Covering the American health care system means we tell some scary stories. This episode of “An Arm and a Leg” sounds like a real horror movie. 

It uses one of Hollywood’s favorite tropes: machines taking over. And the machines belong to the private health insurance company UnitedHealth Group. 

Host Dan Weissmann talks to Stat News reporter Bob Herman about his investigation into Medicare Advantage plans that use an algorithm to make decisions about patient care. The algorithm is owned by a subsidiary of UnitedHealth Group.

Herman tells Weissmann that some of UnitedHealth’s own employees say the algorithm creates a “moral crisis” in which care is unfairly denied.

Scary stuff! Such reporting even has caught the eye of powerful people in government, putting Medicare Advantage plans under scrutiny.

Dan Weissmann

@danweissmann

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

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Transcript: Son of Medicare: Attack of the Machines

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

Dan: Hey there–

So this is kind of a horror story. But it’s not quite the kind of story it might sound like at first.

Because at first, it might sound like a horror story about machines taking over, making all the decisions– and making terrible, horrifying choices. Very age-of-Artificial Intelligence.

But this is really a story about decisions made by people. For money.

It’s also kind of a twofer sequel– like those movies that pit two characters from earlier stories against each other. Like Godzilla vs King Kong, or Alien vs Predator.

Although in this case, I’ve gotta admit, the two monsters are not necessarily fighting each other.

Let’s get reacquainted with them. 

On one side, coming back from our very last episode, we’ve got Medicare Advantage: This is the version of Medicare that’s run by private insurance companies. 

It’s got a bright and appealing side, compared to the traditional Medicare program run by the federal government, because: It can cost a lot less, month to month — saving people money on premiums. And it often comes with extra benefits, like dental coverage, which traditional Medicare doesn’t offer. [I know.]

But Medicare Advantage can have a dark side, which is basically: Well, you end up dealing with private insurance companies for the rest of your life. You need something — a test, a procedure, whatever — they might decide not to cover it.

Which can be scary. 

Our other returning monster — am I really calling them a monster? — well, last time we talked about them, in 2023, we had an expert calling them a behemoth. That’s United HealthGroup. You might remember, they’re not only one of the biggest insurance companies 

— and maybe not-coincidentally the very biggest provider of Medicare Advantage plans —

they’ve also got a whole other business– under the umbrella name Optum. And Optum has spent the last bunch of years buying up a gazillion other health care companies of every kind. 

That includes medical practices — they employ more doctors than anyone else, by a huge margin. It includes surgery centers, and home-health companies, and every kind of middleman company you can imagine that works behind the scenes — and have their hands in a huge percentage of doctor bills and pharmacy visits. 

A few years ago, United bought a company called NaviHealth, which provides services to insurance companies that run Medicare Advantage plans. 

NaviHealth’s job is to decide how long someone needs to stay in a nursing home, like if you’re discharged from a hospital after surgery, but you’re not ready to go home yet.

And the horror story– the stories, as dug up by reporters — starts after United bought NaviHealth.

And according to their reports, it involves people getting kicked out of those nursing homes who aren’t ready to go home. 

People getting sent home who can’t walk up the stairs in their house. Who can’t walk at all. Who are on feeding tubes. People who NaviHealth’s own employees are saying, “Wait. This person isn’t ready to go home.”

But their new bosses have told them: You’re not really making these decisions anymore. 

This is where machines do enter the picture.

NaviHealth’s distinctive offering has always been its proprietary algorithm– an algorithm that makes predictions about how long any given patient might need to stay. 

Before United bought the company, that algorithm was used as a guide, a first-guess. Humans weighed in with their own judgment about what patients needed.

After United bought the company, people inside have told reporters, that changed: The new owners basically told their employees, If the algorithm says someone can go home after x days, that’s when we’re cutting them off.

 Like pretty much any horror movie, this story’s got people running around trying to tell everyone: HEY, WATCH OUT! THERE’S SOMETHING BIG AND DANGEROUS HAPPENING HERE.

And in this case, they’ve actually gotten the attention of some people who might have the power to do something about it. Now, what those people will do? We don’t know yet. 

And, by the way: Yes, I said at the end of our last episode that we’d be talking about Medicaid this time around. That’s coming! But for now, strap in for this one. 

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

So. I said that, like every horror movie, this one has people who are seeing what’s going on and are trying to warn everybody?

Like those movies, we’re gonna follow one of those people, watch them discover the problem, see how deep it goes, and start ringing alarm bells. Let’s meet our guy.

Bob Herman: My name is Bob Herman. I’m a reporter at STAT News

Dan: Stat is an amazing medical news publication. Bob covers the business of medicine there. Bob started working on this story in November 2022, after talking to a source who runs nursing homes. Bob’s source was complaining about Medicare Advantage. 

Bob Herman: There were a lot of payment denials. They just weren’t able to get paid. And just offhandedly, the source mentioned like, um, you know, and they’re attributing everything to this algorithm. This algorithm said, You know, only 17 days for our patients and then time’s up and I went running to Casey Ross 

Dan: Casey is a reporter at Stat who focuses on tech and AI in healthcare. Bob said, hey, what do you think of this? Wanna team up?

Bob Herman: And he was hooked.

Dan: They started talking to people who worked at nursing homes, talking to experts, and talking to families. And it was clear: They were onto something. 

Bob Herman: It took so many families by surprise to be like, what do you mean we’re going home? The, you know, my husband, my wife, my grandma, my grandpa, they can’t go to the bathroom on their own. Like, what do you? It was just, it was so confusing to people. It seemed like such a, a cold calculation,​

Dan: One person they ended up talking with was Gloria Bent. Her husband Gary was sent to a nursing home for rehab after brain surgery for cancer. He was weak. He couldn’t walk. And he had something called “left neglect”: His brain didn’t register that there was a left side of his body. Here’s Gloria testifying before a Senate committee about how — when Gary arrived at the nursing home — the first thing he got was a discharge date. That is…

Gloria Bent: Before the staff of the facility could even evaluate my husband or develop a plan of care, I was contacted by someone who identified themselves as my Navi Health Care Coordinator

Dan: Gloria says when she told the nursing home staff she’d heard from NaviHealth, they groaned. And told her what to expect. 

Gloria Bent: I was told that I had just entered a battlefield, that I could expect a series of notices of denial of Medicare payment accompanied by a discharge date that would be two days after I got that notice.

Dan: Yeah, they said she’d get two days notice. Gloria says the nursing home staff told her she’d have 24 hours to appeal each of those, but even if she won, the denials would keep coming. In fact, they said,

Gloria Bent: If we won a couple of appeals, then we could expect that the frequency with which these denials were going to come would increase.

Dan: All of which happened. NaviHealth started issuing denials July 15, 2022, after Gary had been at the home for a month.

Gloria appealed. She told senators what the doctor who evaluated the appeal found: Gary couldn’t  walk. He couldn’t even move — like from bed to a chair — without help from two people.. That reviewer took Gloria’s side.

Her husband’s next denial came a week after the first. Gloria won that appeal too. She says the reviewer noted that Gary needed maximum assistance with activities of daily living. 

The third denial came four days later, and this time Gloria lost. 

Gary came home in an ambulance: As Gloria testified, he couldn’t get into or out of a car without assistance from someone with special training. 

And when he got into the ambulance, he had a fever. The next morning, he wound up in another ambulance — headed to a hospital with meningitis. He lost a lot of the functioning he’d picked up at the nursing home. 

He died at home a few months later. When Gloria testified in the Senate, all of it was still fresh. She told them that as awful as Gary’s illness and decline had been, the fights with insurance were an added trauma.

Gloria Bent: This should not be happening to families and patients. It’s cruel. Our family continues to struggle with the question that I hear you asking today. Why are people who are looking at patients only on paper or through the lens of an algorithm

making decisions that deny the services judged necessary by health care providers who know their patients.

Dan: Bob Herman calls Gloria’s story heartbreaking, like so many others he’s seen. 

And his attention goes to one part of Gloria’s story beyond denial-by-algorithm. 

Because: It’s not just one denial. It’s that series of denials. You can appeal, but as Gloria testified, the denials speed up. And you have to win every single time. The company only has to win once. 

I mean, unless you’re ready to get a lawyer and take your chances in court– which, in addition to being a major undertaking, also means racking up nursing home bills and legal bills you may never get reimbursed for, while the court process plays out. 

Bob Herman: This appeal system is designed in such a way that people will give up. If you have a job, you know, even if you don’t, and you’re, and you’re also trying to take care of a family member, um, it’s a rigorous monotonous process that will chew people up and spit them out and then the people are inevitably going to give up. And I think in some ways insurers know that.

Dan: Going out on a limb to say: I think so too. So Bob and Casey’s first story on NaviHealth came out in March of 2023. They were the characters in the movie who go, “HEY, I THINK THERE’S SOMETHING REALLY BAD HAPPENING HERE.”

And people started paying attention. Like the U.S. Senate. which held that hearing where Gloria Bent told her story. 

And like the federal agency that runs Medicare — the Centers for Medicare and Medicaid Services, CMS. 

CMS finalized a rule that told insurers: You can’t deny care to people just from using an algorithm. 

And something else happened too: Bob and Casey started suddenly getting a lot MORE information. 

Bob Herman: We received so many responses from people and it just opened the floodgates for former employees, just patients and family members, just everyone across the board.

Dan: And not just former employees. Current employees. And what they learned was: There was absolutely a strategy at work in how this algorithm was being used. It was strategy some people on the inside didn’t feel good about. 

And this strategy got developed after United HealthGroup — and its subsidiary, Optum– bought NaviHealth in 2020. And here’s what NaviHealth employees started telling Casey and Bob about that strategy.

Bob Herman: For some of us, it’s creating this moral crisis. Like we know that we are having to listen to an algorithm to essentially kick someone out of a nursing home, even though we know that they can barely walk 20 feet.

Dan: What Bob and Casey learned from insiders– and how it connects to United’s role as a health care behemoth– that’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering healthcare in America. Their reporters do amazing work, and I’m honored to work with them. We’ll have a little more about KFF Health News at the end of this episode.

So, NaviHealth — the company with the algorithm — got started in 2015.. And the idea behind it was to use data to get people home faster from nursing homes if they didn’t actually need to be there. 

Because there was a lot of evidence that some people were being kept longer than they needed. 

Bob Herman: There is some validity to the idea that there’s, there’s wasteful care in Medicare, like, you know, there’s been cases in the past proving that people stay in a nursing home for way longer than is necessary. And obviously there’s financial incentives for nursing homes to keep people as long as possible. 

Dan: Traditional Medicare does have limits on nursing home care — but if you need “post-acute care” — help getting back on your feet after leaving a hospital traditional Medicare pays in full for 20 days– pretty much no questions asked. One of the selling points of Medicare Advantage — like selling points to policy nerds and politicians — was that it could cut waste, by asking those kinds of questions. NaviHealth and its algorithm were designed to help Medicare Advantage plans ask those questions in a smart way. 

Bob Herman: There were… a lot of believers within NaviHealth that were like, okay, I think we’re doing the right thing. We’re trying to make sure people get home sooner because who doesn’t want to be at home.  

Dan: And as those employees told Bob and Casey: Before United and Optum came in, the algorithm had been there as a guide — a kind of first guess — but not the final word. 

NaviHealth has staff people who interact directly with patients. And back in the day, the pre-United day, Bob and Casey learned that those staff could make their own judgments. 

Which made sense, because the algorithm doesn’t know everything about any individual case. It’s just making predictions based on the data it has.

Bob Herman: And there was just, just this noticeable change after United and OptiMentor that it felt more rigid. There’s no more variation. 

Dan: If the algorithm says you go, you are pretty much going.

Bob Herman: United has said, no, that’s not the case, but obviously these documents and other communications that we’ve gotten kind of say otherwise.

Dan: Because these employees weren’t just talking. They were sharing. Internal memos. Emails. Training materials. All making clear: The company wanted people shipped out on the algorithm’s timetable. 

Bob Herman: Documents came in showing that like this was a pretty explicit strategy. You know, UnitedHealth was telling its employees. Listen, we have this algorithm. We think it’s really good. So when it tells you how many, how many days someone should be in a nursing home, stick to it.

Dan: Stick to it or maybe be fired. Bob and Casey got documents — employee performance goals– saying: How close you stick to the algorithm’s recommendations? That’s part of how we’re evaluating your job performance. 

Bob Herman: It’s okay. Algorithm said 17 days, you better not really go outside of that because your job is on the line. 

Dan: Here’s how closely people were expected to stick to it. In 2022, employee performance goals shared with STAT showed that workers were expected to keep actual time in nursing homes to within three percent of what the algorithm said it should be. Across the board.

So, say you had 10 patients, and the algorithm said they each should get 10 days. That’s 100 days. Your job was to make sure that the total actual days for those patients didn’t go past 103 days.

Then, in 2023, the expectations got more stringent: Stay within one percent of the algorithm’s predictions. 10 patients, the algorithm says 100 days total? Don’t let it get past a hundred and one. 

Bob Herman: Like that is, almost nothing. Like what, what, your hands are tied. If you’re that employee, what are you going to do? Are you going to get fired? Are you going to do what you’re told?

Dan: And one person who ended up talking, to did get fired. 

Bob Herman: Correct. Yes. Uh, Amber Lynch did get fired And what she said was what we had also heard just more broadly was it, it created this internal conflict, like, Oh my God, what I’m doing doesn’t feel right. 

Dan: Amber Lynch was a case manager. She told Bob and Casey about onepatient who couldn’t climb the stairs in his home after knee surgery. But the algorithm said he was ready. Amber’s supervisor said, “Have you asked the nursing home staff if they’ve tried to teach him butt bumping?” Amber grit her teeth and made the suggestion to the rehab director.

Amber Lynch: And she looked at me like I had two heads. She’s like, he is 78 years old. He’s not going to do that. He’s not safe to climb the stairs yet. He’s not doing it. We’re not going to have it butt bump the stairs.

Dan: Amber told Bob and Casey that when she got fired, it was partly for failing to hit the one percent target and partly for being late with paperwork– which she told Bob and Casey she fell behind because her caseload was so heavy.

She wasn’t the only one with that complaint. 

Bob and Casey’s story shows another NaviHealth case manager– not named in the story because they’re still on the job — in their home office, struggling to keep up. 

That week, they were supposed to work with 27 patients and their families. Gather documents, hold meetings. Another week, shortly before, they’d had 40 patients. 

“Do you think I was able to process everything correctly and call everyone correctly the way I was supposed to?” the case manager asked. “No. It’s impossible. No one can be that fast and that effective and capture all of the information that’s needed.”

Bob and Casey watched this case manager fill out a digital form, feeding the algorithm the information it asked for on a man in his 80s with heart failure, kidney disease, diabetes and trouble swallowing, who was recovering from a broken shoulder. 

A few minutes later, the computer spat out a number: 17 days. 

The case manager didn’t have a lot of time or leeway to argue, but they were skeptical that the algorithm could get that number exactly right based on only the data it had. 

And what data is the algorithm working with? What’s it comparing the data on any given patient TO? Bob Herman says that’s a big question.

Bob Herman: It’s something that for sure, like Casey and I, it’s been bothering us. Like, what, how is this whole system? Like, what is it based on? And we were never really given straight answers on that. NaviHealth and Optum and United have said it’s based on millions of patient records over time. The sources of that, it’s, it’s a little unclear, where all that’s coming from. 

Dan: Bob and Casey talked with an expert named Ziad Obermeyer, a professor at the University of California Berkeley School of Public Health, who is not anti-algorithm. He actually builds algorithmic tools for decision making in public health. 

AND he’s done research showing that some widely-used algorithms just scale up and automate things like racial bias.

He told Bob and Casey: Using an algorithm based on how long other, earlier patients have stayed in a nursing home — that’s not a great idea.

Because people get forced out of nursing homes, in his words, “because they can’t pay or because their insurance sucks.” He said, “So the algorightm is basically learning all the inequalities of our current system.”

And leaving aside that kind of bias, it seems unlikely to Bob that any algorithm could predict exactly what every single patient will need every single time. 

No matter how much data it’s got, it’s predicting from averages.

Bob Herman: It reminds me of, like, a basketball game where let’s say someone averages 27 points per game. They don’t have 27 points every single, the game they go out there. It just varies from time to time.

Dan: But the NaviHealth algorithm doesn’t have to be right every time for United to make money using it. 

Using it to make decisions can allow United to boost profits coming and going.

Bob Herman: United health and the other insurance companies that use Navi health. Are using this technology to more or less kick people out of nursing homes before they’re ready. And that is the claims denial side where it’s like, okay, let’s save as much money as we can instead of having to pay it to a nursing home.

Dan: And that’s just one side of it. The insurance side. Claims denial. But United isn’t just in the insurance business. 

United’s Optum side is in every other part of health care. 

Including — in the years since United took over NaviHealth — home health services. The kind of services you’re likely to need when you leave a nursing home.

In 2022, Optum bought one top home health company in what one trade publication called a “monster, jaw-dropping mega-deal” — more than 5 billion dollars. In 2023, Optum made a deal to buy a second mega-provider. 

Bob and Casey’s story says NaviHealth’s shortening nursing home stays is integral to United’s strategy for these acquisitions. It does seem to open up new opportunities.

Bob Herman: You’re out of the nursing home because our algorithm said so. Now we’re going to send you to a home health agency or we’re going to send some home health aides into your home. And by the way, we own them. 

Dan: Oh, right, because: If you’re in a Medicare Advantage plan, your insurer can tell you which providers are covered. 

Bob Herman: So the real question becomes, how much is United potentially paying itself?

Dan: That is: How much might United end up taking money out of one pocket — the health insurance side — and paying itself into another pocket, Optum’s home-health services?

We don’t know the answer to how much United is paying itself in this way, or hoping to. And United has said its insurance arm doesn’t favor its in-house businesses.

But it seems like a reasonable question to ask. Actually, it’s a question the feds seem to be asking.

Optum hasn’t wrapped up its purchase of that second home-health company yet, and in February 2024, the Wall Street Journal and other outlets reported that the U.S. Department of Justice had opened an anti-trust investigation. 

And you don’t have to be in a Medicare Advantage plan run by United to get kicked out of a nursing home on an algorithm’s say-so. 

Bob Herman says NaviHealth sells its algorithm-driven services to other big insurance companies 

He says, put together, the companies that use NaviHealth cover as many as  15 million people — about half of everybody in Medicare Advantage.

Bob Herman: Odds are, if you’re in a Medicare Advantage plan, there’s a, there’s a really good shot that your coverage policies, if you get really sick and need nursing home care, for example, or any kind of post acute care, an algorithm could be at play at some point.

Dan: This is the dark side of Medicare Advantage. 

Bob Herman: Everyone loves their Medicare Advantage plan when they first sign up, right? Because it’s offering all these bells and whistles. It’s, here’s a gym membership. It’s got dental and vision, which regular Medicare doesn’t have. And it’s also just, it’s, it’s cheaper. Like, if it’s just from a financial point of view, if, if you’re a low income senior, How do you turn it down? There’s, there’s so many plans that offer like free, there’s no monthly premiums in addition to all the bells and whistles. But Nobody understands the trade offs , When you’re signing up for Medicare and Medicare Advantage, you’re on the healthier side of, of being a senior, right?

Dan: And none of us can count on staying healthy forever. When you sign up for Medicare  you’re signing up your future self — whether that’s ten or twenty or more years out. That future you, might really need good medical care. 

And at that point, as we explained in our last episode, if Medicare Advantage isn’t working for you, you may not be able to get out of it.

Bob Herman: You could potentially not fully get the care that you need. We shouldn’t assume that, that this couldn’t happen to us because it can. 

Dan: So, yeah. Kind of a horror story. But: Unlike some horror movies, when Bob and Casey started publishing their stories, they started getting people’s attention.

We mentioned the new rules from the feds and the senate hearings after Bob and Casey’s first story in March 2023

Later in the year, when Bob and Casey published their story with documents and stories from inside NaviHealth, a class-action lawsuit got filed.

Since then, CMS has said it will step up audits under its new rules. 

Bob Herman: There was a memo that CMS sent out to Medicare advantage plans that said, Hey, listen, we’re telling you again, do not deny care solely on any AI or algorithms. Like just don’t do it. 

Dan: And in February 2024, the Senate held another hearing. 

Here’s Senator Elizabeth Warren at that hearing, saying these CMS rules aren’t enough. We need stronger guardrails.

Elizabeth Warren: Until CMS can verify that AI algorithms reliably adhere to Medicare coverage standards by law, then my view on this is CMS should prohibit insurance companies from using them in their MA plans for coverage decisions. They’ve got to prove they work before they put them in place.

Dan: So people — people with at least some power– are paying some attention. 

Bob Herman: I don’t think this is necessarily going to escape. Political scrutiny for a while. 

Dan: So, basically, the story isn’t over. 

This isn’t one of those horror movies where the monster’s been safely defeated at the end, and everybody just starts cleaning up the mess. And it’s not one where the monster is just on the loose, unleashing the apocalypse. 

Because it’s not a movie. There’s no ending. There’s just all of us trying to figure out what’s going on, and what we can maybe do about it.

One last thing: I got a lot of emails after our last episode, where we laid out a lot of information about Medicare Advantage and traditional Medicare. Most of it was along the lines of, Thank you! That was really helpful! Which made me feel really good.

And we got a couple notes about things we could have done better. Especially this: We said Traditional Medicare leaves you on the hook for 20 percent of everything, without an out of pocket limit. 

Which is true — but only for Medicare Part B: Doctor visits, outpatient surgeries and tests. Which can add up, for sure.

Medicare Part A — if you’re actually hospitalized — covers most services at 100 percent, after you meet the deductible. In 2024 that’s one thousand, six hundred thirty-two dollars. 

Thanks to Clarke Lancina for pointing that out. 

There have been a bunch of other, amazing notes in my inbox recently, and I want to say: Please keep them coming. 

If you go to arm and a leg show dot com, slash, contact, whatever you type there goes straight to my inbox. You can attach stuff too: documents… voice memos. 

Please let me hear from you. That’s arm and a leg show dot com, slash contact.

I’ll catch you in a few weeks. 

Till then, take care of yourself.

This episode of an arm and a leg was produced by me, Dan Weissmann, with help from Emily Pisacreta, and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and blue dot sessions. Extra music in this episode from Epidemic Sound.

Gabrielle Healy is our managing editor for audience. She edits the first aid kit newsletter. 

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

And Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling and journalism. 

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

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax exempt donations. You can learn more about INN at INN. org. 

Finally, thanks to everybody who supports this show financially– you can join in any time at arm and a leg show dot com, slash, support — and thanks for listening.

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

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

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The Host

Julie Rovner
KFF Health News

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

Florida this week became a major focus for advocates on both main sides of the abortion debate. The Florida Supreme Court simultaneously ruled that the state’s 15-week ban, passed in 2022, can take effect immediately before a more sweeping, six-week ban replaces it in May and that voters can decide in November whether to create a state right to abortion.

Meanwhile, President Joe Biden, gearing up for the general election campaign, is highlighting his administration’s health accomplishments, including drug price negotiations for Medicare.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins University schools of nursing and public health, Tami Luhby of CNN, and Lauren Weber of The Washington Post.

Panelists

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's articles.

Tami Luhby
CNN

@Luhby

Read Tami's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• The Florida Supreme Court’s decisions this week will affect abortion access not only in the state, but also throughout the region. Florida’s six-week ban, which takes effect on May 1, would leave North Carolina and Virginia as the only remaining Southern states offering the procedure beyond that point in pregnancy — and, in North Carolina, abortion is banned at 12 weeks after a woman’s last menstrual period.
• Since the U.S. Supreme Court overturned the constitutional right to an abortion in 2022, six states have voted on their own constitutional amendments related to abortion access. In every case, the side favoring abortion rights has won. But Florida’s measure this fall will appear on the ballot with the presidential race. Could the two contests, waged side by side, boost turnout and influence the results?
• Former President Donald Trump made many attempts during his term to undermine the Affordable Care Act, and this week the Biden administration reversed another one of those lingering attempts. Under a new regulation, the use of short-term insurance plans will be limited to four months — down from 36 months under Trump. The plans, which Biden officials call “junk plans” due to their limited benefits, will also be required to provide clearer explanations of coverage to consumers.
• In other Biden administration news, March has come and gone without the release of an anticipated ban on menthol flavoring in tobacco, and anti-tobacco groups are suing to force administration officials to finish the job. Menthol cigarettes are particularly popular in the Black community, and — like Trump’s decision as president to punt a ban on vaping to avoid alienating voters in 2020 — the Biden administration may be loath to raise the issue this year. Activists say, however, that it may be at the expense of Black lives.
• “This Week in Medical Misinformation” looks at an article from PolitiFact about the health misinformation that persists even with the pandemic mostly in the rearview mirror.

Also this week, Rovner interviews health care analyst Jeff Goldsmith about the growing size and influence of UnitedHealth Group in the wake of the Change Healthcare hack.

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

Julie Rovner: Politico’s “Republicans Are Rushing to Defend IVF. The Anti-Abortion Movement Hopes to Change Their Minds,” by Megan Messerly and Alice Miranda Ollstein.

Tami Luhby: The Washington Post’s “Biden Summons Bernie Sanders to Help Boost Drug-Price Campaign,” by Dan Diamond.

Lauren Weber: The Washington Post’s “Bird Flu Detected in Dairy Worker Who Had Contact With Infected Cattle in Texas,” by Lena H. Sun and Rachel Roubein.  

Joanne Kenen: The 19th’s “Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care,” by Kate Martin, APM Reports.

Also mentioned on this week’s podcast:

• KFF Health News’ “ACA Plans Are Being Switched Without Enrollees’ OK,” by Julie Appleby.
• KFF Health News’ “Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage,” by Susan Jaffe.
• Health Affairs’ “Will the Change Healthcare Incident Change Health Care?” by Jeff C. Goldsmith.
• The Health Care Blog’s “Optum: Testing Time for an Invisible Empire,” by Jeff Goldsmith.

click to open the transcript

Transcript: Florida Limits Abortion — For Now

KFF Health News’ ‘What the Health?’Episode Title: Florida Limits Abortion — For NowEpisode Number: 341Published: April 4, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 4, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this, so here we go.

We are joined today via video conference by Tami Luhby of CNN.

Tami Luhby: Good morning.

Rovner: Joanne Kenen of the Johns Hopkins University Schools of Nursing and Public Health and Politico magazine.

Joanne Kenen: Hi, everybody.

Rovner: And Lauren Weber, the Washington Post.

Lauren Weber: Hello.

Rovner: Later in this episode, we’ll have an interview with Health Policy Analyst and Consultant Jeff Goldsmith about the continuing fallout from the Change Healthcare hack. But first, this week’s news. One of these weeks, we won’t have to lead with abortion news, but this is not that week. On Monday, the Florida Supreme Court ruled separately, but at the same time, that state voters could decide this November whether to make a right to abortion part of the state’s constitution and that the state’s constitution currently does not guarantee that right.

So the state’s 15-week abortion ban signed by Gov. Ron DeSantis in April of 2022 can take immediate effect. But wait, there’s more. First, the decision on the 15-week ban overruled years of precedent that Florida’s Constitution did, in fact, protect the right to abortion. And second, allowing the 15-week ban to take effect automatically triggers an even more sweeping six-week ban that Gov. DeSantis signed in 2023. That will take effect May 1. That’s the one he signed in the middle of the night without an audience people may remember. And this is going to affect far more people than just the population of Florida, right?

Kenen: The whole South. This is it. If you count the South as North Carolina and what we think of as the South, North Carolina is the only state that still has legal abortion, and that is only up to 12 weeks. And there are some conditions and hurdles, but you can still get an abortion in North Carolina.

But to get from a place, people were going to Florida, it’s easier to get from Alabama to Florida than it is from Alabama to even Charlotte. I think I read it’s a 17-hour drive from Florida or something like that. I don’t remember. It’s long. So it’s not just people who live within Florida, but people who live in 11 or 12 states in the American South have far fewer options.

Rovner: And even though the Florida ban feels less than a complete ban because it allows abortions up to six weeks, the fine print actually makes this one of the most restrictive bans in the country. It looks, in effect, like most people won’t be able to get abortions in Florida at all.

Weber: I would say that’s right, Julie. And just to reiterate what Joanne said, 80,000 women get abortions in Florida every year. That’s about one in 12 women in America that get abortions per year, and they will no longer have that kind of access because, at six weeks, a lot of women don’t know they’re pregnant. So, I mean, that’s a very restrictive abortion ban.

Rovner: Remember that six weeks isn’t really six weeks of having been pregnant. Six weeks is six weeks since your last menstrual period, which can be as little as two weeks in some cases.

Kenen: And I also think that even if you do know within six weeks, getting an appointment, given how few places there are in the entire South, even if you know and you get on the phone right away, can you get an appointment before your six weeks is an additional challenge because access is really limited …

Rovner: Right.

Kenen: … intentionally.

Rovner: Yes, and we’ve seen this with other six-week bans. We should point out that some people consider Virginia the South still, and you can go to Virginia, but that’s basically the last place that a good chunk of the country, geographically, if not population-wise, would need to turn to in order to get an abortion.

Well, if that’s not all confusing enough, even if voters do approve the ballot measure in November, the Florida Supreme Court suggested it could still strike down a right to abortion based on a majority of justices findings that the state’s constitution could include personhood rights for fetuses.

I’m having trouble wrapping my head around why the justices would allow a vote whose results they might then overturn. But I guess this is part of the continuing evolution, if you will, to use that word, of this concept of personhood for fetuses and embryos, and what has us talking about IVF, right?

Weber: Yeah, absolutely. I think, as many conservative Christian groups will say, this is the natural line that pro-life is. I mean, they argue, and while they’re pushing this view is not necessarily held by the majority of constituents, but this is their argument that a fetus, an embryo, such as one that could be used in IVF, is a person.

And so, I mean, I think that’s kind of the natural conclusion of pro-life ideology as we’re seeing it right now. And I think it will have a lot of political effects going forward because that IVF is obviously much more popular than abortion. I think we’ll see a lot of voting firepower potentially used on that.

Rovner: Well, I’m so glad you said that because I want to turn to politics. Some Democrats are suggesting that this could boost turnout for Democrats and help, if not put Florida in play for president, maybe the Democrat running to unseat Senator Rick Scott, the Republican.

On the other hand, while abortion ballot questions have done very well around the country, as we know, even in states redder than Florida, there is evidence that some Republicans vote for abortion rights measures and then turn around and vote at the same time for Republicans who would then vote to overturn them.

There are in fact Florida abortion rights advocates who don’t want Democrats to make this issue partisan because they want Republicans to come and vote for the ballot measure, which needs a 60% majority to pass, even if those Republicans then go on to vote for other Republicans. So, who really is helped by this entire mess, or is it impossible to tell at this point?

Weber: I think it’s impossible to tell, but I do think what is complicating is we haven’t seen the presidential race thrown into these abortion ballots. I mean, what we’re looking at is two candidates who potentially are facing a lot of low turnout due to lack of enthusiasm in their bases for both of them. And I am curious if the abortion ballot measures could have much more of an impact on the presidential race than maybe some of these other lower-office races that we’ve seen. I think that’s the main question that I guess we’ll see in November.

Rovner: As we have spoken about many times, President Biden is not super comfortable talking about this issue. He’s an 81-year-old Catholic. It does not come naturally to him to be in favor of abortion rights, which he now is. But Vice President Harris has been sent out. She’s sort of become the standard-bearer for this administration on reproductive health issues, and she’s been very active. And Joanne, you wanted to say something?

Kenen: There are a couple of points. In addition to the abortion ballot initiative. There’s also a marijuana legalization. I think we will see higher turnout and particularly among younger people who have been pretty disaffected this election. So that’s one, whether it affects the presidential race, whether it affects the Senate race. I mean, just as Democrats feel really strong about abortion, Republicans feel really strong about immigration. We don’t know what’s going to happen in November, but I do think this boosts turnout. The second thing to remember, though, is in terms of abortion ballot initiatives have passed every time they’ve come up since the fall of Roe [v. Wade].

This is a 60% threshold, and I do not believe that any state has reached that. I think the highest was about 57%. So even though it may get well over 50, it could get 59.9, the Florida ballot initiative needs 60%. That is a tall order. So you might end up seeing a big turnout, a big pro-abortion rights vote, maybe a big legal weed vote, and the abortion measure could still fail. But I do think it definitely changes the dynamics of Florida from the presidential race on down the ballot. I do think it is a different race than we would’ve seen beforehand.

Rovner: And I will point out, since she didn’t, that Joanne has spent time covering Florida and covering the politics in Florida. So you know where of you speak on this.

Kenen: Well, I lived there for a while, though it was a while ago. The state has, in fact, changed like everything else, including me, right? But I’m somewhat familiar with Florida. I was just there a few weeks ago in fact.

Rovner: And I want to underscore something that Lauren said, which is that we’ve seen all of these ballot measures since Roe was overturned, but we have not seen these ballot measures stacked on top of the presidential race. So I think that will be interesting to watch as we go forward this year.

Well, back here in D.C., the Biden administration issued a long-awaited rule reigning in the use of those short-term health plans that Democrats like to call junk insurance and that President Trump had expanded when he was in office. Tami, what is the new rule, and what will it do?

Luhby: Well, it’s actually curtailing the short-term plans and pretty much reversing the Trump administration rule. So it’s the latest move by the president to contrast his approach to health care with that of former President Donald Trump. Trump extended the duration of the short-term health insurance plans to just under a year and allowed them to be renewed for a total of 36 months. And it was seen as an effort to weaken the Affordable Care Act, draw out younger people, make it more difficult for the marketplace, probably send the older, sicker people there, which would raise premiums, basically cause more chaos in the marketplace.

