due to the new Medicare cap on drug costs for patients. If insurers have to cover even the most expensive drugs, aside from those few whose price will be negotiated, then patients will be more likely to use them and they can set the price higher. Are we ever going to be able to get a handle on what the public says consistently is its biggest health spending headache? Victoria, you kind of previewed this with the talk about doing something about the middlemen, the PBMs.

Knight: Yeah, I think it’s really difficult. I mean, the drug pricing provisions, they only target 20 of the highest-cost drugs. I can’t remember exactly how they determine it, but it’s only 20 drugs and it’s implemented over years. So it’s still leaving out a lot of drugs. We still have years to go before it’s actually going into effect. And I think drugmakers are going to try to find ways around it, raising the prices of other drugs, you’re talking about. And even though they’re hurt by the IRA [Inflation Reduction Act], they’re not completely down and out. So I don’t know what the answer is to rein in drug prices. I think maybe PBM reform, as I said, definitely a bipartisan issue. This Congress … I think will actually have maybe some movement and we’ll see if actually legislation can be passed. But I know they want to talk about it. So, I mean, that could help a little bit. But I think drugmakers are still a huge reason for a lot of these costs. And so it won’t completely go away even if PBMs have some reforms.

Rovner: And certainly the American public sees drug costs as one of the biggest issues just because so many Americans use prescription drugs. So they see every dollar.

Knight: Yes.

Rovner: So the good news is that more people are getting access to medical care. The bad news is that the workforce to take care of them is burned out, angry, and simply not large enough for the task at hand. The people who’ve been most outspoken about that are the nation’s nurses, who’ve given the majority of the care during the pandemic and taken the majority of patient anger and frustration and sometimes even violence. We’re seeing quite a few nurses’ strikes lately, and they’re mostly not striking for higher wages, but for more help. Tami, you talked to some nurses on the picket line in New York last week. What did they tell you?

Luhby: Yeah, I had a fun assignment last week. Since I live in the Bronx, I spent two days with the striking nurses at the Montefiore Medical Center, and there were 7,000 nurses at Mount Sinai Hospital in Manhattan and Montefiore in the Bronx that went on strike for three days. It was a party atmosphere there much of the time, but they did have serious concerns that they wanted to relay and get their word out. There was a lot of media coverage as well. Their main issue was staffing shortages. I mean, the nurses told me about terrible working conditions, particularly in the ER. Some of them had to put babies on towels on the floor of the pediatric ER or tell sick adults that they have to stand because there aren’t even chairs available in the adult ER, much less beds or cots. And every day, they feared for their licenses. One said that she would go to sleep right when she got home because she didn’t want to think about the day because she was concerned she might not want to go back the next day. And she said, heartbreakingly, that she was tired of apologizing to families and patients, that she was stretched too thin to deliver better care, that she was giving patients their medicines late because she had seven other patients she had to give medicine to and probably handle an emergency. So the nurses at Montefiore, interestingly, they’re demanding staffing. But one thing they kept repeating to me, you know, the leaders, was that they wanted enforcement ability of the staffing. They didn’t just want paper staffing ratios, and they wanted to be more involved in recruitment. While the hospitals — interestingly, this is not necessarily over in New York as it probably won’t be elsewhere. These hospitals reached a tentative agreement with the unions, but there’s another battle brewing. The nurses’ contract for the public hospital system expires on March 2, and the union is already warning that will demand better pay and staffing.

Rovner: Yeah. Well, it’s not just the nurses, though. Doctors are burnt out by angry and sometimes ungrateful patients. Doctors in training, too. And I saw one story this week about how pharmacists, who are being asked to do more and more with no more help — a similar story — are getting fried from dealing with short-tempered and sometimes abusive patients. Is there any solution to this, other than people trying to behave better? Is Congress looking at ways to buttress the health care workforce? This is a big problem. You know, they talked about, when they were passing the Affordable Care Act, that if you’re going to give all these people more insurance, you’re going to need more health care professionals to take care of them.

Knight: Yeah.

Rovner: Yet we haven’t seemed to do that.

Knight: Yeah, I know. It’s something that is being talked about. My colleague Peter [Sullivan] at Axios talked to both Sen. [Bernie] Sanders and Sen. [Bill] Cassidy about things they might want to work on on the HELP [Health, Education, Labor & Pensions] Committee. And I know that the nursing workforce shortage is one thing they do actually agree on. So it’s definitely possible. I do think the medical provider workforce shortage is maybe a bipartisan area in this Congress that they could work on. But I mean, they’ve been talking about it forever. And will they actually do something? I’m not sure. So we’ll see. But I know nursing …

Rovner: Yeah, the spirit of bipartisanship does not seem to be alive and well, at least yet, in this Congress.

