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 Department of Health and Human Services underwent an unprecedented purge this week, as thousands of employees from the National Institutes of Health, the FDA, the Centers for Disease Control and Prevention, and other agencies across the department were fired, placed on administrative leave, or offered transfers to far-flung Indian Health Service facilities in such places as New Mexico, Montana, and Alaska. Altogether, the layoffs mean the federal government, in a single day, shed hundreds if not thousands of years of health and science expertise.

Meanwhile, the Supreme Court heard a case about whether states can bar Planned Parenthood from providing non-abortion-related services to Medicaid patients. But by the time the case is settled, it’s unclear how much of Medicaid or the Title X Family Planning Program will remain intact.

 This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.

Panelists

Rachel Cohrs Zhang
Bloomberg News

@rachelcohrs

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• As details trickle out about the major staffing purge underway at HHS, long-serving and high-ranking health officials are among those who have been shown the door: in particular, senior scientists at FDA, including the top vaccine regulator, and even the head veterinarian working on bird flu response.
• The Trump administration has also gutted entire offices, including the FDA’s tobacco division — even though the division’s elimination would not save taxpayer money because it’s not funded by taxpayers. Still, the tobacco industry stands to benefit from less regulatory oversight. Many health agencies have their own examples of federal jobs cut under the auspices of saving taxpayer money when the true effect will be undermining federal health work.
• Democratic Sen. Cory Booker of New Jersey set a record this week during a marathon, 25-hour-plus chamber floor speech railing against Trump administration actions, and he used much of his time discussing the risks posed to Americans’ health care. With Republicans considering deep cuts that could hit Medicaid hard, it’s possible that health changes could be the area that resonates most with Americans and garner key support for Democrats come midterm elections.
• And the tariffs unveiled by President Donald Trump this week reportedly touch at least some pharmaceuticals, leaving the drug industry scrambling to sort out the impact. It seems likely tariffs would raise the prices Americans pay for drugs, as tariffs are expected to do for other consumer products — leaving it unclear how Americans stand to benefit from the president’s decision to upend global trade.

Also this week, Rovner interviews KFF Health News’ Julie Appleby, whose latest “Bill of the Month” feature is about a short-term health plan and a very expensive colonoscopy. Do you have a baffling, confusing, or outrageous medical bill to share with us? You can do that here.

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

Julie Rovner: Stat’s “Uber for Nursing Is Here — And It’s Not Good for Patients or Nurses,” by Katie J. Wells and Funda Ustek Spilda.

Sarah Karlin-Smith: MSNBC’s “Florida Considers Easing Child Labor Laws After Pushing Out Immigrants,” by Ja’han Jones.

Lauren Weber: The Atlantic’s “Miscarriage and Motherhood,” by Ashley Parker.

Rachel Cohrs Zhang: The Wall Street Journal’s “FDA Punts on Major Covid-19 Vaccine Decision After Ouster of Top Official,” by Liz Essley White.

Also mentioned in this week’s podcast:

• Stat’s “Laid-Off HHS Leaders Offered Transfers to Remote Indian Health Service Regions,” by Usha Lee McFarling.
• The Washington Post’s “Fired Health Workers Were Told To Contact an Employee. She’s Dead.” By Lauren Weber.
• Georgia Recorder’s “Bill That Criminalizes Abortion, Undermines IVF Access Gets Georgia House Panel Hearing,” by Jill Nolin.

Click to open the transcript

Transcript: American Health Gets a Pink Slip

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 3, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, Julie. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello hello. 

Rovner: And we welcome back to the podcast Rachel Cohrs Zhang, now at Bloomberg News. 

Rachel Cohrs Zhang: Hi, everyone. 

Rovner: Later in this episode we’ll have my interview with my colleague Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month,” about yet another very expensive colonoscopy. But first, this week’s news. 

We’re going to start this week, as usual, with the latest changes to the Department of Health and Human Services from the Trump administration. But before we dive in, I want to exercise my host prerogative to make a personal observation for those who think that what’s happening here is, quote, “politics as usual.” I am now a month into my 40th year of covering health policy in Washington and HHS in particular. When I began, Ronald Reagan was still president. So I’ve been through Democratic and Republican administrations, and Democratic- and Republican-controlled Congresses, and all the changeovers that have resulted therefrom. 

And obviously the HHS I cover today is far different from the one I covered in 1986, but I can safely say I have never seen such a swift and sweeping dismantling of the structure that oversees the U.S. health system as we’ve witnessed these past 60 days. Agencies and programs that were the result of years of expert consultations and political compromises have been summarily eliminated, and health and science professionals with thousands of years of combined experience cut loose via middle-of-the-night form emails. To call the scope and speed of the changes breathtaking is an understatement, and while I won’t take any more personal time here, if you want to hear me expand further on just how different this all really is, I’m on this week’s episode of my friend Dan Gorenstein’s “Tradeoffs” podcast, which you should all be listening to anyway. 

All right. That said, now let’s dive in. I suppose it was inevitable that we would see the results of last week’s announced reorganization of HHS on April Fools’ Day. Let’s start with who was let go. While the announcement last week suggested it would mostly be redundancies and things like IT and HR and procurement, there were a bunch of longtime leaders included in this purge, right? 

Karlin-Smith: Yeah. At FDA [the Food and Drug Administration] there were some of the most senior scientists, like their Office of New Drugs directors, their chief medical officer, almost everybody who works on policy, legislative affairs, entire communications offices, external affairs. And even in the case where they are laying off people whose job titles might sound extraneous, or not as important to the health of people in the U.S., I think you can sort of debate that, but they did it in such a way that they laid off so many people in those departments that the people they said, We are protecting, because we do at least understand these jobs are important, cannot actually fully do their jobs. So scientists are not able to access the supplies they need. It’s not even clear how people at FDA are going to get paid and do their timesheets and track time given how many people they laid off. 

And it also just seems like there’s been a ton of, again, to the extent they were trying to protect certain positions that they deemed more critical to U.S. health and well-being, like medical reviewers or inspectors, they didn’t quite understand who actually is critical to doing that work, because it’s not just somebody who has, like, “inspector” in the title. Vanity Fair had a great piece about this man who really has saved people in the U.S. from going blind by helping inspectors catch sterility issues in eye drops, and they walk through very clearly how people like him do not have a title of inspector but are absolutely needed to ensure we have drugs that are safe for people in the U.S. So, probably not surprising to people who’ve tracked the administration so far, but it’s been a lot of the move-fast -break-things, and then realize on the back end that they maybe broke things they didn’t necessarily mean to, or don’t actually care as much about whether it’s broken. 

Rovner: Lauren. 

Weber: They got rid of the head veterinarian on the bird flu response. That would seem to be a thing that is surprising. I spoke to a congressman yesterday who said that seems very dumb. It’s not just that. They also eliminated entire swaths of the CDC [Centers for Disease Control and Prevention], small agencies that maybe a lot of people have no idea alphabetically what they do but are pivotal in preventing injury deaths, and in really the preventative and chronic disease care that RFK [Robert F. Kennedy Jr.] has said is really vital to getting America back on track. When we talk about dollars and cents saved in health care, a lot of that is in chronic disease and in preventative care. And to see some of these places get hit so broadly is quite shocking considering the end goal is allegedly to save money. 

Rovner: There are also a lot of things that seem sort of at odds with [President Donald] Trump’s own agenda. David Kessler, the former FDA commissioner, was on TV last night talking about how the people who answer the phones when a doctor wants to get an emergency use authorization for a drug that’s not yet approved. That’s something that’s been a very big deal for Donald Trump. The people who answer the phones got fired. So, when a doctor has a patient who, nothing else will work and they need an experimental drug, and they’re supposed to be able to call FDA. And I think there are rules about how fast FDA is supposed to respond. But now there’s nobody to actually answer the phone and take those requests. 

Karlin-Smith: Yeah, I think the list of things that don’t seem to align is very long. One thing I was talking to somebody about yesterday who said, well, pretty much everybody who deals with tracking pesticides in foods, and food safety at the FDA in regards to pesticides was let go. And making our food system healthier and safer, and concerns about pesticides, has actually been a big focus of RFK. Similarly, Martin Makary talked a lot in his opening speech to FDA employees yesterday about obesity, and they are basically gutting offices that work on pediatrics, minority health. They’ve laid off lots of people in their tobacco division at FDA, and FDA’s tobacco division actually is not funded at all by taxpayer funding. So, I have a hard time understanding how anybody besides the tobacco industry really benefits from this loss. As Lauren said, it’s like every health agency, you can kind of find examples of that. They say America is not healthy, but they’re cutting these top researchers that have found incredible advances in Parkinson’s and some of the chronic diseases he’s most cared about. 

Rovner: They also, I mean, there are some big names who were let go. We didn’t even — the Peter Marks firing at FDA happened last week after we taped, so we haven’t even talked about that. Somebody tell us who Peter Marks is and why everybody’s all freaked out about that. 

Cohrs Zhang: Well, Peter Marks was head of the division of biologics and the top regulator of vaccines, and complicated injectable medicines like insulin products, too, fell under his purview. And I think we saw markets react in a panic on Monday. The shares of vaccine makers like Moderna were falling. And we saw companies selling gene therapies that Peter Marks has been really involved in regulating and championing through some of those processes, they were kind of freaked out because it just creates uncertainty as to kind of what the new philosophy toward these medicines will be. And the Trump administration, we’ve seen, especially on the Marks being pushed out, I think they’ve tried to highlight some of his more controversial actions in the past. 

We saw a White House adviser, Calley Means, was personally attacking Marks for some conflicts he had with vaccine regulators during debate over the covid booster approvals, and just his decisions to overrule recommendations by FDA experts on some innovative medications that some people disagreed with. But the perspective from former officials has been that, like Peter Marks or not, the idea that scientific expertise is being purged in this way is concerning. And it wasn’t just Peter Marks. There’s another regulator at the Office of New Drugs, Peter Stein. who was pushed out. We have Anthony Fauci’s successor at NIH [the National Institutes of Health] was pushed out, Jeanne Marrazzo, as well as a couple other heads of scientific research institutes at NIH. 

Rovner: Anthony Fauci’s wife was pushed out— 

Cohrs Zhang: Yeah. Yeah. 

Rovner: —as the head of the office of bioethics at NIH. 