Rovner: Yeah. And remind us why these plans can be problematic.

Luhby: I will tell you that the short-term plans do not have to adhere to Obamacare’s consumer protections, which is the big difference. For instance, they’re not required to provide comprehensive coverage, and they can discriminate against people with pre-existing conditions, charge them more, deny them, et cetera. As I’d said, the Trump administration heralded them as a cheaper alternative because since they can underwrite, they have typically cheaper premiums. But they also have very limited benefits, or they can have limited benefits depending on the patient or the consumer.

So the Biden rule, which was proposed last month as a series of actions aimed at lowering health care costs, limits the duration of new sales of these controversial plans to three months, with the option of renewal for a maximum of four months. So it’s going on these new plans from 36 months potentially to four months, which was the original idea of these plans because originally they were thought to be for people who might be switching jobs or have a temporary lapse in coverage. They were not intended to be a substitute for full insurance. And it also requires, notably, that the plans provide consumers with a clear explanation of their benefits and inform them of how to find more comprehensive coverage.

Rovner: And obviously this will continue to be controversial, but I think the Democrats, in general, who support the Affordable Care Act feel pretty strongly that this is something that’s going to help them. And as we talked about, we’re not sure yet how the administration is going to play the abortion issue in the campaign, but it is pretty clear that they are doubling down on health care.

One problem for the administration, as we have talked about, is that particularly on really popular things like Medicare drug price negotiations, lots of the public has no idea that that’s happened or if it’s happened that it’s because the Democrats did it. So, in part of an effort to overcome that, Biden invited Bernie Sanders to the White House this week. What was that about?

Luhby: Well, that’s my extra credit. Would you like me to discuss that now?

Rovner: Sure, let’s do that now.

Luhby: OK. So my extra credit is a Washington Post story titled “Biden Summons Bernie Sanders to Help Boost Drug-Price Campaign,” by Dan Diamond. And I have to admit, I hope I can do that here, that I am a fangirl of Dan Diamond’s stories, and even more so now because apparently, the Biden administration gave Dan a heads-up in advance, that since he published a pretty in-depth story an hour before the embargo lifted for the rest of us who were only given a few tidbits of information about what this meeting or what this speech was going to be about at the uncharacteristically late hour of 8:30 at night.

So Dan’s story looked at how the two former rivals, Joe Biden and [Sen.] Bernie Sanders, who were rivals in the 2020 Democratic presidential nomination, how they had very different views on how the nation’s health care system should operate and Dan’s story looked at how they were uniting to improve awareness of Biden’s efforts to lower drug prices and improve his chances in November. Biden invited Sanders to the White House to discuss the administration’s actions on drug prices, including the latest effort to reduce the out-of-pocket cost of inhalers, which really hasn’t gotten a lot of press.

Sanders brings his progressive credentials and his two-decade-plus track record of fighting for lower drug prices and, “naming and shaming individual pharmaceutical companies and executives.” He’s known to be pretty outspoken and fiery. So the story’s a good example of policy meets politics in an election year. It relays that most Americans still don’t know about the administration’s efforts despite the numerous speeches, news releases, and officials’ trips around the country, hence the need to tap Sanders, and it also provides a nice walk down memory lane, revisiting the duo’s battles in the 2020 primary as well as some of former President Trump’s drug price efforts.

Rovner: Yeah. And a little peek behind the journalistic curtain. I think we all got this sort of mysterious note from Sanders’ press people the night before saying, “If you’ll agree to our embargo, we’ll tell you about this secret thing that’s going to happen,” followed by an advisory from the White House saying that Bernie Sanders was coming to the White House to talk about drugs. [inaudible 00:13:30] …

Luhby: Right. And also, uncharacteristically, when I asked for a comment from Sanders directly, they said tomorrow, which is not like Sanders at all.

Kenen: Sanders and Biden were obviously opponents in the primary, but Sanders has really been very supportive of Biden. I think he’s really sort of highlighted the progressive things that Biden has done and stayed quiet about the more centrist things that Biden has done. He’s been a real ally, and he still has a lot of credibility, and I think they sort of like each other in a funny way. You can sort of see it, but that’s their issue.

Luhby: Biden has also been able to do things that other people have not been able to do with the congressional Democrats. Biden has been able to do things that congressional Democrats have tried to for years and have not been able to, and they may not be the extent to which the Democrats would like. If you remember the 2019 Medicare Drug Negotiation bill, I think, was 250 drugs a year. What ended up passing in the IRA [Inflation Reduction Act] was 10 drugs and ramping up, but at least it’s something.

Kenen: And it’s more than 20 years in the making. I mean, this goes way, way back.

Luhby: Mm-hmm.

Rovner: And I was going to underscore something that Joanne said earlier about Florida, which is that both sides are trying to gin up their base, and young people are really fond of Bernie Sanders in a lot of the things that he says, and this may be a way that Biden can ironically use the Medicare drug price negotiation issue to stir up his young person base to get them out to vote. So I was interested in the combination.

Kenen: So it’s Bernie Sanders and legal weed.

Rovner: That’s right. It’s Bernie Sanders and legal weed, at least in Florida.

Kenen: I’m not implying anything about Bernie Sanders’ use of it. It’s just the dynamic for the young voters.

Rovner: Yes. Things to draw young people out to the polls in November. Well, while the Biden administration is doing lots of things using its regulatory power, one thing it is not doing, at least not yet, is banning menthol flavoring in tobacco.

This is a regulation that’s now been sitting around for nearly two years and that officials had promised to finalize by the end of March, which of course was last week and which didn’t happen. So now three anti-tobacco groups have sued to try to force the regulation over the finish line. Somebody remind us why banning menthol is so very controversial.

Weber: It’s controversial in part because a lot of industry will say that banning menthol will lead to over-policing in Black communities. The jury is very much out on if that is an accurate representation or part of the cigarette playbook to keep cigarettes on the market. Look, a presidential election year and things to do with smoking is not new.

When I was at KFF Health News with Rachel Bluth back in the day, we wrote a story about how Trump postponed a vape ban to some extent because he was worried about vaping voters. So I mean, I think what you’re seeing is a pretty clear political calculus by the Biden folks to push this off into the new year, but as activists and public health advocates will say, it’s at the expense of, potentially, Black lives.

Rovner: That’s right.

Weber: So banning menthol cigarettes would really… what it would do is statistically save Black Americans who die from, predominantly from smoking these types of cigarettes. So it’s a pretty weighty decision to put off with a political calculus.

Rovner: He’s taking incoming from both sides. I mean, obviously, there are members of the Black community who say, as you point out, this could lead to an unnecessary crackdown on African American smokers who use menthol more statistically than anybody else does. Although, there’s some young people who use it too. On the other hand, you have people representing public health for the Black community saying, “We want you to ban this” because, as you point out, people are dying from smoking-related illnesses by using this product. So it’s a win-win, lose-lose here that is continuing on. We’ll be interested to see what, if the lawsuit can produce anything.

Well, speaking of things that are controversial, we also have Medicare Advantage. The private plan alternative to traditional Medicare now enrolls more than half of those in the program, many who like the extra benefits that often come with the plans and others who feel that they can’t afford traditional Medicare’s premiums and other cost-sharing. Except one reason those extra benefits exist is because the government is overpaying those Medicare Advantage plans. That’s a vestige of Republican plans to discourage enrollment in original Medicare that date back to the early part of this century.

So now taxpayers are footing more of the Medicare bill than they should. This week’s news is that the federal government is effectively trimming back some of those overpayments. And investors in the insurance companies, who make money from the overpayments, are going crazy. This is the subhead on a story from the Wall Street Journal, “Managed care stocks are set to fall due to disappointment with the government’s decision not to revise the 2025 Medicare payment proposal.” How is this ever going to get sorted out? Somebody always is going to be a loser in this game, either the patients or the insurance companies or the taxpayers. Everybody cannot win here.

Luhby: Right. And Humana got hit really hard when the rule came out because it is really focused on Medicare Advantage. So yeah, the insurers were hit, but as everything with the market, it’s not forever.

Rovner: I’m continually puzzled by … if the payments were equivalent, which was what they were originally supposed to be. Originally, originally back in the 1980s, insurance companies came to Congress and said, “We can provide managed care and Medicare cheaper, so you can pay us 95% of the average that you pay for a fee for service patient. We can make a profit on that.”

Well, that is long since gone. The question is how much more they will make. And as I point out, when they get overpaid, they do have to rebate those back effectively to the patients in terms of higher benefits. And that’s why many of them offer dental coverage and eyeglasses coverage and other types of, quote-unquote, extra benefits that Medicare doesn’t offer.

But also you get this lack of choice, and so we see when people try to leave these plans and go back to traditional Medicare, they can’t, which is only one of the sort of things that I think a lot of people don’t know about how Medicare Advantage works. Another place with an awful lot of small print.

Weber: It’s a lot of small print under a very good marketing name. The name itself implies that you’re making a better choice, but that isn’t necessarily what the small print would say.

Kenen: And there are people who are very satisfied with it and who get great care. I mean, it’s not monolithic. I mean, it is popular. It is growing and growing and growing. It’s partly economic, and there’s some plans that patients like, and there’s word of mouth or that were negotiated as part of union agreements and are actually pretty strong benefits. But they’re also people who are really encountering a lot of trouble with prior authorization, and limited networks, and your doctor’s no longer in it, et cetera, et cetera.

I think that those things, I actually checked with somebody about the provider networks, what we know about who’s dropping out, and I don’t think there’s really up-to-date data, but there is a perception, and you’re hearing it and seeing it online. But they do an incredible amount of marketing, an incredible amount of marketing. And if you’re in it and you like it and you save money and you’re getting great health care, terrific. You’re going to stay in it.

If you’re in it and you don’t like it and you’re not getting great health care and a lot of hassles or you can’t see the right doctors, it’s hard to get out and get back into it depending on what state you’re living … It’s not monolithic. But I think we might be between the financial pressures from the government and some of the debates about some of these things they’re doing there may be some reconsideration. But they have strong backers in Congress and not just Republicans.

Rovner: Oh, yeah. I mean, and as you point out, more than half of the people in Medicare are now on Medicare Advantage. I did want to sort of highlight my colleague Susan Jaffe, who has a story this week about the fact that patients can’t change plans in the middle of the year, but plans can drop providers in the middle of the year, so people may sign up for a health plan because their doctor or their hospital is in it and then suddenly find out mid-year that their doctor and their hospital is no longer in it.

There are occasionally, if you’re in the middle of treatment, there are opportunities sometimes to change, but often there aren’t. People do end up in these plans, and they can be happy for, basically, until they’re not, that there are trade-offs when you do it. And I think, as we point out, there’s so much marketing, and the marketing somehow doesn’t ever talk about the trade-offs that you make when you go into Medicare Advantage.

Luhby: Well, one also thing is that this is the peak 65 year, where the most baby boomers, and where are they coming from? They’re coming from private commercial insurance, so they’re familiar with it, and they were like, “Oh, OK, that’s seemingly very much like my employer plan. Sure, that sounds great. I know how to deal with that.” So that’s one of the things. And one cudgel that the insurers have is they say, “Oh, government, you’re going reduce our payments. We’re going to reduce the benefits and increase the premiums because we’re not going to have all of that extra government funding.” And that can scare the government because they don’t want the insurers to tell their patients, who are older patients who vote, “Oh, because of the government, we can no longer offer you all of these benefits, or we’ve had to raise your premium because of that.” So we’ll see if they actually do that.

Kenen: Joe Biden took away your gym, right?

Luhby: Exactly.

Rovner: [inaudible 00:22:11].

Luhby: And your dental benefits. So that’s always the threat that the insurers roll out. That’s the first thing that they say often, but we’ll see what happens. We don’t know yet until the fall, when enrollment starts, what will actually happen?

Rovner: We saw exactly that in the late ’90s after Congress balanced the budget. They took a big whack out of the payments for what was then, I think, called Medicare Plus Choice. It was the previous version of Medicare Advantage, and a lot of the companies just completely dropped out of the program. And a lot of the people, who as Joanne said, had been in those plants had been very happy, threw a fit and came to Congress to complain, and lo and behold, a lot of those payments got increased again. In fact, that was what led to the big increase in payments in 2003 was the huge cut that they made to payments, which drove a lot of the insurers out of the program. So we do know that the insurers will pack up and leave if they’re not paid what they consider to be enough to stay in the program.

Moving on. One of the things that Jeff Goldsmith talks about in this week’s interview is that our health system has become one of deep distrust between patients, providers, and insurers. Speaking of Medicare Advantage. That is sad and dysfunctional, except that sometimes there are good reasons for that distrust. One example comes this week from my KFF Health News colleague Julie Appleby. It seems that unscrupulous insurance brokers are disenrolling people in Obamacare plans from their health plans and putting them in different plans, which is unbeknownst to them until they find their doctor is no longer in their network or their drug isn’t covered.

The brokers who are doing this can earn bigger commissions. But patients can end up not just having to pay for their own medical care but owing the government money because suddenly they’re in plans getting subsidies that don’t match their incomes. It is a big mess. And it seems that the obvious solution, which would be making it harder for agents to access people’s enrollment information so they can switch them, would delay legitimate enrollment. It has to be easy for agents to basically manipulate people’s applications. So how do you guard against bad actors without inconveniencing everyone? This seems to be the question here and the question for Medicare Advantage, Lauren.

Weber: I was going to say, I mean, I think that’s the question Medicare itself has been dealing with for years. I mean, there’s a reason that many federal prosecutors call this a pay-and-chase situation in which there is rampant Medicare fraud. They prioritize the ease of patients accessing care to the disadvantage of some folks, or in this case, the American taxpayer, in this case, actual patients, being swindled.

But I don’t have an answer. I don’t think anyone really has an answer, considering we’re seeing things like the $2 billion catheter fraud that we’ve talked about here. So I think again, this is one of these things where the government’s been left a little flat-footed in trying to protect against bad actors.

Rovner: Yeah, well, the health sector is what a fifth of the economy now, so I guess it shouldn’t come as much of a surprise that you have not just bad actors, people who are making a lot of money from doing illegal things and find it to be worth their while and that some of them get caught, but presumably most of them don’t. I guess that’s what happens when you have that much money in one place, you need sort of better watchdogs. All right. Well, finally, this week in medical misinformation comes from PolitiFact in a story called “Four Years After Shelter-in-Place, Covid-19 Misinformation Persists.” That’s an understatement.

That last part was mine. At the top of the list says, “We have discussed before is growing resistance to vaccines in general, not just the covid vaccine,” which is not all that surprising considering how many people now believe fictitious stories about celebrities dropping dead immediately after receiving vaccines. There’s even a movie called “Died Suddenly.” Or that government leaders and the superrich orchestrated the pandemic. That’s another popular story that goes around. Or that Dr. Tony Fauci brought the virus to the United States a year before the pandemic. Lauren, health misinformation is your beat. Is it getting any better now that the pandemic is largely behind us, or is it just continuing unabated?

Weber: No, I would argue it’s possibly getting worse because the trust in institutions is at an all-time low. Social media has allowed for fire hose. I mean, it’s made everything … it’s made the public square that used to be more limited, all corners of the country.

I would say that misinformation has led to mistrust about basic medical things, including childhood vaccinations, but also other medical treatment and care. And I think you’re really seeing this kind of post-truth world post-covid, this distrust, this misinfo is going to continue for some time. And there’s too much to cover on my beat. There’s constantly stories around the bend, and I don’t expect that improving anytime soon.

Kenen: Every single time a celebrity, not just dies, because it’s always no matter what happens, it’s blamed on the covid vaccine, but also gets sick. I mean, Princess Kate. We don’t know everything about her health, but I mean, all of us know it wasn’t. Whatever it is, it’s not because the covid vaccine. But if you go online, you hear that that’s whatever she has it’s because she’s vaccinated.

And the other thing is it’s fed into this general vaccine mistrust. So when I wrote about the RSV vaccine, which we talked about a few weeks ago, it wasn’t so much that there’s a campaign against the RSV vaccine. There is somewhat of that. But it’s just this massive, “vaccines are bad.” So it’s spilling over into anything with a needle attached is part of this horrible plot to kill us all. So it’s just sort of this miasma of anti-vaccination that’s hovering over a lot of health care.

Rovner: Well, at the risk of getting a little too bleak, that will be the news for this week. Now, we will play my interview with Jeff Goldsmith, and then we’ll come back and do our extra credits. I am pleased to welcome back to the podcast Jeff Goldsmith, one of my favorite big-picture health system analysts. Jeff has been writing of late about the Change Healthcare hack and the growing size and influence of its owner, UnitedHealth Group, and what that means for the country’s entire health enterprise. Jeff, thanks for joining us again.

Jeff Goldsmith: You bet.

Rovner: So the lead of your latest piece gives a pretty vivid description of just how big United has become, and I just want to read it. “Years ago, the largest living thing in the world was thought to be the blue whale. Then someone discovered that the largest living thing in the world was actually the 106-acre, 47,000-tree Pando aspen grove in central Utah, which genetic testing revealed to be a single organism.

With its enormous network of underground roots and symbiotic relationship with a vast ecosystem of fungi, that aspen grove is a great metaphor for UnitedHealth Group. United, whose revenues amount to more than 8% of the U.S. health system, is the largest health care enterprise in the world.” Let’s pick up from there for people like me who haven’t been paying as much attention as maybe they should have, and still think that United is mainly a health insurance company. That is not true and hasn’t been for some time, has it?

Goldsmith: The difference between United and a health insurance company is that it also has $226 billion worth of care system revenues in it, some of which are services rendered to United and other, believe it or not, services rendered to United competitors. So, there isn’t anything remotely that size in the health insurance world. That $226 billion is more than double the size of Kaiser. Just to give you an idea of the scale.

Rovner: Which, of course, is the other companies that are both insurers and providers. That’s pretty much the only other really big one, right?

Goldsmith: Yes. I have a graphic in the piece that shows the Optum Health part, which is the care delivery part of Optum, is just about the same size as Kaiser, but it generates six and a half billion dollars in profit versus Kaiser’s $323 million. So it dwarfs Kaiser in terms of profitability even though it’s about the same size top line.

Rovner: So split it up for people who don’t know. What are sort of the main components that make up UnitedHealth Group?

Goldsmith: Well, there’s a very large health insurance business, $280 billion health insurance business. Then, there is a care system called Optum Health, which is about $95 billion. It has 90,000 affiliated or employed docs, a huge chain of MedExpress urgent care centers, surgery centers, a couple of very large home health care agencies. So that’s the care delivery part of United.

There’s Optum Insight, which is about $19 billion. That’s the part that Change Healthcare was inside of. It’s a business intelligence and corporate services business, and consulting business, that also manages care systems financials. And then, finally, there’s Optum Rx, which is about $116 billion, so a little bit more than half of Optum’s total, and that is a pharmacy benefit management company. Believe it or not, the third-largest one. So there are bigger pharmacy benefits management companies than Optum, but those are the three big pieces.

Rovner: I feel like this is almost as big as a lot of the government health programs, isn’t it?

Goldsmith: Yeah. I mean, I can’t remember top line how big the VA [Department of Veterans Affairs] is these days, but it’s VA scale, but it’s in a bunch of little pieces scattered all over the United States. I mean, that’s the big part of all of this. The care system is in at least 30 states. I have a map showing where some of the locations are. That map took me months to find. There isn’t a real registry of what the company owns, but it is a vast enterprise. And they’re great assets, if you’ll pardon a financial term for them.

Some of the finest risk-bearing multispecialty group practices in the United States are a part of Optum: Healthcare Partners based in Los Angeles; The Everett Clinic; the former Fallon Clinic, and Atrius in New England, which are the two finest risk-bearing, multispecialty physician groups in the Northeast. They weren’t dredging the bottom here at all. They got a tremendous number of high-quality groups that they’ve pulled together in the organization. The issue is it really an organization or is it a collection of assets that have been acquired at a very rapid pace over a period of the last 15 years.

Rovner: One of the things that I think the Change Healthcare hack proved for a lot of people is that nobody realized what a significant percentage of claims processing could go through one company. You have to wonder, have regulators, either at the state or federal level, kind of fallen down on this and sort of let this happen so that when somebody hacks into it, half the system seems to go down?

Goldsmith: The federal government challenged the Change acquisition and basically lost in court. They were unable to make the case. They were arguing that Change controlling all of these transactions of not only United but a lot of other insurers gave them access to information that enabled United to have some type of unfair competitive advantage. It was a difficult argument to make that didn’t make it. But the result of the Change acquisition was that about a third of the U.S. health system’s money flowed through one company’s leaky pipes.

And what we’re sort of learning as we learn more about Change is that there were something like a hundred separate programs inside Change, all of which somehow were vulnerable to this hack. And I think that’s one of the things that I think when [Sen.] Ron Wyden and [Sen.] Mark Warner get around to getting some facts about this, they’re going to wonder how did that happen. How could you have that many applications, that loosely tied together, that they were vulnerable to something like this?

And what my spies tell me is that a hacker, and it could have been a single hacker, not a country, but one guy was able to drop down into all of those data silos, vacuum out the data, and then delete the backups, so that United was basically left with no claims trail, no provider directories, nothing, and has had to reconstruct them; panicky reconstruction here in the last six weeks.

Rovner: Which I imagine is what’s taking so long for some of these providers to get back online.

Goldsmith: Julie, the part I don’t understand, is if it is true that that Change was processing a trillion and a half dollars worth of claims a year, a month interruption is $125 billion. That’s $125 billion that didn’t get paid to providers of care after the fact of them rendering the care. So the extent of the damage done by this is difficult to comprehend.

I mean, I have a lot of provider contacts and friends. Some of them, believe it or not, had no Change exposure at all because their main payers didn’t use Change. Some of them, it was all their payers used, and cash flow just ceased, and they had to go to the bank and borrow money to make their payrolls. None of this, for some reason, has made it in its full glory out into the press, and it isn’t that there aren’t incredibly high-quality business reporters in this field. There are.

Rovner: I know. I live in Maryland. I’ve driven over the Francis Scott Key Bridge in Baltimore. I know what it means. I mean, basically took apart the Baltimore Beltway. I mean, no longer goes in a circle. And I know how big the Port of Baltimore is, and I feel like everybody can understand that because it’s visceral. You can see it. There’s video of the bridge falling down. There isn’t video of somebody hacking into Change Healthcare and stopping a lot of the health system in its tracks.

Goldsmith: The metaphor that occurred to me, as you know, I’m a metaphor junkie, was actually Deepwater Horizon, and of course, we had a camera on that gushing well the whole time. This is like a gusher of red ink, a Deepwater Horizon-sized gusher of red ink that went on for a month. From what I’m able to understand, people are able to file the claims now. How many people have actually been paid for the month or six weeks’ worth of work they’ve done is elusive. And I still don’t have access to really good facts on how much of what they owed people they’ve actually paid.

I do know a lot of my investor analyst friends are waiting for United’s first-quarter financials to drop, which will probably show a four- or five-day drop in their medical loss ratio because of all the claims they were not able to pay, and therefore money was sitting in their coffers earning, what, 5% interest. That’s going to be kind of a festival when the first-quarter financials drop. And, of course, it isn’t just United, Humana, the Elevance, Cigna, all the rest of them. A lot of these folks use Change to process their claims. So there’s going to be a swollen offer here on the health insurance side from a month of not paying their bills.

Rovner: Well, is it the next Standard Oil? Is it going to have to be taken apart at some point?

Goldsmith: Yeah, but I mean, the question is, on what basis? Our health care system is so vast and fragmented, even a generous interpretation of antitrust laws, you’d have trouble finding a case. The Justice Department or FTC [Federal Trade Commission] is going to try again. But I’ll tell you, I think they’ve got their work cut out for them. I think the real issue isn’t anti-competitiveness, it’s a national security issue. If you have a third of the health systems dollars flowing through one company’s leaky pipes, that’s not an antitrust problem. It’s a national security problem, and I think there are some folks in the U.S. Senate that are righteously pissed about this.

There’s a lot of fact-finding that needs to happen here and a lot of work that needs to be done to make this system more secure. And I’ve also argued to make it simpler. Change was processing 15 billion transactions a year. That’s 44 transactions for every man, woman, and child in the country, and that was only a third of them. What are we doing with 100 billion transactions? What’s up with that? It beggars the imagination to believe that we to minutely manage every single one of those transactions. That is just an astonishing waste of money. It’s also an incredible insult to our care system. The assumption that there at any moment, every one of those folks could potentially be ripping us off, and we can’t have that.

Rovner: So we’re spending all of this money to try and not be ripped off for presumably less money.

Goldsmith: Hundreds of billions of dollars, but who’s counting?

Rovner: It’s kind of a depressing picture of what our health system is becoming, but I feel like it is kind of an apt picture for what our health system has become.

Goldsmith: It’s the level of mistrust. The idea that every one of his patients is trying to get a free lunch, and every doctor is trying to pad his income. We’ve built a system based on those twin assumptions. And when you think about them for a minute, they really are appalling assumptions. Most of what motivated me when I had cancer was fear.

I wasn’t trying to get stuff I wasn’t entitled to or didn’t need. I wanted to figure out a way to not be killed by the thing in my throat. And my doctors were motivated by a fear that if they let me go, maybe my heirs would sue them. I guess this idea that we are just helpless pawns of a behaviorist model of incentives, I think the economists ran wild with this thesis. And I think it’s given us a system that doesn’t work for anybody.

Rovner: Is there a way to fix it?

Goldsmith: I think we ought to cut the number of transactions in half. We ought to go and look at how many prior authorizations are really needed. Is this a model we really want to continue with, effectively universal surveillance of every clinical decision? We ought to be paying in bundles. We ought to pay our primary care physicians monthly for every patient that they see that’s a continuing patient and not chisel them over every single thing they do. We ought to pay for complex care in bundles where a cancer treatment is basically one transaction instead of hundreds.

I think we could get a long way to simplifying and reducing the absurd administrative overburden by doing those things. I also think that the idea that we have 1,100 health insurers. United’s the biggest, but it’s not by any means the only health insurer. There’s 1,100 rule sets that determine what data you need in order to pay a claim and whether a claim is justified or not. I think that’s a crazy level of variation. So I think we need to attack the variation. We’ve had health policy conversations about this for years and not done anything, and I think it’s really time to do it.

Rovner: Maybe this will give some incentive to some people to actually do something. Jeff Goldsmith, thank you so much.

Goldsmith: Julie. It’s good talking to you.

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

Weber: Yeah. I think we’re all keeping an eye on this in this podcast, but the title of this story is “Bird Flu Detected in Dairy Worker Who Had Contact With Infected Cattle in Texas,” which was written by my colleagues, Lena Sun and Rachel Roubein. Also, great pieces by Helen Branswell in the Texas Tribune on this as well.

But, essentially, just so listeners know, there has been a case of human bird flu detected, which is very concerning. As all of us on this podcast know, avian human flu is one of the worst-case scenarios in terms of a pathogen and infectiousness. As of right now, this is only one person. It seems to be isolated. We don’t know. We’ll see how this continues to mutate, but definitely something to keep an eye on for potential threat risk. TBD.

Rovner: Yeah. It is something I think that every health reporter is watching with some concern. Although, as you point out, we really don’t know very much yet. And so far, we have not seen. I think what the experts are watching for is human-to-human transmission, and we haven’t seen that yet.

Kenen: And this person seems to have a mild case, from the limited information we have, which is also a good sign for both that individual and everybody else in terms of spreadability.

Rovner: But we will continue to watch that space. Joanne.

Kenen: Well, you said enough bleak, but I’m afraid this is somewhat bleak. This is a piece by Kate Martin from APM Reports, which is part of American Public Media, and it was published in cooperation with The 19th, and the headline is “Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care.” So there’s a very, very strong sort of everybody points to it as great law in Illinois saying that what kind of care hospitals have to provide to sexual assault victims and what kind of testing and counseling and everything. This whole series of services that legally they must do, and they’re not doing it. Even in cases of children being assaulted, they’re sending people 40 miles away, 80 miles away, 40 miles away. They’re not doing rape kits. They’re not connecting them to the counselors, et cetera. It is a pretty horrifying story. It begins with a story of a 4-year-old because they didn’t do what they were supposed to do. The father was the suspected perpetrator, and because the hospital didn’t do what they should have done he still has joint custody of this little girl.

Rovner: My story this week is from our podcast colleague, Alice [Miranda] Ollstein, and her Politico colleague, Megan Messerly, and it’s called “Republicans Are Rushing to Defend IVF. The Anti-Abortion Movement Hopes to Change Their Minds.” And it’s about the fact that while maybe not trying to outlaw IVF entirely, the anti-abortion movement does want to dramatically change how it’s practiced in the U.S.

For example, they would like to decrease the number of embryos that can be created and transplanted, both of which would likely make the already expensive treatment even more expensive still. Anti-abortion activists also would like to ban pre-implantation genetic testing so that, “Defective embryos can’t be discarded.” Except that couples with genes for deadly diseases often turn to IVF exactly because they don’t want to pass those diseases on to their children, and they would like to test them before they are implanted.

In other words, the anti-abortion movement may or may not be coming for contraception, but it definitely is coming for IVF. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our technical guru, Francis Ying, and our editor Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Tami, where can we find you?

Luhby: I’m at cnn.com.

Rovner: There you go. Joanne.

Kenen: @JoanneKenen on X, and @joannekenen1 on Threads. 

Rovner: Lauren.

Weber: @LaurenWeberHP on X

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

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

In its first abortion case since the overturning of Roe v. Wade in 2022, the Supreme Court this week looked unlikely to uphold an appeals court ruling that would dramatically restrict the availability of the abortion pill mifepristone. But the court already has another abortion-related case teed up for April, and abortion opponents have several more challenges in mind to limit the procedure in states where it remains legal.

Meanwhile, Republicans, including former President Donald Trump, continue to take aim at popular health programs like Medicare, Medicaid, and the Affordable Care Act on the campaign trail — much to the delight of Democrats, who feel they have an advantage on the issue.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.

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Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• At least two conservative Supreme Court justices joined the three more progressive members of the bench during Tuesday’s oral arguments in expressing skepticism about the challenge to the abortion drug mifepristone. Their questions focused primarily on whether the doctors challenging the drug had proven they were harmed by its availability — as well as whether the best remedy was to broadly restrict access to the drug for everyone else.
• A ruling in favor of the doctors challenging mifepristone would have the potential to reduce the drug’s safety and efficacy: In particular, one FDA decision subject to reversal adjusted dosing, and switching to using only the second drug in the current two-drug abortion pill regimen would also slightly increase the risk of complications.
• Two conservative justices also raised the applicability of the Comstock Act, a long-dormant, 19th-century law that restricts mail distribution of abortion-related items. Their questions are notable as advisers to Trump explore reviving the unenforced law should he win this November.
• Meanwhile, a Democrat in Alabama flipped a state House seat campaigning on abortion-related issues, as Trump again discusses implementing a national abortion ban. The issue is continuing to prove thorny for Republicans.
• Even as Republicans try to avoid running on health care issues, the Heritage Foundation and a group of House Republicans have proposed plans that include changes to the health care system. Will the plans do more to rev up their base — or Democrats?
• This Week in Medical Misinformation: TikTok’s algorithm is boosting misleading information about hormonal birth control — and in some cases resulting in more unintended pregnancies.

Also this week, Rovner interviews KFF Health News’ Tony Leys, who wrote a KFF Health News-NPR “Bill of the Month” feature about Medicare and a very expensive air-ambulance ride. If you have a baffling or outrageous medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: KFF Health News’ “Overdosing on Chemo: A Common Gene Test Could Save Hundreds of Lives Each Year,” by Arthur Allen.

Alice Miranda Ollstein: Stat’s “Fetal Tissue Research Gains in Importance as Roadblocks Multiply,” by Olivia Goldhill.

Sarah Karlin-Smith: The Washington Post’s “The Confusing, Stressful Ordeal of Flying With a Breast Pump,” by Hannah Sampson and Ben Brasch.

Lauren Weber: Stateline’s “Deadly Fires From Phone, Scooter Batteries Leave Lawmakers Playing Catch-Up on Safety,” by Robbie Sequeira.

Also mentioned on this week’s podcast:

• The Washington Post’s “Nikki Haley Wants ‘Consensus’ on Contraception. It’s Not That Easy,” by Julie Rovner.
• Politico’s “Justices Were Skeptical of Abortion Pills Arguments. Anti-Abortion Groups Have Backup Plans,” by Alice Miranda Ollstein.
• Politico’s “Why Portland Failed Where Portugal Succeeded in Decriminalizing Drugs,” by Carmen Paun and Aitor Hernández-Morales.

click to open the transcript

Transcript: The Supreme Court and the Abortion Pill

KFF Health News’ ‘What the Health?’Episode Title: ‘The Supreme Court and the Abortion Pill’Episode Number: 340Published: March 28, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 28, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this, so here we go.

We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Morning, everybody.

Rovner: And Lauren Weber of The Washington Post.

Lauren Weber: Hello, hello.

Rovner: Later in this episode, we’ll have my Bill of the Month interview with my KFF Health News colleague Tony Leys, about Medicare confusion and a really expensive air ambulance ride. But first, this week’s news.

So the big news of the week here in Washington were the oral arguments at the Supreme Court on a case that could seriously restrict the availability of the abortion pill mifepristone. This was the first major abortion case to come before the justices since they overturned Roe v. Wade in 2022, and the buildup to this case was enormous. But judging from the oral arguments, it seems like this huge case might kind of fizzle away? Alice, you were there. What happened?