Knight: Yeah, well, between the House and the Senate. Yeah, well, we’ll see.

Kenen: But the nursing shortage is, I mean, been documented and talked about for many, many years now and hasn’t changed. The doctor shortage is more controversial because there’s some debate about whether it’s numbers of doctors or what specialties they go into. I mean, and, also, do they go to rich neighborhoods or poor neighborhoods? I mean, if you’re in a wealthy suburb, there’s plenty of dermatologists. Right? But in rural areas, certain urban areas … So it’s not just in quantity. It’s also an allocation both by geography and specialty. Some of that Congress could theoretically deal with. I mean, the graduate medical education residency payment … they’ve been talking about reforming that since before half of the people listening to this were born. There’s been no resolution on a path forward. So some of these are things that Congress can nudge or fix with funding. Some of it is just things that have to happen within the medical community, some cultural shift. Also student debt. I mean, one reason people start out saying they’re going to go into primary care and end up being orthopedic surgeons is their debt. So it’s complicated. Some of it is Congress. Not all of it is Congress. But Congress has been talking about this for a very, very, very, very, very long time.

Rovner: I will point out — and Joanne was with me when this happened — when Congress passed the Balanced Budget Act in 1997, they cut the number of residencies that Medicare would pay for with the promise — and I believe this is in the report, if not in the legislation — that they would create an all-payer program to help pay for graduate medical education by the next year, 1998. Well, now it’s 2023, and they never did that.

Kenen: They meant the next century.

Rovner: We’re a fifth — almost a quarter of the way — through the next century, and they still haven’t done it.

Kenen: And if you were on the front lines of covid, the doctors and the nurses, I mean, at the beginning they had no tools. So many people died. They didn’t know how to treat it. There were so many patients, you know, in New York and other places early on. I mean, it was these nurses that were holding iPads so that people could say goodbye to their loved ones. I don’t think any of us can really understand what it was like to be in that situation, not for 10 minutes, but for weeks and over and over …

Rovner: And months and years, in some cases.

Kenen: Right. But I mean, the really bad … it’s years. But these crunches, the really traumatic experiences, I mean, we’ve also talked in the past about the suicide rate among health care providers. It’s been not just physically exhausting, it’s become emotionally unimaginable for those of us who haven’t been in those ICU or ERs.

Rovner: Well, it’s clear that the pandemic experiences have created a mental health crisis for a lot of people. Clearly, people on the front lines of health care, but also lots of other people. This week, finally, a little bit of good news for at least one population. Starting this week, any U.S. military veteran in a mental health crisis can get free emergency care, not just at any VA [Department of Veterans Affairs] facility, but at any private facility as well. They don’t even have to be in the VA health system because many former members of the military are not actually eligible for VA health care. This is for all veterans. It’s actually the result of a law passed in 2020 and signed by then-President [Donald] Trump. How much of difference could this change, at least, make? I mean, veterans in suicidal crises are also, unfortunately, fairly common, aren’t they?

Kenen: Yeah, but I mean, we have a provider shortage, so giving them greater access to a system that doesn’t have enough providers, I mean, will it help? I would assume so. Is it going to fix everything? I would assume not. You know, we don’t have enough providers, period. And there are complicated reasons for that. And that’s also … they’re not all doctors. They’re, you know, psychologists and social workers, etc. But that’s a huge problem for veterans and every human being on Earth right now. I mean, everybody was traumatized. There’s degrees of how much trauma people had, but nobody was untraumatized by the last three years. And the ongoing stresses. You can be well-adjusted traumatized. You could be in-crisis traumatized. But we’re all on that spectrum of having been traumatized.

Knight: Yeah.

Rovner: Well, lots more work to do. OK. That’s the news for this week. Now it is time for our extra-credit segment, where we each recommend a story we read this week we think you should read, too. Don’t worry if you miss it; we will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?