Cohrs Zhang: Truly, and I think we had heard that some of these more politically sensitive center leader positions would be at risk. We’ve heard this for a very long time, but it seems like they took advantage of the chaos to implement some of these high-level cuts to people that they may have disagreed with. But, like, people will be filling those positions. I don’t know that there’s a cost-saving argument there. But it certainly seems like they were trying to push out senior leaders with a lot of experience. 

Rovner: It also feels like, the way that people were let go seems, to put it bluntly, purposely cruel, like sending out RIF [reduction in force] notices at 5 a.m. and then having people find out they’ve been let go when they stand in long lines only to find out that their IDs no longer work, or CMS [Centers for Medicare & Medicaid Services] employees being directed to contact a person who died last year. Is there a strategy here? Lauren, you wanted to add something. 

Weber: I wrote a story on the CMS employees being told to contact someone who was dead. And I spoke to one of this woman Anita Pinder’s former colleagues who said she was just heartbroken. She said CMS employees who got that email had gone to this woman’s funeral, and what a gut punch. She said, Look — this person who was talking to me is a former CMS employee — said: Look, you know, there always is a way to reorganize. It’s not that there isn’t waste or ability to consolidate or streamline in the federal government. She’s like, That’s not my problem. My problem, this woman told me, was that it was done in such a way that you really can’t take that back. People getting a dead woman’s name as their point of contact to contest their firings is something that is difficult to take back. 

Rovner: I guess my question is: Is this just sloppy, or are they actually trying to be cruel in this? Because it certainly feels like they’re trying to be cruel. 

Karlin-Smith: I think it’s possible. It’s both, a combination, one or the other. Again, it seems like the people who are doing this are not expert, right? They didn’t actually take the time to assess HHS and all what the agency does to understand what people do for the government beyond just looking at their job titles. And so some of it may be intentional cruelty, and some of it just may be really just rushing and not understanding the process. I mean, there were other notices at FDA that were signed by somebody that no longer worked there. People’s performance scores were wrong. The sense is they didn’t follow the normal process of, like, when you do a RIF, you have to give — there’s certain people that get preferences and who stays and who goes and whether it’s veteran status, disability, all those things. 

And I think some of that will probably result in legal challenges down the line, including they got rid of certain offices, or everybody in them, that were mandated by Congress. So some of it’s probably sloppy, but some of it is — right? — they don’t really care how they treat people, because there is like a very clear message that comes from their rhetoric of kind of lack of respect for government bureaucracy. 

Rovner: And I know some of these senior leaders, they figured out that they can’t just summarily fire them. So a number of them were offered transfers to the Indian Health Service in places like Alaska and Montana, and they were given 36 hours to decide whether they would accept the transfer. And we are told that Secretary Kennedy is very concerned about Native populations and the Indian Health Service, which is short of workers in a lot of places. But this seemed to be insulting to both the people who were given these quote-unquote “transfers” and to the Indian Health Service, because it wasn’t sending the Indian Health Service what it actually needs, which are practitioners, doctors and nurses, and laboratory workers. It was sending research analysts and bench scientists and people whose qualifications do not match what the IHS needs. 

Karlin-Smith: Right. They wanted to send, I think, the FDA’s tobacco head to the IHS to do, I think, medical care. So it enraged people in the IHS. 

Rovner: Yeah, I don’t think the Native population was really thrilled about this, either. Lauren, you wanted to add something. 

Weber: Yeah, I would just say that this is a playbook the Trump administration has executed in other government agencies. Members of the FBI, top leaders of the FBI were reassigned to child sex trafficking crimes or faraway distant lands in the hopes of getting them to resign. So, I think we are seeing that play out at HHS, but it certainly is a tactic they’ve used in other federal agencies to, quote-unquote, “drain the swamp.” 

Rovner: Right. And in the first Trump administration, they did move some offices out of Washington to the middle of the country, if you will, and most people obviously didn’t go. And now there’s a lot of expertise that, again, that we lost. I think that really can’t be overstated, is how much expertise is being pushed out the door right now, in terms of things that, as I said, this administration says that it wants to do or get accomplished. Meanwhile, Secretary Kennedy has been invited — or should I say summoned — to come testify next week before the Senate health committee at the behest of Republican Chairman Bill Cassidy, Democratic ranking member Bernie Sanders. So far Congress has mostly just been kind of sitting back and watching all of this happen. Is there any indication that that’s about to change? 

Karlin-Smith: I think Democrats are pushing a little bit harder, but I’m not sure they have enough power or have enough, again, momentum yet to actually do what they can with their power. I’m interested to see how Cassidy handles this hearing going forward because his statement the day of the big reduction in force seemed to suggest that the media was maybe unfairly reporting on it and that Kennedy may have another side to the story to share to justify it. And it didn’t sound like somebody that was necessarily going to go particularly hard at RFK. It seemed like somebody who wanted to give him a chance to justify his moves. But we’ll see what happens. I think Cassidy has been, despite RFK walking back a lot of his promises he made to Cassidy around vaccines and so forth, Cassidy has not been that willing to go hard on him so far. 

Rovner: Yeah, the other thing we’ve seen is that most of the big health groups that you would expect to be out on the front lines, hair on fire, have actually been keeping their heads down through most of these huge changes. But that seems to be maybe changing a little bit, too. This is a pretty dramatic change to get not a huge response from. I’ve seen way lesser changes get way bigger responses. 

Cohrs Zhang: Yeah, I think I spend a lot of time thinking about what is going to be the last straw for some of these organizations. And I think we saw some more effective organizing from the, like, medical device industry when actual medical device reviewers were laid off, and I think they went public pretty quickly, and those people were rehired. But I think it’s important to remember that some of these larger trade organizations in these companies are looking at a broader picture here. And there are all these different pieces of the puzzle. And certainly I think we’ve seen some trade groups that represent, like, pharmaceutical companies criticize some of the cutbacks at HHS, but also for now they were spared in a tariff announcement this week. 

And so I think they are trying to walk this tightrope where they have to figure out how to get the wins that they think they need and take losses in other place, and hope it kind of all evens out for them. So, I think they’re in a tough situation, and I think there’s much more concern behind the scenes than we’re seeing spill out into the public. But I think at some point maybe the line will be crossed, and I just don’t think we’ve seen that quite yet. 

Karlin-Smith: Yeah, I think the dam is definitely starting to break a bit, though. I was shocked — I guess, what day was it, Tuesday, when all this happened? — when finally late in the day, pharma sent a statement, and it was more scathing than you might even expect. And I think it was the first time they’ve actually responded to anything I’ve asked them to respond to that the administration does. And they said that it’s going to raise crucial questions about the FDA’s ability to fulfill its role. And so I think that is a big sign because, as Rachel mentioned, the medical device community was willing to stick their neck out there when they felt they were really harmed. Smaller trade associations have been starting to push back, but the silence has really been notable, and notable I think by people outside who were hoping that these powerful industries that have sort of more connections to the Republican Party would use that leverage, and they sort of felt abandoned by them. So, I think that is a significant crack to follow. 

Rovner: I feel like everybody’s waiting for somebody else to stand up and see if they get their head chopped off. I agree. I mean, I’m hearing, quietly, I’m hearing the concern, too, but publicly not so much. Well, moving to Capitol Hill, Congress is in this week. Well, they were in. We’ll get to the House in a minute. But first in the Senate, New Jersey’s Cory Booker set a new record for holding the floor, which is saying something for a place where being long-winded is basically a prerequisite. Twenty-five hours and five minutes, besting by almost an hour the 1957 filibuster against the Civil Rights Act by Strom Thurmond of South Carolina. Much of what Booker talked about during his more than a day on the Senate floor was health care. Is this still the issue that Democrats are hoping to ride to their political return? 

Weber: I was going to say, if the massive Medicaid cuts that are forecast come through, I do think that will be the midterm political return of Democrats. I think the writing is on the wall politically for Republicans if those do go through, which is why I think you’re seeing a lot of Republican leaders start to say: Oh, no. No, no, no. We don’t want some of these Medicaid cuts like this. But to be determined how that actually plays out. 

Rovner: Rachel. 

Cohrs Zhang: I was just going to say that Democrats are just trying to figure out something that will break through to people. They’re just trying to throw spaghetti at the wall and see if there’s some strategy they can find to get through to people. And I think this, just given the viewership of Sen. Booker’s speech, seemed to break through in a way and felt like even though Democrats do have really limited levers of power in Washington right now, that at least somebody was doing something, you know. And that’s kind of the takeaway that I had from that speech. 

But I will say I think Congressman Jake Auchincloss appeared after White House adviser Calley Means criticized the scientific establishment and HHS and was defending these cuts, and Congressman Auchincloss, I think, did have a more forceful tone in pushing back and just arguing for the scientific advances that have happened and had some really camera-ready little tidbits about the new administration being run by like conspiracy theorists and podcast bros. And I think they’re trying to figure out how to push back and how to get through to people and what approaches are going to work. And I think that was just a new tactic that we saw break through. 

Rovner: Well, if the Democrats did want to make a statement about Medicaid, they could make a stand against President Trump’s nominee to head the Medicaid program, as well as Medicare and the ACA [Affordable Care Act], Dr. Mehmet Oz. That vote is scheduled in the Senate for today after we finish taping. But we’re not really seeing that much pushback. Are we, Lauren? 

Weber: Not so far. I guess we’ll see. We’re taping before this happens. But Mehmet Oz really waltzed through his confirmation hearing process. It’s rare that you see someone who will lead such a massive agency on health care mention the multiple Daytime Emmys he’s won, but I think that helped in his charming of legislators. His daytime bona fides were on high display. He was able to dodge multiple questions about what he would do about cuts to Medicaid, and even Democratic senators were inviting him to come to church. I would be surprised if we see some sort of big stand today. 

Rovner: He was super well prepped, which we said — we did a special after the hearing — which is of all of the Trump nominees, I think he was the best prepped of anybody I’ve seen. He was ready with tidbits from every single member of the committee. But I will say that, going back years, and as I said, you know, 40 years, this is a position that one party or the other has frequently blocked, not for reasons that the nominee was not qualified but because they wanted to make a point about something that was going on at the agency. And it kind of surprises me that we haven’t seen that sort of thing. There were years where we did not have a Senate-approved head of Medicare and Medicaid. Sarah, as you pointed out, there were years when we didn’t have a Senate-approved head of the FDA for the same reason. Had nothing to do with the nominee. Had everything to do with the party that was out of power trying to use that as leverage to make a point. And we’re just not even seeing the Democrats try that. 