Ollstein: Yeah, Sarah and I were both there. We got to hang out in the obstructed-view section of the press section. Luckily, most of the justices’ voices are easily recognizable. So even from behind the curtain, we could tell what was going on. What was obviously expected was that the court’s three more-progressive justices would take a really skeptical and hard look at this case brought by anti-abortion doctors.

But what was somewhat more surprising is that several, at least two, arguably three, of the conservatives joined them in their skepticism. And they really went after two core pieces of this challenge to the FDA. One on “standing,” whether these doctors can prove that they have been harmed by the availability of these pills in the past and are likely to be in the future. There was a lot of talk about how the FDA doesn’t require these doctors to do or not do anything, and the case relies on this speculative chain of events, from the FDA approving these pills to someone seeking out one of these doctors, in particular, to treat them after taking one, and that being way too loose a connection to establish standing.

The other piece that the conservative justices were maybe not in favor of was the demand for this sweeping universal ruling, restricting access to the pills for everyone. They were saying, “Wouldn’t something more tailored to just these doctors make more sense instead of imposing this policy on everyone in the nation?” So that really undermines their case a lot. Although, caveat, you cannot tell how the court’s going to rule based on oral arguments. This is just us reading the tea leaves. Maybe they’re playing devil’s advocate, but it is telling.

Rovner: Yeah, somebody remind us what could happen if the justices do reach the merits of this case. Obviously from the oral argument, it looks like they’re going to say that these particular doctors don’t have standing and throw the case out on that basis. But if in case, as Alice says, they decide to do something else, what could happen here? Sarah, this is a big deal for drug companies, right?

Karlin-Smith: Right. So in terms of the actual abortion pill mifepristone itself, the approval of the drug is not on the line at this point. That was taken off the table, though a lower court did try and restrict the drug entirely. What’s on the table are changes FDA made to its safety programs for the drug since 2016 that have had the impact of making the drug more available to people later in pregnancy. It’s just easier to access. You no longer have to go to a health provider and take the drug there. You can pick it up at a pharmacy, it can be sent via mail-order pharmacy. It’s just a lot easier to take and has made it more accessible. So those restrictions could basically go back in time to 2016.

Rovner: And I know. I remember at some point, one of the people arguing the case was there for Danco, the company that makes the pill, or the brand-name company that makes the pill. And at some point, they were saying if they rolled back the restrictions to 2016, they’d have to go through the labeling process all over again because the current label would be no longer allowed. And that would delay things, right?

Karlin-Smith: Right. All of the drug that is currently out there would be then deemed misbranded and it’s not superfast to have to update it. The other thing, I don’t think this came up that much on arguments but it’s been raised before is that actually, you can make a strong case that going back to [the] 2016 state might be actually potentially more dangerous for people because they actually also adjusted the dosing of mifepristone a bit. So there’s actually been changes that people might actually say actually would create more potential. … If you believe these doctors might actually be injured in the sense of they would see more women in the ER because of adverse events from these drugs, there’s a case you can make that actually says it would be more unsafe if you go back to 2016 than if you operate under the current way the drug is administered today.

Ollstein: This also didn’t come up, but Sarah is exactly right. And, if this case did end up in the future going after the original FDA approval of mifepristone, providers around the country have said they would switch to a misoprostol-only regimen where people just take the second of the two pills that are usually taken together. And that brings up a very similar issue to what Sarah just mentioned because if that happens, there is a, not hugely, but slightly greater risk of complications if that happens. And so, exactly, the relief that these doctors are seeking could, in fact, lead to more people coming for treatment in the future.

Rovner: Well, it seemed like the one … the merits of this case that the justices did ask about was the idea of judges substituting their medical judgment for that of the FDA. That’s obviously a big piece of this. I was surprised to see even some of the conservative justices, particularly Amy Coney Barrett, wondering maybe if that was a great idea.

Ollstein: It was also just so notable how much talk there was of just the particulars of reproduction and abortion and women’s bodies. You just don’t hear that a lot in the Supreme Court, and I don’t know if that is a function of there being more women than before sitting on the Supreme Court. You heard about how to diagnose ectopic pregnancies without an ultrasound. You heard about pregnancies being dated by the person’s last menstrual period. I don’t know when I’ve heard the words “menstrual period” said in the Supreme Court before, but we heard them this week.

Rovner: And it was notable, and several people noted it, all three attorneys who argued this case were women. Both the attorney for the plaintiff, the solicitor general, Elizabeth Prelogar, who is a woman, and the attorney for Danco were all women. And the women, the four, now four women on the court, were very active in the questioning and it was. I’ve sat through a lot of reproductive health arguments at the Supreme Court and it was, to me at least, really refreshing to hear actual specifics and not euphemisms, but that were to the point of what we were talking about here, which often these arguments are not.

So one of the things that came up that we did expect was some discussion of the 1873 Comstock Act, mostly brought up by Justices [Samuel] Alito and [Clarence] Thomas. This is the long-dormant anti-vice law that could effectively impose a nationwide ban on abortion if it is resurrected and enforced, right?

Ollstein: Yes. So this was really interesting because this was not part of the core case arguments, but it’s something that the challengers really want to be part of the court arguments. And you had two of the court’s justices, arguably furthest to the right, really grilling the attorneys on whether the FDA should have taken Comstock into account when it approved mail delivery of abortion pills. And the solicitor general said, “Not only would that have been inappropriate, it would arguably have been illegal for the FDA to have done that.” She was saying, “The FDA is by statute only supposed to consider the safety and efficacy of a drug when creating policies.” If it had said, “Oh, we’re not going to do this thing that the science indicates we should do,” which is allow mail delivery because of this long-dormant law that our own administration put out a memo saying it shouldn’t ban delivery of abortion pills, that would’ve been completely wrong.

Now, they asked the same of the attorney for the challengers and she obviously was in favor of taking the Comstock Act into account. And so I think it’s a sign that this is not the last we’re going to hear of this.

Karlin-Smith: I believe the solicitor general also did reference the fact that FDA did to some degree acknowledge the Comstock Act, but deferred to the Biden administration’s Justice Department’s determination that, first of all, not only has this law not really been enforced for years, but that it doesn’t actually ban the mail distribution of a legal, approved drug.

And the other thing, again, they went into this a little bit more in briefs, but FDA has its role and sometimes other agencies have other laws they operate on and you can operate on separate planes. So FDA and DEA [Drug Enforcement Administration] often have to intersect when you’re talking about controlled substances like opioids and so forth. And what happens there is actually, FDA approves the drug and then DEA comes back in later and they do the scheduling of it and then the drug gets on the market. But FDA doesn’t have to take into account and say, “Oh, we can’t approve this drug because it’s not scheduled that they approve it.” Then DEA does the scheduling. So it seems like they’re twisting FDA’s role around Comstock a little bit.

Weber: Just to echo some of that, I think a lot of court watchers and a lot of abortion protectors were alarmed by the mention of the Comstock Act over and over again and are watching to see if there will be a fair amount of road-mapping laid out in the legal opinions that Alito and Thomas are expected to give, likely in dissent to the decision probably to dismiss this case. And I think it’s really interesting that this is coinciding with a lot of reporting that we’ve talked about on this podcast over and over again of Donald Trump talking about a 15- to 16-week abortion ban and his advisers, who are setting a roadmap for his presidency were he to win, talking explicitly about how they would revive the Comstock Act.

So all of these things taken together would seem to indicate that it would certainly play a role if the administration were to be a Trump administration.

Rovner: Perfect segue to my next question, which is that assuming this case goes away, Alice, you wrote a story about backup plans that the anti-abortion groups have. What are some of those backup plans here?

Ollstein: Yeah, I thought it was important for folks to remember that even though this is a huge deal that this case even got this far to the Supreme Court, it is far from the only way anti-abortion advocates and elected officials are working to try to cut off access to these pills. They see these pills as the future of abortion. Obviously, they’ve gained popularity over the recent years and now have jumped from just over half of abortions to more than two-thirds just recently. And so there are bills in Congress and in state legislatures. There are model draft bills that these anti-abortion groups are circulating. There are other lawsuits, and like you said, there are these policy plans trying to lay a groundwork for a future Trump administration to do these things through executive orders, going around Congress. There’s not a lot of confidence of winning a filibuster-proof majority in the Senate, for instance. And so while congressional plans also include attempting to use the appropriations process, as happened unsuccessfully this year, to ban abortion, I think people see the executive branch route as a lot more fruitful.

In addition to all of that, there are also just pressure campaigns and protest campaigns. It’s the same playbook that the anti-abortion movement [used] to topple Roe. They are good at playing the long game, and so there are plans to pressure the pharmacies like Walgreens and CVS that have agreed to dispense abortion pills. I just think that you’re seeing a very throw-everything-against-the-wall-and-see-what-sticks kind of strategy amongst these groups.

Rovner: Meanwhile, as Lauren already intimated, abortion is playing a major role in this year’s campaigns and elections. This week, a Democrat in deep-red Alabama flipped a Statehouse seat running on a reproductive freedom platform. She actually went out and campaigned on trying to reverse the state’s abortion ban. Meanwhile, Donald Trump, who earlier hinted that he might favor some sort of national ban, with exceptions for rape and incest and threats to life, said the quiet part out loud last week, telling a radio show that “people are agreeing on a 15-week ban.” That’s exactly what Republicans running for reelection in the Senate don’t want to hear right now. This has not gone well for Republicans in discussions of abortion as we saw this week in Alabama.

Weber: Yeah. As someone who was born in Alabama — and I’ve talked about this on this podcast, there are a fair amount of influencers that are regular people that I follow that live in Alabama — the IVF ruling was a huge shock to the system for conservative Alabama, especially women, and I think this win by a Democrat in the Deep South like this is a real wake-up call. And probably why all the Republican senators don’t want to talk about abortion or any sort of ban, or really get close to this reproductive issue because it is a real weak spot as this race unfolds with two candidates that are arguably both unpopular with both of their parties.

So this could become a turnout game, and if one side is more activated due to feeling very strongly about IVF, abortion, et cetera, that really could play out in not only the presidential race but the trickle-down races that are involved.

Rovner: I was amused. There’s the story that The Hill had this week about Senate Republicans wincing at Trump actually coming out for a federal ban. And one of them was Josh Hawley, who is not only very avowedly pro-life but whose wife argued the case for the plaintiffs in the Supreme Court, and yet he was saying he doesn’t want to see this on a federal level because he’s up for reelection this year.

Karlin-Smith: It’s interesting because one thing we’ve seen is that when there’s been specific abortion measures that people got to vote for at the state or local level, abortion rights are very popular. But then people have always raised this question of, “Well, would this look the same if you were voting more for a candidate, a person, and you were thinking about their broader political positions, not just abortion?” And this case in Alabama, I think, is a good example when you see that that can carry the day and it’s people who care about abortion rights may be willing to sacrifice potentially other political positions where they might be more aligned with a candidate if that’s an issue that’s a top priority.

Rovner: Yeah. And I think a lot of people took away, the Democrat in Alabama won by 60%, she got 60% of the vote. And she’d run before and lost, I think they said by 7%. It was more than a fluke. She really won overwhelmingly, and I think that raised an awful lot of eyebrows. Speaking of health care and politics and Donald Trump, the presumptive Republican presidential nominee also reiterated his desire to, and again, I quote from his post, this time on Truth Social, “Make the ACA much, much, much better for far less money or cost to our grest,” I presume he meant great, “American citizens who have been decimated by Biden.” This harkens back to all the times when he as president repeatedly promised a replacement for the ACA coming within a few weeks and which never materialized.

Does anybody think he has anything specifically in mind now? I guess as we’ve talked about with abortion, but haven’t really said, there is this Heritage Foundation document that’s supposed to be the guiding force should he get back into office.

Ollstein: But if I’m correct, even that document — which is like a wish list, dreamland, they could do whatever they want, “This is what we would love to do” — even that doesn’t call for repealing Obamacare entirely. It calls for chipping away at it, allowing other alternatives for people to enroll in. But I think it’s telling that even in their wildest dreams, they are not touching that stove again after the experience of 2017.

Weber: Julie, I’m just sad you didn’t read that in all caps. I feel like you really missed an opportunity to accurately represent that tweet.

Rovner: I also didn’t read the whole thing. It’s longer than that. That was just the guts of it. Well, one group that is not afraid to shy away from the specifics is the Republican Study Committee in the U.S. House, which has released its own proposed budget for fiscal 2025. That’s the fiscal year that starts this Oct. 1. The RSC’s membership includes most but not all of Republicans in the U.S. House. And it used to be the most conservative caucus before there was a Freedom Caucus. So it’s now the more moderate of the conservative side of the House.

I should emphasize that this is not the proposed budget from House Republicans. There may or may not be one from the actual House Budget Committee. It’s due April 15, by the way, the budget process — even though the president just signed the last piece of spending legislation for fiscal 2024 — the 2025 budget process is supposed to start as soon as they get back.

In any case, the RSC budget, as usual, includes some pretty sweeping suggestions, including raising the retirement age, block-granting Medicaid, repealing most of the Affordable Care Act and Medicare’s drug price negotiation authority, and making Medicare a “premium support program,” which would give private plans much more say over what kind of benefits people get and how much they pay for them. Basically, it’s a wish list of every Republican health proposal for the last 25 years, none of which have been passed by Congress thus far.

The White House and Democrats, not surprisingly, have been all over it. Both the president and the vice president were on the road this week, talking up their health care accomplishments, part of their marking of the 14th anniversary of the ACA, and blasting the Republicans for all of these proposals that some of them may or may not support or may or may not even know about. Republicans desperately don’t want 2024 to become a health care election, but it seems like they’re doing it to themselves, aren’t they?

Ollstein: So putting out these kinds of policy plans before an election, it’s a real double-edged sword because you want to rev up your own supporters and give your base an idea of “Hey, if you put us in power, this is what we will deliver for you.” But it also can rev up the other side, and we’re seeing that happen for sure. Democrats very eagerly jumped on this to say, “This shows why you can’t elect Republicans and put them in control. They would go after Obamacare, go after Medicare, go after Medicaid, go after Social Security,” all of these very sensitive issues.

And so yeah, we are definitely seeing the backlash and the weaponization of this by Democrats. Are we seeing this inspire and excite the right? I haven’t really seen a ton of chatter on the right about the Republican Study Committee budget, but if you have, let me know.

Rovner: As the campaign goes on, we’ll see more people throwing things against the wall. I think you’re right. I think the Republicans want this election to be about inflation and the border, so, I’m sure we will also hear more about that. Well, moving on, I have a segment this week that I’m calling “This Week in Things That Didn’t Work Out as Planned.” First up was hard-drug decriminalization in Oregon. Longtime listeners will remember when we talked about Oregon voters approving a plan in 2020 to have law enforcement issue $100 citations to people caught using small amounts of hard drugs like cocaine and heroin, along with information on where they can go to get drug treatment. But the drug treatment program basically failed to materialize, overdoses went up, and drug users gathered in public on the streets of Portland and other cities to shoot up.

Now the governor has signed a bill recriminalizing the drugs that had been decriminalized. I feel like this has echoes of the deinstitutionalization movement of the 1960s when people with serious mental illness were supposed to be released from facilities and provided community-based care instead. Except the community-based care also never materialized, which basically created part of the homeless problem that we still have today.

So in fact, we don’t really know if drug decriminalization would work, at least not in the way it was designed. But Alice, you point to a story that one of your colleagues has written about a place where it actually did work, right?

Ollstein: Yeah, so they did a really interesting comparison between Oregon and the country Portugal, and made a pretty convincing case that Oregon did not give this experiment the time or the resources to have any chance of success. Basically, Oregon decriminalized drugs, they barely funded and stood up services to help people access treatment. And then after just a couple of years, politicians panicked at the backlash and are backpedaling instead of giving this, again, the time and resources to actually achieve what Portugal has achieved over decades, which is a huge drop in overdose deaths.

But in addition to more time and resources, you can’t really carve this out of just basic universal health care, which Portugal has, and we definitely do not. And so I think it’s a really interesting discussion of what is needed to actually have an impact on this front.

Rovner: Yeah, obviously it’s still a big problem, and states and the federal government and localities are still trying to figure out how best to grapple with it. Well, next in our things that didn’t work out as planned is arbitration for surprise medical bills. Remember when Congress outlawed passing the cost of insurer-provider billing disputes to patients? Those were these huge bills that suddenly were out-of-network. The solution to this was supposed to be a process to fairly determine what should be paid for those services. Well, researchers from the Brookings Institution have taken a deep dive into the first tranche of data on the program, which is from 2023, and found that at least early on the program is paying nearly four times more than Medicare would reimburse for the disputed services, and that it has the potential to raise both premiums and in-network service prices, which is not what lawmakers intended.

I feel like this was kind of the inevitable result of continuing compromises when they were writing this bill to overcome provider opposition. They were afraid they wouldn’t get paid enough, and so they kept pushing this process and now, surprise, they’re getting paid probably more than was intended. Is there some way to backpedal and fix this? Lauren, you look like you have feelings here.

Weber: I take us back to the name of this podcast, “What the Health?” I feel like this sums up everything in health care. Literally, legislators try to get a fix that it turns out could actually worsen the problem because the premiums and so on could continue to escalate in a never-ending war for patients to share more of the burden of the cost. So it’s good that we have this research and know that this is what’s happening, but yeah, again, this is the name of the podcast. How is this the health care system as we know it?

Karlin-Smith: Also, again, you start to understand why other countries just have these — as much as they’re politically unpopular in the U.S. — these systems where they just set the prices because trying to somehow do it in a more market-based way or these negotiating ways, you end up with these pushes and pulls and you never quite achieve that cost containment you want.

Rovner: Yeah, although we have gotten the patient out of the middle. So in that sense, this has worked, but certainly …

Karlin-Smith: Right, for the people actually getting the surprise bills, they’ve been helped. Again, assuming that down the line, as Lauren mentioned, it doesn’t just raise all of our inpatient bills and our premiums.

Rovner: Yes, we will all be employed forever trying to explain what goes on in the health care system. Finally, diabetes online tools, all those cool apps that are supposed to help people monitor their health more closely and control their disease more effectively. Well, according to a study from the Peterson Health Technology Institute, the apps don’t deliver better clinical benefits than “usual care,” and they increase health spending at the same time — the theme here.

This is the first analysis released by this new institute created to evaluate digital health technology. Although not surprisingly, makers of the apps in question are pushing back very hard on the research. Technology assessment has always been controversial, but it clearly seems necessary if we’re ever going to do something about health spending. So somebody’s going to have to do this, right?

Weber: As we move into this ever more digital health world where billions of dollars are being spent in this space, it’s really important that someone’s actually evaluating the claims of if these things work, because it’s a lot of Medicare money, which is taxpayer dollars, that get spent on some of these tools that are supposedly supposed to help patients. And I believe, in this case, they found a 0.4% improvement, which did not justify, I think it was several hundred dollars worth of investment every year, when other tactics could be used. So quite an interesting report, and I’m very curious, and I’m sure many other digital health creators, too, are curious to see who they’ll be targeting next.

Karlin-Smith: It’s an old story in U.S. health care, right? That the tech people are going to come in and save us all, and then what happens when they come into it and realize that there’s root problems in our system that are not easily solved just by throwing more complicated money and technology at it. So these are certainly not the first people that thought that some innovative technological system would work.

Rovner: So in drug news this week, Medicare has announced it will cover the weight loss drug Wegovy, which is the weight loss version of the drug Ozempic. But not for weight loss, rather for the prevention of heart disease and stroke, which a new clinical trial says it can actually help with. Sarah, is this a distinction without a difference and might it pave the way for broader coverage of these drugs in Medicare?

Karlin-Smith: Distinction does matter. CMS [Centers for Medicare & Medicaid Services] has been pretty clear in guidance. This does not yet open the door for somebody who is just overweight to have the drug in Medicare. And health plans will have a lot of leeway, I think, to determine who gets this drug through prior authorization, and so forth. Some people have speculated they might only be willing to provide it to people that have already had some kind of serious heart event and are overweight. So not just somebody who seems high risk of a heart attack.

So I think at least initially, there’s going to be a lot of tight control over at AHIP. The biggest insurance trade group has indicated that already, so I don’t think it’s going to be as easy to access as people want it to be.

Rovner: Meanwhile, a separate study has both good and bad news about these diabetes/weight loss medications. Medicare is already spending so much money on them because it does cover them for diabetes, that the drugs could soon be eligible for price negotiations. Could that help bring the price down for everyone? Or is it possible that if Medicare cuts a better deal on these drugs everybody else is going to have to pay more?

Karlin-Smith: You mean outside of Medicare or just …?

Rovner: Yeah, I mean outside of Medicare. If Medicare negotiates the price of Ozempic because they’re already covering it so much for diabetes, is that going to make them raise the price for people who are not on Medicare? I guess that’s the big question about Medicare drug price negotiation anyway.

Karlin-Smith: Yeah. Certainly, people have talked about that a little bit. I think the sense that you can raise prices a lot in the private market. People are skeptical of that. There’s also these drugs because they’re actually old enough that they’re getting to the point of Medicare drug price negotiation under the new law. They’re actually more heavily rebated than people realize. The sense is that both private payers and Medicare are actually getting decent rebate levels on them already. Again, they’re still expensive. The rebates are very secretive. They don’t always go to the patients. But there’s some element of these drugs being slightly more affordable than is clearly transparent.

Rovner: There’s a reason that so many people on Ozempic for diabetes can be on Ozempic for diabetes, in other words. Finally, “This Week in Medical Misinformation”: Lauren, you have a wild story about birth control misinformation on TikTok. So we’re going from the Medicare to the younger cohort. Tell us about it.

Weber: Yeah. As everyone on this podcast is aware, we live in a very fractured health care system that does not invest in women’s health care, that is underfunded for years, and a lot of women feel disenfranchised by it. So it’s no surprise that physicians told myself and my reporting [colleague] Sabrina Malhi to some extent that misinformation is festering in that kind of gray area where women feel like they’re sometimes not listened to by their physician or they’re not getting all their information. And instead, they’re turning to their phone, and they’re seeing these videos that loop over and over and over again, which either incorrectly or without context, state misinformation about birth control. And the way that algorithms work on social media is that once you engage with one, you see them repeatedly. And so it’s leaving a lot of younger women in particular, physicians told us, with the impression that hormonal birth control is really terrible for them and looking to get onto natural birth control.

But, what these influencers and conservative commentators often fail to stress, which your physician would stress if you had this conversation with them, is that natural forms of birth control, like timing your sex to menstrual cycles to prevent pregnancy, can be way less effective. They can have an up to 23% failure rate, whereas the pill is 91% effective, the IUD is over 99% effective. And so physicians we talked to said they’re seeing women come in looking for abortions because they believe this misinformation and chose to switch birth controls or do something that impacted how they were monitoring preventing pregnancy. And they’re seeing the end result of this.

Rovner: And obviously there are side effects to various forms of hormonal birth control.

Weber: Yes. Yes.

Rovner: That’s why there are lots of different kinds of them because if you have side effects with one, you might be able to use another. I think the part that stuck out to me was the whole “without context,” because this is a conversation that if you have with a doctor, they’re going to talk about, it’s like, “Well, if you’re having bad side effects with this, you could try this instead. Or you could try that, or this one has a better chance of having these kinds of side effects. And here’s the effectiveness rate of all of these.” Because there actually is scientific evidence about birth control. It’s been used for a very long time.

Ollstein: Oh, yeah. And I think it’s important to remember that this is not just random influencers on TikTok promoting this message. You’re hearing this from pretty high-level folks on the right as well, raising skepticism and even outright opposition to different forms of birth control. The hormonal pills, devices like IUDs that are really effective. They are saying that they are abortifacients in some circumstances when that is not accurate according to medical professionals. And there was just this really interesting backlash recently. I interviewed Kellyanne Conway and she said her polling found that if Republican politicians came out in favor of access to birth control, that would help them. And then she got this wave of criticism after that, accusing her of promoting promiscuity. And so there’s a big fight over contraception on the right, and it’s, Lauren found in her great story, trickling down to regular folks who are trying to figure out how to use it or not use it.

Rovner: I will link to a story that I wrote a couple of weeks ago about how contraception has always been controversial among Republicans. And it still is. Lauren, you want to say one last thing before we move on?

Weber: No, I think Julie, your point that you mentioned, birth control side effects are real and it is important for patients to speak with their physicians. And what physicians told me is that over the years, their guidance and their training has changed to better involve patients in that decision-making. So women many years ago may not have gotten that same walking-through. And also, birth control is often stigmatized, especially for younger populations. And so all of this feeds into, as Alice has pointed out, and as this piece walks through, how some of these influencers with more holistic paths that they’re possibly selling you, and conservative commentators are getting in these women’s phones and they’re trusting them because they don’t necessarily have a relationship with their physician.

Rovner: They don’t necessarily have a physician to have a relationship with. All right, well, that is the news for this week. Now we will play my Bill of the Month interview with Tony Leys, and then we’ll be back with our extra credits.

I am pleased to welcome to the podcast my colleague Tony Leys, who reported and wrote the latest KFF Health News-NPR Bill of the Month installment. Thank you for joining us, Tony.

Tony Leys: Thanks for having me.

Rovner: So this month’s patient passed away from her ailment, but her daughter is still dealing with the bill. Tell us who this story is about and what kind of medical procedure was involved here.

Leys: Debra Prichard was from rural Tennessee. She was in generally good health until last year when she suffered a stroke and several aneurysms. She twice was rushed to a medical center in Nashville, including once by helicopter ambulance. She later died at age 70 from complications of a brain bleed.

Rovner: Then, as we say, the bill came. I think people by now generally know that air ambulances can be expensive, but how big is this bill?

Leys: It was $81,739 for a 79-mile flight.

Rovner: Wow. A lot of people think that when someone dies, that’s it for their bills. But that’s not necessarily the case here, right?

Leys: No, it’s on the estate then.

Rovner: So they have been pursuing this?

Leys: Right. That would amount to about a third of the estate’s value.

Rovner: Now, Debra Prichard had Medicare, and Medicare caps how much patients can be charged for air ambulance rides. So why didn’t this cap apply to this ride?

Leys: Yeah, if she’d had full Medicare coverage, the air ambulance company would’ve only been able to collect a total of less than $10,000. But unbeknownst to her family, Prichard had only signed up for Medicare Part A, which is free to most seniors and covers inpatient hospital care. She did not sign up for Medicare Part B, which covers many other services including ambulance rides, and it generally costs about $175 a month in premiums.

Rovner: I know. Medicare Part B used to be “de minimis” in premium, so everybody signed up for it, but now, Medicare Part B can be more expensive than an Affordable Care Act plan. So I imagine that there are people who find that $175 a month [is] more than their budget can handle.

Leys: Right. And there is assistance available for people of moderate incomes. It’s not super well publicized, but she may very well have been eligible for that if she’d looked into it.

Rovner: So what eventually happened with this bill?

Leys: Well, her estate faced the full charge. The family’s lawyer is negotiating with the company and they’re making some progress, last we heard.

Rovner: But as of now, the air ambulance company still wants the entire amount from the estate?

Leys: They put in a filing against the estate to that effect, but they apparently are negotiating it.

Rovner: So what’s the takeaway here for people who think they have Medicare or think, no, they don’t have Part B, but think it might cost too much?

Leys: Well, the takeaway is Medicare coverage sure is complicated. There’s free help available for seniors trying to sort it out. Every state has a program called the State Health Insurance Assistance Programs, and they have free expert advice and they can point you to programs that help pay for that premium if you can’t afford it. I don’t know about you, Julie, but I plan to check in with those programs before I sign up for Medicare someday.

Rovner: Even I plan to check in with those programs, and I know a lot about this.

Leys: If Julie Rovner wants assistance, everyone should get it.

Rovner: Everyone should get assistance. Yes, that’s my takeaway, too. Medicare is really complicated. Tony Leys, thank you very much.

Leys: Thanks for having me.

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

Karlin-Smith: I’ve looked at a Washington Post story, “The Confusing, Stressful Ordeal of Flying With a Breast Pump,” by Hannah Sampson and Ben Broch, and it’s essentially about how there’s no federal rule that protects people flying with a breast pump and being able to bring it on the plane as a carry-on, not a checked bag, and the problems this could cause. If you are pumping breast milk and need to pump it, you often need to pump it as often as every three hours, sometimes even less. And there are medical consequences that can happen if you do not. And the current system in place is just left to each airline to have its own policy. And it seems like flying is the luck of the draw of whether these staff members even understand this policy. And a lot of this seems to date back to basically when the laws that were put in place that protect people with various sorts of medical needs to be able to bring their devices on planes, the kinds of breast pumps people use today really didn’t exist.

But some of this is just an undercurrent of a lack of appreciation for the challenges of being a young parent and trying to feed your kid and what that entails.

Rovner: Maybe we should send it to the Supreme Court. They could have a real discussion about it. People would learn something. Sorry. Alice, why don’t you go next?

Ollstein: Sure. So I have a piece from Stat by Olivia Goldhill called “Fetal Tissue Research Gains in Importance as Roadblocks Multiply.” And it’s about how the people in the U.S. right now doing research that uses fetal tissue — this is tissue that’s donated from people who’ve had abortions, and it’s used in all kinds of things, HIV research, different cancers — it could be really, really important. And the piece is about how that research has not really recovered in the U.S. from the restrictions imposed by the Trump administration.

Not only that, the fear that those restrictions would come back if Trump is reelected is making people hesitant to really invest in this kind of research. And already they’re having to source fetal tissue from other countries at great expense. And so just a fascinating window into what’s going on there.

Rovner: Yeah, it is. People think that these policies that flip and flip back it’s like a switch, and it’s not. It really does affect these policies and what happens. Lauren?

Weber: So I picked a story from Stateline, which by the way, I just want to fan girl about how much I love Stateline all the time. Anyways, the title is “Deadly Fires From Phone, Scooter Batteries Leave Lawmakers Playing Catch-Up on Safety,” written by Robbie Sequeira. And I just have anecdotal bias because my sister’s apartment next to her caught on fire due to one of these scooter batteries. But, in general, as the story very clearly lays out, this is a real threat. Lithium batteries, which are proliferating throughout our society, whether they’re scooter batteries or other different types of technology, are harder to fight when they light on fire and they are more likely to light on fire accidentally. And there’s really not a good answer. As lawmakers are trying to get more funding or try to combat this or limit the amount of lithium batteries you can have in a place, people are dying.

There was a 27-year-old journalist, Fazil Khan, who passed away from a fire of this sort. You’re seeing other folks across the country face the consequences. And it’s really quite frightening to see that modern firefighting has made so many strides but this is a different type of blaze, and I think we’ll see this play out for the next couple of years.

Rovner: I think this is a real public health story because this is one of those things where if people knew a lot more about it, there are things you can do, like don’t store your lithium-ion battery in your apartment, or don’t leave it charging overnight. Take it out of the actual object. There are a lot of things that you could do to prevent fires, but the point of this story is that these fires are really dangerous. It’s really scary.

All right, well, my story this week is from my KFF Health News colleague Arthur Allen. It’s called “Overdosing on Chemo: A Common Gene Test Could Save Hundreds of Lives Each Year,” and it’s about a particular chemotherapy drug that works well for most people, but for a small subset with a certain genetic trait can be deadly. There’s a blood test for it, but in the U.S., it’s not required or even recommended in some cases. It’s a really distressing story about how the FDA, medical specialists, cancer organizations can’t seem to reach an agreement about something that could save some cancer patients from a terrible death.

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

Weber: Just on X, @LaurenWeberHP

Rovner: Sarah?

Karlin-Smith: @SarahKarlin or @sarahkarlin-smith, depending on the various social media platform.

Rovner: Alice?

Ollstein: @AliceOllstein on X, and @alicemiranda on Bluesky

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

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

The Affordable Care Act was signed into law 14 years ago this week, and Health and Human Services Secretary Xavier Becerra joined KFF Health News’ Julie Rovner on this week’s “What the Health?” podcast to discuss its accomplishments so far — and the challenges that remain for the health law.

Meanwhile, Congress appears on its way to, finally, finishing the fiscal 2024 spending bills, including funding for HHS — without many of the reproductive or gender-affirming health care restrictions Republicans had sought.

This week’s panelists are Julie Rovner of KFF Health News, Mary Agnes Carey of KFF Health News, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Mary Agnes Carey
KFF Health News

@maryagnescarey

Read Mary Agnes' stories.

Tami Luhby
CNN

@Luhby

Read Tami's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• The Supreme Court will hear oral arguments next week in a case that could decide whether the abortion pill mifepristone will remain easily accessible. The case itself deals with national restrictions rather than an outright ban. But, depending on how the court rules, it could have far-reaching results — for instance, preventing people from getting the pills in the mail and limiting how far into pregnancy the treatment can be used.
• The case is about more than abortion. Drug companies and medical groups are concerned about the precedent it would set for courts to substitute their judgment for that of the FDA regarding drug approvals.
• Abortion-related ballot questions are in play in several states. The total number ultimately depends on the success of citizen-led efforts to collect signatures to gain a spot. Such efforts face opposition from anti-abortion groups and elected officials who don’t want the questions to reach the ballot box. Their fear, based on precedents, is that abortion protections tend to pass.
• The Biden administration issued an executive order this week to improve research on women’s health across the federal government. It has multiple components, including provisions intended to increase research on illnesses and diseases associated with postmenopausal women. It also aims to increase the number of women participating in clinical trials.
• This Week in Medical Misinformation: The Supreme Court heard oral arguments in the case Murthy v. Missouri. At issue is whether Biden administration officials overstepped their authority when asking companies like Meta, Google, and X to remove or downgrade content flagged as covid-19 misinformation.