Knight: The story that I’m recommending is called “‘The Last of Us’ Zombie Fungus Is Real, and It’s Found in Health Supplements.” It’s in The Washington Post by Mike Hume. “The Last of Us” is a new HBO show everyone’s kind of talking about. And, basically, people become zombies from this fungus. Turns out that fungus is real in real life. It’s spread by insects that basically infect people and then kind of take over their minds and then shoot little spores out. And in the show, they do that as well, except they don’t spread by spores. They spread by bites. But it’s used in health supplements for different things like strength, stamina, immune boost. So it’s kind of just a fun little dive into a real-life fungus.

Rovner: To be clear, it doesn’t turn people into zombies.

Knight: Yes. To be clear, it does not turn people into zombies. If you eat it, that will not happen to you. But it is based on a real-life fungus that does infect insects and make them zombies.

Rovner: Yes. [laughter] It’s definitely creepy. Tami.

Luhby: My story is by my fantastic CNN colleagues this week. It’s called “ER on the Field: An Inside Look at How NFL Medical Teams Prepare for a Game Day Emergency.” It’s by my colleagues Nadia Kounang, Amanda Sealy, and Sanjay Gupta. Listen, I don’t know anything about football, but I happened to be watching TV with my husband when we flipped to the channel with the Bills-Bengals game earlier this month, and we saw the ambulance on the field. So like so many others, I was closely following the story of Damar Hamlin’s progress. What we heard on the news was that the team and the medical experts repeatedly said that it was the care on the field that saved Hamlin’s life. So Nadia, Amanda, and Sanjay provide a rare behind-the-scenes look at how hospital-quality treatment can be given on the field when needed. I learned that — from the story and the video — that there are about 30 medical personnel at every game. All teams have emergency action plans. They run drills an hour before kickoff. The medical staff from both teams review the plan and confirm the details. They station certified athletic trainers to serve as spotters who are positioned around the stadium to catch any injuries. And then they communicate with the medical team on the sidelines. But then — and this is what even my husband, who is a major football fan, didn’t know this — there’s the all-important red hat, which signifies the person who is the emergency physician or the airway physician, who stands along the 30-yard line and takes over if he or she has to come out onto the field. And that doctor said, apparently, they have all the resources available in an emergency room and can essentially do surgery on the field to intubate a player. So I thought it was a fascinating story and video even for non-football fans like me, and I highly recommend them.

Rovner: I thought it was very cool. I read it when Tami recommended it. Although my only question is what happens when there’s a team, one whose color is red and there are lots of people wearing red hats on the sidelines?

Luhby: That’s a good point.

Rovner: I assume they still can find the doctor. OK, Joanne.

Kenen: There was a piece in The Atlantic by Katherine J. Wu called “Covid Couldn’t Kill the Handshake.” It had a separate headline, depending on how you Googled it, saying “Don’t Fear the Handshake.” So, basically, we stopped shaking hands. We had fist bumps and, you know, bows and all sorts of other stuff. And the handshake is pretty much back. And yes, your hands are dirty, unless you’re constantly washing them, your hands are dirty. But they are not quite as dirty as we might think. We’re not quite as dangerous as we may think. So, you know, if you can’t get out of shaking someone’s hand, you probably won’t die.

Rovner: Good. Good to know. All right. My extra credit this week is a story I wish I had written. It’s from Roll Call, and it’s called “NIH Missing Top Leadership at Start of a Divided Congress,” by Ariel Cohen. And it’s not just about not having a replacement for Dr. Tony Fauci, who just retired as the longtime head of the National Institute for Allergy and Infectious Diseases last month, but about having no nominated replacement for Frances Collins, who stepped down as NIH [National Institutes of Health] director more than a year ago. In a year when pressure on domestic spending is likely to be severe, as we’ve been discussing, and when science in general and NIH in particular are going to be under a microscope in the Republican-led House, it doesn’t help to have no one ready to catch the incoming spears. On the other hand, Collins’ replacement at NIH will have to be vetted by the Senate HELP Committee with a new chairman, Bernie Sanders, and a new ranking member, Bill Cassidy. I am old enough to remember when appointing a new NIH director and getting it through the Senate was a really controversial thing. I imagine we are back to exactly that today.

OK. That’s our show for this week. As always, if you enjoyed the podcast, you could subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying, and to our KHN webteam, who have given the podcast a spiffy new page. As always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m still at Twitter, for now, where I’m @jrovner. Tami?

Luhby: I’m @Luhby — L-U-H-B-Y

Rovner: Victoria.

Knight: @victoriaregisk

Rovner: Joanne.

Kenen: @JoanneKenen

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

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