Weber: I guess we’ll see this afternoon. You could be forecasting what’s going to happen, Julie. But I think on top of him being well prepped, Oz does have a history in health care, is a very accomplished surgeon. But what is fascinating to me is that he’s coming back to the Senate after a 2014 grilling by the Senate on his pushing of supplements and other things for, quote, “fat blasting” and, quote, “weight loss” products. And it’s just the turnaround of daytime TV star to failed Senate candidate to potential administrator for CMS, which runs hundreds of millions Americans’ health insurance, potentially at a very consequential period in which there are massive cuts to them, is really going to be something. 

Rovner: Yes. Yet another eye-opening thing out of this administration. Well, over in the House, things are a little more confusing. On Tuesday, the usually unified Republicans rejected a rule, normally a party-line , because Speaker Mike Johnson was using it to avoid a vote on a bill that would allow new parents to vote by proxy, basically granting them parental leave. I did not have this fight on my bingo card for this year. It’s actually less a partisan fight than one between younger — read, childbearing age — members of Congress and older ones from both parties. I’m kind of surprised that this of all things is what stopped the House from doing business this week. 

Cohrs Zhang: Yeah, I think that it is an interesting contrast here because House Republicans have had this very pro-family rhetoric in the campaign, but they also have been so against remote work in any fashion, and members of Congress travel really far. There’s a time in pregnancy when you can no longer fly on a plane. And so I think given Republicans’ really, really slim majority in the House, it puts them in kind of a pickle where they need these votes to keep the majority, but it kind of sits at the intersection of all these different forces at play. So, I think, yeah, just a really weird political pickle that House Republicans have found themselves in this week. 

Rovner: Yeah, and of course this was a member of the House Freedom Caucus, a Republican member of the House Freedom Caucus, who was pushing this, who got a majority of the House to sign her discharge petition, which is supposed to bring this bill to the floor. So, we will see how that one plays out. Obviously, with everything else that’s going on, it’s not the biggest story, but it sure is interesting. 

Well, the big non-health news of the week are the tariffs that President Trump announced in the Rose Garden Wednesday afternoon. There is a health care angle to this story. The tariffs reportedly include at least some drugs and drug ingredients that are manufactured overseas. This, again, feels like it’s going to do exactly the opposite of what the president says he wants to do in terms of reducing drug prices, right? 

Weber: I mean, yes, yes. That would seem to be exactly how that is likely to go. Even look at drugs we get from Canada. They’re going to have tariffs on them. I think we have to wait and see exactly what happens. Trump has had a history of proposing these and then taking them back. Obviously these are much more sweeping than the ones we’ve seen so far. So, I think it, the jury is out on how exactly this will play out over the next couple weeks. 

Rovner: Right. And I said there’s also the exception process, right? 

Karlin-Smith: So, yeah, there’s been I think a lot of confusion and lack of clarity around exactly what happened yesterday here. It seems like the drug industry did get some key exemptions, but people are trying to kind of clarify some of those, including, like: Do you just apply to finished product? Do ingredients that they need lower down in the supply chain get impacted? So, I think it seems like pharma at least got some amount of a win here and got some of the typical exemptions for medicines, but people are not confident in all of that and how it’s going to play out. And I’ve seen sort of mixed reactions from analysts in the space. But yeah, it’s just like other parts of the economy that people have talked about with tariffs. It’s not entirely clear how the average American consumer would actually benefit from these tariffs versus having to just pay more money for goods. 

Rovner: We are apparently going to tariff penguins from islands off the coast of Australia. That much we seem clear on this morning. Turning to abortion, this week, as we mentioned last week, the Supreme Court heard a case out of South Carolina testing whether a state can kick Planned Parenthood not just out of the federal Family Planning Program, Title X, but whether Planned Parenthood can be disallowed from providing Medicaid services as well. Now, Planned Parenthood gets way more money from Medicaid than it does from Title X, and neither program allows the use of federal funds to pay for abortion. I will say that again: Neither program allows the use of federal funds to pay for abortion. Interestingly, it seems the high court might actually be leaning towards Planned Parenthood in this case, not because the conservative justices have any sympathy towards Planned Parenthood but because the court has fairly recently made it clear that the provision of Medicaid law that says patients can choose any qualified provider actually means what it says: The patient can choose any qualified provider. 

At the same time, though, the Trump administration this week declined to distribute a big swath of that Title X funding. And you have to wonder whether, even if Planned Parenthood wins this South Carolina case, what’s going to be left of either Title X or the Medicaid program. Possibly a Pyrrhic victory coming here? It seems that this administration is just whacking things, and even if the court ultimately says you can’t kick them out, there’s going to be nothing for them to stay in. 

Karlin-Smith: Well, the any-willing-provider debate struck me as sort of most interesting here because that type of clause seems to be something you typically see conservatives want to put into a government health program. They don’t feel comfortable kind of restricting people and choices in that way around who they see. So that was one of the elements of this case. The other thing that I think is being watched is this argument that the state is making around, like, how you enforce disagreements, I guess, around how the Medicaid program is being operated. And that seems like it could have a lot of long-lasting impacts as well if people, depending on if the court weighs in on that and so forth, just what rights people have to contest problematic decisions made in state Medicaid programs. 

Rovner: Yeah, for the first hour of the debate, the word “abortion” wasn’t mentioned. The word “Planned Parenthood” wasn’t mentioned. This was really about whether patients actually have a right to sue over not being able to get the kind of care that they want, which has been a long-standing fight in Medicaid, back to, I think, pretty much the beginning of Medicaid. So, we’ll see how this one comes out. Well, turning to the states and another case we have talked about, Texas wants to prosecute a New York doctor who was acting legally under New York law from prescribing abortion pills via telemedicine to a Texas patient. The latest is that the court clerk in Ulster County, New York, has refused to file a judgment for the $100,000 fine that Texas says the New York doctor owes. 

At the other end of the spectrum, in Georgia, meanwhile, lawmakers held a hearing on a bill that would — and I’m quoting from a Georgia state news service here — “ban abortions in Georgia from the moment of fertilization and codify it as a felony homicide crime unless a pregnant woman was threatened with violence to have the procedure.” Now, under this bill, both the woman and the doctor could be charged with murder. This bill is unlikely to be enacted this year, but I feel like the Overton window on this continues to move towards maybe punishing women with poor pregnancy outcomes. 

Karlin-Smith: Well, and punishing women who have trouble getting pregnant, as some of the opponents of this bill are arguing. It’s not clear whether it will really be possible to do IVF procedures if the bill was enacted how it was written. And even it seems like some of the reason why some pretty anti-abortion groups are concerned about this law, because they feel uncomfortable that it’s penalizing or going after the woman rather than other people involved in the abortion system. 

Rovner: I feel like we’ve been creeping this direction for a while, though. Obviously, this bill’s probably not going to move this cycle, but it got a hearing. We’ve seen a lot of things like this introduced. We’ve rarely seen it progress to the hearing stage. Another thing that bears watching. So, last week in the segment that I’m now calling “MAHA [Make America Healthy Again] in the States,” we talked about West Virginia banning food dyes and additives. Well, hold my beer — um, make that water, says Utah. Utah has now become the first state to ban fluoride in public water systems, something takes effect next month. Lauren, I feel like states are rushing to match RFK Jr. Is that what we’re seeing? 

Weber: There is some interest at the state level, but I also think it speaks to RFK’s limitations. I think everybody always thinks the game is always in D.C., but there’s a lot the states can do. And so I think it’ll be fascinating to kind of see how this continues to play out. 

Rovner: Yeah, well, we will keep watching it. All right, that is this week’s health news. Now we will play my interview with KFF Health News’ Julie Appleby. Then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast KFF Health News’ other Julie, Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month.” Julie, welcome back. 

Julie Appleby: Thanks for having me. 

Rovner: So, this month’s patient is yet another with a gigantic colonoscopy bill, but there’s a twist with this one. Tell us who he is and, important for this story, what kind of health insurance he has. 

Appleby: Yes, absolutely. His name is Tim Winard, and he lives in Addison, Illinois. He bought his own health insurance after he left his management job to launch his own business. So he shopped around a little bit. This is the first time he’s bought insurance. And he chose a short-term policy, which is good for six months in his state. And the first six months went pretty well. And he was still working on starting his business, so he signed up for another short-term policy with a different insurer. And this one cost about $500 a month. 

Rovner: So, remind us again. What is short-term health insurance? And how is it different from most employer and Affordable Care Act coverage? 

Appleby: Right. These types of policies have been sold for years. They’re generally intended for people who are, like, between jobs or maybe just getting out of school. They’re a temporary bridge to more comprehensive insurance, and as such they are not considered Affordable Care Act-qualified plans. So they don’t have to meet the rules that are set under the Affordable Care Act. So, for example, they might look like comprehensive major medical policies, but they all have sort of significant caveats. And some of these might surprise people who are accustomed to work-based or ACA plans. So, for example, like in Tim Winard’s plan, some set specific dollar caps on certain types of medical care, and sometimes those are, like, per day or per visit or something like that, and they can be sometimes far below what it actually costs. 

And all of them — this is a key difference with ACA plans — all of these types of short-term plans screen applicants for health conditions, and they can reject people because of health problems or exclude those conditions from coverage. Many also do not cover drugs or maternity care. So people really have to read their policies carefully to see what they cover and what they don’t cover. 

Rovner: So this is sort of like pre-ACA. It’s cheap because it doesn’t cover that much. 

Appleby: Exactly. That’s why they can offer them lower premiums. Now, again, some people with a subsidized ACA plan, these are not necessarily cheaper, but for others these are less expensive. 

Rovner: So back to our patient this month. He does what we always advise and calls his insurance company before he goes for this, because it is obviously scheduled care, not an emergency. What did they tell him? 

Appleby: Well, I think he only asked where he could go. He was concerned that he would go to a facility that was in-network, and they told him he could pretty much go anywhere. He did not ask about cost in that phone call. 

Rovner: Yeah, so he gets his colonoscopy. Everything turns out OK medically. And then, as we say, the bill comes. How big was it? 

Appleby: He was left owing $7,226 after his plan paid about $817 towards the bill. They got a little bit of a discount for being insured, but then he was still left owing more than $7,000. 

Rovner: And what was the explanation for him owing that much? Just a reminder that this should have been fully covered if he’d had an ACA plan, right? 