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

Julie Rovner: The Washington Post’s “Arizona Lawmaker Tells Her Abortion Story to Show ‘Reality’ of Restrictions,” by Praveena Somasundaram. (Full speech here.)

Alice Miranda Ollstein: CNN’s “Why Your Doctor’s Office Is Spamming You With Appointment Reminders,” by Nathaniel Meyersohn.

Tami Luhby: KFF Health News’ “Georgia’s Medicaid Work Requirement Costing Taxpayers Millions Despite Low Enrollment,” by Andy Miller and Renuka Rayasam.

Mary Agnes Carey: The New York Times’ “When Medicaid Comes After the Family Home,” by Paula Span, and The AP’s “State Medicaid Offices Target Dead People’s Homes to Recoup Their Health Care Costs,” by Amanda Seitz.

Also mentioned on this week’s podcast:

• NPR’s “Standard Pregnancy Care Is Now Dangerously Disrupted in Louisiana, Report Reveals,” by Rosemary Westwood.
• The Washington Post’s “As the Cost of Storing Frozen Eggs Rises, Some Families Opt to Destroy Them,” by Amber Ferguson.

Click to open the transcript

Transcript: The ACA Turns 14

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 21, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go.

We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Tami Luhby of CNN.

Tami Luhby: Hello.

Rovner: And my KFF Health News colleague Mary Agnes Carey.

Mary Agnes Carey: It’s great to be here.

Rovner: Later in this episode to mark the 14th anniversary of the Affordable Care Act, we’ll have my interview with Health and Human Services Secretary Xavier Becerra, but first, this week’s news. So it appears our long national nightmare following the progress of the fiscal 2024 spending bill for the Department of Health and Human Services is nearly over, nearly halfway through the fiscal year. The White House, House, and Senate have, as far as we can tell, reached a compromise on the last tranche of spending bills, which is a good thing because the latest temporary spending bill runs out at midnight Friday. Funding for the Department of Health and Human Services, from what I’ve seen so far, is basically flat, which is a win for the Democrats because the Republicans had fought for a cut of something in the neighborhood of 22%.

Now, assuming this all happens, the House is scheduled to vote, as we speak now, on Friday at 11 a.m., leaving the Senate not very much time to avert a possible partial shutdown. Democrats seem also to have avoided adding all manner of new restrictions on reproductive and gender-affirming health care to the HHS part of the bill. It’s the last big train leaving the station likely until after the election. So Alice, we’ll get to the add-ons in a minute, but have you seen anything in the HHS funding worthy of note or did they manage to fend off everything that would’ve been significantly newsworthy?

Ollstein: Like you said, it is basically flat. It’s a small increase, less than 1% overall for HHS, and then a lot of individual programs are just completely flat, which advocacy groups argue is really a cut when you factor in inflation. The cost of providing services and buying medications and running programs and whatnot goes up. So flat funding is a cut in practice. I’m hearing that particularly from the Title X family planning folks that have had flat funding for a decade now even as demand for services and costs have gone up.

So I think that in the current environment, Democrats are ready to vote for this. They don’t want to see a shutdown. And in the House, the bill passage will depend on those Democratic votes because they are likely to lose a lot of Republicans. Republicans are mad that there weren’t deeper cuts to spending and, as you alluded to, they’re mad that they didn’t get these policy rider wins they were banking on.

Rovner: As I’ve mentioned, since this is a must-pass bill, there are always the efforts to add non-spending things to it. And on health care, apparently, the effort to add the PBM, pharmacy benefit regulation bill we’ve talked about so much failed, but lawmakers did finally get a one-year deal to extend PEPFAR, the international AIDS/HIV program. Alice, you’ve been dutifully following this since it expired last year. Remind us why it got held up and what they finally get.

Ollstein: What happened in the end is it is a one-year reauthorization that’s a so-called clean reauthorization, meaning they are not adding new anti-abortion restrictions and provisions that the Republicans wanted. So what we reported this week is, like any compromise, no one’s happy. So Republicans are upset that they didn’t get the anti-abortion restrictions they wanted, and I’ll explain more on that in a second, and Democrats are upset that this is just a one-year reauthorization. It’s the first reauthorization that’s this sort of short-term stopgap length. In the program’s decades of history, it’s always been a full five-year reauthorization up until now. But the fight over abortion and accusations that program funds were flowing to abortion providers really split Congress on this.

Even though you had mainstream leadership Republicans who were saying, “Look, we just want to reauthorize this as-is,” you had a small but very vocal contingent of hard-line anti-abortion lawmakers backed by some really influential groups like the Heritage Foundation and SBA [Susan B. Anthony Pro-Life America] who were saying, “No, we have to insist on a shorter-term reauthorization,” so that they hope Trump will be in office next year and can impose these exact same anti-abortion restrictions through executive action. So they’re basically trying to punt control of the program into what they hope is a more favorable environment, where either they’ll have the votes in Congress to make these changes and restrictions to the program or they can do it through the White House.

Rovner: So basically, the fight over PEPFAR, not over. So as I already mentioned, Saturday is the 14th anniversary of the Affordable Care Act, which you’ll hear more about in my interview with HHS Secretary Becerra, but I wanted to pose to you guys one of the questions that I posed to him. As Nancy Pelosi famously predicted, at least according to public opinion polls, the more people learned about the health law, indeed, the more they are liking it. But it still lacks the popularity and branding of big government health programs, like Medicare and Medicaid, and I think lots of people still don’t know that lots of the provisions that they like, things like letting your adult children stay on your health plan until they’re 26 or banning preexisting condition exclusions, those were things that came from the Affordable Care Act. Any theories as to why it is still so polarizing? Republicans didn’t love Medicare and Medicaid at the beginning either, so I don’t think it’s just that Republicans still talk about it.

Luhby: Part of it I think is because there are so many provisions and they’re not labeled the Affordable Care Act like Medicare is. Actually to some extent, Medicaid may not be as well known in some states because states have different Medicaid programs and different names and so do the ACA exchanges. So that’s part of it, but also, things like why do you get a free mammogram and why you get to go for a routine checkup every year; that’s not labeled as an Affordable Care Act provision, that’s just the preventive services. So I think that it would be difficult now after 14 years to bring all of that into the everyday branding by doctors and health providers. But that’s certainly what the administration and advocates are trying to do by sending out a lot of messages that list all of the benefits of the ACA.

Rovner: I will say this is the biggest full-court press I’ve seen an administration do on the ACA in quite a while. Obviously, it’s a presidential election year and it’s something that the Biden administration is proud of, but at least I would think that maybe just all the publicity might be part of their strategy. Mac, you wanted to say something.

Carey: No, absolutely. It’s going to be part of the Biden reelection campaign. They’re going to be pushing it, talking a lot about it. We have to remember we’ve had this ringside seat to all the Republican opposition to the Affordable Care Act. All the conversation about we’re going to repeal it and put something better in, former President Trump is still sending that message out to the electorate. I don’t know how much confusion, if any confusion, it creates, but to Tami’s point, you’ve got millions of people that have gotten coverage under the Affordable Care Act but millions more have benefited by all these provisions we’re talking about: the preventive care provisions, leaving adult kids up to 26 on your health insurance plan, that kind of thing.

Also, give it time. Fourteen years is a long time, but it’s not the time of Medicare, which was created in 1965, and Medicaid. So I think over time, the Affordable Care Act is part of the fabric and it will continue to be. But absolutely, for sure, President Biden is going to run on this, like you said, Julie, full-court press, talk extensively about it in the reelection campaign.

Ollstein: It makes sense that they’re leaning really hard on Obamacare as a message because, even if everyone isn’t familiar with it, a lot more people are familiar with it and like it than, polling shows, on the Biden administration’s other big health care accomplishment, which is drug price negotiation, which polling shows that most people, and even most seniors, who are the ones who are set to benefit the most, aren’t aware that it exists. And that makes sense because they’re not feeling the impact of the lower prices yet because this whole thing just started and it won’t be until 2026 that they’ll really actually experience cheaper medications. But people are already feeling the direct impact of Obamacare on their lives, and so it does make sense that they’re going to lean really hard on this.

Rovner: Of course, we went through the same thing with Obamacare, which also didn’t take full effect until, really, this is really the 10th anniversary of the full effect of the Affordable Care Act because it didn’t take effect until 2014. Tami, you wanted to add something.

Luhby: No, I was going to say it’s also the seventh anniversary of the Trump administration and congressional Republicans trying to tear apart the Affordable Care Act and repeal and replace it, which is the messaging that you’re seeing now is very similar to what you saw in 2017. It’s just surprising to me that with very intensive messaging on both sides at that time about what the Republicans saying what the problems are and the Democrats saying what all of the benefits are, — including the protections for people with preexisting conditions and the other things we’ve mentioned — that more people don’t associate those provisions with the ACA now. But the Biden administration is trying to revive all of that and remind people, as they did in 2018 in the successful midterm elections for the Democrats, that the ACA does provide a lot of the benefits that they are taking advantage of and appreciate.

Rovner: I think, in some ways, the 2017 fight was one of the best things that ever happened to the ACA in terms of helping people understand what actually was in it, because the Democrats managed to frighten people about things that they liked being taken away. Here we go again. All right, let us turn to abortion. There’s a new report out from the Guttmacher Institute that finds a dramatic jump in the use of medication abortion in 2023, the first full year since the Supreme Court reversed the nationwide right to abortion in the Dobbs [v. Jackson Women’s Health Organization] case, more than 60% of abortions use medication rather than a procedure last year. This news comes as the Supreme Court next week prepares to hear oral arguments in a case that could dramatically restrict availability of the abortion pill mifepristone. Alice, remind us what’s at stake in this case. It’s no longer whether they’re going to just outright cancel the approval.

Ollstein: That’s right. So the Supreme Court is taking up the narrowed version of this from the 5th Circuit. So what’s at stake are national restrictions on abortion pills, but not a national outright ban like you mentioned. But those restrictions could be really sweeping and really impactful. It would prevent people from getting the pills through the mail like they currently do. It would prevent people from potentially getting them in any other way other than directly from a doctor. So this would apply to red states and blue states alike. It would override abortion rights provisions in blue states that have done a lot to increase access to the pills. And it would also restrict their use back to the first seven weeks of pregnancy instead of 10, which is a big deal because people don’t often find out they’re pregnant until getting close to that line or beyond.

So this is a really big deal, and I think you can really see, especially from the flurry of amicus briefs have been filed, that anxiety about this case in the medical community and the pharmaceutical community, the scientific community, it goes way beyond the impact just on abortion. People are really worried about setting a precedent where the FDA’s scientific judgment is second-guessed by courts, and they worry that a win for the anti-abortion groups in this case would open the door to people challenging all kinds of other medications that they have an issue with: contraception, covid vaccines, HIV drugs, the list goes on and on, gender-affirming care medications, all sorts of things. So there are the bucket of potential impacts on abortion specifically, which are certainly significant, and then there’s the bigger slippery slope fears as well.

Rovner: Also, this is obviously still way political. More than just the abortion pill. It’s been a while since we’ve talked about state ballot measures. We, I think, feel like we spent all of last year talking about abortion state ballot measures. Alice, catch us up real quick on where we are. How many states have them? And what is this campaign against, by the anti-abortion people, to try to prevent them from getting on the ballot?

Ollstein: Check me if I’m wrong, but I don’t believe we know for sure about, especially the states that have citizen-led ballot initiatives where people are gathering signatures. So Florida had one of the earliest deadlines and they did meet their signature threshold. But they are now waiting on the state Supreme Court to say whether or not they have a green light to go forward this fall. A lot of other states are still collecting signatures. I think the only states we know for sure are the ones where the state legislature is the one that is ordering it to be put on the ballot, not regular citizens gathering signatures.

We still don’t know, but things are moving forward. I was just in Arizona reporting on their efforts. Things are moving forward there. Things are moving forward in Montana. They just got a court ruling in their favor to put something on the ballot. And things are moving forward in Missouri, a lot of places. So this could be really huge. Of course, like you mentioned, anti-abortion groups and anti-abortion elected officials are doing a lot of different things to try to prevent this from going on the ballot.

It’s interesting, you heard arguments over the last couple years against this being more along the lines of, “Oh, this is allowing these out-of-state big-money groups to swoop in and mislead and tell us what to do,” and those were the anti-abortion arguments against allowing people to vote on this directly. Now, you’re hearing, I’m hearing, more arguments along the lines of, “This shouldn’t be something subject to a popular vote at all. We shouldn’t put this up for a vote at all.” They consider this a human rights issue, and so I think that’s a really interesting evolution as well, particularly when the fall of Roe [v. Wade] was celebrated for returning the question of abortion access to the people, but maybe not these people specifically.

Rovner: I’ve been interested in seeing some of these anti-abortion groups trying to launch campaigns to get people not to put signatures on petitions. That’s moving it back a step I don’t think I’d ever seen. I don’t think I’ve ever seen a campaign to say, “Don’t sign the petition that would put this on the ballot to let people vote on it.” But that’s what we’re seeing, right?

Ollstein: Well, that’s what I went to Arizona to see firsthand is how that’s working, and it’s fascinating. They really worry that if it gets on the ballot, it’ll pass. It has in every state so far, so it’s reasonable for them to assume that. So they’re trying to prevent it from getting on the ballot. The way they’re doing that is they’re tracking the locations of signature gatherers and trying to go where they are and trying to intervene and hold up signs. I saw this firsthand. I saw it at a street fair. People were gathering signatures and several anti-abortion demonstrators were standing right in front of them with big signs and trying to argue with people and deter them from signing. It was not working, from what I observed. And from the overall signature count statewide, it was not working in Arizona. But it’s fascinating that they’re trying this.

Carey: I was going to say just our reporting from our KFF Health News colleagues found that 13 states are weighing abortion-related ballot measures, most of which would protect abortion rights. To your point, the scope is pretty extensive. And for all the reasons Alice just discussed, it’s quite the issue.

Rovner: Yeah, and we will obviously talk more about this as the election gets closer. I know we talk about Texas a lot on this podcast, but this week, I want to highlight a study from next door in Louisiana, also a very strong anti-abortion state. A new report from three groups, all of which support abortion rights, charges that, as in Texas, women with pregnancy complications are being forced to wait for care until their conditions become critical. And in some cases, women with nonviable pregnancies are being forced to have C-section surgery because their doctors don’t dare use medication or other less-risky procedures in case they could be accused of performing an abortion.

At some point, you have to think that somebody is going to have a malpractice case. Having a C-section because your doctor is afraid to terminate a nonviable pregnancy seems like pretty dangerous and rather aggressive way to go. This is the first I’ve ever heard of this. Alice, have you heard anything about this?

Ollstein: Not the C-section statistics specifically, but definitely the delays in care and some of the other impacts described in that report have absolutely been reported in other states and in legal challenges that have come up in Texas, in Oklahoma, in Tennessee, in Idaho by people who were denied abortions and experienced medical harms because of it. So I think that fits into the broader pattern. And it’s just more evidence about how this is having a chilling effect on doctors. And the exact letter of the law may be one thing, and you have elected officials pointing to exemptions and provisions in the law, but the chilling effect, the fear and the confusion in the medical community, is something in addition to that.

Rovner: As we put it out before, doctors have legitimate fears even if they don’t want to get dragged into court and have to hire lawyers and take time off — even if they’re innocent, even if they have what they consider to be pretty strong evidence that whatever it was that they did was legitimate under the law in terms of taking care of pregnant women. A lot of them, they don’t want to come under scrutiny, let’s put it that way, and it is hard to blame them about that.

Meanwhile, the backlash over the Alabama Supreme Court decision that fertilized embryos for IVF have legal rights is continuing as blue states that made themselves safe spaces for those seeking abortion are now trying to welcome those seeking IVF. Anybody think this is going to be as big a voting issue as abortion this fall? It’s certainly looking like those who support IVF, including some Republicans, are trying to push it.

Carey: I would think yes, it absolutely will be because it has been brought into the abortion debate. The actual Alabama issue is about an Alabama law and whether or not this particular, the litigants who sued were … it was germane and covered by the law, but it’s been brought into the abortion issue. The whole IVF thing is so compelling, about storage of the embryos and what people have to pay and all the restrictions around it and some of the choices they’re making. I guess that you could say more people have been touched by IVF perhaps than the actual abortion issue. So now, it’s very personal to them and it’s been elevated, and Republicans have tried to get around it by saying they support it, but then there’s arguments that whether or not that’s a toothless protection of IVF. It came out of nowhere I think for a lot of politicians and they’ve been scrambling and trying to figure it out. But to your point, Julie, I do wonder if it will be elevated in the election. And it was something they didn’t think they’d have to contend with, rather, and now they do.

Rovner: Obviously, it’s an issue that splits the anti-abortion community because now we’ve had all these very strong pro-lifers like Mike Pence saying, “I created my family using IVF.” Nikki Haley. There are a lot of very strong anti-abortion Republicans who have used IVF. So you’ve got some on the far … saying, “No, no, no, you can’t create embryos and then destroy them,” and then you’ve got those who are saying, “But we need to make sure that IVF is still available to people. If we’re going to call ourselves pro-life, we should be in favor of people getting pregnant and having babies, which is what IVF is for.” Alice, I see you nodding your head.

Ollstein: Yeah. So we’re having sort of a frustrating discourse around this right now because Democrats are saying, “Republicans want to ban IVF.” And Republicans are saying, “No, we don’t. We support IVF. We love IVF. IVF is awesome.” And neither is totally accurate. It’s just missing a lot of nuance. Republicans who say they support IVF also support a lot of different kinds of restrictions on the way it’s currently practiced. So they might correctly argue that they don’t want to ban it entirely, but they do want it practiced in a different way than it is now, such as the production of many embryos, some of which are discarded. So I think people are just not being asked the right questions right now. I think you got to get beyond, “Do you support IVF?” That gives people a way to dodge. I think you really have to drill into, “OK. How specifically do you want this regulated and what would that mean for people?”

Carey: Right, and the whole debate with some of the abortion rights opponents, some of them want the federal government to regulate it. Mike Johnson, speaker of the House, has come out and said, “No, no, that can be done at the state level.” So they’ve got this whole split internally in the party that is, again, a fight they didn’t anticipate.

Rovner: Well, Mac, something that you alluded to that I was struck by was a piece in The Washington Post this week about couples facing increasing costs to store their IVF embryos, often hundreds of dollars a year, which is forcing them to choose between letting the embryos go or losing a chance to possibly have another child. It’s obviously a big issue. I’m wondering what the anti-IVF forces think about that. As we’ve seen in Alabama, it’s not like you can just pick your embryos up in a cooler and move them someplace else. Moving them is actually a very big deal.

I don’t wish to minimize this, but I remember you have storage units for things, not obviously for embryos. One of the ways that they make money is that they just keep raising the cost because they think you won’t bother to move your things, so that you’ll just keep paying the increased cost. It feels like that’s a little bit of what’s happening here with these stored embryos, and at some point, it just gets prohibitively expensive for people to keep them in storage. I didn’t realize how expensive it was.

Carey: They’re all over the place. In preparing for this discussion, I’ve read things about people are paying $600 a year, other people are paying $1,200 a year. There’s big jumps from year to year. It can be an extremely expensive proposition. Oh, my goodness.

Rovner: IVF itself, I think as we’ve mentioned, is also extremely expensive and time-consuming, and emotionally expensive. It is not something that people enter into lightly. So I think we will definitely see more as we go. There’s also women’s health news this week that doesn’t have to do with reproduction. That’s new. Earlier this week, President Biden issued an executive order attempting to ensure that women are better represented in medical research. Tami, what does this order do and why was it needed?

Luhby: Well, it’s another attempt by the Biden administration, as we’ve discussed, to focus on reproductive health and reproductive rights. During the State of the Union address earlier this month, Biden asked Congress to invest $12 billion in new funding for women’s health research. And there are actually multiple components to the executive order, but the big ones are that it calls for supporting research into health and diseases that are more likely to occur midlife for women after menopause, such as rheumatoid arthritis, heart attacks, osteoporosis, and as well as ways to improve the management of menopause-related issues.

We are definitely seeing that menopause care is of increasing focus in a multitude of areas including employer health insurance, but the executive order also aims to increase the number of women participating in clinical trials since they’re poorly represented now. We know that certain medications and certain treatments have different effects on women than men, but we don’t really know that that well because they’re not as represented in these clinical trials. Then it also directs agencies to develop and strengthen research and data standards on women’s health across all of the relevant research and funding opportunities in the government.

Rovner: I’ll say that this is an issue I have very strong feelings about because I covered the debate in 1992 about including women in medical research. At the time, doctors didn’t want to have women in clinical trials because they were worried about hormones, and they might get pregnant, and we wouldn’t really know what that meant for whatever it was that we were testing. Someone suggested that “If you’re going to use these treatments and drugs on women, maybe you should test them on women too.” Then I won an award in 2015 for a story about how they still weren’t doing it, even though it was required by laws.

Carey: And here we are, 2024.

Rovner: Yeah, here we are. It just continues, but at least they’re trying. All right, finally, this week in medical misinformation, we travel to the Supreme Court, where the justices heard oral arguments in a case brought by two Republican state attorneys general charging that the Biden administration, quote, “coerced” social media platforms, Google, Meta, and X, into downgrading or taking down what public health officials deemed covid disinformation. I didn’t listen to the arguments, but all the coverage I saw suggested that the justices were not buying what the attorneys general were selling.

Yet another public-health-adjacent case to watch for a decision later this spring, but I think this is really going to be an important one in terms of what public officials can and cannot do using their authority as public health officials. We’re obviously in a bit of a public health trust crisis, so we will see how that goes.

All right, that is the news for this week. Now, we will play my interview with HHS Secretary Xavier Becerra, then we will be back with our extra credits.

I am so pleased to welcome back to the podcast Health and Human Services Secretary Xavier Becerra. I’ve asked him to join us to talk about the Affordable Care Act, which was signed into law 14 years ago this weekend. Mr. Secretary, thanks so much for coming back.

Xavier Becerra: Julie, great to be with you on a great week.

Rovner: So the Affordable Care Act has come a long way, not just in the 14 years since President Obama signed it into law, but in the 10 years since the healthcare.gov website so spectacularly failed to launch, but this year’s enrollment setting a record, right?

Becerra: That’s right, and you should have said, “You’ve come a long way, baby.”

Rovner: So what do we know about this year’s enrollment numbers?

Becerra: Another record breaker. Julie, every year that President Biden has been in office, we have broken records. Today, more Americans have health insurance than ever in the history of the country. More than 300 million people can now go to a doctor, leave their child in a hospital and know they won’t go bankrupt because they have their own health insurance. That’s the kind of peace of mind you can’t buy. Some 21.5 million Americans today look to the marketplace on the Affordable Care Act to get their coverage. By the way, the Affordable Care Act overall, some 45 million Americans today count on the ACA for their health care insurance, whether it’s through the marketplace, through Medicaid, or some of these basic plans that were also permitted under the ACA.

Rovner: Obviously, one of the reasons for such a big uptake is the expanded subsidies that were extended by the Inflation Reduction Act in 2022, but those expire at the end of next year, the end of 2025. What do you think would happen to enrollment if they’re not renewed?

Becerra: Well, and that’s the big question. The fact that the president made health care affordable was the big news. Because having the Affordable Care Act was great, but if people still felt it was unaffordable, they wouldn’t sign on. They now know that this is the best deal in town and people are signing up. When you can get health insurance coverage for $10 or less a month in your premiums, that’s a great deal. You can’t even go see a movie at a theater today for under $10. Now, you can get health care coverage for a full month, Julie. Again, as I always tell people, that doesn’t even include the popcorn and the refreshment at the movie theater, and so it’s a big deal. But without the subsidies, some people would still say, “Ah, it’s still too expensive.” So that’s why the president in his budget calls for extending those subsidies permanently.

Rovner: So there are still 10 states that haven’t taken up the federal government’s offer to pay 90% of the costs to expand Medicaid to all low-income adults in their states. I know Mississippi is considering a bill right now. Are there other states that you expect could join them sometime in the near future? Or are any of those 10 states likely to join the other 40?

Becerra: We’re hoping that the other 10 states join the 40 that have come on board where millions of Americans today have coverage. They are forsaking quite a bit of money. I was in North Carolina recently where Gov. [Roy] Cooper successfully navigated the passage of expansion for Medicaid. Not only was he able to help some 600,000-plus North Carolinians get health coverage, but he also got a check for $1.6 billion as a bonus. Not bad.

Rovner: No, not bad at all. So many years into this law, I feel like people now understand a lot of what it did: let adult children stay on their parents’ health plans until the age of 26; banning most preexisting condition exclusions in health coverage. Yet most people still don’t know that those provisions that they support were actually created by Obamacare or even that Obamacare and the Affordable Care Act are the same thing. Medicare has had such great branding success over the years. Why hasn’t the ACA?

Becerra: Actually, Julie, I think that’s changing. Today, about two-thirds of Americans tell you that they support the marketplaces in the Affordable Care Act. I think we’re actually now beginning an era where it’s no longer the big three, where you had Social Security, Medicare, and Medicaid and everyone protects those. Today, I think it’s the big four, the cleanup hitter being marketplace. Today, you would find tens of millions of Americans who would say, “Keep your dirty, stinking hands off of my marketplace.”

Rovner: Well, we will see as that goes forward. Obviously, President Biden was heavily involved in the development of the Affordable Care Act as vice president, as were you as a member of the House Ways and Means Committee at the time. What do you hope is this administration’s biggest legacy to leave to the health law?

Becerra: Julie, I think it’s making it affordable. The president made a commitment when he was first running to be president. He said on health care he was going to make it more affordable for more Americans with better benefits, and that’s what he’s done. The ACA is perfect proof. And Americans are signing up and signaling they agree by the millions. To go from 12 million people on the Affordable Care Act marketplace to 21.5 million in three years, that’s big news.

Rovner: So if I may, one question on another topic. Next week, the Supreme Court’s oral arguments occur in the case it could substantially restrict the availability of the abortion pill mifepristone. Obviously, this is something that’s being handled by the Justice Department, but what is it about this case that worries you most as HHS secretary, about the potential impact if the court rolls back FDA approval to the 2016 regulations?

Becerra: Well, Julie, as you well know from your years of covering health care, today there are Americans who have less protection, fewer rights, than many of us growing up. My daughters, my three daughters today, have fewer protections and access to health care than my wife had when she was their age. That’s not the America most of us know. To see another case where, now, medication abortion, which is used by millions of Americans — in fact, it’s the most common form of care that is received by a woman who needs to have abortion services — that is now at stake. But we believe that if the Supreme Court believes in science and it believes in the facts, because mifepristone has been used safely and effectively publicly for more than 20 years, that we’re going to be fine.

The thing that worries me as much, not just in the reduction of access to care for women in America, is the fact that mifepristone went through a process at the FDA similar to scores and scores of other medications that Americans rely on, that have nothing to do with abortion. And if the process is shut down by the Supreme Court for mifepristone, then it’s probably now at risk for all those other drugs, and therefore those other drugs that Americans rely on for diabetes, for cancer, who knows what, might also be challenged as not having gone through the right process.

Rovner: I know the drug industry is very, very worried about this case and watching it closely, and so will we. Mr. Secretary, thank you so much for joining us.

Becerra: Always good to be with you, Julie.

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

Luhby: OK, my extra credit this week is an article about Georgia’s unique Medicaid program from KFF Health News’ Andy Miller and Renuka Rayasam. It’s titled “Georgia’s Medicaid Work Requirement Costing Taxpayers Millions Despite Low Enrollment.” And I’m really glad they did this story. I and many others wrote about Georgia launching this program initially but haven’t done follow-up. So I was very happy to see this story.

As many of our listeners probably know, the Trump administration allowed multiple states to impose work requirements in Medicaid for the first time in the program’s history in 2018. But the efforts were eventually stopped by the courts in all states except Georgia. Georgia was allowed to proceed with adding its work requirement to Medicaid because it was actually going to expand coverage to allowing adults with incomes up to 100% of the poverty line to qualify. So the Georgia Pathways to Coverage initiative began last June.

Andy and Renuka took a look at how it’s faring, and the answer is actually not so well. Only about 3,500 people have signed up, far short of the 25,000 that the state projected for the first year. What’s more, the program has cost taxpayers at least $26 million so far, with more than 90% of that going towards administrative and consulting costs rather than actual medical care for low-income people.

By contrast, expanding Medicaid under the Affordable Care Act to people with 138% of the poverty line would make at least 359,000 uninsured Georgia residents newly eligible for coverage and reduce state spending by $710 million over two years. That’s what the advocates are pushing. So we’ll see what happens in coming months. One thing that’s also noted in the story is that about 45% of Pathways applications were still waiting to be processed.

Rovner: I will point out that we did talk a couple of weeks ago about the low enrollment in the Georgia program. What we had not seen was how much it’s actually costing the states per enrollee. So it is really good story. Alice, why don’t you go next?

Ollstein: Yeah, so I have some very relatable news from CNN. It’s called “Why Your Doctor’s Office Is Spamming You With Appointment Reminders.” It’s about why we all get so many obnoxious repeat reminders for every medical appointment. It both explains why medical practices that operate on such a tiny profit margin are so anxious about no-shows and last-minute cancellations, and so that’s part of it. But also part of it is that there are all these different systems that don’t communicate with one another. So the prescription drug system and the electronic medical records system and the doctor’s office’s own system are all operating in parallel and not coordinating with one another, and that’s why you get all these annoying multiple reminders. The medical community is becoming aware that it’s backfiring because the more you get, the more you start tuning them out and you don’t pay attention to which ones might be important. So they are working on it. So a somewhat hopeful piece of news.

Rovner: Raise your hand if you have multiple patient portals that you have to deal with for your multiple …

Ollstein: Oh, my God, yes.

Rovner: I will note that everybody’s hands go up. Mac?

Carey: I have not one but two stories on a very important issue: Medicaid estate recovery. The first is from Paula Span at The New York Times. The headline says it all, “When Medicaid Comes After the Family Home.” And the second story is an AP piece by Amanda Seitz, and that’s titled “State Medicaid Offices Target Dead People’s Homes to Recoup Their Health Care Costs.” Now, these stories are both about a program that’s been around since 1993. That’s when Congress mandated Medicaid beneficiaries over the age of 55 that have used long-term care services, and I’m talking about nursing homes or home care, that states must try to recover those expenses from the beneficiaries’ estates after their deaths.

As you can imagine, this might be a problem for the beneficiaries. They might have to sell a family home, try to find other ways to pay a big bill from Medicaid. Rep. Jan Schakowsky, she’s a Democrat of Illinois, has reintroduced her bill. It’s called the Stop Unfair Medicaid Recoveries Act. She’s trying to end the practice. She thinks it’s cruel and harmful, and her argument is, in fact, the federal and state governments spend way more than what they collect, and these collections often go after low-income families that can’t afford the bill anyway.

So even though it’s been around, it’s important to read up on this. A critical point in the stories was do states properly warn people that assets were going to be recovered if they enroll a loved one in Medicaid for long-term care and so on. So great reading, people should bone up on that.

Rovner: This is one of those issues that just keeps resurfacing and doesn’t ever seem to get dealt with. Well, my story this week is from The Washington Post, although I will say it was covered widely in dozens of outlets. It’s called “Arizona Lawmaker Tells Her Abortion Story to Show ‘Reality’ of Restrictions.” On Monday, Arizona State Sen. Eva Birch stood up on the Senate floor and gave a speech unlike anything I have ever seen. She’s a former nurse at a women’s health clinic. She’s also had fertility issues of her own for at least a decade, having both had a miscarriage and an abortion for a nonviable pregnancy in between successfully delivering her two sons.

Now, she’s pregnant again, but with another nonviable pregnancy, which she plans to terminate. Her point in telling her story in public on the Senate floor, she said, was to underscore how cruel — her words — Arizona’s abortion restrictions are. She’s been subject to a waiting period, required to undergo an invasive transvaginal ultrasound to obtain information she and her doctor already knew about her pregnancy, and to listen to a lecture on abortion, quote, “alternatives,” like adoption, which clearly don’t apply in her case.

While she gave the speech on the floor, several of her Democratic colleagues stood in the camera shot behind her, while many of the Republicans reportedly walked out of the chamber. I will link to the story, but I will also link to the entire speech for those who want to hear it.

OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our fill-in editor for today, Stephanie Stapleton. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Mary Agnes, where are you hanging out these days?

Carey: I’m hanging out on X, @MaryAgnesCarey.

Rovner: Alice?

Ollstein: @AliceOllstein on X, and @alicemiranda on Bluesky.

Rovner: Tami?

Luhby: The best place to find me is at cnn.com.

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

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

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

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

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

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna's stories.

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's articles.

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories.

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned on this week’s podcast:

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

Click to open the transcript

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

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

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

Margot Sanger-Katz: Good morning, everybody.

Rovner: Anna Edney of Bloomberg News.

Anna Edney: Hi there.

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

Joanne Kenen: Hey, everyone.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: We’re getting to that next.

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

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

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

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

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

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

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

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

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

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

Rovner: Yes.

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

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

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

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

Rovner: Yeah, that’s true.

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

Rovner: That’s next.

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

Rovner: You are such a good job, Joanne.

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: And to its stock price.

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

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

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

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

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

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

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

Kenen: I think two weeks ago.

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

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

Kenen: The House version.

Edney: The House version.

Kenen: Yes.

Edney: Yeah.

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

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

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

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

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

Rovner: It’s ideology.

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: That’s certainly true.

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

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

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

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

Kenen: And it’s not just about health.

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

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

Kelly Henning: Thank you for having me.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Did not read that part.

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

Rovner: True. Anna.

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

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

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

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

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

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

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

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

Rovner: Anna.

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

Rovner: Joanne.

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

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

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

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

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

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

Panelists

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned on this week’s podcast:

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

click to open the transcript

Transcript: The State of the Union Is … Busy

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

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

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

Alice Miranda Ollstein: Hello.

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

Sarah Karlin-Smith: Hi, everybody.

Rovner: And Sandhya Raman, of CQ Roll Call.

Raman: Good morning.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: I have that on a T-shirt.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Alice.

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

Rovner: Sandhya.

Raman: @SandhyaWrites on X and on Blue Sky.

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

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

Reverberations from the Alabama Supreme Court’s first-in-the-nation ruling that embryos are legally children continued this week, both in the states and in Washington. As Alabama lawmakers scrambled to find a way to protect in vitro fertilization services without directly denying the “personhood” of embryos, lawmakers in Florida postponed a vote on the state’s own “personhood” law. And in Washington, Republicans worked to find a way to satisfy two factions of their base: those who support IVF and those who believe embryos deserve full legal rights.

Meanwhile, Congress may finally be nearing a funding deal for the fiscal year that began Oct. 1. And while a few bipartisan health bills may catch a ride on the overall spending bill, several other priorities, including an overhaul of the pharmacy benefit manager industry, failed to make the cut.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Riley Griffin of Bloomberg News, and Joanne Kenen of Johns Hopkins University’s schools of nursing and public health and Politico Magazine.

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Rachel Cohrs
Stat News

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Riley Griffin
Bloomberg

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Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's articles.

Among the takeaways from this week’s episode:

• Lawmakers are readying short-term deals to keep the government funded and running for at least a few more weeks, though some health priorities like preparing for a future pandemic and keeping down prescription drug prices may not make the cut.
• After the Alabama Supreme Court’s decision that frozen embryos are people, Republicans find themselves divided over the future of IVF. The emotionally charged debate over the procedure — which many conservatives, including former Vice President Mike Pence, believe should remain available — is causing turmoil for the party. And Democrats will no doubt keep reminding voters about it, highlighting the repercussions of the conservative push into reproductive health care.
• A significant number of physicians in Idaho are leaving the state or the field of reproductive care entirely because of its strict abortion ban. With many hospitals struggling with the cost of labor and delivery services, the ban is only making it harder for women in some areas to get care before, during, and after childbirth — whether they need abortion care or not.
• A major cyberattack targeting the personal information of patients enrolled in a health plan owned by UnitedHealth Group is drawing attention to the heightened risks of consolidation in health care. Meanwhile, the Justice Department is separately investigating UnitedHealth for possible antitrust violations.
• “This Week in Health misinformation”: Panelist Joanne Kenen explains how efforts to prevent wrong information about a new vaccine for RSV have been less than successful.

Also this week, Rovner interviews Greer Donley, an associate professor at the University of Pittsburgh School of Law, about how a 150-year-old anti-vice law that’s still on the books could be used to ban abortion nationwide.

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

Julie Rovner: ProPublica’s “Their States Banned Abortion. Doctors Now Say They Can’t Give Women Potential Lifesaving Care,” by Kavitha Surana.

Rachel Cohrs: The New York Times’ “$1 Billion Donation Will Provide Free Tuition at a Bronx Medical School,” by Joseph Goldstein.

Joanne Kenen: Axios’ “An Unexpected Finding Suggests Full Moons May Actually Be Tough on Hospitals,” by Tina Reed.

Riley Griffin: Bloomberg News’ “US Seeks to Limit China’s Access to Americans’ Personal Data,” by Riley Griffin and Mackenzie Hawkins.

Also mentioned on this week’s podcast:

• The Washington Post’s “Florida Lawmakers Postpone ‘Fetal Personhood’ Bill After Alabama IVF Ruling,” by Lori Rozsa.
• Stat’s “Congress Punts on PBM Reform Efforts,” by Rachel Cohrs and John Wilkerson.
• Politico Magazine’s “There’s a New Life-Saving Vaccine. Why Won’t People Take It?” by Joanne Kenen.
• Stat’s “Experts Say Scale of Change Cyberattack Shows Risks of Centralized Claims Processing,” by Brittany Trang, Tara Bannow, and Bob Herman.
• The Wall Street Journal’s “U.S. Opens UnitedHealth Antitrust Probe,” by Anna Wilde Mathews and Dave Michaels.
• CNN’s “Opinion: It’s Too Dangerous to Allow This Antiquated Law to Exist Any Longer,” by David S. Cohen, Greer Donley, and Rachel Rebouché.

click to open the transcript

Transcript: Alabama’s IVF Ruling Still Making Waves

KFF Health News’ ‘What the Health?’Episode Title: Alabama’s IVF Ruling Still Making WavesEpisode Number: 336Published: Feb. 29, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 29, at 10 a.m. Happy leap day, everyone. As always, news happens fast and things might’ve changed by the time you hear this, so here we go.

We are joined today via video conference by Rachel Cohrs of Stat News.

Rachel Cohrs: Hi, everybody.

Rovner: Riley Ray Griffin of Bloomberg News.

Riley Griffin: Hello, hello.

Rovner: And Joanne Kenen of the Johns Hopkins University schools of nursing and public health and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: Later in this episode we’ll have my interview with University of Pittsburgh law professor Greer Donley about that 150-year-old Comstock Act we’ve talked about so much lately. But first, this week’s news.

So as we tape this morning, the latest in a series of short-term spending bills for the fiscal year that began almost five months ago, is a day and a half away from expiring, and the short-term bill for the rest of the government is 15 days from expiring. And apparently the House and Senate are in the process of preparing yet another pair of short-term bills to keep the government open for another week each, making the new deadlines March 8 and March 22. I should point out that the Food and Drug Administration is included in the first set of spending bills that would expire, and the rest of HHS [Department of Health and Human Services] is in the second batch.

So what are the chances that this time Congress can finish up the spending bills for fiscal 2024? Rachel, I call this Groundhog Day, except February’s about to be over.

Cohrs: Yeah, it’s definitely looking better. I think this is the CR [continuing resolution] where, as I’m thinking about it, the adults are in the room and the negotiations are actually happening. Because we had a couple of fake-outs there, where nobody was really taking it seriously, but I think we are finally at a place where they do have some agreement on some spending bills. The House hopefully will be passing some of them, and I’m optimistic that they’ll get it at least close within that March 8-March 22 time frame to extend us out a few more months until we get to do this all over again in September.

At least right now, which it could change, they do have a couple of weeks, but it’s looking like the main kind of health care provisions that we were looking at are going to be more of an end-of-year conversation than happening this spring.

Rovner: Which is anticipating my next question, which is a bunch of smaller bipartisan bills that were expected to catch a ride on the spending bill train seemed to have been jettisoned because lawmakers couldn’t reach agreement. Although it does look like a handful will make it to the president’s desk in this next round, and its last round, of fiscal spending bills for fiscal 2024.

Let’s start with the bills that are expected to be included when we finally get to these spending bills, presumably in March.

Cohrs: So, from my reporting, it sounds like that there’s going to be an extension of funding for the really truly urgent programs that are expiring. We’re talking community health center funding, funding for some public health programs. It’s funding for safety-net hospitals through Medicaid. Those policies might be extended. There’s a chance that there could be some bump in Medicare payments for doctors. I haven’t seen a final number on that yet, but that’s at least in the conversation for this round.

Again, there’s going to be more cuts at the end of this year. So, I think we’ll be continuing to have this conversation, but those look like they’re in for now. Again, we don’t have final numbers, but that’s kind of what we’re expecting the package to look like.

Kenen: And the opioids is under what you described as public health, right, or is that still up in the air?

Cohrs: I think we’re talking SUPPORT Act; I think that is up in the air, from my understanding. With public health programs talking, like, special diabetes reauthorization — there are a couple more small-ball things, but I think SUPPORT Act, PAHPA [Pandemic and All Hazards Preparedness Act], to my understanding, are still up in the air. We’ll just have to wait for text. That hopefully comes soon.

Rovner: Riley, I see you nodding too. Is that what you’re hearing?

Griffin: Yeah. Questions about PAHPA, the authorizations for pandemic and emergency response activities, have been front of mind for folks for months and months, particularly given the timing, right? We are seeing this expire at a time when we’ve left the biggest health crisis of our generation, and seeing that punted further down the road I think will come as a big disappointment to the world of pandemic preparedness and biodefense, but perhaps not altogether unexpected.

Rovner: So Rachel, I know there were some sort of bigger things that clearly got left on the cutting room floor, like legislation to do something about pharmacy benefit managers and site-neutral payments in Medicare. Those are, at least for the moment, shelved, right?

Cohrs: Yes. That’s from my understanding. Again, I will say now they bought themselves a couple more weeks, so who knows? Sometimes a near-death experience is what it takes to get people moving in this town. But the most recent information I have is that site-neutral payments for administering drugs in physicians’ offices, that has been shelved until the end of the year and then also reforms to how PBMs [pharmacy benefit managers] operate. There’s just a lot of different policies floating around and a lot of different committees and they just didn’t come to the table and hash it out in time. And I think leadership just lost patience with them.

They do see that there’s another bite at the apple at the end of the year. We do have a lot of members retiring, Cathy McMorris Rodgers on the House side, maybe [Sen.] Bernie Sanders. He has not announced he’s running for reelection yet. So I think that’s something to keep in mind for the end of the year. And there also is a big telehealth reauthorization coming up, so I think they view that as a wildly popular policy that’s going to be really expensive and it’s going to be another … give them some more time to just hash out these differences.

Kenen: I would also point out that this annual fight about Medicare doctor payments was something that was supposedly permanently fixed. Julie and I spent, and many other reporters, spent countless hours staking out hallways in Congress about this obscure thing that was called SGR, the sustainable growth rate, but everyone called it the “doc fix.” It was this fight every year that went on and on and on about Medicare rates and then they replaced it and it was supposed to be, “We will never have to deal with this again.”

I decided I would never write another story about it after the best headline I ever wrote, which was, “What’s up, doc fix?” But here we are again. Every single year, there’s a fight about …

Rovner: Although this isn’t the SGR, it’s just …

Kenen: They got rid of SGR, that era was over. But what we’ve learned is that era will probably never be over. Every single year, there will be a lobbying blitz and a fight about Medicare Advantage and about Medicare physician pay. It’s like leap year, but it happens every year instead of every four.

Rovner: Because lobbyists need to get paid too.

All right, well, I want to turn to abortion where the fallout continues from that Alabama Supreme Court ruling earlier this month that found frozen embryos are legally children. Republicans, in particular, are caught in an almost impossible position between portions of their base who genuinely believe that a fertilized egg is a unique new person deserving of full legal rights and protections, and those who oppose abortion but believe that discarding unused embryos as part of the in vitro fertilization process is a morally acceptable way for couples to have babies.

In Alabama, where the ruling has not just stopped IVF clinics from operating in the state, but has also made it impossible for those in the midst of an IVF cycle to take their embryos elsewhere because the companies that would transport them are also worried about liability, the Republican-dominated legislature is scrambling to find a way to allow IVF to resume in the state without directly contradicting the court’s ruling that “personhood” starts at fertilization.

This seems to be quite a tightrope. I mean, Riley, I see you nodding. Can they actually do this? Is there a solution on the table yet?

Griffin: No, I don’t think there’s a solution on the table yet, and there are eight clinics in Alabama that do this work, according to the CDC [Centers for Disease Control and Prevention]. Three of them have paused IVF treatment across the board. We’ve been in touch with these clinics as days go by as we see some of these developments, and they’re not changing their policies yet. Some of these efforts by Republicans to assure that there won’t be criminal penalties, they’re not reassuring them enough.

So, it certainly is a tightrope for providers and patients. It’s also a tightrope, as you mentioned, Julie, for the Republican Party, which is divided on this matter, and for Republican voters, who are also divided on this matter. But ultimately, this whole conversation comes back to what constitutes a human being? What constitutes a person? And the strategy of giving rights to an embryo allows abortion laws to be even more restrictive across this country.

Rovner: Yeah, I can’t tell you how many stories I’ve written about “When does life begin?” over the last 30 years, because that’s really what this comes down to. Does life begin at fertilization? Does it begin … I mean, doctors, I have learned this over the years, that conception is actually not fertilization. Conception is when basically a fertilized egg implants in a woman’s uterus. That’s when pregnancy begins. So there’s this continuing religious and scientific and ethical and kind of a quagmire that now is front and center again.

Joanne, you wanted to add something?

Kenen: No. I mean, I thought [Sen.] Lindsey Graham had one of the best quotes I’ve seen, which is, “Nobody’s ever been born in a freezer.” So this is a theological question that is turning into a political question. And even the proposed legislation in Alabama, which would give the clinics immunity or a pardon, I mean, pardon means you committed a crime. In this case, a murder, but you were pardoned for it. I mean, I don’t think that’s necessarily … and it’s only good for this was a stopgap that would, if it passes, I believe it would be just till early 2025.

So it might get these clinics open for a while. They may come up with some way of getting families that are in the middle of fertility treatments to be able to complete it, but other states could actually go the way Alabama went. We have no guarantee. There are people pushing for that in some of the more conservative states, so this may spread. The attempt in Congress, in the Senate, to bring up a bill that would address it …

Rovner: We’ll get to that in a second.

Kenen: I mean, Alabama’s a conservative state, but the governor, who was a conservative anti-abortion governor, has said she wants to reopen the clinics and protect them, but they haven’t come up with the formula to do that yet.

Rovner: So speaking of other states, when this decision came down in Alabama, Florida was preparing to pass its own personhood bill, but now that vote has been delayed at the request of the bill’s sponsor. The, I think, initial reaction to the Alabama decision was that it would spur similar action in other states, as you were just saying, Joanne, but is it possible that the opposite will happen, that it will stop action in other states because those who are pushing it are going to see that there’s a huge divide here?

Griffin: That hesitation certainly signals that that’s a possibility. The pause in pushing forward that path in Florida is a real signal that there is going to be more debate within the Republican Party.

One thing I do want to mention is a lot of focus has been on whether clinics in Alabama or otherwise would stop IVF treatment altogether. But I think equally important is how the clinics that are continuing to offer IVF treatment, what changes they’re making. The ones that we’re seeing, are speaking with in Alabama that are continuing to offer IVF, are changing their consent forms. They are fertilizing fewer eggs, they’re freezing eggs, but they’re not fertilizing them because they don’t want to have excess wastage, in their perspective, that could lead them to a place of liability.

So all these things ultimately have ramifications for patients. That is more costly. It means a longer timeline. It also means fewer shots on goal. It means that it is potentially harder for you to get pregnant, at the end of the day. So I want to center the fact that clinics that are continuing to offer IVF are facing real changes here too.

Rovner: We know from Texas that when states try to indemnify, saying, “Well, we won’t prosecute you,” that that’s really not good enough because doctors don’t want to run the chance of ending up in court, having to hire lawyers. I mean, even if they’re unlikely to be convicted and have their licenses taken away, just being charged is hard enough. And I think that’s what’s happening with doctors with some of these abortion exceptions, and that’s what’s happening with these IVF clinics in places where there’s personhood.

Sorry, Joanne. Go ahead.

Kenen: Egg-freezing technology has gotten better than it was just a few years ago, but egg-freezing technology, to the best of my knowledge, egg-freezing technology, though improved, is nowhere near as good as freezing an embryo. Particularly now they can bring embryos out to what they call the blastocyst stage. It’s about five days. They have a better chance of successful implantation.

In addition to the expense of IVF, and it’s expensive and most people don’t have insurance cover[age] for it, it means you’re going through drugs and treatment and all of us have had friends, I think, who’ve gone through it or relatives. It is just an incredibly stressful, emotionally painful process.

Rovner: Well, you’re pumping yourself full of hormones to create more eggs, so yeah.

Kenen: And you’re also trying to get pregnant. If you’re spending $20,000 a cycle or whatever it is, and pumping yourself full of hormones, doing all this, it means that having a child is of utmost importance to you.

And the emotional trauma of this, if you listen to the … we’ve heard interviews in the last few days of women who were about to have a transfer and things like that, the heartbreak is intense, and fertility is not like catching a cold. It’s really stressful and sad, and this is just causing anguish to families trying to have a child, trying to have a first child, trying to have a second child, whatever, or trying to have a child because there’s a health issue and they want to do the pre-implantation genetic testing so that they don’t have another child die. I mean, it’s really complicated and terrible costs on all kinds of costs, physical, emotional, and financial.

Rovner: Yeah, there are lots of layers to this.

Well, meanwhile, this decision has begun to have repercussions here on Capitol Hill. In the Senate, the Democrats are, again, while it’s in the news, trying to force Republicans into taking a stand on this issue by bringing up a bill that would guarantee nationwide access to IVF. This is a bill that they tried to bring up before and was blocked by Republicans. On Wednesday, a half a dozen senators led by Illinois’ Tammy Duckworth, a veteran who used IVF to have her two children, chided Republicans on the floor who failed again to let them bring up the IVF bill. This time, as last time, it was blocked by Republican Sen. Cindy Hyde-Smith of Mississippi.

I imagine the Democrats aren’t going to let this go anytime soon though. They certainly indicated that this is not their last attempt at this.

Kenen: No. Why should they? If anyone thought that the politics of abortion were going to subside by November, this has just given it … I don’t even have a word for how much it’s been reinvigorated. This is going to stick in people’s minds, and Republicans are divided on IVF, but there’s no path forward. Democrats are going to be trying again and again, if they can, and they’re going to remind voters of it again and again.

Rovner: And in the Republican House, they’re scrambling to figure out again, as in Alabama, how to demonstrate support for IVF without running afoul of their voters who are fetal personhood supporters.

Just to underline how delicate this all is, the personhood supporting anti-abortion group, Susan B. Anthony [Pro-Life America], put out a statement this week, not just thrashing the Democrats’ bill, which one would expect, but also the work going on by Republicans in Alabama and in the U.S. House for not going far enough. They point out that Louisiana has a law that allows for IVF, but not for the destruction of leftover embryos. Although that means, as Riley was saying before, those embryos have to be stored out of state, which adds to the already high cost of IVF.

It is really hard to imagine how Republicans at both the state and federal level are going to find their way out of this thicket.

Kenen: It’s a reproductive pretzel.

Griffin: It’s a reproductive pretzel where two-thirds of Americans say frozen embryos shouldn’t be considered people. So I mean, there is data to suggest that this isn’t a winning selling point for the Republican Party, and we saw that play out with presidential candidate Donald Trump immediately distancing himself from the Alabama Supreme Court decision. So, what a pretzel it is.

It’s going to be interesting to see how this pans out as the logistical hurdles continue to arise. And some are basic. I mean, I spoke last week with one clinic in Alabama that said that they had had dozens, I think they said 30 to 40, embryos that had been abandoned over decades going back as 2008, and they had tried to reach people by phone, by mail, by email. They had just been left behind. What do you do in that situation? They had been prepared to dispose of those embryos and now they’re sitting on shelves. Is that the answer? Is the only answer to have shelves and shelves of frozen embryos?

Rovner: Yeah, I mean, it is. It is definitely a pretzel.

Kenen: There was a move at one point to allow them to be adopted. I think …

Rovner: It’s still there. It’s still there.

Kenen: Right, but I don’t know what kind of consent you need. I mean, if the situations where someone left the frozen embryo and doesn’t respond or their email, they’ve changed their email or whatever, there may be some kind of way out for this mess that involves the possibility of adopting them at some point down the road, and they may not be biologically viable by that point. But when I was thinking of what are the political outs, what is the exit ramp, I haven’t heard any politicians talk about this yet, but that occurred to me as something that might end up figuring into this.

And the other thing, just to the point as to how deeply divided, I think many listeners know this, but for the handful who don’t, the illustration of how deeply divided even very anti-abortion Republicans are, is [former Vice President] Mike Pence, his family was created through IVF, and he’s clearly, he’s come out this week. I mean, there’s no question that Mike Pence is anti-abortion, there’s not a lot of doubt about that, but he has come forth and endorsed IVF as a life-affirming rather, as a good thing.

Rovner: And I actually went and checked when this all broke because Joanne probably remembers in the mid-2000s when they were talking about stem cell research that President George W. Bush had a big event with what were called “snowflake children,” which were children who were born because they were adopted leftover embryos that someone else basically gestated, and that …

Kenen: But I don’t think they’ll call them “snowflake” anymore.

Rovner: Yeah. Well, that adoption agency is still around and still working and still accepting leftover embryos to be adopted out. That does still exist. I imagine that’s probably of use in Louisiana too, where you’re not allowed to destroy leftover embryos.

Well, meanwhile, we have some new numbers on something else we’ve been talking about since Dobbs [v. Jackson Women’s Health Organization]. Doctors who deliver babies in states with abortion bans are choosing to leave rather than to risk arrest or fines for providing what they consider evidence-based care. In Idaho, according to a new report, 22% of practicing obstetricians stopped practicing or left the state from August 2022 to November 2023. And, at the same time, two hospitals’ obstetric programs in the state closed, while two others report having trouble recruiting enough doctors to keep their doors open.

I would think this is going to particularly impact more sparsely populated states like Idaho, which also, coincidentally or not, are the states that tend to have the strictest abortion bans. I mean, it’s going to be … this seems to be another case where it’s going to be harder, where abortion bans are going to make it harder to have babies.

Cohrs: Yeah. I mean, we’re already seeing a trend of hospital systems being reluctant to keep OB-GYN delivery units open anyway. We’ve seen care deserts. It’s really not a profitable endeavor unless you have a NICU [neonatal intensive care unit] attached. So I think this just really compounds the problems that we’ve been hearing about staffing, about rural health in general, recruiting, and just makes it one step harder for those departments that are really important for women to get the care they need as they’re giving birth, and just making sure that they’re safe and well-staffed for those appointments leading up to and following the birth as well.

Kenen: Right. And at a time we’re supposedly making maternal mortality a national health priority, right? So you can’t really protect women at risk, and, as Rachel said, it’s during childbirth, but it’s for months after. And without proper care, we are not going to be able to either bring down the overall maternal mortality rates nor close the racial disparities.

Griffin: I was just going to say, I highly recommend a story the New Yorker did this past January, “Did an Abortion Ban Cost a Young Texas Woman Her Life?” It’s a view into many of these different themes and will show you a real human story, a tragic one at that, about what these deserts, how they have consequential impact on people’s lives for both mother and baby.

Rovner: Yeah, and we talked about that when it came out. So if you go back, if you scroll back, you’ll find a link to it in the show notes.

I was going to say March is when we get “Match Day,” which is when graduating medical students find out where they’re going to be completing their training. And we saw just sort of the beginnings last year of kind of a dip in graduating medical students who want to become OB-GYNs who are applying to programs in states with abortion bans. I’ll be really curious this year to see whether that was a statistical anomaly or whether really people who want to train to be OB-GYNs don’t want to train in states where they’re really worried about changing laws.

We have to move on. I want to talk about something I’m calling the most under-covered health story of the month, a huge cyberattack on a company called Change Healthcare, which is owned by health industry giant UnitedHealth [Group]. Change processes insurance claims and pharmacy requests for more than 300,000 physicians and 60,000 pharmacies. And as of Wednesday, its systems were still down a week after the attack.

Rachel, I feel like this is a giant flashing red light of what’s at risk with gigantic consolidation in the health care industry. Am I wrong?

Cohrs: You’re right, which is why a couple of my colleagues did cover it as just this important red flag. And there are new SEC [Securities and Exchange Commission] reporting rules as well that require more disclosure around these kind of events. So I think that will …

Rovner: Around the cyberattacks?

Cohrs: Yes, around the cyberattacks, yes. But I think just the idea that, we’ll talk about this later too, but that Change is owned by UnitedHealth and just so much is consolidated that it really does create risks when there are vulnerabilities in these very essential processes. And I think a lot of people just don’t understand how many health care companies, they don’t provide any actual care. They’re just helping with the backroom kind of operations. And when you get these huge conglomerates or services that are bundled together under one umbrella, then it really does show you how a very small company maybe not everyone had heard of before this week could take down operations when you go to your pharmacy, when you go to your doctor’s office.

Rovner: Yeah, and there are doctors who aren’t getting paid. I mean, there’s bills that aren’t getting processed. Everything was done through the mail and it was slow and everybody said, “When we digitize it, it’s all going to be better and it’s all going to happen instantly.” And mostly what it’s done is it’s created all these other companies who are now making money off the health care system, and it’s why health care is a fifth of the U.S. economy.

But anticipating what you were about to say, Rachel, speaking of the giant consolidation in the health industry by UnitedHealth, I am not the only one, we are not the only ones who have noticed. The Wall Street Journal reported this week that the Justice Department has begun an antitrust investigation of said UnitedHealthcare, which provides not only health insurance and claims processing services like those from Change Healthcare, but also through its subsidiary Optum, owns a network of physician groups, one of the largest pharmacy benefit managers, and provides a variety of other health services. Apparently one question investigators are pursuing is whether United favors Optum-owned groups to the detriment of competing doctors and providers.

I think my question here is what took so long? I know that the Justice Department looked at it when United was buying Change Healthcare, but then they said that was OK.

Cohrs: Yeah. I will say I think this is a great piece of reporting here, and these are excellent questions about what happens when the vertical integration gets to this level, which we just really haven’t seen with UnitedHealthcare, where they’re aggressively acquiring provider clinics. I think it was a home health care company that they were trying to buy as well.

So I think it is interesting because now that the acquisitions have happened on some of these, there will be evidence and more material for investigators to look at. It won’t be a theoretical anymore. So I will be interested to see just how this plays out, but it does seem like the questions they’re asking are pretty wide-ranging, certainly related to providers, but also related to an MLR [medical loss ratio]. What if you own a provider that’s charging your insurance company? How does that even work and what are the competitive effects of that for other practices? So I think …

Rovner: And MLRs, for those who are not jargonists, it’s minimum loss ratios [also known as medical loss ratio], and it’s the Affordable Care Act requirement that insurers spend a certain amount of each dollar on actual care rather than overhead and profit and whatnot. So yeah, when you’re both the provider and the insurer, it’s kind of hard to figure out how that’s going.

I am sort of amazed that it’s taken this long because United has been sort of expanding geometrically for the last decade or so.

Kenen: It’s sort of like the term vertical integration, which is the correct term that Rachel used, but as she said that, I sort of had this image of a really tall, skinny, vertical octopus. There’s more and more and more things getting lumped into these big, consolidating, enormous companies that have so much control over so much of health care and concentrated in so few hands now. It’s not just United. I mean, they’re big, but the other big insurers are big too.

Cohrs: Right. I did want to also mention just that we’re kind of seeing this play out in other places too, like Eli Lilly creating telehealth clinics to prescribe their obesity medications. Again, there’s no evidence that they’re connected to this in any way, but I think it is going to be a cautionary tale for other health care companies who are looking into this model and asking themselves, “If UnitedHealthcare can do it, why can’t we do it?” It will be interesting to see how this plays out for the rest of the industry as well.

Rovner: Yeah, when I started covering health policy, I never thought I was going to become a business reporter, but here we are.

Moving on to “This Week in Health Misinformation,” we have Joanne, or rather an interesting, and as it turns out, extremely timely story about vaccines that Joanne wrote for Politico Magazine. Joanne, tell us your thesis here with this story.

Kenen: I wanted to look at how much the public health and clinician community had learned about combating misinformation, sort of a real-life, real-time unfolding before our eyes, which was the rollout of the RSV vaccine.

And I think the two big takeaways, I mean, it’s a fairly … I guess there were sort of three takeaways from that article. One, is they’ve learned stuff but not enough.

Two, is that it’s not that there was this huge campaign against the RSV vaccine, there is misinformation about the RSV vaccine, but basically it just got subsumed into this nonstop, ever-growing anti-vaccine movement that you didn’t have to target RSV. Vaccines is a dirty word for a section of the population.

And the third thing I learned is that the learning about fighting disinformation, the tools we have, you can learn about those tools and deploy those tools, but they don’t work great. There’ve been some studies that have found that what they call debunking or fact-checking, teaching people that what they believe is untrue, that they say, “Ah, that’s not right,” and then a week later they’re back to their original, as little as one week in some studies. One week, you’re back to what you originally thought. So we just don’t know how to do this yet. There are more and more tools, but we are not there.

Rovner: Well, and I say this story is timely because we’re looking at a pretty scary measles outbreak in Florida and a Florida surgeon general who has rejected all established public health advice by telling parents it’s up to them whether to send their exposed-but-unvaccinated children to school rather than keep them home for the full 21 days that measles can take to incubate.

The surgeon general has been publicly taken to task by, among others, Florida’s former surgeon general. I can remember several measles outbreaks over the years, often in less-than-fully-vaccinated communities, but I can’t remember any public health officials so obviously flouting standard public health advice.

Joanne, have you ever seen anything like this?

Kenen: No. It’s like his public stance is like, “Measles, schmeasles.” It’s like a parent has the right to decide whether they’re potentially contagious, goes to school and infects other children, some of whom may be vulnerable and have health problems. It is this complete elevation of medical liberty or medical freedom completely disconnected to the fact that we are connected to one another. We live in communities. We supposedly care about one another. We don’t do a very good job of that, and this is sort of the apotheosis of that.

Rovner: And one of the main reasons that public schools require vaccines is not just for the kids themselves, but for kids who may have younger siblings at home who are not yet fully vaccinated. That’s the whole idea behind herd immunity, is that if enough people are vaccinated then those who are still not fully vaccinated will be protected because it won’t be floating around. And obviously in Florida, measles, which is, according to many doctors, one of the most contagious diseases on the planet, is making a bit of a comeback. So it is sort of, as you point out, kind of the end result of this demonization of all vaccines.

Kenen: And our overall vaccination rate for childhood immunization has dropped and it’s dropped, I’d have to fact-check myself, I think what you need for herd immunity is 95% and it’s …

Rovner: I think it’s over 95.

Kenen: And that we’re down to maybe 93[%]. I mean, this number was in that article that I wrote, but I wrote it a few weeks ago and I may be off by a percentage point, so I want to sort of clarify that nobody should quote me without double-checking that. But basically, we’re not where we need to be and we’re not where we were just a few years ago.

Rovner: Another space we will continue to watch.

Well, that is this week’s news. Now we will play my interview with law professor Greer Donley, and then we will come back and do our extra credits.

I am thrilled to welcome to the podcast, Greer Donley, associate dean for research and faculty development and associate professor of law at the University of Pittsburgh Law School. She’s an expert in legal issues surrounding reproductive health in general and abortion in particular, and someone whose work I have regularly relied on over the past several years, so thank you so much for joining us.

Greer Donley: I’m so happy to be here. Thanks for having me.

Rovner: So I’ve asked you here to talk about how an anti-abortion president could use an 1873 law called the Comstock Act to basically ban abortion nationwide. But first, because it is still so in the news, I have to ask you about the controversy surrounding the Alabama Supreme Court’s ruling that frozen embryos for in vitro fertilization are legally children. Do you think this is a one-off, or is this the beginning of states really, fully embracing the idea of personhood from the moment of fertilization?

Donley: Man, I have a lot to say about that. So I’ll start by saying that first of all, this is the logical extension of what people have been saying for a long time about, “If life starts at conception, this is what that means.” So in some sense, this is one of those things where people say, “Believe people when they tell you something.” Folks have been saying forever, “Life starts at conception.” This is a logical outgrowth of that. So in some sense, it’s not particularly surprising.

It’s also worth noting that states have been moving towards personhood for decades, often through these kind of state laws, like wrongful death, which is exactly what happened here. So this is the first case that found that an embryo outside of a uterus was a children for this purpose of wrongful death, but many states had been moving in the direction of finding a fetus or even an embryo that’s within a pregnant person to be a child for the purpose of wrongful death for a while now. And that has always been viewed as the anti-abortion movement towards personhood. In some sense, this is just kind of the logical outgrowth, the logical extension, of the personhood movement and the permission that Dobbs essentially gave to states to go as far as they wanted to on this question.

So whether or not this is going to be the beginning of a new trend is, I think, in my mind, going to be really shaped by public backlash to the Alabama decision, particularly. I think that many folks within the anti-abortion movement, again, they mean what they say. They do believe that this is a life and it should be treated as any other life, but whether or not they are going to perceive this as the ideal political climate in which to push that agenda is another question.

And my personal view is that, given the backlash to the Alabama Supreme Court, you might see folks retreating a little bit from this. I think we’re starting to see a little bit of that, where more moderate people within the Republican Party are going to say, “This is not the moment to go this far,” or maybe even, “I’m not sure I actually support this logical outgrowth of my own opinion,” and so we’re going to have to kind of …

Rovner: “I co-sponsored this bill, but I didn’t realize that’s what it would do.”

Donley: Exactly. Right? So we’re going to, I think, really have to see how people’s views change in response to the backlash.

Rovner: Let us go back to Comstock. Who was this person, Anthony Comstock? What does this law do and why is it still on the books 151 years after it was passed?

Donley: Ugh, yes, OK. So Anthony Comstock, he is what people often call, “The anti-vice crusader.” This law passed in 1873. It’s actually a series of laws, but we often compile them and call them the Comstock Act.