Appleby: That’s correct. Under the ACA, screening colonoscopies and other types of cancer screenings are covered without a copay for the patient. But he didn’t have an ACA plan here. So, what was the explanation? Well, this time he did email his insurance company, which is Companion Life Insurance of Columbia, South Carolina, and they wrote him back, and they told him his policy classified the procedure and all of its costs, including the anesthesia, under his policy’s outpatient surgery facility benefit. What is that? you might ask. Well, in his policy, that benefit caps insurance payments within that facility to a maximum of a thousand dollars per day. So, the most they were going to pay towards this was a thousand dollars, because they classified the whole thing as an outpatient procedure with that cap. And this surprised Winard because he thought the cancer screening was covered and he would only owe 20% of the bill, not almost the entire thing, basically. 

Rovner: So how did this eventually work out? 

Appleby: Well, we reached out and tried to reach Companion Life, and we also talked to Scott Wood, who works as a program manager and is a co-founder of a marketing company that markets Companion Life and other insurance plans. And he thought there was some room for interpretation in the billing and in the policy language. So he asked Companion Life to take another look. And shortly after that, Winard said he was contacted by his insurer, and a representative told him that upon reconsideration the bill had been adjusted. And he wasn’t really given a reason why that happened, but as it turns out his new bill showed he owed only $770. 

Rovner: Which is, I assume, about what he expected when he went into this, right? 

Appleby: That’s, yes, correct. He didn’t think he was going to have to pay as much as it was initially billed at. 

Rovner: So, what’s the takeaway here other than to come to us if you have a bill that you can’t deal with? 

Appleby: Right. Well, I think experts say to be very cautious and read the plans very carefully if you’re shopping for a short-term plan. And realize they have some of these limits and they may not cover everything. They may not cover preexisting conditions. And this could become more widespread in the coming years as — short-term plans have been somewhat of a political football. So, out of concern that people would choose them over more comprehensive coverage, President Barack Obama’s administration limited them to terms of three months. Those rules were lifted during the first Trump administration, and he allowed the plans to again be sold as 364-day policies, just one day short of a year, and then you could try to get another one. Or in some cases the insurer could opt to renew them. 

And then Joe Biden came in, and President Biden called them “junk insurance,” and he restricted the policies to four months. So, it’s been bouncing back and forth, back and forth. Everybody really expects the Trump administration to do what it did the last time and make them available for longer periods. So I think if we’re going to hear more about short-term plans. They may become more common. And again, it’s just a matter of trying to understand what you’re buying, and why they might be less expensive in your mind than an ACA plan, but they might not turn out to be. 

Rovner: And you can always ask for an estimate, right? 

Appleby: And always ask for an estimate. That’s a given. Experts always say, before any kind of scheduled procedure, call your insurer, call the provider, ask for an estimate on how much this might cost you out-of-pocket. 

Rovner: Good. And if all else fails, then you can write to us. 

Appleby: There you go. 

Rovner: Julie Appleby, thank you very much. 

Appleby: Thanks for having me. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week? 

Cohrs Zhang: All right. My extra credit is a piece in The Wall Street Journal, and the headline is “FDA Punts on Major COVID-19 Vaccine Decision After Ouster of Top Official,” by Liz Essley White. It’s a great story, and I think, as we talked about earlier, I’m thinking about: What are the breaking points for companies, for industries, as they look at how the HHS is changing? And I think one of those metrics is if the FDA starts missing deadlines to approve products. I think this one is a little bit of a special case because it is a covid-19 vaccine, which is, like, the most highly politicized medical product right now. But I think there could be other cases, and I think industry is watching this so closely to see if some of these changes at FDA really do bleed into approvals, whether the approval process will be politicized, whether they’re going to start missing deadlines. And given just the amount of financial support that industry provides to fund routine activities, I think this was kind of a really good marker in this process as we learn what the impacts are. 

Rovner: Yeah, agree. Lauren. 

Weber: I read “Miscarriage and Motherhood” by Ashley Parker, now at The Atlantic. And I’ve got to be honest — if you read it, be in a place where you can cry. It’s an incredibly moving piece about tragedies of miscarriage, and frankly about women’s health care, and how little support and understanding there is in general about what surrounds that entire field. And some of the fascinating parts in it is when Ashley details going in for a D&C [dilation and curettage] and being told that is an abortion. And it’s kind of an interesting interplay between how what words mean, what people understand what words mean, and what exactly parenthood entails in modern America today. 

Rovner: And how extremely common miscarriage is. I think people just don’t realize, because it’s something that’s just not talked about very much. It’s a really beautiful story. Sarah. 

Karlin-Smith: I looked at an MSNBC piece [“Florida Considers Easing Child Labor Laws After Pushing Out Immigrants”] by Ja’han Jones, about Florida considering easing their child labor laws after pushing out immigrants. And, yeah, the state is considering bills that would allow very young teenagers to work overnight, to maybe work at the kinds of jobs that would normally be seen as too unsafe for such young people. And, yeah, it just seems like an interesting sort of consequence of pushing out immigrant workers. But also it comes after some really moving reports over the past few years, too, about just how dangerous some of this work is, and how even under current law that is supposed to prevent this, particularly immigrants and the most vulnerable workers have ended up with young people in this job, and they’ve really — these types of jobs — and they’ve been harmed by it. 

Rovner: Who could have possibly seen this coming? Sorry. My extra credit this week is from Stat, and it’s called “Uber for Nursing is Here — and It’s Not Good for Patients or Nurses,” by Katie J. Wells and Funda Ustek Spilda. And it’s yet another case of something that sounds really good, using an app to help nurses who want to find extra work and set their own schedules get it, and helping facilities that need extra help find workers. But like so many of these things, it’s not as rosy as it appears unless you’re the one that’s collecting the fees from the app. Workers are basically all temps. They may not be familiar with the facilities they’ve been assigned to, much less the patients, which doesn’t always result in optimal care. And they bid against each other for who will do the job for the lowest rate, creating a race to the bottom for wages. It’s another one of those quote-unquote “advances” that’s a lot less than meets the eye. 

All right, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys these days? Rachel, you’re still on LinkedIn, right? 

Cohrs Zhang: Still on LinkedIn. Still on X. I do have a Bluesky account, too. But any and all the places. 

Rovner: Excellent. Sarah. 

Karlin-Smith: Yeah, I’m at Bluesky, some X, some LinkedIn, @SarahKarlin or @sarahkarlin-smith. 

Rovner: Lauren. 

Weber: I’m still on X, and I am on Bluesky, @LaurenWeberHP. And as a member of — a congressional staffer asked me: Does the “HP” really stand for “health policy”? And yes, it does. So, still there. 

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

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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.

Two months into the new administration, federal workers and contractors remain off-balance as the Trump administration ramps up its efforts to cancel jobs and programs — even as federal judges declare many of those efforts illegal and/or unconstitutional.

As it eliminates programs deemed duplicative or unnecessary, however, President Donald Trump’s Department of Government Efficiency is also cutting programs and workers aligned with Health and Human Services Secretary Robert F. Kennedy Jr.’s “Make America Healthy Again” agenda.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Rachel Roubein of The Washington Post.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories.

Among the takeaways from this week’s episode:

• Kennedy’s comments this week about allowing bird flu to spread unchecked through farms provided another example of the new secretary of health and human services making claims that lack scientific support and could instead undermine public health.
• The Trump administration is experiencing more pushback from the federal courts over its efforts to reduce and dismantle federal agencies, and federal workers who have been rehired under court orders report returning to uncertainty and instability within government agencies.
• The second Trump administration is signaling it plans to dismantle HIV prevention programs in the United States, including efforts that the first Trump administration started. A Texas midwife is accused of performing illegal abortions. And a Trump appointee resigns after being targeted by a Republican senator.

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

Julie Rovner: The Washington Post’s “The Free-Living Bureaucrat,” by Michael Lewis.

Rachel Roubein: The Washington Post’s “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” by Carolyn Y. Johnson.

Sarah Karlin-Smith: KFF Health News’ “Scientists Say NIH Officials Told Them To Scrub mRNA References on Grants,” by Arthur Allen.

Jessie Hellmann: Stat’s “NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease,” by Elaine Chen.

Also mentioned in this week’s podcast:

• The Wall Street Journal’s “Trump Administration Weighing Major Cuts to Funding for Domestic HIV Prevention,” by Liz Essley White, Dominique Mosbergen, and Jonathan D. Rockoff.
• The Washington Post’s “Disabled Americans Fear Losing Protections if States’ Lawsuit Succeeds,” by Amanda Morris.

click to open the transcript

Transcript: Federal Health Work in Flux

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi. 

Rovner: Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hello. 

Rovner: No interview today, but, as usual, way more news than we can get to, so let us jump right in. In case you missed it, there’s a bonus podcast episode in your feed. After last week’s Senate Finance Committee confirmation hearing for Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services, my KFF Health News colleagues Stephanie Armour and Rachana Pradhan and I summarized the hearing and caught up on all the HHS [Department of Health and Human Services] nomination actions. It will be the episode in your feed right before this one. 

So even without Senate-confirmed heads at — checks notes — all of the major agencies at HHS, the department does continue to make news. First, Robert F. Kennedy Jr., the new HHS secretary, speaks. Last week it was measles. This week it was bird flu, which he says should be allowed to spread unchecked in chicken flocks to see which birds are resistant or immune. This feels kind of like what some people recommended during covid. Sarah, is there any science to suggest this might be a good idea? 

Karlin-Smith: No, it seems like the science actually suggests the opposite, because doctors and veterinary specialists are saying basically every time you let the infection continue to infect birds, you’re giving the virus more and more chances to mutate, which can lead to more problems down the road. The other thing is they were talking about the way we raise animals, and for food these days, there isn’t going to be a lot of genetic variation for the chickens, so it’s not like you’re going to be able to find a huge subset of them that are going to survive bird flu. 

And then the other thing I thought is really interesting is just it doesn’t seem economically to make the most sense either as well, both for the individual farmers but then for U.S. industry as a whole, because it seems like other countries will be particularly unhappy with us and even maybe put prohibitions on trading with us or those products due to the spread of bird flu. 

Rovner: Yeah, it was eyebrow-raising, let us say. Well, HHS this week also announced its first big policy effort, called Operation Stork Speed. It will press infant formula makers for more complete lists of ingredients, increase testing for heavy metals in formula, make it easier to import formula from other countries, and order more research into the health outcomes of feeding infant formula. This feels like maybe one of those things that’s not totally controversial, except for the part that the FDA [Food and Drug Administration] workers who have been monitoring the infant formula shortage were part of the big DOGE [Department of Government Efficiency] layoffs. 