The late 1800s were a moment of change, where many people in this country were for the first time being exposed to the idea that abortion is immoral for religious reasons. Before that for a long time, in the early 1800s, people regularly purchased products to try to what they call, “Bring on the menses,” or menstrual regulation. So it was not uncommon. It was a fairly commonly held view up until late 1800s that the pregnancy was nothing until it was a quickening, there was a quickening where the pregnant person felt movement.

So Comstock was one of the people who was really kind of a part of changing that culture in the late 1800s, and he had the power as the post office inspector of investigating the mail throughout our country. So he was influential not only in helping to pass a law that made it illegal to ship through interstate commerce all sorts of things that he considered immoral, which explicitly included abortion and contraception, but also used vague terms like “anything immoral.” And he was the person that was then in charge of enforcing those laws by actually investigating the mail. His investigations led to pretty horrible outcomes, including many people killing themselves after he started investigating them for a variety of Comstock-related crimes at the time.

So obviously, this law was passed before women had the right to vote, in a completely different time period than we exist today, and it really remained on the books by an accident of history, in my mind.

So in the early 1900s, there was a series of cases. This was the moment where we particularly saw a huge movement towards birth control. So as that movement was going on, you saw a lot of litigation in the courts that were interpreting the Comstock laws related to contraception, finding that it had to be narrowly limited to only unlawful contraception or unlawful abortion. Because the Comstock laws, by its terms, which this should shock everybody who’s hearing me, has literally no exceptions, not even for the life of the pregnant person. And it is so broad that it would ban abortion nationwide from the beginning of a pregnancy without exception. Procedural abortion, pills, everything.

Rovner: And people think of this as the U.S. mail, but it’s not just the U.S. mail. It’s basically any way you move things across state lines, right?

Donley: Right. Because we live in a national economy now, so there’s nothing in medicine that exists in a purely intrastate environment. So every abortion provider in the country is dependent on them and their state mail to get things that they need for procedural abortion and pills.

In the early to mid-1900s, right around the 1930s, there was a series of cases that said this law only applied for unlawful contraception and abortion because they had to read that term into the law. Eventually in the late 1930s, you saw the federal government stop enforcing it completely. And then you had the constitutional cases came out that found a right to contraception and abortion, and so the law was presumed unconstitutional for half a century. No one was repealing it because everyone assumed that it was never going to come back to life. In comes Dobbs, in come the modern anti-abortion movement, and now we are here.

Rovner: Yeah. So how could a President Trump, if he returns to the White House, use this to ban abortion nationwide?

Donley: Yes, because this law was never repealed, and because the case that presumptively made it unconstitutional, Roe v. Wade, and the cases that came after that, are now no longer good law, presumptively the law, like a zombie, comes back to life.

And so the anti-abortion movement is now trying to reinterpret the law, right? We’re talking about such a long period of time and all those 1930s cases, since that time period, you have the rise of what we call textualism, which is a theory of statutory interpretation that really likes to stick to the text. That was something that’s been around for a while, but in modern jurisprudence, that has become increasingly important, and the anti-abortion movement sees, “Well, all these judges are now textualists, and we can say this law is still good. By its clear terms, it bans shipping through interstate commerce anything that could be used for an abortion. Voila. We have our national abortion ban without having to get a single vote in Congress. All we need is a Republican president that will enforce the law as it’s written and on the books today,” and that is their theory.

Rovner: And that’s included, I think, in one of the briefs that was filed today in the abortion pill case, right?

Donley: Absolutely. In that case, that’s a case concerning the regulation of mifepristone, one of the abortion pills, that’s before the Supreme Court this summer. You had parties saying, “The law is clear and it is as broad as it’s written,” essentially.

Rovner: Well, this doesn’t apply to contraception anymore, right?

Donley: Right. So right after the Supreme Court case Griswold [v. Connecticut], which found a constitutional right to contraception, but before Roe, you had the Congress actually repealed the portion of Comstock related to contraception. But again, it was before Roe, so they didn’t repeal the part related to abortion, and then Roe came in and made that part presumptively unconstitutional.

Of course, going back in time, we would say, “You got to repeal that law. You have no idea what the future may be,” but I don’t think people really saw this moment coming. They should have. We should have all been preparing for this more. But, yeah.

Rovner: One of the things that I don’t think I had appreciated until I read the op-ed that you co-wrote, thank you very much, is that there could be a reach-back here. It’s not even just abortions going forward, right?

Donley: Right. So the idea here is that, generally, laws have a statute of limitations, right? So you could potentially have a President Trump come in, say that he’s going to start enforcing this law immediately, and even if the second Jan. 1 comes, people stop shipping anything through interstate commerce, he could still go back and say, “Well, the statute of limitations is five years.” So you go back in time for five years and potentially bring charges against someone.

So one of the important pieces of advocacy that we might have in this moment is to really encourage President Biden, if he were to not win the election, to preemptively essentially pardon anybody for any Comstock-related crimes to make sure that that can’t be used against them. That’s a power he actually has and will be a very important power for him to use in that instance. But it’s quite alarming how Comstock could be used in this period, but also retrospectively.

Rovner: Last question, and I know the answer to this, but I think I need to remind listeners, if Congress doesn’t have to pass anything to implement a nationwide ban, why haven’t previous anti-abortion Republican presidents tried to do this?

Donley: While Roe and [Planned Parenthood of Southeastern Pennsylvania v.] Casey were good law, there was no way that they could possibly do that. It would’ve been unconstitutional for them to try to criminalize people for exercising their constitutional right to reproductive health care for abortion. So we’re really in a new moment where essentially the Supreme Court overturned those cases while President Biden was in office, and so the real question is whether a Republican administration could come in and change everything.

Rovner: We shall see. Greer Donley, thank you so much for coming to explain this.

Donley: Thank you for having me.

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

Rachel, you were the first to choose this week. Why don’t you go first?

Cohrs: The article I chose is in The New York Times. The headline is “$1 Billion Donation Will Provide Free Tuition at a Bronx Medical School” by Joseph Goldstein. And it’s about how this 93-year-old widow of an early investor in Berkshire Hathaway has given $1 billion to a medical school in the Bronx to pay for students’ tuition. And I think her idea behind it is that it will open up the pool of students who might be able to go to medical school. I imagine applications might increase to this school as well. And she was a professor at the school during her career as well.

To me, it’s not a scalable solution necessarily for the cost of medical education, but I think it does highlight how broke everything is. When we’re talking about Medicare payment to doctors, I think one of the arguments they always use is doctors have debt and there’s inflation and costs have gone up so much, and I think the cost of education in this country certainly is one factor in that, that it’s really hard to address from a simply health care policy standpoint.

So I think not necessarily a scalable solution, but will definitely make a difference in a lot of students’ lives and just give them more freedom to practice in the specialty that they might want to, which we all know we need more primary care doctors and doctors in a variety of different settings. So I think it’s a rare piece of good news.

Rovner: Yeah, it might not be scalable, but it’s not the first, which is kind of … I remember, in fact, NYU is now having a no-tuition medical school. UCLA, although I think UCLA is only for students who can demonstrate financial need. But in doing those earlier stories, and I have not updated this, at the time, which is a couple of years ago, the average medical student debt graduating is over $250,000. So you can see why they feel like they need to be in more lucrative specialties because they’re going to be paying their student loans back until they’re in their 40s, most of them. This is clearly a step in that direction.

Riley, why don’t you go next?

Griffin: Yeah. I wanted to share a story that I’ve been fairly obsessed with over the last month. It’s one of my own. It’s “US Seeks to Limit China’s Access to Americans’ Personal Data.” This week, the Biden administration announced that it is issuing, or has at this point issued, an executive order to secure Americans’ sensitive personal data, and we broke this story about a month ago.

Why it is so interesting to the health world is, one of the key parts that was a motivating factor in putting together this executive order, is DNA, genomic data. The U.S., the National Security Council, our national security apparatus is really concerned about what China and other foreign adversaries are doing with our genetic information. And we can get more into that in the story itself, but it is fascinating, and now we’re seeing real action to regulate and protect and ensure that that bulk data doesn’t get into the hands of people who want to use it for blackmail and espionage.

Rovner: Yeah, it was super scary, I will say. Joanne?

Kenen: I couldn’t resist this one. It’s in Axios. It’s by Tina Reed, and the headline is “An Unexpected Finding Suggests Full Moons May Actually Be Tough on Hospitals.” Caveat, before I go on, there is research out there that proves what I’m about to say is wrong.

But anyway, a company that makes panic buttons, so a hospital security company that one of the things they do is provide panic buttons, they did a study of how and when these panic buttons are used, and they found they go up during full moons. And they also found that other things rise during full moons. GI [gastro-intestinal] disorders go up, ambulance rides connected to motor vehicle accidents go up, and psychiatric admissions go up. So maybe that research that I cited at the beginning saying this is hogwash needs to be reevaluated in some subcategories.

Rovner: There’s always new things to find out in science.

My extra credit this week is from ProPublica. It’s called “Their States Banned Abortion. Doctors Now Say They Can’t Give Women Potential Lifesaving Care,” by Kavitha Surana. It’s another in a series of stories we’ve seen about women with serious pregnancy complications that are not immediately life-threatening, but who nevertheless can’t get care that their doctors think they need.

This story, however, is written from the point of view of the doctors, specifically members of an abortion committee at Vanderbilt Hospital in Nashville who are dealing with the Tennessee ban that’s one of the strictest in the nation. It’s really putting doctors in an almost impossible position in some cases, feeling that they can’t even tell patients what the risks are of continuing their pregnancies for fear of violating that Tennessee law. It’s a whole new window into this story that we keep hearing about and a really good read.

OK. That is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us too. Special thanks as always to our very patient technical guru, Francis Ying, and our editor, Emmarie Huetteman.

As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me hanging around at Twitter, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads.

Joanne, where are you hanging these days?

Kenen: Mostly at Threads, @joannekenen1. I still occasionally use X, and that’s @JoanneKenen.

Rovner: Riley, where can we find you on social media?

Griffin: You can find me at X @rileyraygriffin.

Rovner: And Rachel?

Cohrs: I’m at X @rachelcohrs and on LinkedIn more these days, so feel free to follow me there.

Rovner: There you go. We’ll be back in your feed next week. Until then, be healthy.

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Pharmaceutical companies that manufacture insulin made headlines last year when they voluntarily agreed to provide discount cards that lower the monthly cost of insulin for many people to $35. 

But getting your hands on this card — and persuading a pharmacist to accept it — can be a hassle.

In this episode of “An Arm and a Leg,” producer Emily Pisacreta speaks with “insulin activists” and pharmaceutical experts to find out what this change in prices means for people with diabetes and why the fight for affordable insulin isn’t over yet.

Dan Weissmann

@danweissmann

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

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Transcript: Wait, Is Insulin Cheaper Now?

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

Dan: Hey there. Right after the holidays, I got an email from a listener named Brianna.It started, “Happy new year Dan! I was just reading the news about the price of insulin going down to $35! Is that for everyone?”

And I was like, Huh. I had a sense that there was some news about the price of insulin, but 35 dollars a month for everyone? That sounded like a BIG reduction. And big news.I googled the latest stories, and I was… not totally sure what I was seeing.

I was definitely seeing some new stories about people paying 35 bucks from here on out. And there seemed to be some federal law involved, and politicians were patting themselves on the back. But it just wasn’t totally clear: Was insulin now 35 dollars for everyone? Did the outrageous price of insulin get solved while I wasn’t looking?

And I mean, I’ve kinda been looking. We’ve done a couple of episodes about the price of insulin already — because insulin is iconic. It represents the wild cost of prescription drugs in this country. More than 8 million Americans take insulin to treat their diabetes – and for some, going without it could actually kill you.

And its price got jacked up so much — huge multiples over like ten years — — that one in four of those people who couldn’t go without… took to rationing: Seeing how much they could go without, short of actually dying.

So I asked our senior producer Emily Pisacreta to take the case.

Emily: I feel more like the senior insulin correspondent, which is fine with me as the resident type 1 diabetic! And a lot has happened since the last time we talked about insulin on this show. We really do need an update.

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

Today we have a question: what’s going on with insulin? Is it $35 now?

Emily: Well, there have been some BIG improvements — bigger than I thought when I started reporting. A lot of people can get their monthly supply of insulin for just $35. But it is oversimplified to say it just costs $35 now. And the people who have been fighting to lower the price of insulin over the past decade? They’re still very pissed. So let me walk you through what changed, what led to those changes, and what’s still unresolved.

Dan: OK!

Emily: For years now, there’s been a giant push from people with diabetes to get the federal government to do something about the high cost of insulin. In 2022, finally something came through. I’m talking about a provision in Inflation Reduction Act.

Dan: Yes– I remember this– the Inflation Reduction Act was a big infrastructure bill that included, like renewable energy subsidies, and– honestly, this is the reason that I remember the bill, because we did an episode about this part–  letting medicare negotiate some drug prices?

Emily: Exactly. It said people on Medicare would be able to get a month’s supply of insulin for no more than $35 out of pocket. But of course that left a big gaping hole. BECAUSE that’s cool for people on Medicare, but what about the rest of us? And the pharma companies were feeling the heat. Here’s President Biden in his State of the Union last year:

President Biden: Big pharma has been unfairly charging people hundreds of dollars, four to $500 a month making record profits. Not anymore. Not anymore.

Emily: By the way, those pharma companies? There’s three of them who make insulin.

That’s the American company Eli Lilly, the Danish company Novo Nordisk, and the French company Sanofi. OK so: not long after  Joe Biden talked about their record profits, the insulin makers were back in the news. …

Eli Lilly was the first to announce they were going to slash prices on several of their most popular insulins, and limit out of pocket spending to $35 a month.

Fox News: This is a big story.

 Next, Novo Nordisk and Sanofi made similar announcements. 

CNN: Millions of Americans are affected by this major news this morning for millions of people suffering from diabetes and high prescription drug costs.

Basically, the insulin manufacturers all said hey, you’re not covered by this Medicare thing? We’re going to bring your copay down to $35 ourselves. So if you have commercial insurance Print out this card, take it to the pharmacy, and your copay will be no more than $35 for a month’s supply of insulin.

Dan: And what if you’re uninsured?

Emily: Well, they have a card for that, too.

Dan: OK so what I’m hearing is you need a card.

DAN: Yes. How do you get one?

Emily: The insulin makers set special phone numbers you can call. Or you can visit their websites, fill out a little form, and download the card.

Dan: Sounds simple, unless I’m missing something?

Emily: In all honesty, I had no problem with those steps. But I wouldn’t assume that’s the case for everyone. And I’m also not rationing insulin right now.

Zoe Witt: When you are rationing insulin, maybe you aren’t even fully rationing insulin yet, but you don’t know how you’re going to get Your next prescription, your next fill of insulin…You are in crisis. Like, you, you do not have the capability to sift through these websites. It’s very confusing. It’s very overwhelming.

Emily: This is someone who frequently speaks to people struggling to afford insulin.

Zoe Witt: my name is Zoe Witt. I work with Mutual Aid Diabetes.

Emily: Mutual Aid Diabetes. That’s an all volunteer group that has banded together to help diabetics get what they need, when they need it. They help people with cash and with free diabetes supplies, including insulin, no questions asked. That means Zoe knows the ins and outs of every obstacle to getting insulin.

Zoe Witt: Our healthcare system is like a whack a mole from hell.

Emily:  And Zoe reminds me: if you’re not taking enough insulin, you probably feel awful. Maybe not even thinking straight. And it can affect your eyes, making it hard to read.

Zoe Witt: It just is unmanageable

Emily: Zoe says they talk with people all the time who are too stressed out or too debilitated to download these cards and use them.  Diabetes folks walk people through the process. And once someone has the card… Mutual Aid Diabetes gives people the 35 bucks, too, if they say they need it. Because $35 can be a barrier for a lot of people. And it’s actually $70 sometimes if you use 2 types of insulin at once, which lots of people do… myself included.

Dan: Wow. OK. But then once people have the cards they typically have no problem?

Emily: Well, your pharmacist has to know what they’re doing, too. So sometimes it means a patient having to educate their pharmacist– or even bring the doctor in to help troubleshoot — which is no picnic. And people with diabetes are always having to deal with insurance roadblocks at the pharmacy, so I don’t want to make anything sound simpler than it is. 

Dan: It’s like a whack a mole from hell!

Emily: Exactly! And the cards don’t solve everything. Especially this: if you have insurance, these cards only apply to the insulin your insurance plan already covers. If you normally need a prior authorization to get the right insulin for you… that is still the case.

Dan: Right. Okay.  like prior authorization is this roadblock to getting all kinds of treatment, that you and your doctor agree that you should have, and your insurance company can say, we disagree. We’re s not authorizing this. And then you’re stuck. 

Emily: Right. 

Dan:But in terms of what the pharma companies. can do to kind of offer you a deal. They’re basically doing it. Is that right? 

Emily: I think that’s fair to say. 

Dan: That’s super interesting. All right. So it’s not solved, but this is a big step forward. And what’s not solved is: some people are still on the hook for the list price for insulin — the price without any discounts or insurance or whatever. But you found big improvements there too, right? 

Emily: Yes! When the companies announced all these discount cards, they announced a whole other big change, too. Slashing the list prices of a bunch of different insulins by up 75%. So a vial that once was north of $300 is now being listed at around $70.

Dan: OK, that sounds like a big improvement.

Emily: It’s a big, big deal. Actual price reductions are what diabetes advocates have been demanding all along. And… while these are still the highest prices in the world for these same insulins, to see them drop from triple to double digits, it’s wild.

Dan: I sense that there’s a “but” here.

Emily: Well, the Big Three didn’t lower the price of every type of insulin, only ones that have been around since the 1990s or early 2000s. Newer insulins that work faster or last longer are not included here.

Dan: And I’m guessing not all insulins work the same way.

Emily: Right. Some people can switch between types or brands of insulin easily. For other people, there can be allergies or one works better with their body with another kind. It’s complicated. It’s medicine! AND… there have been some issues with pharmacies actually stocking lower list price insulin. That is a whole ‘nother saga… an episode for another day. But the important thing is… a bunch of insulin is a lot cheaper now.

Dan: Wow. Emily, you said right at the top: The changes here are bigger and better than you realized before you started reporting. 

Emily: Yes but there’s still a lot more to say. 

Right. After the break, we’ll’ hear from you about why these changes happened NOW. And what it means for people with diabetes and really all of us…

[midroll]

So. We have seen some big changes in the last year — including DRUG COMPANIES expanding their discount programs and lowering the sticker prices on insulin, dramatically. Why now? I’m guessing this wasn’t because they had a big change of heart.

Emily: I can’t speak to what’s in pharma’s hearts. But I did talk to someone who knows a lot about pharma’s brain.

Ed Silverman: my name is Ed Silverman, and I work at Stat News, a health and life sciences website,

Emily: I’m a big fan of Stat News

Dan: Me too, man! Their reporting is great.

Emily:  And Ed Silverman. He’s been covering the pharmaceutical industry for almost 30 years. He thinks activism from people with diabetes over the years created political pressure that played a big role in the decision to slash prices. But there was also something kind of hidden at work.

Ed Silverman: It’s not altruism, here was a real mechanism, government mechanism in place that helped change the equation and therefore the thinking back at the companies.

Dan: OK… what is he talking about?

Emily: So, Dan: do you remember the stimulus bill, the American Rescue Plan?

Dan: I’m starting to feel like this episode is a quiz on recent-ish legislation. And I think I’m gonna do pretty well here:.The American Rescue Plan was a trillion dollar stimulus that Joe Biden got passed right after he got into office– am I right?

Emily: OK, hotshot. Do you remember how in part 8 section 9816 they sunsetted the limit on the maximum rebate for single source drugs and innovator multiple source drugs?

Dan:  Um, busted. No. 

Emily: Ok so here’s the deal: it’s obviously kinda wonky so I’ll simplify– in that little section Congress made a tweak to Medicaid, basically raising penalties on drug-makers for jacking up prices too far, too fast. So if you’re a pharma company who has raised the price of a drug by a lot very quickly, which is true of insulin, and a lot of people on Medicaid use your drug, which is also true of insulin, then you have to pay a big penalty. In the case of insulin, that penalty would be more than you’d make selling the insulin to Medicaid. A LOT more: So, unless you bring the price back down, you’re going to owe Medicaid a lot of moolah. And those penalties were set to kick in January 1st 2024.

Dan: So you’re telling me: Part of what the pharma companies did here came right out of a small part of a giant federal law from 2021.

Emily: Yep. And there’s another big wheel turning in the background here. Novo Nordisk and Eli Lilly, two companies who really got their start by selling insulin, now make other diabetes drugs — drugs that are now increasingly used for weight loss. And it’s a bonanza.

GMA: It is literally the hottest drug in the country right now.

Fox News: all people are talking about these days is Ozempic, wegovy. Oh my gosh, this person lost 20 pounds. This person lost 50 pounds.

Ozempic Ad: [Jingle:] “Oh, Oh, Oh, Ozempic![Announcer:] Once weekly Ozempic is helping many people with type 2 diabetes like James lower their blood sugar.

Emily: Drugs like Ozempic, Wegovy, Mounjaro. They’ve been in super high demand. And there’s been a ton of hype about their various potential health benefits. For weight loss, for heart health. Scientists are even interested in whether it can help people with substance use disorders. Meanwhile, for Eli Lilly and Novo Nordisk, the returns on these drugs dwarf anything else they’re selling. Novo Nordisk even became the biggest company in Europe – for like a minute… but still.

Dan: OK, this is interesting, but what does it have to do with the price of insulin?

Emily: I’d wondered… maybe these companies can just better afford to buy some political peace by lowering insulin prices, because they are making so much bank on these new drugs, ? Ed Silverman had a take on that.

Ed Silverman: It makes perfect sense that these cash cows, these medicines that are used for diabetes and, weight loss are going to become increasingly important to their bottom line more than other medicines

Emily: More than insulin. And they’re selling so much so fast, they can hardly keep up with demand. Which could end up affecting people who need insulin.

Dan: Wait, how?

Emily:  Look, for example, in November, Novo Nordisk said they were investing 3 and half billion dollars into ramping up production of injection pens for  Wegovy, one of their top drugs in this category. Less than a week later, Novo announced they would be phasing out one of their insulin products  from the US market – an insulin called Levemir. It’s one of the insulins whose prices they just dropped. And… coincidence… Levemir also comes in a pen.

Dan: So Novo Nordisk is phasing out an insulin pen so they can make more Wegovy pens?

Emily: Well, we don’t know that for sure. But Novo Nordisk did tell me that “manufacturing constraints” were part of why they’re dumping Levimir. They said it was one of several reasons and also wrote: “We made this decision after careful consideration and are confident that given the advanced notice, U.S. patients will have access to alternative treatments and can transition to other options.    

Dan: Huh. OK.

Emily: But even if pulling this insulin Levemir off the market had nothing to do with their trouble meeting the demand for their big blockbuster drug… it brings to mind an important question about all the changes we talked about today — whether it’s the copay savings or the lowered list prices. Here’s Ed Silverman.

Ed Silverman there’s no guarantee that the companies will keep these in place. Maybe after time, some of the attention on insulin is diverted and maybe eighteen months from now, one company might quietly roll back some of the Benefits, if you want to use that word, there’s nothing requiring them to maintain the steps they’ve taken.

Emily: I asked all three insulin makers about this. None of them promised there would never be any backsies. Lilly wrote back “Lilly is committed to ensuring all patients can access any Lilly medicine they need” — and touted their efforts to date. Similarly, Sanofi wrote “We continually review our affordability offerings to support our aim that no one should struggle to pay for their insulin. Novo Nordisk’s response was “Novo Nordisk increases the price of some of our medicines each year, in response to changes in the healthcare system, market conditions, and the impact of inflation.” 

Dan: Yeah, that especially does not sound like a pinky-swear, no-backsies kind of response.   

Emily: AND  that’s not much comfort for insulin activists. Folks like Shaina Kasper, who works for T1International. They’re a group that’s been at the forefront of this fight for years.  I Asked her…

Emily-on-tape: So is this issue of high insulin prices just resolved now?

Shaina Kasper: No, it hasn’t been. It’s been really frustrating…

Emily Shaina and others are worried that the announcements from the manufacturers about savings cards and voluntary list price reductions will take the pressure off the government to do something more sweeping. Because for now…

Shaina: The manufacturers really hold all of the power here And if patients are counting on these programs to literally be able to survive, that has life and death consequences

Dan: This question about who holds the power, it reminds me of a story we did a few months ago… the one about how the writer John Green led a kind of online crusade targeting the drug-maker Johnson & Johnson. And how, even though the pressure campaign worked — J & J ended up allowing lower-priced versions of an important tuberculosis drug — activists who worked on the issue were like: It’s a problem that Johnson & Johnson has the power to say yes or no here..

Emily: Exactly. That which pharma giveth, pharma can taketh. At least the way things are set up now. Now I should say, all three companies told me they plan to continue their affordability offerings. But if insulin continues to be the poster child for high drug prices, prices virtually everyone in America agrees are too high…it does raise the question: are voluntary programs from pharmaceutical companies the solution we want? To Zoe from Mutual Aid Diabetes, the answer is no. They find these manufacturer savings cards kind of a bitter pill… no pun intended.

Zoe Witt: there’s certainly no justice in these programs, 

Emily: And zoe for one would say that justice is overdue. 

Zoe Witt: These companies have price gouged us. for years, making obscene amounts of money. Then, presumably, as, we’re often told is the justification for these ridiculous prices, they did research and development for more diabetes drugs, which are Ozempic, Monjoro, etc. And now, these companies, for, the next 15 years, are set to make, billions and billions of dollars, on these drugs,

Emily: I asked the big three insulin manufacturers about what Zoe said – about how angry folks like them are over the cost of insulin. Novo Nordisk said “we continually review and revise our offerings as well as work with diverse stakeholders to create solutions for differing patient needs. ”  And Sanofi and Lily both said something very similar.

Emily: So… in the end– or at least for now– here’s the answer to our listener’s question…. There are more avenues than ever to get a month’s supply of insulin for $35. Great. It may be a lot easier to avoid rationing your insulin now than it was a couple years ago. That’s also really great. But people with diabetes do not think this fight is over.

Dan: So what DO they want?

Emily: Some people still want the federal government to just put a cap on what people pay for insulin, like by law.. Others are working to build alternatives to the existing pharmaceutical industry, like California’s CalRx program.

Dan: Cal Rx… now you’re calling back our story from the last time we talked about insulin.

Emily: Yep, Cal Rx is the state of California’s attempt to enter the insulin market, to introduce some low priced generics and sell them essentially at cost. Other states are joining in. Even if some of these specific plans fall apart — even if California somehow can’t get its government-sponsored insulin to market, even if Pharma rolls back some of the discounts…the past few years have been enormous for people with diabetes. Mostly because they’ve found each other.

Zoe Witt: I was rationing insulin in 2018, I didn’t even know that there was a term for it. I didn’t know other people were doing it. I know a lot of people died that year. And there were multiple occasions where I, in retrospect, definitely almost died. And the one good thing that has, that has happened between now and then is that people have been talking about it and People are now more comfortable telling others that they’re struggling, that they can’t get their insulin.

Emily: Connecting with Mutual Aid Diabetes or other networks to get or give help.

Zoe Witt: We’re all keeping each other alive, like to me, that’s the number one thing that has changed.

Emily: I think that’s a huge lesson here, and a takeaway that’s not new on this show. Keeping each other alive — or even just keeping each other from getting bankrupted by the medical system — is up to us. And while a mutual aid group modeled exactly like Mutual Aid Diabetes may not work for every disease or every drug, Zoe says they’re more than willing to talk to anyone who might be interested in trying.

Zoe Witt: I mean, we’ve even had people ask, like, is there like a mutual aid asthma or something like for inhalers? 

Emily: Their advice? 

Zoe Witt: I think that, you know, to start,  you would want, like,  probably at least, like, five to ten ”ride-or dies,” like, people that are really willing to, like, go the extra mile, 

Dan: Five to ten– that just does not sound like that many! (I mean, I think.) One thing I’m taking away is:  This is a lot of activism over a long time, that eventually had a big effect. Another thing I’m taking away here? Sneaky policy changes — like lifting the Medicaid rebate cap — can make a huge difference. God bless whatever nerds are writing the next little bit of law to sneak into a giant bill, like a hacker with a virus.

Emily: Totally. OK. I gotta take a shot, and eat my lunch.

Dan: Go for it. We’ll be back with a new episode in a few weeks. Till then, take care of yourself.

This episode of an arm and a leg was produced by Emily Pisacreta and me, Dan Weissman and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and blue dot sessions. 

Gabrielle Healy is our managing editor for audience. She edits the first aid kit newsletter. 

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

And Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling and journalism. 

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

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax exempt donations. You can learn more about INN at INN. org. 

Finally, thanks to everybody who supports this show financially– you can join in any time at arm and a leg show dot com, slash, support — and thanks for listening.

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

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The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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

The Alabama Supreme Court’s groundbreaking ruling last week that frozen embryos have legal rights as people has touched off a national debate about the potential fallout of the “personhood” movement. Already the University of Alabama-Birmingham has paused its in vitro fertilization program while it determines the ongoing legality of a process that has become increasingly common for those wishing to start a family. 

Meanwhile, former President Donald Trump is reportedly leaning toward endorsing a national, 16-week abortion ban. At the same time, former aides are planning a long agenda of reproductive health restrictions should Trump win a second term.

This week’s panelists are Julie Rovner of KFF Health News, Lauren Weber of The Washington Post, Rachana Pradhan of KFF Health News, and Victoria Knight of Axios.

Panelists

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Rachana Pradhan
KFF Health News

@rachanadpradhan

Read Rachana's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• The Alabama Supreme Court’s decision on embryonic personhood could have wide-ranging implications beyond reproductive health care, with potential implications for tax deductions, child support payments, criminal law, and much more.
• Donald Trump is considering a national abortion ban at 16 weeks of gestation, according to recent reports. It is unclear whether such a ban would go far enough to please his conservative supporters, but it would be far enough to give Democrats ammunition to campaign on it. And some are looking into using a 19th-century anti-smut law, the Comstock Act, to implement a national ban under a new Trump presidency — no action from Congress necessary.
• New reporting from KFF Health News draws on many interviews with clinicians at Catholic hospitals about how the Roman Catholic Church’s directives dictate the care they may offer patients, especially in reproductive health. It also draws attention to the vast number of religiously affiliated hospitals and the fact that, for many women, a Catholic hospital may be their only option.
• Questions about President Joe Biden’s cognitive health are drawing attention to ageism in politics — as well as in American life, with fewer people taking precautions against the covid-19 virus even as it remains a serious threat to vulnerable people, especially the elderly. The mental fitness of the nation’s leaders is a valid, relevant question for many voters, though the questions are also fueled by frustration with a political system in which many offices are held by older people who have been around a long time.

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 “New CMS Rules Will Throttle Access Researchers Need to Medicare, Medicaid Data,” by Rachel M. Werner.

Lauren Weber: The Washington Post’s “They Take Kratom to Ease Pain or Anxiety. Sometimes, Death Follows,” by David Ovalle.

Rachana Pradhan: Politico’s “Red States Hopeful for a 2nd Trump Term Prepare to Curtail Medicaid,” by Megan Messerly.

Victoria Knight: ProPublica’s “The Year After a Denied Abortion,” by Stacy Kranitz and Kavitha Surana.

Also mentioned on this week’s podcast:

• The New York Times’ “Trump Privately Expresses Support for a 16-Week Abortion Ban,” by Maggie Haberman, Jonathan Swan, and Lisa Lerer.
• The New York Times’ “Trump Allies Plan New Sweeping Abortion Restrictions,” by Lisa Lerer and Elizabeth Dias.
• Politico’s “Trump Allies Prepare to Infuse ‘Christian Nationalism’ in Second Administration,” by Alexander Ward and Heidi Przybyla.
• KFF Health News’ “The Powerful Constraints on Medical Care in Catholic Hospitals Across America,” by Rachana Pradhan and Hannah Recht.
• The Washington Post’s “Tax Records Reveal the Lucrative World of Covid Misinformation,” by Lauren Weber.
• KFF Health News’ “Do We Simply Not Care About Old People?” by Judith Graham.
• Stat’s “A Neuropsychologist Clarifies Science on Aging and Memory in Wake of Biden Special Counsel Report,” by Annalisa Merelli.

click to open the transcript

Transcript: Alabama Court Rules Embryos Are Children. What Now?

KFF Health News’ ‘What the Health?’Episode Title: Alabama Court Rules Embryos Are Children. What Now?Episode Number: 335Published: Feb. 22,2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 22, 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 Lauren Weber of The Washington Post.

Lauren Weber: Hello, hello.

Rovner: Victoria Knight of Axios.

Victoria Knight: Hello, everyone.

Rovner: And my KFF Health News colleague Rachana Pradhan.

Rachana Pradhan: Hi, there. Good to be back.

Rovner: Congress is out this week, but there is still tons of news, so we will get right to it. We’re going to start with abortion because there is lots of news there. The biggest is out of Alabama, where the state Supreme Court ruled last week that frozen embryos created for IVF [in vitro fertilization] are legally children and that those who destroy them can be held liable. In fact, the justices called the embryos “extrauterine children,” which, in covering this issue for 40 years, I never knew was a thing. There are lots of layers to this, but let’s start with the immediate, what it could mean to those seeking to get pregnant using IVF. We’ve already heard that the University of Alabama’s IVF clinic has ceased operations until they can figure out what this means.