Roubein: I talked to some experts about this idea, and, like you said, they thought it kind of sounded good, but they basically needed more details. Like, what does it mean? Who’s going to review these ingredients? To your point, some people did say that the agency would need to staff up, and there was a neonatologist who is heading up infant formula that was hired after the 2022 shortage who was part of the probationary worker terminations. However, when the FDA rescinded the terminations of some workers, so, that doctor has been hired back. So I think that’s worth noting. 

Rovner: Yes. This is also, I guess, where we get to note that Calley Means, one of RFK Jr.’s, I guess, brain trusts in the MAHA movement, has been hired as, I guess, in an Elon Musk-like position in the White House as an adviser. But this is certainly an area where he would expect to weigh in. 

Hellmann: Yeah, I saw he’s really excited about this on Twitter, or X. There’s just been concerns in the MAHA movement, “Make America Healthy Again,” about the ingredients that are in baby formula. And the only thing is I saw that he also retweeted somebody who said that “breast is best,” and I’m just hoping that we’re not going back down that road again, because I feel like public health did a lot of work in pushing the message that formula and breast milk is good for the child, and so that’s just another angle that I’ve been thinking about on this. 

Rovner: Yes, I think this is one of those things that everybody agrees we should look at and has the potential to get really controversial at some point. While we are on the subject of the federal workforce and layoffs, federal judges and DOGE continue to play cat-and-mouse, with lots of real people’s lives and careers at stake. Various judges have ordered the reinstatement, as you mentioned, Rachel, of probationary and other workers. Although in many cases workers have been reinstated to an administrative leave status, meaning they get put back on the payroll and they get their benefits back, but they still can’t do their jobs. At least one judge has said that does not satisfy his order, and this is all changing so fast it’s basically impossible to keep up. But is it fair to say that it’s not a very stable time to be a federal worker? 

Karlin-Smith: That’s probably the nicest possible way to put it. When you talk to federal workers, everybody seems stressed and just unsure of their status. And if they do have a job, it’s often from their perspective tougher to do their job lately, and then they’re just not sure how stable it is. And many people are considering what options they have outside the federal government at this point. 

Rovner: So for those lucky federal workers who do still have jobs, the Trump administration has also ordered everyone back to offices, even if those offices aren’t equipped to accommodate them. FDA headquarters here in Maryland’s kind of been the poster child for this this week. 

Karlin-Smith: Yeah, FDA is an interesting one because well before covid normalized working from home and transitioned a lot of people to working from home, FDA’s headquarters couldn’t accommodate a lot of the new growth in the agency over the years, like the tobacco part of the FDA. So it was typical that people at least worked part of their workweek at home, and FDA really found once covid gave them additional work-from-home flexibilities, they were able to recruit staff they really, really needed with specialized degrees and training who don’t live near here, and it actually turned out to be quite a benefit from them. 

And now they’re saying everybody needs to be in an office five days a week, and you have people basically cramped into conference rooms. There’s not enough parking. People are trying to review technical scientific data, and you kind of can’t hear yourself think. Or you’re a lawyer — I heard of a situation where people are basically being told, Well, if you need to do a private phone call because of the confidentiality around what you’re doing, go take the call in your car. So I think in addition to all of the concerns people have around the stability of their jobs, there’s now this element of, on a personal level, I think for many of them it’s just made their lives more challenging. And then they just feel like they’re not actually able to do, have the same level of efficiency at their work as they normally would. 

Rovner: And for those who don’t know, the FDA campus is on a former military installation in the Maryland suburbs. It’s not really near any public transportation. So you pretty much have to drive to get there. And I think that the parking lots are not that big, because, as you pointed out, Sarah, the workforce is now bigger than the headquarters was created to accommodate it. And we’re seeing this across the government. This week it happened to be FDA. You have to ask the question: Is this really just an effort to make the government not work, to make federal workers, if they can’t fire them, to make them quit? 

Hellmann: I definitely think that’s part of the underlying goal. If you see some of the stuff that Elon Musk says about the federal workforce, it’s very dismissive. He doesn’t seem to have a lot of respect for the civil servants. And they’ve been running into a lot of pushback from federal judges over many lawsuits targeting these terminations. And so I think just making conditions as frustrating as possible for some of these workers until they quit is definitely part of the strategy. 

Roubein: And I think this is overlaid with the additional buyout offers, the additional early retirement offers. There’s also the reduction-in-force plans that federal workers have been unnerved about, bracing for future layoffs. So it’s very clear that they want to shrink the size of the federal workforce. 

Rovner: Yeah, we’ve seen a lot of these people, I’ve seen interviews with them, who are being reinstated, but they’re still worried that now they’re going to be RIF-ed. They’re back on the payroll, they’re off the payroll. I mean there’s nothing — this does not feel like a very efficient way to run the federal government. 

Karlin-Smith: Right. I think that’s what a lot of people are talking about is, again, going back to offices, for many of these people, is not leading to productivity. I talked to one person who said: I’m just leaving my laptop at the office now. I’m not going to take it home and do the extra hours of work that they might’ve normally gotten from me. And that includes losing time to commute. FDA is paying for parking-garage spaces in downtown Silver Spring [Maryland] near the Metro so that they can then shuttle people to the FDA headquarters. I’ve taken buses from that Metro to FDA headquarters. In traffic, that’s a 30-minute drive. They’re spending money on things that, again, I think are not going to in the long run create any government efficiency. 

And in fact, I’ve been talking to people who are worried it’s going to do the opposite, that drug review, device review, medical product review times and things like that are going to slow. We talked about food safety. I think The New York Times had a really good story this week about concerns about losing the people. We need to make sure that baby formula is actually safe. So there’s a lot of contradictions in the messaging of what they’re trying to accomplish and how the actions actually are playing out. 

Rovner: Well, and finally, I’m going to lay one more layer on this. There’s the question of whether you can even put the toothpaste back in the tube if you wanted to. After weeks of back-and-forth, the federal judge ruled on Tuesday that the dissolution of USAID [the U.S. Agency for International Development] was illegal and probably unconstitutional, and ordered email and computer access restored for the remaining workers while blocking further cuts. But with nearly everybody fired, called back from overseas, and contracts canceled, USAID couldn’t possibly come close to doing what it did before DOGE basically took it apart, right?. 

Karlin-Smith: You hear stories of if someone already takes a new job, they’re lucky enough to find a new job, why are they going to come back? Again, even if you’re brought back, my expectation is a lot of people who have been brought back are probably looking for new jobs regardless because you don’t have that stability. And I think the USAID thing is interesting, too, because again, you have people that were working in all corners of the world and you have partnerships with other countries and contractors that have to be able to trust you moving forward. And the question is, do those countries and those organizations want to continue working with the U.S. if they can’t have that sort of trust? And as people said, the U.S. government was known as, they could pay contractors less because they always paid you. And when you take that away, that creates a lot of problems for negotiating deals to work with them moving forward. 

Rovner: And I think that’s true for federal workers, too. There’s always been the idea that you probably could earn more in the private sector than you can working for the federal government, but it’s always been a pretty stable job. And I think right now it’s anything but, so comes the question of: Are we deterring people from wanting to work for the federal government? Eventually one would assume there’s still going to be a federal government to work for, and there may not be anybody who wants to do it. 

Roubein: Yeah, you saw various hiring authorities given to try and recruit scientists and other researchers who make a lot, lot more in the public health sector, and some of those were a part of the probationary workforce because they had been hired recently under those authorities. 

Rovner: Yeah, and now this is all sort of coming apart. Well, meanwhile, the cuts are continuing even faster than federal judges can rule against them. Last week, the administration said it would reduce the number of HHS regional offices from 10 to four. Considering these are where the department’s major fraud-fighting efforts take place, that doesn’t seem a very effective way of going after fraud and abuse in programs like Medicare and Medicaid. Those regional offices are also where lots of beneficiary protections come from, like inspections of nursing homes and Head Start facilities. How does this serve RFK Jr.’s Make America Healthy Again agenda? 

Karlin-Smith: I think it’s not clear that it does, right? You’re talking about, again, the Department of Government Efficiency has focused on efficiency, cost savings, and Medicare and Medicaid does a pretty good job of fighting fraud and making HHS OIG [Office of Inspector General], all those organizations, they collect a lot of money back. So when you lose people— 

Rovner: And of course the inspector general has also been laid off in all of this. 

Karlin-Smith: Right. It’s not clear to me, I think one of the things with that whole reorganization of their chief counsel is people are suggesting, again, this is sort of a power move of HHS wanting to get a little bit more control of the legal operations at the lower agencies, whether it’s NIH [the National Institutes of Health] or FDA and so forth. But, right, it’s reducing head count without really thinking about what people’s roles actually were and what you lose when you let them go. 

Rovner: Well, the Trump administration is also continuing to cut grants and contracts that seem like they’d be the kind of things that directly relate to Make America Healthy Again. Jessie, you’ve chosen one of those as your extra credit this week. Tell us about it. 

Hellmann: Yeah. So my story is from Stat [“NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease”], and it’s about a nationwide study that tracks patients with prediabetes and diabetes. And it was housed at Columbia University, which as we know has been the subject of some criticism from the Trump administration. They had lost about $400 million in grants because the administration didn’t like Columbia’s response to some of the protests that were on campus last year. But that has an effect on some research that really doesn’t have much to do with that, including a study that looked at diabetes over a really long period of time. 

So it was able to over decades result in 200 publications about prediabetes and diabetes, and led to some of the knowledge that we have now about the interventions for that. And the latest stage was going to focus on dementia and cognitive impairment, since some of the people that they’ve been following for years are now in their older ages. And now they have to put a stop to that. They don’t even have funding to analyze blood samples that they’ve done and the brain scans that they’ve collected. So it’s just another example of how what’s being done at the administration level is contradicting some of the goals that they say that they have. 

Rovner: Yeah, and it’s important to remember that Columbia’s funding is being cut not because they deemed this particular project to be not helpful but because they are, as you said, angry at Columbia for not cracking down more on pro-Palestinian protesters after Oct. 7. 

Well, meanwhile, people are bracing for still more cuts. The Wall Street Journal is reporting the administration plans to cut domestic AIDS-HIV programming on top of the cuts to the international PEPFAR [President’s Emergency Plan for AIDS Relief] program that was hammered as part of the USAID cancellation. Is fighting AIDS and HIV just way too George W. Bush for this administration? 

Hellmann: It’s interesting because President [Donald] Trump unveiled the Ending the HIV Epidemic initiative in his first term, and the goal was to end the epidemic in the United States. And so if they were talking about reducing some of that funding, or I know there were reports that maybe they would move the funding from CDC [the Centers for Disease Control and Prevention] to HRSA [the Health Resources and Services Administration], it’s very unclear at this point. Then it raises questions about whether it would undermine that effort. And there’s already actions that the Trump administration has done to undermine the initiative, like the attacks on trans people. They’ve canceled grants to researchers studying HIV. They have done a whole host of things. They canceled funding to HIV services organizations because they have “trans” in their programming or on their websites. So it’s already caused a lot of anxiety in this community. And yeah, it’s just a total turnaround from the first administration. 

Rovner: I know the Whitman-Walker clinic here in Washington, which has long been one of the premier AIDS-HIV clinics, had just huge layoffs. This is already happening, and as you point out, this was something that President Trump in his first term vowed to end AIDS-HIV in the U.S. So this is not one would think how one would go about that. 

Well, it’s not just the administration that’s working to constrict rights and services. A group of 17 states, led by Texas, of course, are suing to have Biden-era regulations concerning discrimination against trans people struck down, except as part of that suit, the states are asking that the entirety of Section 504 of the Rehabilitation Act be declared unconstitutional. Now, you may never have heard of Section 504, but it is a very big deal. It was the forerunner of the Americans With Disabilities Act, and it prevents discrimination on the basis of disability in all federally funded activities. It is literally a lifeline for millions of disabled people that enables them to live in the community rather than in institutions. Are we looking at an actual attempt to roll back basically all civil rights as part of this war on “woke” and DEI [diversity, equity, and inclusion] and trans people? 

Hellmann: The story is interesting, because it seems like some of the attorneys general are saying, That’s not our intent. But if you look at the court filings, it definitely seems like it is. And yeah, like you said, this is something that would just have a tremendous impact. And Medicaid coverage of home- and community-based services is one of those things that states are constantly struggling to pay for. You’re just continuing to see more and more people need these services. Some states have waiting lists, so— 

Rovner: I think most states have waiting lists. 

Hellmann: Yeah. It’s something, you have to really question what the intent is here. Even if people are saying, This isn’t our intent, it’s pretty black-and-white on paper in the court records, so— 

Rovner: Yeah, just to be clear, this was a Biden administration regulation, updating the rules for Section 504, that included reference to trans people. But in the process of trying to get that struck down, the court filings do, as you say, call for the entirety of Section 504 to be declared unconstitutional. This is obviously one of those court cases that’s still before the district court, so it’s a long way to go. But the entire disability community, certainly it has their attention. 

Well, we haven’t had any big abortion news the past couple of weeks, but that is changing. In Texas, a midwife and her associate have become the first people arrested under the state’s 2022 abortion ban. The details of the case are still pretty fuzzy, but if convicted, the midwife who reportedly worked as an OB-GYN doctor in her native Peru and served a mostly Spanish-speaking clientele, could be sentenced to up to 20 years in prison. So, obviously, be watching that one. Meanwhile, here in Washington, Hilary Perkins, a career lawyer chosen by FDA commissioner nominee Marty Makary to serve as the agency’s general counsel, resigned less than two days into her new position after complaints from Missouri Sen. Josh Hawley that she defended the Biden administration’s position on the abortion pill mifepristone. 

Now, Hilary Perkins is no liberal trying to hide out in the bureaucracy. She’s a self-described pro-life Christian conservative hired in the first Trump administration, but she was apparently forced out for the high crime of doing her job as a career lawyer. Is this administration really going to try to evict anyone who ever supported a Biden position? Will that leave anybody left? 

Roubein: I think what’s notable is Sen. Josh Hawley here, who expressed concerns and I had heard expressed concerns to the White House, and the post on X from the FDA came an hour before the hearing. There were concerns that he was not going to make it out of committee and— 

Rovner: Before the Marty Makary hearing. 

Roubein: Yes, sorry, before the vote in the HELP [Health, Education, Labor and Pensions] Committee on Marty Makary. And Hawley said because of that, he would vote to support him. What was interesting is two Democrats actually ended up supporting him, so he could have passed without Hawley’s vote. But I think in general it poses a test for Marty Makary when he’s an FDA commissioner, and how and whether he’s going to get his people in and how he’ll respond to different pressure points in Congress and with HHS and with the White House. 

Rovner: And of course, Hawley’s not a disinterested bystander here, right? 

Karlin-Smith: So his wife was one of the key attorneys in the recent big Supreme Court case that was pushed down to the lower courts for a lack of standing, but she was trying to essentially get tighter controls on the abortion pill mifepristone. But it seems like almost maybe Hawley jumped too soon before doing all of his research or fully understanding the role of people at Justice. Because even before this whole controversy erupted, I had talked to people the day before about this and asked them, “Should we read into this, her being involved in this?” And everybody I talked to, including, I think, a lot of people that have different views than Perkins does on the case, that they were saying she was in a role as a career attorney. You do what your boss, what the administration, wants. 

If you really, really had a big moral problem with that, you can quit your job. But it’s perfectly normal for an attorney in that kind of position to defend a client’s interest and then have another client and maybe have to defend them wrongly. So it seems like if they had just maybe even picked up the phone and had a conversation with her, the whole crisis could have been averted. And she was on CNN yesterday trying to plead her case and, again, emphasize her positions because perhaps she’s worried about her future career prospects, I guess, over this debacle. 

Rovner: Yeah, now she’s going to be blackballed by both sides for having done her job, basically. Anyway, all right, well, one big Biden initiative that looks like it will continue is the Medicare Drug Price Negotiation program. And we think we know this because CMS announced last week that the makers of all of the 15 drugs selected for the second round of negotiations have agreed to, well, negotiate. Sarah, this is news, right? Because we were wondering whether this was really going to go forward. 

Karlin-Smith: Yeah, they’ve made some other signals since taking over that they were going to keep going with this, including last week at his confirmation hearing, Dr. Oz, for CMS, also indicated he seemed like he would uphold that law and they were looking for ways to lower drug costs. So I think what people are going to be watching for is whether they yield around the edges in terms of tweaks the industry wants to the law, or is there something about the prices they actually negotiate that signal they’re not really trying to get them as low as they can go? But this seems to be one populist issue for Trump that he wants to keep leaning into and keep the same consistency, I think, from his first administration, where he always took a pretty hard line on the drug industry and drug pricing. 

Rovner: And I know Ozempic is on that list of 15 drugs, but the administration hasn’t said yet. I assume that’s Ozempic for its original purpose in treating diabetes. This administration hasn’t said yet whether they’ll continue the Biden declaration that these drugs could be available for people for weight loss, right? 

Karlin-Smith: Correct. And I think that’s going to be more complicated because that’s so costly. So negotiating the price of drugs saves money. So yes, basically because Ozempic and Wegovy are the same drug, that price should be available regardless of the indication. But I’m more skeptical that they continue that policy, because of the cost and also just because, again, HHS Secretary Robert F. Kennedy seems to be particularly skeptical of the drugs, or at least using that as a first line of defense, widespread use, reliance on that. He tends to, in general, I think, support other ways of medical, I guess, treatment or health treatments before turning to pharmaceuticals. 

Rovner: Eating better and exercising. 

Karlin-Smith: Correct, right. So I think that’s going to be a hard sell for them because it’s just so costly. 

Rovner: We will see. All right, that is as much news as we have time for this week. Now, it is time for our extra-credit segment, that’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Jessie, you’ve done yours already this week. Rachel, why don’t you go next? 

Roubein: My extra credit, the headline is “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” In The Washington Post by my colleague Carolyn Y. Johnson. And I thought the story was particularly interesting because it really dove into the personal level. You hear about all these cuts from a high level, but you don’t always really know what it means and how it came about. So the backstory is the National Institutes of Health terminated dozens of research grants that focused on why some people are hesitant to accept vaccines. 

And Carolyn profiled one researcher, Nisha Acharya, but there was a twist, and the twist was she doesn’t actually study how to combat vaccine hesitancy or ways to increase vaccine uptake. Instead, she studies how well the shingles vaccine works to prevent the infection, with a focus on whether the shot also prevents the virus from affecting people’s eyes. But in the summary of her project, she had used the word “hesitancy” once and used the word “uptake” once. And so this highlights the sweeping approach to halting some of these vaccine hesitancy research grants. 

Rovner: Yeah that was like the DOD [Department of Defense] getting rid of the picture of the Enola Gay, the plane that dropped the atomic bomb, because it had the word “Gay” in it. This is the downside, I guess, of using AI for these sorts of things. Sarah. 

Karlin-Smith: I took a look at a KFF story by Arthur Allen, “Scientists Say NIH Officials Told Them to Scrub mRNA References on Grants,” and it’s about NIH officials urging people to remove any reference to mRNA vaccine technology from their grants. And the story indicates it’s not yet clear if that is going to translate to defunding of such research, but the implications are quite vast. I think most people probably remember the mRNA vaccine technology is really what helped many of us survive the covid pandemic and is credited with saving millions of lives, but the technology promise seems vast even beyond infectious diseases, and there’s a lot of hope for it in cancer. 

And so this has a lot of people worried. It’s not particularly surprising, I guess, because again, the anti-vaccine movement, which Kennedy has been a leader of, has been particularly skeptical of the mRNA technology. But it is problematic, I think, for research. And we spent a lot of time on this call talking about the decimation of the federal workforce that may happen here, and I think this story and some of the other things we talked about today also show how we may just decimate our entire scientific research infrastructure and workforce in the U.S. outside of just the federal government, because so much of it is funded by NIH, and the decisions they’re making are going to make it impossible for a lot of scientists to do their job. 

Rovner: Yeah, we’re also seeing scientists going to other countries, but that’s for another time. Well, my extra credit this week, probably along the same lines, also from The Washington Post. It’s part of a series called “Who Is Government?” This particular piece [“The Free-Living Bureaucrat”] is by bestselling author Michael Lewis, and it’s a sprawling — and I mean sprawling — story of how a mid-level FDA employee who wanted to help find new treatments for rare diseases ended up not only figuring out a cure for a child who was dying of a rare brain amoeba but managed to obtain the drug for the family in time to save her. It’s a really good piece, and it’s a really excellent series that tells the stories of mostly faceless bureaucrats who actually are working to try to make the country a better place. 

OK, that’s this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys these days? Sarah? 