Pradhan: I think that that is the immediate fallout right now. We’ve seen Alabama’s arguably flagship university saying that they are going to halt. And I believe some of the coverage that I saw, there was even a woman who was about to start a cycle or was literally about to have embryos implanted and had to encounter that extremely jarring development. Beyond the immediate, and of course, Julie, I’m sure we’ll talk about this, a bit about the personhood movement and fetal rights movement in general, but a lot of the country might say, “Oh, well, it’s Alabama. It’s only Alabama.” But as we know it, it really just takes one state, it seems like these days, to open the floodgates for things that might actually take hold much more broadly across the country. So that’s what I’m …

Rovner: It’s funny, the first big personhood push I covered was in 2011 in Mississippi, so next door to Alabama, very conservative state, where everybody assumed it was going to win. And one of the things that the opposition said is that this would ban most forms of birth control and IVF, and it got voted down in Mississippi. So here we are, what, 13 years later. But I mean, I think people don’t quite appreciate how IVF works is that doctors harvest as many eggs as they can and basically create embryos. Because for every embryo that results in a successful pregnancy, there are usually many that don’t.

And of course, couples who are trying to have babies using IVF tend to have more embryos than they might need, and, generally, those embryos are destroyed or donated to research, or, in some cases — I actually went back and looked this up — in the early 2000s there was a push, and it’s still there, there’s an adoption agency that will let you adopt out your unused embryos for someone else to carry to term. And apparently, all of this, I guess maybe not the adoption, but all the rest of this could theoretically become illegal under this Alabama Supreme Court ruling.

Pradhan: And one thing I just want to say, too, Julie, piggybacking on that point too is not just in each cycle that someone goes through with IVF — as you said, there are multiple embryos — but it often takes two people who want to start a family, it often takes multiple IVF cycles to have a successful pregnancy from that. It’s not like it’s a one-time shot, it usually takes a long time. And so you’re really talking about a lot of embryos, not just a one-and-done situation.

Rovner: And every cycle is really expensive. I know lots of people who have both successfully and unsuccessfully had babies using IVF and it’s traumatic. The drugs that are used to stimulate the extra eggs for the woman are basically rough, and it costs a lot of money, and it doesn’t always work. It seems odd to me that the pro-life movement has gotten to the point where they are stopping people who want to get pregnant and have children from getting pregnant and having children. But I guess that is the outflow of this. Lauren, you wanted to add something?

Weber: Yeah, I just wanted to chime in on that. I mean, I think we’re really going to see a lot of potential political ramifications from this. I mean, after this news came down, and just to put in context, the CDC [Centers for Disease Control and Prevention] reported in 2021 that there were 91,906 births via IVF. So that’s almost 92,000 families in 2021 alone. You have a political constituency of hundreds of thousands of parents across the U.S. that feel very strongly about this because they have received children that they paid a lot of money for and worked very hard to get. And it was interesting after this news came down — I will admit, I follow a lot of preppy Southern influencers who are very apolitical and if anything conservative, who all were very aggressively saying, “The only reason I could have my children is through this. We have to make a stand.”

I mean, these are not political people. These are people that are — you could even argue, veering into tradwife [traditional wife] territory in terms of social media. I think we’re really going to see some political ramifications from this that already are reflected in what Donald Trump has recently been reported as feeling about how abortion limits could cost him voters. I do wonder if IVF limits could really cause quite an uproar for conservative candidates. We’ll see.

Rovner: Yeah. Well, Nikki Haley’s already gotten caught up in this. She’s very pro-life. On the other hand, she had one of her children using IVF, which she’s been pretty frank about. She, of course, got asked about this yesterday and her eyes had the deer-in-the-headlights look, and she said, “Well, embryos are children,” and it’s like, “Well, then what about your extra embryos?” Which I guess nobody asked about. But yeah, I mean clearly you don’t have to be a liberal to use IVF to have babies, and I think you’re absolutely right. I want to expand this though, because the ruling was based on this 2018 constitutional amendment approved by voters in Alabama that made it state policy to, quote, “Recognize and support the sanctity of unborn life and the rights of unborn children.”

I should point out that this 2018 amendment did not directly try to create fetal personhood in the way that several states tried — and, as I mentioned, failed — in the 2010s, yet that’s how the Alabama Supreme Court interpreted it. Now, anti-abortion advocates in other states, Rachana, you mentioned this, are already trying to use this decision to apply to abortion bans and court cases there. What are the implications of declaring someone a person at the moment of fertilization? It obviously goes beyond just IVF, right?

Knight: Well, and I think you mentioned already, birth control is also the next step as well. Which basically they don’t want you to have a device that will stop a sperm from reaching an egg. And so I think that could have huge ramifications as well. So many young women across the U.S. use IUDs or other types of birth control. I know that’s one application that people are concerned about. I don’t know if there are others.

Rovner: Yeah, I’ve seen things like, if you’re pregnant, can you now drive in the HOV [high-occupancy vehicle] lane because you have another person?

Pradhan: I think that’s one of the more benign, maybe potential impacts of this. But I mean, if an embryo is a child, I mean it would affect everything from, I think, criminal laws affecting murder or any other … you could see there being criminal law impacts there. I think also, as far as child support, domestic laws, involving families, what would you — presumably maybe not everyone that I imagine who are turning to fertility treatments to start a family or to grow a family may not have a situation where there are two partners involved in that decision. I think it could affect everything, frankly. So much of our tax estate laws are impacted by whether people have children or not, and so …

Rovner: And whether those children have been born yet.

Pradhan: … tax deductions, can you claim an embryo as a dependent? I mean, it would affect everything. So I think they’re very wide, sweeping ramifications beyond the unfortunate consequences that some people might face, as Lauren said, which is that they’re just trying to start a family and now that’s being jeopardized.

Rovner: I think Georgia already has a law that you can take a tax deduction if you’re pregnant. I have been wondering, what happens to birthdays? Do they cease to mean anything? It completely turns on its head the way we think about people and humans, and I mean obviously they say, “Well, yeah, of course it is a separate being from the moment of fertilization, but that doesn’t make it a legal person.” And I think that’s what this debate is about. I did notice in Alabama — of course, what happened, what prompted this case was that some patient in a hospital got into the lab where the frozen embryos were kept and took some out and literally just dropped them on the floor and broke the vial that they were in. And the question is whether the families who belong to those embryos could sue for some kind of recourse, but it would not be considered murder because, under Alabama’s statutes, it has to be a child in utero.

And obviously frozen embryos are not yet in utero, they’re in a freezer somewhere. In that sense it might not be murder, but it could become — I mean, this is something that I think people have been thinking about and talking about obviously for many years, and you wonder if this is just the beginning of we’re going to see how far this can go, particularly in some of the more conservative states. Well, meanwhile, The New York Times reported last week that former President Trump, who’s literally been on just about every side of the abortion debate over the years, is leaning towards supporting a 16-week ban — in part, according to the story, because it’s a round number. Trump, of course, was a supporter of abortion rights until he started running for president as a Republican.

And, in winning the endorsement of skeptical anti-abortion groups in 2016, promised to appoint only anti-abortion judges and to reimpose government restrictions from previous Republican administrations. He did that and more, appointing the three Supreme Court justices who enabled the overturn of Roe v. Wade. But more recently, he’s seen the political backlash over that ruling and the number of states that have voted for abortion rights, including some fairly red states, and he’s been warning Republicans not to emphasize the issue. So why would he fail to follow his own advice now, particularly if it would animate voters in swing states? He keeps saying he’s not in the primaries anymore, that he’s basically running a general-election campaign.

Knight: I mean, I think to me, it seems like he’s clearly trying to thread the needle here. He knows some of the more social conservative of his supporters want him to do something about abortion. They want him to take a stand. And so he decided on allegedly 16 weeks, four months, which is less strict than some states. We saw Florida was 10 weeks. And then some other states …

Rovner: I think Florida is six weeks now.

Knight: Oh, sorry, six weeks. OK.

Rovner: Right. Pending a court decision.

Knight: Yeah. And then other states, in Tennessee, complete abortion ban with little room for exceptions. So 16 weeks is longer than some other states have enacted that are stricter. Roe v. Wade was about 24 weeks. So to me, it seems like he’s trying to find some middle ground to try to appease those social conservatives, but not be too strict.

Rovner: Although, I mean, one of the things that a 16-week ban would not do is protect all the women that we’ve been reading about who are with wanted pregnancies, who have things go wrong at 19 or 20 or 21 weeks, which are before viability but after 16 weeks. Well, unless they had — he does say he wants exceptions, and as we know, as we’ve talked about every week for the last six months, those exceptions, the devil is in the details and they have not been usable in a lot of states. But I’m interested in why Trump, after saying he didn’t want to wade into this, is now wading into this. Lauren, you wanted to add something?

Weber: Yeah, I wanted to echo your point because I think it’s important to note that 16 weeks is not based, it seems like, on any scientific reason. It sounds like to me, from what I understand from what’s out there, that 20 weeks is more when you can actually see if there’s heart abnormalities and other issues. So it sounds like from the reporting the Times did, was that he felt like 16 weeks was good as,  quote, “It was a round number.” So this isn’t exactly, these weak timing of bans, as I’m sure we’ve discussed with this podcast, are not necessarily tied towards scientific development of where the fetus is. So I think that’s an important thing to note.

Rovner: Yes. Rachana.

Pradhan: I mean, I think, and we’ve talked about this, but it’s the perennial danger in weighing in on any limit, and certainly a national limit, but any limit at all, is that 16 weeks, of course as the anti-abortion movement and I think many more people know now, the CDC data shows that the vast majority of abortions annually occur before that point in pregnancy. And so there are, of course, some anti-abortion groups that are trying to thread the needle and back a more middle-ground approach such as this one, 15 weeks, 16 weeks, banning it after that point. But for many, it’s certainly not anywhere good enough. And I think if you’re going to try to motivate your conservative base, I still have a lot of questions about whether they would find that acceptable. And I think it depends on how they message it, honestly.

If they say, “This is the best we can do right now and we’re trying,” that might win over some voters. But on the flip side, it’s still enough for Democrats to be able to run with it and say any national ban obviously is unacceptable to them, but it gives them enough ammunition, I think, to still say that former President Trump wants to take your rights away. And I think, as Lauren noted, genetic testing and things these days of course can happen and does happen before 16 weeks. So there might be some sense of whether there might be, your child has a lethal chromosomal disorder or something like that, that might make the pregnancy not viable. But the big scan that happens about midway through pregnancy is around 20 weeks, and that’s often when you, unfortunately, some people find out that there are things that would make it very difficult for their baby to survive so …

Rovner: Well, it seems that no matter what Trump does or says he will do if he’s elected in November, it’s clear that people close to him, including former officials, are gearing up for a second term that could go way further than even his very anti-abortion first term. According to Politico, a plan is underway for Trump to govern as a, quote, “Christian nationalist nation,” which could mean not just banning abortion, but, as Victoria pointed out, contraception, too, or many forms of contraception. A separate planning group being run out of the Heritage Foundation is also developing far-reaching plans about women’s reproductive health, including enforcement of the long-dormant 19th century Comstock Act, which we have talked about here many times before. But someone please remind us what the Comstock Act is and what it could mean.

Weber: I feel like you’re the expert on this. I feel like you should explain it.

Rovner: Oh boy. I don’t want to be the expert on the Comstock Act, but I guess I’ve become it. It’s actually my favorite tidbit about the Comstock Act is that it is not named after a congressman. It is named after basically an anti-smut crusader named Anthony Comstock in the late 1800s. And it bans the mailing of, I believe the phrase is “lewd or obscene” information, which in the late 1880s included ways to prevent pregnancy, but certainly also abortion. When the Supreme Court basically ruled that contraception was legal, which did not happen until the late 1960s — and early 1970s, actually —, the Comstock Act sort of ceased to be. And obviously then Roe v. Wade, it ceased to be.

But it is still in the books. It’s never been officially repealed, and there’s been a lot of chatter in anti-abortion movements about starting to enforce it again, which could certainly stop if nothing else, the distribution of the abortion pill in its tracks. And also it’s anything using the mail. So it could not just be the abortion pill, but anything that doctors use to perform abortions or to make surgical equipment — it seems that using Comstock, you could implement a national ban without ever having to worry about Congress doing anything. And that seems to be the goal here, is to do as much as they can without even having to involve Congress. Yes.

Pradhan: Julie, I’m waiting for the phrase “anti-smut crusader” to end up on a campaign sign or bumper sticker, honestly. I feel like we might see it. I don’t think this election has gotten nearly weird enough yet. So we still have nine months to go.

Rovner: Yeah. I’m learning way more about the Comstock Act than I really ever wanted to know. But meanwhile, Rachana, it does not take state or federal action to restrict access to reproductive health care. You have a story this week about the continuing expansion of Catholic hospitals and what that means for reproductive health care. Tell us what you found.

Pradhan: Well, yes, I would love to talk about our story. So myself and my colleague Hannah Recht, we started reporting the story, just for background, before the Supreme Court’s Dobbs decision, obviously anticipating that that is what was going to happen. And our story really digs into, based on ample interviews with clinicians, other academic experts, reading lots of documents about what the ethical and religious directives for Catholic health care services, which is what all, any health facility, a hospital, a physician’s office, anything that deems itself Catholic, has to abide by these directives for care, and they follow church teaching. Which we were talking about fertility treatments and IVF earlier actually, so in vitro fertilization is also something that the Catholic Church teaches is immoral. And so that’s actually something that they oppose, which many people may not know that.

But other things that the ERDs [ethical and religious directives] so to speak, impact are access to contraception, access to surgeries that would permanently prevent pregnancy. So for women that would be removing or cinching your fallopian tubes, but also, for men, vasectomies. And then, of course, anything that constitutes what they would call a direct abortion. And that affects everything from care for ectopic pregnancies, how you can treat them, to managing miscarriages. The lead story or anecdote in our story is about a nurse midwife who I spoke with, who used to work at a Catholic hospital in Maryland and talked to me about, relayed this anecdote about, a patient who was about 19 or 20 weeks pregnant and had her water break prematurely.

At that point, her fetus was not viable and that patient did not want to continue her pregnancy, but the medical staff there, what they would’ve done is induce labor with the intent of terminating the pregnancy. And they were unable to do that because of ERDs. And so, we really wanted to look at it systemically, too. So we looked at that combined with state laws that protect, shield hospitals from liability when they oppose providing things like abortions or even sterilization procedures on religious grounds. And included fresh new data analysis on how many women around the country live either nearby to a Catholic hospital or only have Catholic hospitals nearby. So we thought it was important.

Rovner: That’s a little bit of the lead because there’s been so much takeover of hospitals by Catholic entities over the last, really, decade and a half or so, that women who often had a choice of Catholic hospital or not Catholic hospital don’t anymore. That Catholic hospital may be the only hospital anywhere around.

Pradhan: Right and if people criticize the story, which we’ve gotten some criticism over it, one of the refrains we’ll hear is, “Well, just go to a different hospital.” Well, we don’t live in a country where you can just pick any hospital you want to go to — even when you have a choice, insurance will dictate what’s in-network versus what’s not. And honestly, people just don’t know. They don’t know that a hospital has a religious affiliation at all, let alone that that religious affiliation could impact the care that you would receive. And so there’s been research done over the years showing the percentage of hospital beds that are controlled by Catholic systems, et cetera, but Hannah and I both felt strongly that that’s a useful metric to a point, but beds is not relatable to a human being. So we really wanted to boil it down to people and how many people we’re talking about who do not have other options nearby. How many births occur in Catholic hospitals so that you know those people do not have access to certain care if they deliver at these hospitals, that they would have in other places.

Rovner: It’s a continuing story. We’ll obviously post the link to it. Well, I also want to talk about age this week. Specifically the somewhat advanced age of our likely presidential candidates this year. President [Joe] Biden, currently age 81, and former President Trump, age 77. One thing voters of both parties seem to agree on is that both are generically too old, although voters in neither party seem to have alternative candidates in mind. My KFF Health News colleague Judy Graham has a really interesting piece on increasing ageism in U.S. society that the seniors we used to admire and honor we now scorn and ignore. Is this just the continuing irritation at the self-centeredness of the baby boomers or is there something else going on here that old people have become dispensable and not worth listening to? I keep thinking the “OK, boomer” refrain. It keeps ringing in my ears.

Weber: I mean, I think there’s a mix of things going on here. I mean, her piece was really fascinating because it also touched upon the fact — which all of us here reported on; Rachana and I wrote a story about this back in 2021 — on how nursing homes really have been abandoned to some extent. I mean, folks are not getting the covid vaccine. People are dying of covid, they die of the flu, and it’s considered a way of life. And there is almost an irritation that there would be any expectation that it would be any differently because it’s a “Don’t infringe upon my rights” thought. And I do think her piece was fascinating because it asks, “Are we really looking at the elderly?”

I mean, I think that’s very different when we talk about politicians. I mean, the Biden bit is a bit different. I mean, I think there is some frustration in the American populace with the age of politicians. I think that reached a bit of a boiling point with the Sen. [Dianne] Feinstein issue, that I think is continuing to boil over in the current presidential election. But that said, we’re hurtling towards an election with these two folks. I mean, that’s where we’re at. So I think they’re a bit different, but I do think there is a national conversation about age that is happening to some degree, but is not happening in consideration to others.

Well, I was going to say, I think the other aspect is that these people are in the public all the time, or they’re supposed to be. President Biden is giving speeches. Potential candidate President Trump, GOP main candidate, he’s in the spotlight all the time, too. And so you can actually see when they mess up sometimes. You can see potentially what people are saying is signs of aging. And so I think it’s different when they’re literally in front of your eyes and they’re supposed to be making decisions about the direction of this country, potentially. So I think it’s somewhat a valid conversation to have when the country is in their hands.

Rovner: Yeah, and obviously the presidency ages you. [Barack] Obama went in as this young, strong-looking guy and came out with very gray hair, and he was young when he went in. Bill Clinton, too, was young when he was elected and came out looking considerably older. And so Biden, if people have pointed out, looks a lot older now than he did when he was running back in 2020. But meanwhile, despite what voters and some special councils think — including the one who said that Biden was what a kindly old man with a bad memory — neuroscientists say that it’s actually bunk that age alone can determine how mentally fit somebody is, and that even if memory does start to decline, judgment and wisdom may improve as you age. Why is nobody in either party making this point? I mean, the people supporting Biden are just saying that he’s doing a good job and he deserves to continue doing a good job. I mean, talk about the elephant in the room and nobody’s talking about it at all with Trump.

Pradhan: Yeah, I mean, I think probably the short answer is that it’s not really as politically expedient to talk about those things. I thought it was really interesting. Yeah, I really appreciated Stat News had this really interesting Q&A article. And then also there was this opinion piece in The New York Times that, this line struck me so much about, again, both about Biden’s age and his memory. And this line I thought was so fascinating because it just is telling how people’s perceptions can change so much depending on the discourse. So it pointed out that Joe Biden is the same age as Harrison Ford, Paul McCartney, Martin Scorsese. He’s younger than Berkshire Hathaway CEO Warren Buffett, who is considered to be one of the shrewdest and smartest investors, I think, and CEOs of modern times. And no one is saying, “Well, they’re too old to be doing their jobs” or anything. I’m not trying to suggest that people who have concerns about both candidates’ age[s] are not valid, but I think we sometimes have to double-check why we might be being led to think that way, and when it’s not really the same standards are not applied across the board to people who are even older than they are.

Rovner: I do think that some of the frustration, I think, Lauren, you mentioned this, is that in recent years, the vast majority of leadership positions in the U.S. government have been held by people who are, shall we say, visibly old. I mean Nancy Pelosi is still in Congress, but she at least figured out that she needed to step down from being speaker because I think the three top leaders in the House were all in their either late 70s or early 80s. The Senate has long been the land of very old people because you get elected to a six-year term. I mean, Chuck Grassley is 90 now, is he not? Feinstein wasn’t even, I don’t think, the oldest member of the Senate. So I think it’s glaring and staring us in the face. Rachana, you wanted to add something before we moved on.

Pradhan: Well, I think probably, and a lot of that too is just I think probably a reflection of voters’ broader gripes or concerns about the fact that we have people who hold office for an eternity, to not exaggerate it. And so people want to see new leadership, new energy, and when you have public officeholders who hold these jobs for … they’re career politicians, and I think that that is frustrating to a lot of people. They want to see a new generation, even regardless of political party, of ideas and energy. And then when you have these octogenarians holding onto their seats and run over and over and over again, I think that that’s frustrating. And people don’t get energized about those candidates, especially when they’re running for president. They just don’t. So it’s a reflection of just, I think, broader concerns.

Knight: And I think one more thing too was, I mean, Sen. Feinstein died while she was in office. I mean, people also may be referencing Ruth Bader Ginsburg on the Supreme Court, and it’s the question of, should you be holding onto a position that you may die in it, and not setting the way for the new person to take over and making that path available for the next people? Is that the best way to lead in whatever position you’re in? I think, again, Rachana said that’s frustrating for a lot of people.

Rovner: And I think what both parties have been guilty of, although I think Democrats even more than Republicans, is preparing people, making sure that that next generation is ready, that you don’t want to go from these people with age and wisdom and experience to somebody who knows nothing. You need those people coming up through the ranks. And I think there’s been a dearth of people coming up through the ranks lately, and I think that’s probably the big frustration.

Pradhan: I’m not sure if this is still true now, but I certainly remember, I think when Paul Ryan was speaker of the House, I remember the average age of the House Republican conference was significantly younger than that of Democrats. And they would highlight that. They would say, “Look, we are electing a new generation of leaders and look at these aging Democrats over here.” And that might still be true, but I certainly remember that that was something that they tried to capitalize on, oh-so-long ago.

Rovner: As we talked about last week, there are now a lot of those not-so-young Republicans, but not really old, who are just getting out because it is no fun anymore to be in Congress. Which is a good segue because … oh, go ahead.

Knight: Oh, I was just saying one thing Republicans do do in the House, at least they do have term limits on the chairmanships to ensure people do not hold onto those leadership positions forever. And Democrats do not have that. That’s at least in the House.

Rovner: But then you get the expertise walking out the door. It’s a double-edged sword.

Knight: Which is, not all the ones that are leaving have reached their term limits, which is the interesting thing actually. But yes, that expertise can walk out the door.

Rovner: Well, speaking of Congress, here in Washington, as I mentioned at the top, Congress is in recess, but when they come back, they will have I believe it is three days before the first raft of temporary spending bills expire. Victoria, is this the time that the government’s going to actually shut down, or are we looking at yet another round of short-term continuing resolutions? And at some point automatic cuts kick in, right?

Knight: Yeah, the eternal question that we’ve had all of this Congress, I think both sides do not want to shut down. I saw some reporting this morning that was saying [Senate Majority Leader] Chuck Schumer is talking to [House Speaker] Mike Johnson, but he also, Schumer did not want to commit to a CR [continuing resolution] yet either. So it’s possible, but we said that every time and they’ve pulled it off. I think they just know a shutdown is so, not even maybe necessarily politically toxic, but potentially —because I don’t know how much the public understands what that means …

Rovner: Because they don’t understand who’s at fault.

Knight: Right. Who’s at fault …

Rovner: … when it does shut down. They just know that the Social Security office is closed.

Knight: Right, but I just know they know it’s dysfunctional or it just can make things messy when that happens; it’s harder for agencies and things like that. So we’ll see. So the deadline is next Friday for the first set of bills. It’s just four bills then, and then the next deadline is March 8 for the other eight bills. There’s some talk that we may see a package over the weekend, but it’s Mike Johnson’s deciding moment. Again, he’s getting pressure from the House Freedom Caucus to push for either spending cuts or policy riders that include anti-abortion riders, anti-gender-affirming care, a lot. There’s a whole list of things that they sent yesterday they want in bills, and so he’s going to have to …

Rovner: Culture wars is the shorthand for a lot of those.

Knight: Yes, exactly. And so House Freedom Caucus sent a letter yesterday, and so Mike Johnson’s going to have to decide does he want to acquiesce to any House Freedom Caucus demands or does he want to work? But if he doesn’t want to do that, then he’s going to have to pass any funding bills with Democratic votes because he does not have enough votes with the Republicans alone, if Freedom Caucus people and people aligned in that direction don’t vote for any funding bills. If he does that, if he works with Democrats, then there is talk that they might file a motion to vacate him out of the speakership. So it’s the same problem that Kevin McCarthy had. The one thing going for Johnson is that he doesn’t have the baggage that Kevin McCarthy had, a lot of political baggage. A lot of people had ill will towards him, just built up over the years. Johnson doesn’t seem to have that as much, and also Republicans, do they want to be leadership-less again?

Rovner: Because that worked so well the first two times.

Knight: Right, so he has got to decide again who he wants to work with. And it doesn’t seem like we know yet how that’s going to go, and that will determine whether the government shuts down or not.

Rovner: But somebody also reminded me that on April 1, if they haven’t done full-year funding, that automatic cuts kick in. I had forgotten that. So I mean, they can’t just keep rolling these deadlines indefinitely. This presumably is the last time they can roll a deadline without having other ramifications.

Knight: Absolutely. And Freedom Caucus, actually, I think that’s partly why they don’t want to agree to something, because they want the 1% cuts across the board. So that was part of the deal made last year under Kevin McCarthy was, if they don’t come up with full funding bills by April 1, there will be a 1% cut put into place. And so the more hard-liners [are] like, “Great, we’re going to cut funding, so we want to do that.” And then Democrats don’t want that to happen. And so yeah, it’s the last time that they can potentially do a CR before that.

Rovner: Yeah, just a reminder, for those who are not keeping track, that April 1 is six months, halfway through the fiscal year for them to have not finished the fiscal year spending bills.

Knight: And one more note is that usually they’re starting on this coming year spending bills by this point in Congress. So we’re still working on FY24 bills. We should be working on FY25 bills already. So they’re already behind. It’s dysfunctional.

Rovner: I think it’s fair to say the congressional budget process has completely broken down. Well, moving on to “This Week in Medical Misinformation,” we have a case of doing well by doing no good. Lauren, tell us about your story looking into the profits that accrued to anti-vaccine and anti-science groups during the pandemic.

Weber: So I took a look at a bunch of tax records, and what I found is that four major nonprofits that rose to prominence during the covid pandemic by capitalizing on the spread of misinformation collectively gained more than $118 billion from 2020 to 2022. And were able to deploy that money to gain influence in statehouses, courtrooms, and communities across the country. And it’s a pretty staggering figure to tabulate all together. And what was particularly interesting is there was four of these different groups that I was directed to look at by experts in the field, and one of them includes Children’s Health Defense, which was founded by Robert F. Kennedy Jr., and they received, in 2022, $23.5 million in contributions, grants, and other revenue. That was eight times what they got before the pandemic. And that kind of story was reflected in these other groups as well. And it just shows that the fair amount of money that they were able to collect during this time as they were promoting content and other things.

Rovner: Yeah, I mean literally misinformation pays. While we’re on this subject, I would also note that this week there’s a huge multinational study of 99 million people vaccinated against covid that confirmed previous studies showing an association between being vaccinated and developing some rare complications. But a number of stories, at least I thought, overstated the risks of the study that it actually identified. Most failed to include the context that almost every vaccine has the possibility of causing adverse reactions in some very small number of people. The question of course, when you’re evaluating vaccines, is if the benefit outweighs the benefit of protecting against whatever this disease or condition outweighs the risk of these rare side effects.

I would also point out that this is why the U.S. actually has something called the [National] Vaccine Injury Compensation Program, which helps provide for people, particularly children, who experience rare complications to otherwise mandatory vaccines. Anyway, that is the end of my rant. I was just frustrated by the idea that yes, yes, we know vaccines sometimes have side effects. That’s the nature of vaccines. That’s one of the reasons we study them.

All right, anyway, 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 kffhealthnews.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?

Knight: So my extra credit this week is a story in ProPublica called “The Year After a Denied Abortion.” It’s by [photographer] Stacy Kranitz and [reporter] Kavitha Surana. And it was a very moving photo essay and story about a woman who was denied an abortion in Tennessee literally weeks to a month after Roe v. Wade was overturned in June 2022, and this was in July 2022. She got pregnant and was denied an abortion. And so it followed her through the next year of her life after that happened. And in Tennessee, it’s one of the strictest abortion bans in the nation. Abortion is banned and there are very rare exceptions. And so this woman, Mayron Michelle Hollis, she already had some children that had been taken out of her care by the state, and so she was already fighting custody battles and then got pregnant. And Tennessee is also a state that doesn’t have a very robust safety-net system, so it follows her as she has a baby that’s born prematurely, has a lot of health issues, doesn’t have a lot of state programs to help her.

She was afraid to go through unemployment because she had had issues with that before. The paperwork situation’s really tough. There’s just so much stress involved also with the situation. She eventually ends up kind of relapsing, starting drinking too much alcohol, and she ends up in jail at the end of the story. And so it just talks about how if there is not a robust safety net in a state, if you’re kind of forced to have a pregnancy that you maybe are not able to take care of, it can be really tough financially and psychologically and tough for the mother and the child. So it was a really moving story and there were photos following her through that year.

Rovner: Lauren.

Weber: I wanted to shout out my colleague who I actually sit next to, David Ovalle, who is wonderful at The Washington Post. He wrote an article called “They Take Kratom to Ease Pain or Anxiety. Sometimes, Death Follows.” And, as our addiction reporter for the Post, he did a horribly depressing but wonderful job actually calculating how many kratom deaths or deaths associated with kratom have happened in recent years. And what he found through requests is that at least 4,100 deaths in 44 states and D.C. were linked to kratom between 2020 and 2022, which is public service journalism at its best. I mean, I think people are clear that there is more risks with this, but I think that it’s emerging actually how those risks are. And he catalogs through the hard numbers, which is often what it requires for folks to pay attention, that this is something that is interactive with other medications which is causing death, in some cases, on death certificates. So pretty moving story, he talked to a lot of the families of folks that have died and it really makes you wonder about the state of regulation around kratom.

Rovner: Yeah, and then, I mean, all food diet supplements that are basically unregulated by the FDA because Congress determined in the 1990s that they should be unregulated because the supplement industry lobbied them very heavily and we will talk about that at some other time. Rachana.

Pradhan: My extra credit is a story in Politico by Megan Messerly. It’s titled “Red States Hopeful for a 2nd Trump Term Prepare to Curtail Medicaid.” The short version is work requirements are in, again. There was an effort previously that Republicans wanted to impose employment as a condition of receiving Medicaid benefits, and then they were very quickly, a couple of states, were sued. Only one program really got off the ground, Arkansas. And what happened as a result is because of the paperwork burdens and other things, thousands of people lost coverage. So currently the Biden administration, of course, is not OK at all with tying any type of work, volunteer service, you name it, to Medicaid benefits. But I think Republicans would be — the story talks about how Republicans would be eager to go and pursue that policy push again and curtail enrollment as a result of that.

So I thought that was, it’s an interesting political story. One thing it did make me wonder though, just as an aside is, there’s also been discussion on the flip side, the states in the story, which focus on South Dakota and Louisiana, states that many of them have already expanded coverage to cover the ACA [Affordable Care Act] population, but there are also still states that have not expanded Medicaid under the ACA’s income thresholds. And those conservative states might find it slightly more palatable to do so if you allow them to impose these types of conditions on the program. And so I think we will see what happens.

Rovner: Although, as we talked about not too long ago, Georgia, one of the states that has not expanded Medicaid under the Affordable Care Act now has a work requirement for Medicaid. And they’ve gotten something in the neighborhood, I believe, of like 2,700 people who’ve signed up out of a potential 100,000 people who could be covered if they actually expanded Medicaid. So another space that we will watch.

Well, my extra credit this week is from Stat News and, warning, it’s super nerdy. It’s called “New CMS Rules Will Throttle Access Researchers Need to Medicare, Medicaid Data.” It’s by Rachel Werner, who’s a physician researcher at the University of Pennsylvania, and it’s about a change recently announced by the Centers for Medicare & Medicaid Services that will make it more difficult and more expensive for researchers to work with the program’s data, of which there is a lot. Since the new policy was announced earlier this month, according to CMS, in response to an increase in data breaches, I’ve heard from a lot of researchers who are worried that critical research won’t get done and that new researchers won’t get trained if these changes are implemented because only certain people will have access to the data because you’ll have to pay every time somebody else gets access to the data. Again, it’s an incredibly nerdy issue, but also really important. So the department is taking comment on this and we’ll see if they actually follow through.

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

Pradhan: Still on X, hanging on, @rachanadpradhan.

Rovner: Victoria.

Knight: I’m also on X @victoriaregisk.

Rovner: Lauren?

Weber: Still on X @LaurenWeberHP.

Rovner: I think people have come sort of slithering back. We will be back in your feed next week. Until then, be healthy.

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

A federal judge in Texas has turned back the first challenge to the nascent Medicare prescription-drug negotiation program. But the case turned on a technicality, and drugmakers have many more lawsuits in the pipeline.

Meanwhile, Congress is approaching yet another funding deadline, and doctors hope the next funding bill will cancel the Medicare pay cut that took effect in January.

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

Panelists

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Rachel Cohrs
Stat News

@rachelcohrs

Read Rachel's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• Rep. Cathy McMorris Rodgers (R-Wash.), chair of the powerful House Energy and Commerce Committee, announced she would retire at the end of the congressional session, setting off a scramble to chair a panel with significant oversight of Medicare, Medicaid, and the U.S. Public Health Service. McMorris Rodgers is one of several Republicans with significant health expertise to announce their departures.
• As Congress’ next spending bill deadline approaches, lobbyists for hospitals are feverishly trying to prevent a Medicare provision on “site-neutral” payments from being attached.
• In abortion news, anti-abortion groups are joining the call for states to better outline when life and health exceptions to abortion bans can be legally permissible.
• Senate Finance Chairman Ron Wyden (D-Ore.) is asking the Federal Trade Commission and the Securities and Exchange Commission to investigate a company that collected location data from patients at 600 Planned Parenthood sites and sold it to anti-abortion groups.
• And in “This Week in Health Misinformation”: Lawmakers in Wyoming and Montana float bills to let people avoid getting blood transfusions from donors who have been vaccinated against covid-19.