Karlin-Smith: A little bit everywhere. X, Bluesky, LinkedIn — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Jessie. 

Hellmann: I’m @jessiehellmann on X and Bluesky, and I’m also on LinkedIn more these days. 

Rovner: Great. Rachel. 

Roubein: @rachelroubein at Bluesky, @rachel_roubein on X, and also on LinkedIn. 

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

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

As abortion and other reproductive issues gain more prominence in the looming election, some Republicans are trying to moderate their anti-abortion positions, particularly in states where access to the procedure remains politically popular. 

Meanwhile, open enrollment is underway for Medicare, even as some health plans are challenging in court the federal government’s decision to reduce their quality ratings — with millions of dollars at stake. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Sarah Karlin-Smith of the Pink Sheet, and Victoria Knight of Axios.

Panelists

Rachel Cohrs Zhang
Stat News

@rachelcohrs

Read Rachel's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Among the takeaways from this week’s episode:

• With polls showing more voters citing abortion as a top voting issue, some candidates with long track records opposing abortion rights are working to moderate their positions.
• Many older Americans will spend less on prescription drugs next year due to a new out-of-pocket pricing cap, among other changes in store as provisions of the 2022 Inflation Reduction Act take effect. But some are realizing the limits on those benefits, as deeper problems persist in drug pricing, insurance coverage, and access.
• The FDA is reconsidering a weight-loss drug decision that caused confusion for patients and compounding pharmacies. Compounded drugs are intended for individual issues, like needing a different dosage — and while the process can be used to augment mass manufacturing during times of drug shortages, it is not well suited to address access and pricing issues.
• In abortion news, a comprehensive study shows abortions have increased since the overturn of Roe v. Wade, even among women in states with strict restrictions — and those states are seeing higher infant mortality rates, according to separate research. And an effort is underway to revive in a Texas court the challenge to mifepristone’s FDA approval. The last challenge failed because the Supreme Court found the plaintiffs lacked standing.

Also this week, Rovner interviews Tricia Neuman, senior vice president of KFF and executive director of its Program on Medicare Policy, about Medicare open enrollment and the changes to the program for 2025. 

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

Julie Rovner: NBC News’ “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks.  

Sarah Karlin-Smith: Vanity Fair’s “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health,” by Katherine Eban. 

Rachel Cohrs Zhang: The Atlantic’s “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch.  

Victoria Knight: NPR’s “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year,” by Rosemary Westwood and Jack Jenkins.

Also mentioned on this week’s podcast:

• The New York Times’ “Abortions Have Increased, Even for Women in States With Rigid Bans, Study Says,” by Claire Cain Miller and Margot Sanger-Katz.
• CNN’s “Infants Died at Higher Rates After Abortion Bans in the US, Research Shows,” by Deidre McPhillips.

click to open the transcript

Transcript: Less Than Two Weeks To Go

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 24, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. 

Today we are joined via video conference by Rachel Cohrs Zhang of Stat News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: Victoria Knight of Axios. 

Victoria Knight: Hello, everyone. 

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

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Later in this episode we’ll have my interview with my friend and KFF colleague Tricia Neuman about Medicare open enrollment and what to expect in Medicare in the coming year. 

But first, this week’s news. We will start on the campaign trail since Election Day is now less than two weeks away. Let that sink in. Abortion is, at least according to many polls, on the upswing as a voting issue and, probably not coincidentally, abortion-adjacent issues, like contraception, are also getting more attention. But while it’s clear that Democrats are still pretty much the party of abortion rights and Republicans are pretty much the party representing anti-abortion activists, we’re seeing some Republican candidates working pretty hard to muddy the waters. Yes? 

Knight: Yeah, it’s been interesting this election cycle. We have seen some Republicans saying that they are pro-choice. And this is at a time when, finally, on the Democratic side in Congress, there really are not many anti-abortion Democrats left. We have in the House congressman Henry Cuellar [of Texas] is really the only one left. [Pennsylvania] Sen. Bob Casey, we’ve kind of seen him swing over time to be more in the camp of pro-choice, pro-abortion rights and so … 

Rovner: … which was really, in Casey’s case, really interesting, because his father, who was the governor of Pennsylvania, was sort of the original anti-abortion Democrat back in the early 1990s. 

Knight: Yeah. I’m interested to see if this works in — we’re seeing, particularly in some more moderate, swinging House seats, that Republicans are trying to message in this way that they’re more moderate on abortion, saying they’re more pro-choice. I’m interested to see if this actually works. And then we have perhaps this caucus within the House, if that works, that are more moderate. I mean, you already see in the current makeup of the House, there are some House Republicans, particularly the New York Republicans, that were really careful in this 118th Congress when they were having to vote on certain bills that would restrict, for example, access to mifepristone. That was kind of a rider in the FDA appropriations bill, and they didn’t want to vote for it, and they helped cause chaos on the House floor for that bill, particularly, because they didn’t want to pass it because they knew that would look bad on their record and they were having to run for the House again. So, will this messaging work for the kind of new people that are running this cycle? I’m not sure, but we’ll see. 

Rovner: I was kind of surprised to see Liz Cheney this week (who was out campaigning with Vice President [Kamala] Harris), who’s strongly anti-abortion, has been her entire career, actually pipe up on her own — and she’s not running for anything; she’s basically a person without a party at the moment — but say that even though she’s anti-abortion, she is not in favor of some of the things that are happening with some of these abortion bans, like women having miscarriages not being able to get immediate medical [care]. I was fascinated to see somebody who, with as strong anti-abortion credentials as she has, speak out about these things that one would assume even people who are anti-abortion would not be against. We do see the anti-abortion group saying making abortion illegal doesn’t make it illegal to treat ectopic pregnancies and miscarriage care, even though it gets all muddled when you’re actually on the ground doing it and you’re a doctor facing potential jail time. 

Knight: Well, and I think the thing is, people are seeing the realities of the abortion bans a couple of years in. I think that’s really the consequences. … When these first happened two years ago, people can say all these kind of things, but now that they’ve been in place for a couple years and women have died, we’re hearing these stories from news outlets of how that happens and it’s often women that want the babies. It’s like people are having to moderate their stances somewhat, I think. 

Rovner: It’s — there’s nuance. … Politics is not great with nuance, but we’re seeing nuance. 

Well, one abortion-adjacent story that jumped out at me this week is happening in Florida, where it seems that the office of Florida Gov. Ron DeSantis himself was behind legal threats to TV stations running ads in favor of the ballot measure that would enshrine abortion rights in the state’s constitution. According to the Tampa Bay Times, “Florida Department of Health general counsel John Wilson said he was given prewritten letters from one of DeSantis’ lawyers … Oct. 3 and told to send them under his own name, he wrote in a sworn affidavit.” Wilson subsequently resigned rather than send out more letters. In between, a judge warned the state to cease and desist with the threat, saying, and I quote, “It’s the First Amendment, stupid.” I have honestly never seen anything quite like this, although I would also point out I’ve never seen anything quite like Florida’s surgeon general recommending against people getting vaccines. What the heck is going on in Florida? 

Cohrs Zhang: I think we’ve seen state officials in Florida try to enact their will and challenge public health recommendations. Certainly, we saw that happen during the covid-19 pandemic. They were trying to put out their own guidelines on vaccination, and so I don’t think it’s a particular surprise. I think it is just uglier than usual now that we get the full backstory on how these letters came to be. And court cases take a long time, and I think that’ll extend to beyond the next couple of weeks. But it’s an interesting publicity stunt for what it is, and yeah I … 

Rovner: I wouldn’t want to be one of the TV stations threatening to have its license canceled, although the head of the FCC, I think, got involved too and said, “Um, this is not how this works.” 

Cohrs Zhang: Yeah, I think so. I don’t expect that the court would find that political ads you don’t like are illegal, so, yeah. 

Rovner: Yeah, I don’t think the governor can tell you to pull political ads that they don’t like. Pretty sure that’s not how these things work. 

Well, meanwhile, given the very real possibility that Donald Trump will return to the White House, the D.C. rumor mill is already spinning out names of those who could fill Cabinet and other senior health posts. What are you guys hearing? And is RFK Jr. really going to end up in some big health policymaking job? 

Knight: That’s funny that you say that because I was just having a talk with my editors about the names that we’re hearing. I have heard, and I am sure Rachel and Sarah have names on their mind as well, but someone said this to me, I think it’s funny: A very 2004 pick would be Bobby Jindal. He’s at the America First Policy Institute, which has a lot of former Trump administration people there, and it’s kind of seen this swing, I think recently, now that Project 2025 is kind of like no one wants to touch Project 2025 anymore. It seems like more people are, like, OK, AFPI is the place to pick people from if there’s a new Trump administration. And there’s been some stories this week about the chief of staff potentially coming from AFPI. So, people have been telling me Bobby Jindal, but I think he seems to have some solid grounding in that. You probably are more familiar with him, Julie, than I am, but … 

Rovner: Oh, yes. I’ve known him since 2004. I’ve known him since before 2004. He was actually … he was brought to Washington by Democratic Sen. John Breaux to staff a Medicare commission back in, I think it was the very late 1990s. He served in Congress, he was the governor of Louisiana, and he served in HHS [the Department of Health and Human Services] in the George W. Bush administration. So he’s got lots of experience, and he’s coincidentally all over Twitter this week with a paid ad, trashing Kamala Harris’ support for “Medicare for All,” which, of course, she hasn’t supported since 2019. But yeah, suddenly Bobby Jindal, who we hadn’t seen in a while, is kind of everywhere. He was one of the bright young lights about, what, eight years ago? 

Knight: Right, right. 

Rovner: But I guess before Trump, he was one of the bright young Republican lights. So yeah, I keep hearing his name too. 

Cohrs Zhang: I don’t know … 

Rovner: Go ahead, Rachel. 

Cohrs Zhang: I was just going to say that I don’t think there are a lot of people that we’ve been talking to who are worried about RFK himself getting appointed to one of these posts, but I think there has been a lot of buzz about some of his allies, like Calley and Casey Means. I know my colleague Isa Cueto did a great — just, profile of kind of who they are and kind of how their rise has just been so meteoric, and I think we’re also seeing some allies. So people who rose in the conservative movement over skepticism, over vaccine mandates, and just like the whole public health establishment have really gotten a new platform. And so I think people are a little nervous, as we’ve reported, both health care industry leaders who are worried about anti-pharmaceutical industry sentiment, anti-science sentiment, and even establishment Republican leaders and officials who served in prior Trump administrations that the picks could be more extreme than a Bobby Jindal establishment-Republican type and that this could be taking a turn. 