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

Julie Rovner: Stateline’s “Government Can Erase Your Medical Debt for Pennies on the Dollar — And Some Are,” by Anna Claire Vollers.

Alice Miranda Ollstein: Politico’s “‘There Was a Lot of Anxiety’: Florida’s Immigration Crackdown Is Causing Patients to Skip Care,” by Arek Sarkissian.

Rachel Cohrs: Stat’s “FTC Doubles Down in Welsh Carson Anesthesia Case to Limit Private Equity’s Physician Buyouts,” by Bob Herman. And Modern Healthcare’s “Private Equity Medicare Advantage Investment Slumps: Report,” by Nona Tepper.

Lauren Weber: The Wall Street Journal’s “Climate Change Has Hit Home Insurance. Is Health Insurance Next?” by Yusuf Khan.

Also mentioned on this week’s podcast:

• The Washington Post’s “U.S. Investigates Alleged Medicare Fraud Scheme Estimated at $2 Billion,” by Dan Diamond, Lauren Weber, and Dan Keating.
• Super Bowl ads from Pfizer, Power to the Patients, and the American Values 2024 super PAC.
• KFF Health News’ “Rapper Fat Joe Says No One Is Making Sure Hospitals Post Their Prices,” by Julie Appleby.

click to open the transcript

Transcript: Biden Wins Early Court Test for Medicare Drug Negotiations

KFF Health News’ ‘What the Health?’Episode Title: Biden Wins Early Court Test for Medicare Drug NegotiationsEpisode Number: 334Published: Feb. 15, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 15, 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: Lauren Weber of The Washington Post.

Lauren Weber: Hello, hello.

Rovner: And Rachel Cohrs of Stat News.

Rachel Cohrs: Hi everyone.

Rovner: No interview this week, but we do have a special Valentine’s Day surprise. But first, the news. We’re going to start this week in federal district court, where the drug industry has lost its first legal challenge to the Biden administration’s Medicare drug price negotiation program, although on a technicality. Rachel, which case was this, and now what happens?

Cohrs: This was the capital “P” PhRMA trade association. And this case was a little bit of a stretch, anyways, because they were trying to find some way to get a judge in Texas to hear it. Because the broader strategy is for companies and trade groups to spread out across the country and try to get conflicting decisions from these lower courts.

Rovner: Which would force the Supreme Court to take it?

Cohrs: Exactly, yes. Or make it more likely. So PhRMA, in this case, they had recruited, there’s a national group that represents infusion centers and that was headquartered in Texas. The judge ultimately ended up ruling that this association didn’t follow the right procedure to qualify for judicial review and threw them off the case. And then they were like, well, if you throw them off the case, then there’s nobody in Texas, you can’t hear this here. So that was the ultimate decision there, but this could come back up. It was dismissed without prejudice. So this isn’t the end of the road for this lawsuit.

And it’s important to keep in mind that this wasn’t a ruling on any of the substance of the arguments. And trade groups generally are going to have less of an argument for standing, or it’s going to be a harder argument than the companies themselves that actually have drugs up for negotiation.

Rovner: And they’re suing too, the drug companies?

Cohrs: They are suing too. Yeah, just for everybody to keep on your calendars, there’s a judge in New Jersey who is hoping to have a quadruple oral argument on four of these cases, so stay tuned. That could be coming early next month. But these are very much moving. I think we are going to get insight on some of these arguments pretty soon, but this case is not quite that test case yet.

Rovner: All right, well, we’ll get to it eventually. Well, moving on to Capitol Hill. When we were taping last week, Sen. Bernie Sanders was holding his much-publicized hearing to grill drug company CEOs about their too-high prices. Rachel, you were there. Did anything significant happen?

Cohrs: I think it was kind of expected. I don’t think we were trying to find any innovative legislative solutions here. Honestly, it seemed, just from a candid take, that a lot of these lawmakers were not very well-prepared for questioning. There were a couple of notable exceptions, but we didn’t learn a whole lot new about why drug prices are high in the United States, how our system works differently from other countries.

I did find some useful nuggets in the CEO’s testimony about how low the net prices are for some of their medications, that they’re already offering a 70% discount, a 90% discount, which to me just kind of put into perspective some of the discounts we could be hearing in the Medicare negotiation program. That oh, even if it’s a 90% discount, that might not even be different from what they’re paying now. So just interesting to file a way for the future, but I think it was mostly a non-event for the CEOs who, for some reason, had to, under the threat of subpoena, come make these arguments. So it seemed like much ado about not a whole lot of substance.

Rovner: That was sort of my theory going in, but you always have to watch just in case. Well, also on Capitol Hill, the chairman of the powerful House Energy and Commerce Committee announced she will retire at the end of the Congress. Cathy McMorris Rodgers, who’s a Republican from Washington, was in her first term as chair of the committee that oversees parts of Medicare, all of Medicaid, as well as the entire U.S. Public Health Service.

I imagine this is going to set off a good bit of jockeying to take her place. And why would somebody step down early from such a powerful position? Do we have any idea?

Cohrs: Have you seen …? Oh, go ahead.

Ollstein: Facing Congress is what you say? Yes. This is part of a wave of retirements we’ve been seeing recently, including from some other committee chairs who could have theoretically continued to be powerful committee chairs for several years to come. People are taking this as part of the bad sign for Republicans. Either a sign that they don’t believe they’re going to hold the majority after this November’s election, or they’re just so fed up with the struggles they’ve had governing over the last few years and the inability to get anything done. And people are thinking, well, maybe I can get something done in a different role, not in Congress, because certainly, we’re not doing too much here to be proud of.

Rovner: Yeah, I feel like Cathy McMorris Rodgers is kind of this poster child for a very conservative Republican who’s not the far-right-wing MAGA type, who actually wants to do legislation. She just wants to do Republican legislation, and that seems to be getting harder in the House.

Ollstein: Right, right. And there’s a concern that, particularly on the right within Republicans, that we’re losing a health policy brain trust. We’re losing the people that have been really integral to a lot of the nitty-gritty policy work over the years, and they’re not being replaced with people who have that interest. They’re being replaced with people who are more focused on culture wars and other things. And so there’s concern in the future about the ability to cobble together things like Medicare reimbursement rates, or these technical things that aren’t really part of the culture wars.

Rovner: Yeah, I think we mentioned at some point that Mike Burgess is also retiring, also high up on the Energy and Commerce Committee. And he’s a doctor who’s really had his hands into some of this really nerdy stuff, like on Medicare physician reimbursement. And that will be obviously just a big loss of institutional memory there.

Cohrs: For the future of the committee, I know congressman Brett Guthrie has kind of thrown his hat in the ring to succeed her. Unclear who exactly is going to win this race, but he is the chairman of the health subcommittee, does bring some health expertise. So the E&C committee deals with a lot of different priorities, but if he were to succeed her, then I think we would see, at least at the top of the committee, some of the expertise remain.

Rovner: Well, meanwhile, in all of this jockeying, the next round of temporary government funding bills expires on March 1 and March 8, respectively, which is getting pretty close. And that brings back efforts to cancel the 3.4% pay cut that doctors got for Medicare patients in January. Where are we on funding, and are any of these health issues that people are out lobbying on going to make it into this next round? Is there going to be a next round?

Cohrs: Yeah, we don’t know if there’s going to be a next round, I don’t think. But at least the sources I’ve talked to have said that a full cancellation of the 3.4% cut for Medicare or payments to doctors is off the table at this point. They are hoping to do some sort of partial relief. They haven’t decided on percentages for that yet. And it’s unclear how much money will be available from pay-fors. It is still very much squishy, not finalized, two, three weeks out from the deadline, but I think …

Rovner: Two weeks.

Cohrs: There is some agreement on some relief, which has not been the case thus far for doctors. So I think that’s a positive sign.

Ollstein: Yeah. Overall, the chatter is about the need for yet another CR [continuing resolution] because the work is not getting done in time to meet these deadlines. That seems to be where we’re headed. Obviously, that will piss off a lot of members on the right who don’t want another CR, who didn’t want the last couple CRs. And so once again, we are staring down a possible shutdown.

Rovner: And I had forgotten, somebody reminded me, that even if they get another temporary funding bill, starting in April, there are automatic cuts if they’re not finished with this year’s funding bills. Which, I don’t know, is there any indication that they’re going to be finished with them by April either? I have not seen a lot of progress here. They’ve been fighting over other things, which is fine to fight over other things, but I’m not noticing a lot happening on the spending bills.

I’m seeing a lot of shaking heads. I guess nobody else is noticing either. Well, we will obviously keep watching that space because next week, we will only be one week away.

Well, another Medicare policy that supporters are hoping to get into one or another of these spending bills is creating something called more site-neutral payments in Medicare. Currently, Medicare pays hospitals and hospital outpatient departments, and sometimes even hospital-owned physician practices, more than it pays non-hospital affiliated providers for the exact same service.

The theory is that hospitals need higher payments because they have higher fixed costs, like keeping emergency rooms open 24/7. But it costs Medicare many billions of taxpayer dollars for this differential in payments. And this has become quite the lobbying frenzy for the hospital industry, yes?

Cohrs: Yes. I think it’s something that they can all get on board with hating, and I think they view it similarly to the drug pricing debate as a slippery slope. The policy Congress really is looking at now is a $3 billion, very small slice of all the services that could potentially be subjected to site-neutral payments. But the whole pie here is $150 billion potentially for Medicare.

We’re talking hundreds of billions of dollars for commercial payments. So I think they are really pushing to get to lawmakers, especially, from what I’ve talked to Senate Republicans, they are just not on board with it, they’re worried about the rural hospitals. And if they can connect to those things, which they have been successful in doing so far, they’re just not going to get very far.

I mean, if you look at the Senate Finance Committee, you have Mike Crapo from Idaho, Republican leadership. You have [John] Barrasso from Wyoming. There’s really just so many rural states that even Chuck Grassley, who is a moderate on a lot of health policy issues, talked about his rural hospitals in Iowa as soon as I asked him about this. So they’re not there yet right now, but I think hospitals are trying to keep it that way.

Rovner: And it was ever thus that the Senate is much more rural-focused than the House because pretty much every single senator has at least part of a rural area that they represent. Lauren, you wanted to add something?

Weber: Yeah, I just wanted to say, I always find it funny when rural hospitals come up as a cudgel by the big hospital associations, who don’t seem to look out for them the vast majority of the time when they’re closing. But as you pointed out, the Senate is much more rural-focused. So I do agree with all of you all, that I question whether or not this will have much ground to gain.

Rovner: Yeah. And the other thing that I keep wanting to point out is that there’s all this talk on Capitol Hill among Republicans of cutting the spending bills, the appropriations, and we’re going to balance the budget. Well, there’s just not enough money in the appropriation bills to do anything to the deficit. The money is in things like Medicare. I mean, that’s where, if you really want to make a dent in the deficit, you’re going to do it. And, as we’re seeing with this particular fight, every time they want to do something that’s going to save money, it’s going to hurt somebody. And I mean, there are obviously legitimate concerns about rural hospitals that are in trouble, particularly in states that haven’t expanded Medicaid, but that’s one of the reasons. It’s not so much the spending bills that make it hard to do anything about the deficit. It’s fights like these.

Meanwhile, for better or worse, another reason that Medicare costs so much is that it’s subject to a lot of fraud. Lauren, I have seen a lot of Medicare fraud stories over the years, but you’ve got one that was discovered in a pretty novel way. So tell us about it.

Weber: Yeah, my colleagues Dan Diamond, Dan Keating, and I found out early last week — we got a tip from the National Association of ACOs [Accountable Care Organizations] saying that they had seen this massive spike in catheter billing. When we did some digging into the companies they had identified — and to be clear, that spike of catheter billing was worth an alleged $2 billion in billings to Medicare. So when we talk about site-neutral payments, that’s almost what you would get for site-neutral payments: the $2 billion in Medicare fraud, but regardless.

So my colleagues and I dug in. So Dan, Dan, and I called around, and we found links between the seven companies that were charging Medicare for catheters that folks never received. I want to point out, I spoke to this lovely woman in Ponta Vedra Beach, Florida. She’s 74, Aileen Hatcher, who spotted this diligently going through her Medicare form, but as she said, she went to her — literally, these are her words — she’s like, “I went to my old lady luncheon and told them all this was on my Medicare statement.” And they said, “Oh, we don’t read those because we don’t pay Medicare the money. So we don’t read the explanation of benefits to see what we’ve been charged.”

And, unfortunately, I think that is what happens a lot of times with Medicare fraud. It goes unnoticed because folks aren’t the ones paying the dollars. But the bottom line is this was so large and so many people called into Medicare that Dan and I discovered that there is an ongoing federal investigation. Three of the companies, former owners that I called, confirmed to me that FBI had interviewed them or was talking to them about these folks that had taken over the companies and started charging Medicare this much money. And Dan also got some sources on that front as well.

So, I mean, it’s a pretty massive Medicare fraud scheme. I’ll give a call-out here. If anyone here has been affected by catheter and Medicare fraud, please give me an email. We’d love to hear more. I think it speaks to the fact that Medicare fraud — we all know this because we cover this — Medicare fraud is as old as time. It continues to happen, especially durable medical equipment Medicare fraud. But this is so much money. And it is wild that even though we talked to so many people that called Medicare over and over and over again, these folks were able to get away with billing for a very long time.

Rovner: What I found really fascinating about the story, though, is that it was the doctors in the ACOs that spotted it because — we’ve talked about these accountable care organizations — they’re accountable for how much it costs to take care of their patients.

The patients aren’t paying for it, as they point out, but these doctors, it’s coming right out of their bonuses and what they’re charged and how much they get for Medicare. So there’s finally somebody with a real incentive to spot this kind of fraud, because, basically, it was taking money from them. Right?

Weber: That’s exactly right. I think that’s why they were so hot to have some movement on this because, as they pointed out, they could lose millions of dollars in bonuses for better taking care of their patients.

It’s wild that it gets to this point. Like I said, we had all these people that called in to Medicare and many fraud lawyers we talked to said, “Look, why aren’t the NPIs [National Provider Identifiers] turned off?” Great question.

Rovner: Yeah. Anyway, I was fascinated by this story, and as I told Lauren earlier, I’m not a big fan of Medicare fraud stories just because there are so many of them. But this one is like, oh, maybe we finally have somebody … the ACOs can become bounty hunters for Medicare fraud, which would not be a bad thing.

All right, well, moving on to abortion this week, we have spent a lot of time talking about how doctors who perform abortions and patients who need them in emergencies have been trying to get state officials to spell out when the exceptions to state bans apply. Well, now it seems that it’s the other side looking for clarification.

Stat News reports that several anti-abortion groups have joined doctors and patients in urging the Texas Medical Board to spell out which conditions would qualify for the exception to the ban, and not subject doctors who guess wrong to potential prison terms and loss of their medical licenses.

Meanwhile, legislation moving through the House in South Dakota, endorsed by multiple anti-abortion groups, would require the state to make a video explaining how its ban works and under what circumstances. Alice, what’s going on here?

Ollstein: I think it’s this interesting confluence and it’s an interesting development because, at first, anti-abortion groups were insisting that the laws were perfectly clear. And that doctors were either willfully or mistakenly misinterpreting them. As more and more stories came forward of women being turned away while experiencing a medical emergency and suffering harm as a result, a lot of those women are part of lawsuits now.

They were saying the law is fine. In some cases, these anti-abortion groups wrote the laws themselves or advised on them saying, your interpretation is what’s wrong. The law is fine. But I think as so many of these stories are coming out, that’s not proving enough. And now they’re going back and saying, OK, well, maybe there do need to be some clarifications. They don’t want changes. There’s different camps because some people do want changes. Some people say, OK, we need more exceptions. We need more carve-outs to avoid these painful stories. Whereas other anti-abortion forces and elected officials say, no, we don’t need to change the law. We just need to clarify it and explain it. And so I think that’s going to be an ongoing tension.

Rovner: Yeah, I know one of the big themes earlier in this whole fight — I won’t say earlier this year, it was mostly last year — was redefining things as not abortions. That if you’re terminating an ectopic pregnancy, that’s not an abortion. Well, that is an abortion.

Ollstein: Medically, yes.

Rovner: So apparently, the … right. The renaming has not worked so far. So now I guess they’re trying to clarify things. Lauren, you wanted to add something?

Weber: Yeah, I just wanted to say, when you kick things to the medical board, I think people see that as an unbiased unpolitical organization. But medical boards are often appointed by the governor. So, in this case, Gov. [Greg] Abbott. And also take Ohio, for example: I believe that one of their medical board leaders is the head of the right-to-life movement.

I haven’t looked at Texas’. But kicking it to the medical board to make a decision — putting aside the fact that most medical boards are incredibly inadequate at their actual job, which is disciplining doctors, they’re not necessarily known for their competence — is that you also deal with some of the politics involved in this as well.

Rovner: So in South Dakota, it would kick this to the South Dakota Department of Health, which, of course, is controlled by the governor, who’s a Republican and pro-lifer. And so it’s hard to imagine what sort of doing a video explaining this is going to do to clarify things any further than they already think the law has gone. But at least … I’m fascinated by the effort here, that this is going on in multiple states. Speaking of state legislators, in Missouri, they’re working on a bill to create an abortion ban exception for children 12 and under — obviously thinking of the 10-year-old in Ohio in 2022 [who] had to go to Indiana to get a pregnancy terminated. But one Republican state senator complained that “a 1-year-old could get an abortion under this.” This is a serious question: Should legislators have to pass a basic biology test to make laws about reproductive health? As we know, 1-year-olds cannot get pregnant.

Ollstein: I mean, this was a more glaring example. We see this over and over in a lot more subtle ways, too, where doctors and medical societies are pointing out that these laws are drafted using language that is not medically accurate at all. And it can be small things in terms of when someone should qualify for a medical exemption to an abortion ban. Some states have language around if it would cause “irreversible damage.” That’s not a term doctors use in that circumstance, things like that. Or a major bodily function would be impaired if they don’t get an abortion. Well, what is a major bodily function? That’s not defined. And so, yes, this was an almost laughable example of this, but I think that it’s a sign of something more pervasive and maybe less obvious.

Rovner: Yeah, I mean, I have listened to a lot of state debates with a lot of legislators saying things that are, as I say, kind of laughably inaccurate. Sorry, Lauren.

Weber: Oh, I would just say as a Missourian and as someone who lived in Missouri until a year ago, this gentleman, in particular, it does seem like has a history of making somewhat inflammatory statements that he knows will be picked up by the media. I mean, I think he brought a flamethrower to an event. I mean, I think that’s part of the shtick. But welcome to Missouri politics. You never know what you’re going to get.

Ollstein: And of course, we have the famous assertion that people can’t get pregnant as a result of rape because the body knows how to shut it down, which is obviously not …

Rovner: Which happened in a Missouri Senate race.

Ollstein: Yes. Yep. Exactly. So Missouri, once again, covering itself in glory.

Rovner: All right, well, something we haven’t talked about a lot recently are crisis pregnancy centers, which are usually storefronts for anti-abortion organizations that often lure women seeking abortions by offering free pregnancy tests and ultrasounds so that they can then talk them into carrying their pregnancies to term. The centers are getting more and more public support from states. One estimate is that government support totaled some $344 million in fiscal 2022. So that was a couple of years back. And increasingly as abortion clinics close in states with bans, crisis pregnancy centers, which typically don’t have medical professionals on staff and aren’t technically medical facilities, may be the only resource available to pregnant women. It seems that could have some pretty serious ramifications. Yes?

Ollstein: I mean, I think people don’t realize just how vast the network of these centers are. They outnumber abortion clinics by a lot in a lot of states, including states that support abortion rights. They’re very, very pervasive. And this is becoming a huge focus for the anti-abortion movement. It was basically the theme of this year’s March for Life, was these sort of resources. In part, it is an attempt to show a kinder face of the movement and change public opinion. Obviously, like we discussed, there are all these painful stories coming out about people being denied care. And so promoting these stories of places that provide some form of something, some services, it’s not necessarily medical care, but …

Rovner: They provide diapers and strollers and car seats. I mean, they do actually … many of them actually provide services for babies once they’re born.

Ollstein: Right. Right, right, right. And so I think there is going to be a huge focus on this in the policy space, both in terms of directing more taxpayer funding to these centers, which progressives vehemently oppose.

And so I think this is going to be a big focus going forward. It already has in Texas. Texas has directed a lot of money towards what they call alternatives to abortion, which include these centers. And so I think it’s going to be a big focus going forward.

Rovner: Well, one other thing about crisis pregnancy centers, because they are not medical facilities, they are not subject to HIPAA medical privacy rules. And it turns out that is important. According to an investigation by Senate Finance Committee Chairman Ron Wyden, a company gathered and sold location data for people whose phones were in or around 600 separate Planned Parenthood locations, without the patients’ consent, to use an anti-abortion advertising.

Wyden is asking the SEC and the FTC to investigate the company, but this raises broader questions about information privacy, particularly in the reproductive health space. I remember right after Roe v. Wade was overturned, there were lots of warnings to women who were using period-tracking apps and other things about the concern about people who you may not want to know your private medical situation being able to find out your private medical situations. Is there any indication that there’s any way from the federal government point of view to crack down on this?

Ollstein: So I don’t know about that specifically, but there is a bigger effort on privacy and digital privacy and how it relates to abortion. We’re still waiting on the release of the final HIPAA rule from the Biden administration, which will extend more protections around abortion data, I think. But, because it’s HIPAA, it does only apply to certain entities and these centers are not among them. Another area I’ve been hearing concern about is research. A researcher at a university who is studying people who have abortions or don’t have abortions, their data is not protected. And so they are very stressed out about that, and that’s compromising medical research right now. So there’s a lot of these different areas of concern. And as we so often see, technology evolves a hell of a lot faster than government evolves to regulate it and address it. And that is just an ongoing concern.

Rovner: Yes, it is. And at some point, we’ll talk about artificial intelligence, but not today. Actually, right now, I want to turn to the Super Bowl. Yes, the Super Bowl. In between all the ads for blockbuster movies, beer, cars, and snack foods, and, right, a football game, there were three ads aimed directly at health policy issues.

In one, the nonprofit price transparency advocacy group Power to the Patients got musicians Jelly Roll, Lainey Wilson, and Valerie June to basically call hospitals and insurance companies greedy. It’s not clear to me if this was a free PSA or if this group paid for it, but I suspect the latter.

Does anybody know who this group is? They seem to have lots of access to big names for what seems to be a kind of obscure health issue. I mean, everybody’s for transparency, but I don’t think I’ve ever seen a Super Bowl ad about it.

Cohrs: This is not their first Super Bowl. It’s backed by Cynthia Fisher who is married to the CEO of Sam Adams, parent company. And he’s also a member of the Koch family. But she has been passionate about health care price transparency for years. I mean, was in President [Donald] Trump’s ear, has made the legal argument that the authority existed under the Affordable Care Act. Lobbied to get these regulations passed. And she has definitely employed unusual or unorthodox techniques, like Super Bowl ads, like painting murals, like hosting parties and concerts for health staff and health policy people in D.C. And I think she’s also lobbying for the codification of these transparency regulations.

And it is a little wonky, but I think her frustration is that she lobbied so hard to get these price transparency regulations and everyday people don’t even know that it should be available for them. And obviously academics disagree over how useful that information is for everyday people. But I think she has just taken it upon herself to do the PR campaign for these regulations that she believes could help people make more educated decisions about care that isn’t necessarily emergency care, like MRIs, that kind of thing. So she’s been around for years and has been very active.

I think Fat Joe is another celebrity that she’s brought onto the case. Jelly Roll — I hadn’t seen him do an event with her before or an ad. But I think there’s an ever-expanding cast of celebrities where this is just … it seems like a pretty noncontroversial issue. So I mean, Busta Rhymes, like French Montana, there’s been a lot of people involved in this campaign and I expect it to be ongoing.

Rovner: I feel like she’s kind of the Mark Cuban of price transparency, where Mark Cuban is all into drug prices. Alice, you want to add something?

Ollstein: Well, it’s just funny to me because, as we’ve discussed many, many times on this podcast, transparency goes not very far in helping actual patients. And so it’s funny that a group called Power to the Patients is going all in on this issue when, as we know, the vast majority of health care people need they cannot shop around for and, even when they can, it’s not something people are always able or willing to do.

And so transparency gets a lot of bipartisan support and sounds good in theory, but we’ve seen in terms of what’s been implemented so far in terms of hospital prices, et cetera, that it doesn’t do that much to bring down prices or empower people.

Rovner: Although, I don’t know, getting famous people to care about health policy can’t be a terrible thing. Lauren, did you want to add something too?

Weber: No, I just wanted to say, I mean, I will say as much as we’re all clear on price transparency, what this all means, the Super Bowl is a new audience. So, I mean, if you’re going to spend your money, at least you’re spending it — and that was the most watched TV program, I believe, of all time — so you’re spending it in a way that you’re getting some eyeballs on it.

Rovner: All right, well, that was not the only ad. Next, a company that clearly did pay for its ad was Pfizer, which used a soundtrack by Queen and talking paintings and statues to celebrate science and declare war on cancer. This is also one I don’t think I had seen before. I mean, what is Pfizer up to here? I mean, obviously, Pfizer can afford a Super Bowl ad. There’s no question about that, but why would they want to?

Cohrs: I mean, Pfizer has not been performing great financially lately. And I think they pulled out of the lobbying organization biome and chose to spend money on a Super Bowl ad, which I think is a really interesting choice. I mean, I don’t know what the dues are, but a Super Bowl ad is an expensive thing.

And I think there has been this attack on science, as a whole, and I think there’s an outstanding question of how to rebuild trust. And I think that this was Pfizer’s unorthodox tactic of trying to equate themselves with more credible, historical scientists who are less controversial. Yeah, my colleague did a good story on it.

Rovner: Yeah, like Einstein.

Cohrs: Right.

Rovner: Well, we’ll link to all of these ads. If you haven’t seen them there, they’re definitely worth watching. Well, finally, and in keeping with the occasional politics that does creep into Super Bowl ads, the super PAC supporting the presidential candidacy of independent anti-vaxxer Robert F. Kennedy Jr. paid $7 million for an ad that was basically a remake of the 1960 ad for his uncle John F. Kennedy, when he was running for president, which provoked an outcry from several of his Kennedy cousins who have repeatedly disavowed RFK Jr.’s candidacy and his causes.

For his part, the candidate apologized to his family members and said he didn’t have anything to do with the ad directly, because it was the super PAC. But then he pinned it to his Twitter profile, where he has more than 2½ followers. I can’t help but wonder if they’re going after football fans who actually believe the whole Taylor Swift-Travis Kelsey thing is a conspiracy.

No comment on Robert F. Kennedy Jr. and pissing off his entire family? We will move ahead then.

Speaking of conspiracy theories, in “This Week in Health Misinformation,” we have — drum roll — blood transfusions. Seems that there are a significant number of people who believe that getting blood from someone who has been vaccinated against covid, using the mRNA vaccines, will somehow change their DNA or otherwise harm them. And state legislators are listening.

In Wyoming, a state representative has introduced a bill that would require the labeling of blood from a covid-vaccinated donor. So prospective recipients could refuse it, at least in nonemergency situations. And in Montana, there’s a bill that would go even further, banning blood donations from the covid-vaccinated. That one appears to not be going anywhere, but this could have serious implications. It would create blood shortages, I imagine, even in rural areas where fewer people are vaccinated than in some of the urban areas. But I mean, this strikes me as not an insignificant kind of movement.

Ollstein: Well, it seems troubling on two fronts. One, we already have blood shortages and we already have dangerously low vaccination rates and not just covid vaccination rates. The hesitancy and anti-vax sentiment is spilling over into routine childhood vaccinations and all kinds of things.

And so I think anything that appears to give that sort of stigma and conspiracy a veneer of credibility, like state law for instance, threatens to further entrench those trends.

Rovner: All right, well, that is this week’s news. We will do our extra credits in a minute, but first, as promised, we have the winners of the KFF Health News “Health Policy Valentines” contest. This year’s winner, and we will post the link to the poem and its accompanying illustration, is from Jennifer Reck.

It goes, “Darling, this Valentine’s Day, let’s grab our passports and fly away to someplace where the same drugs cost a fraction of what they do in the States.” I have asked the panel to each choose a finalist of their own to read. So, Lauren, why don’t you start?

Weber: “The paperwork flirts with my affections, a dance of denials, full of rejections. My heart yearns for you, my sweet medication, but insurance insists on prior authorization.”

Rovner: And who’s that from?

Weber: That’s from Sally Nix. Excellent work, Sally.

Rovner: Alice.

Ollstein: OK, I have one from Kara Gavin. It’s “My love for you, darling, is blinding / Like a clinical trial pre-findings / But I fear we shall part / And I’ll lose my heart/ Because of Medicaid unwinding!” Very topical.

Rovner: Very. Rachel.

Cohrs: OK, this is from Andrea Ferguson. “Parental love is beautiful and guess what makes it stronger? A paid parental leave policy to stay with baby longer.”

Rovner: Very nice. Thank you all who entered. And we’ll do this again next year. All right, now it is time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?

Ollstein: I have a piece from my colleague Arek Sarkissian, down in Florida, and it is about how the state’s immigration law is deterring immigrants from seeking health care. And one of the areas they’re most concerned about is maternal health care. We already are in a maternal health crisis and the law requires hospitals that receive Medicaid funding to ask people about their immigration status when they come in for care. What a lot of people don’t know is that they don’t have to answer, but this fear of being asked and potentially being flagged for deportation enforcement, et cetera, is making people avoid care. And so there’s just a lot of concern about this and a lot of attempts to educate folks in the immigrant community. Obviously, Florida has a very large immigrant community. And it just reminded me of the fears that were happening early in the pandemic when the public charge rule under Trump was in effect and it was deterring immigrants from seeking care.

And in the middle of a pandemic, when we’re dealing with an infectious disease that doesn’t care if you have citizenship or not, having a large segment of the population avoid care is dangerous for everyone.

Rovner: Indeed. Lauren.

Weber: So I chose an article titled “Climate Change Has Hit Home Insurance. Is Health Insurance Next?” by Yusuf Khan in The Wall Street Journal. And, I mean, look, the insurers are — they’re looking out for their bottom line. And the bottom line is that climate change does have health impacts. So the question is, will that start to hit premiums? The sad answer, in part of this article, is that, unfortunately, the people often most affected by climate change don’t have health insurance. So that may not affect premiums as much as we expect, but I think this is a really fascinating test case of how when climate change comes for your money, you’ll start to see it validated more. So I’ll be curious to see how this plays out with the various health insurers.

Rovner: Yeah, obviously, we’re already seeing people not being able to get home insurance in places like Florida and California because of increasing fires and increasing hurricanes and increasing flooding in some places. Rachel?

Cohrs: So mine is a package deal. It’s two stories related to private equity investment in health care. The first is a piece in Modern Healthcare by Nona Tepper on a Medicare Advantage report by the Private Equity Stakeholder Project. And it just kind of highlighted the downturn in investment in Medicare Advantage, like marketing companies and brokers, consultants.

And I thought it was an interesting take because, I think so often, we see reporting about how private equity is expanding its investment in a certain sector. But this, I think, was an interesting indicator where, oh, it’s turning downward so dramatically. And I think that it’s interesting to track the tail end of more regulation or whatever rule comes out. How does that impact investment? And we talk a lot about that in the pharmaceutical space. But I thought this was a great interesting creative take on the Medicare Advantage side of things.

And also just highlighting some reporting from my colleague Bob Herman about the FTC doubling down on the Welsh Carson’s anesthesia case to limit private equity’s physician buyouts. So the FTC is taking on Welsh Carson, a powerful private equity firm, and other private equity firms asked for the case to be dismissed. And Bob does a great job breaking down these really complicated arguments by the FTC as to why they’re not backing down. They’re not going to cut a deal, they want this case to go forward.

So it will be interesting to watch as this develops, but I think Bob makes a great argument. There are applications for other cases as well and for the FTC and being able to attack these complex corporate arrangements where they’re using subsidiaries to drive prices up for physician services and other things. So definitely worth a read from Bob.

Rovner: Yes, another theme of the Federal Trade Commission getting more and more involved in health care in general and private equity in health care in particular. My extra credit this week is from Stateline by Anna Claire Vollers, and it’s called “Government Can Erase Your Medical Debt for Pennies on the Dollar — And Some Are.” It’s about how a growing number of states and cities are buying up and forgiving medical debt for their residents. Backers of the plans point out that medical debt is a societal problem that deserves a societal solution. And that relieving people’s debt burdens can actually add to economic growth. So it’s a good return on a small investment. It’s obviously not going to solve the medical debt problem, but it may well buy some government goodwill for some of the people of these states and cities.

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

Weber: Still just on Twitter @LaurenWeberHP, or X, I guess.

Rovner: Alice.

Ollstein: On X @AliceOllstein and on Bluesky @alicemiranda.

Rovner: Rachel.

Cohrs: I’m @rachelcohrs on X and also getting more engaged on LinkedIn lately. So feel free to follow me there.

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

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