Rovner: Sarah, what are you hearing with FDA? 

Karlin-Smith: I mean, it’s a little less clear, I think, who might end up in FDA, but the sentiment has been probably a more typical Trump pick than maybe we got last time. FDA was sort of insulated in some ways, I think, from some of the drama, if you will, of the Trump administration last time. Scott Gottlieb was able to run FDA with pretty hands-off from other parts of the administration, and I think he ran FDA more like you would expect a traditional Republican to run FDA, not necessarily a Trump Republican. And I think people are recognizing that FDA will be a lot more vulnerable this time around that we’re probably not going to get another kind of Scott Gottlieb to save FDA if Trump is president. There’s certainly more concerns about how that impacts staff turnover as well, among civil service folks. 

Rovner: Yeah, we will see. 

All right, well, moving on. Open enrollment for Medicare began last week and continues until Dec. 7. That’s when people on Medicare can join or change their private prescription drug and/or Medicare Advantage plans. We explore this in more detail in my interview later in this episode with KFF’s Tricia Neuman. We know that most people with Medicare and most people with private insurance, where they can change plans during an open enrollment season, don’t actually bother to do anything. But this year there really are a lot of changes coming in Medicare, particularly on the prescription drug side. Why is it extra important this year that people take a look at their coverage? 

Karlin-Smith: So, some of the big changes with the IRA [Inflation Reduction Act] that kick in this year for Medicare and the prescription side, like the $2,000 out-of-pocket cap. Your plan actually has to cover that. One thing, I was at a conference this week and they’re saying that drug has to be, actually be on your plan for you to reap those savings of hitting that cap, which seems obvious, but … 

Rovner: Oh, I don’t know. I think people don’t quite realize that. It’s like they think that there’s a $2,000 cap no matter what, and it’s important. It’s, like, if your drug is not one of the drugs that’s covered by your plan, does not count. 

Karlin-Smith: Right, and so it’s looking for all of those things to make sure all the pieces of your plan actually fit together with your medical needs. There’s been, I think, a reduction, in some degree, into the amount of particularly Part D stand-alone plans for people who elect to use traditional Medicare for their other health benefits. So you may just want to look a little bit more closely at what the options are, what the premiums are, because some of these changes to Part D have impacted premiums a bit, though the federal government has stepped in to try to alleviate that. 

But I think this is seen as an adjustment year for the plans because one of the ideas behind the IRA is to put both health insurance companies as well as the pharmaceutical companies more on the hook, in some ways, for the cost of drugs. The old way Part D plans worked, the government ended up bearing a lot of the costs of the drugs to a point where it didn’t give a lot of incentives for both the drug companies to want to lower the prices, for the insurance companies to push for that. So I think it may take a little bit of time for them to figure out now how to adjust the benefits and the premiums and so forth, given this new dynamic. So people just may want to pay a little bit more close attention for premium aspects and others as well to the plans they’re picking. 

Rovner: And if you’re helping someone on Medicare, which I know many people are, it’s good to do a little extra homework this year. 

Well, another story that caught my eye is a survey of independent drugstores that suggests many of them won’t stock the very expensive drugs that Medicare negotiations are making less expensive, because they would actually lose money dispensing them. Sarah, is this an unexpected glitch, and can it be fixed, or is this just the price of bringing down drug prices? 

Karlin-Smith: I would say not entirely unexpected. These independent pharmacies have warned CMS [the Centers for Medicare & Medicaid Services] and tried to push in guidance so that when they’re dispensing a drug, basically, they will be entitled to get quicker rebates from the drug companies so that they can make stocking these drugs more reasonable for them. And these pharmacies, I think in particular, have been raising alarm bells outside of Medicare drug price negotiations for a while now, that they’re being placed in these difficult positions where they have to buy drugs at whatever the wholesale acquisition cost is. And then there’s all of this insurance back-end stuff going on, and they sometimes get reimbursed by the plans and so forth for less than they’ve actually bought the drugs. 

So it’s not just a Medicare drug price negotiation issue here. Some of it is, again, about the time that the pharmaceutical companies have to rebate the costs and they ask Medicare for a bit of leeway. And others, it’s just this broader way our system works, where they’re buying wholesale. You have a patient come to the counter that pays their small portion of it, their plan pays, whatever, and everybody has to sort of, right at the end … and these pharmacies are saying, “We can’t afford to do that.” I do think, politically, if this becomes a problem, if patients can’t get the negotiated prices/drugs at the pharmacies they’re used to, this could be politically problematic for the IRA moving forward. Even though, again, I’m not entirely sure. It’s illuminating a broader problem in the system that I think existed without it. 

Rovner: Right, it’s all a big mess, and it’s underlining it. 

Karlin-Smith: Right, but that doesn’t mean that politics won’t come into play and blame drug price negotiation. And certainly, anytime an opposing party hates something — we know Democrats are really into this, Republicans aren’t, and I’m sure they will try and blame it on the IRA as much as possible. And we’ll see if CMS maybe realizes that they had a little more leverage to try and make this a little bit easier and fixes it for the next round. 

Rovner: Yeah. Before we leave Medicare, I want to talk briefly about Medicare Advantage. This Medicare Advantage market is so valuable to insurers and so competitive that we now have at least two lawsuits charging that Medicare wrongly lowered the number of quality stars some plans received. Now, this feels like a restaurant suing Yelp for lowering its rating from four stars to three, but in Medicare Advantage, this is a really big deal, right, when they lose a star? 

Cohrs Zhang: Right, I think if the Yelp rating was worth $70 million, or whatever that figure is, then yeah, maybe they would sue. So I think we certainly — I think it’s a measure that is so important to insurers, to regulators, but that individual people might not understand. And there were some really interesting details from that lawsuit about the potential that there was one call-center call that tipped the balance into a quality measure and that there might’ve been some technical difficulties, and it does just cast these larger questions that I think I’ll be interested to see what documents come out during these lawsuits. And just questioning how useful these metrics really are, if that really was the case. 

Rovner: Yeah, I found it, I also was taken aback. It’s like, really, one call to a customer service center didn’t happen properly, and so the whole plan loses a star? That seemed a little bit dramatic, but yes, like you, I’ll be interested to see. There’s a lot of pressure on Medicare Advantage from every conceivable angle, but we are now in litigation over it. 

Well, while we are on the subject of private health companies suing the federal government, the compounding pharmacies who have been legally selling unapproved copies of the very popular and very expensive diabetes/obesity drugs Mounjaro and Zepbound have apparently successfully gotten the FDA to reverse its earlier finding, based on the pharmaceutical manufacturers’ say-so, that those drugs are no longer in shortage. That’s a decision that would’ve made it illegal for the compounders to continue to make and sell those drugs. At the same time, Novo Nordisk, maker of the very popular and very expensive diabetes/obesity drugs Ozempic and Wegovy, are trying to get the FDA to stop compounders from copying their drugs, which are still in shortage. Can somebody please explain what’s going on here? 

Karlin-Smith: So, basically, compounding is where pharmacists can sometimes make drugs in a more customized fashion because a person maybe can’t swallow a pill or needs a slightly different dose or a different inactive ingredient, but there’s not … 

Rovner: And they add flavoring for kids too, right? 

Karlin-Smith: Right. 

Rovner: Isn’t that a big compounding thing? 

Karlin-Smith: But it’s not supposed to be something that takes the place of mass-manufactured drugs. But one of the times when it kind of can — and FDA, after some big safety incidents in 2013, developed a sort of scheme where there can be some degree mass compounding, but there’s a little bit more safety oversight from their end. 

And one of the cases where you can do more compounding is when a drug is in shortage. But once FDA flipped the switch and said, “Oh, OK, actually, these drugs are no longer in shortage,” that makes it illegal. So these companies sued. My understanding from talking to legal experts is it’s not necessarily clear that FDA is entirely reversing course and agreeing that drugs aren’t in shortage. They’re agreeing to re-look at their decision, which may mean they are going to bolster their case so when they get back into court, they have a much clearer documentation of why the drugs are actually out of shortage. But in the meantime, we have probably at least another four weeks or so where everybody can compound these products. 

At the same time, I think Novo Nordisk and, actually, Eli Lilly before them had also submitted a similar citizen petition to FDA trying to basically get these drugs from being on lists where you really could not compound them at all. And there’s clearly a lot of money at stake here. These are probably some of the most well-known drugs right now with huge markets in the U.S., but they’re also really expensive and they haven’t been picked up and covered by a lot of insurance plans, particularly when you’re talking about the weight loss element. I think for Type 2 diabetes, there’s pretty good coverage. And the thing here that’s really so significant is this is probably one of the first times in the U.S. where we’ve seen this mass-market compounding for a drug kind of at the beginning-ish of its exclusivity, at least when you’re talking about weight loss — again, not diabetes. And it’s not like a niche thing. So many people are using it,  through compounding. And again, it’s really like … 

Rovner: The advertising is everywhere on social media. 

Karlin-Smith: Right, I mean, that just surprised me, I think, at first to begin with, how open these companies were about it being available via compounding pharmacies. And so I think FDA is in a really tricky position, particularly if they can clearly document it’s not a shortage situation anymore, because there still probably is going to be a lot of demand because of the cheaper prices coming from compounders, because of health insurance coverage issues. But, again, the compounding system is not meant to address those sorts of price and access issues. Right? It’s supposed to be for very particular situations where people really can’t use the exact manufactured drug, in most cases. And so maybe this tension will force us to address the other issues of price and insurance coverage, but it’s an awkward position for FDA to be in. 

And again, because, I think, it’s just also important just to go backtrack and remember, you know, FDA facilitates an important role of inspecting the manufacturing facilities, ensuring every lot is being manufactured to a consistent quality, approving the drug to begin with. So there’s certainly this delicate dance of you want people to be able to get drugs they need and you also don’t want this kerfuffle to undermine the entire drug-approval system we have that ensures that when you get a drug, a prescription drug, you know it’s a certain quality. 

Rovner: And it is what it says it is. 

Karlin-Smith: Right. 

Rovner: Yes. All right, well, turning back to abortion. A new study out this week suggests that not only has the number of abortions not gone down since the Supreme Court overturned Roe v. Wade, it actually might’ve gone up. Now there are lots of caveats with these numbers and, clearly, one big reason is the loosening of restrictions on obtaining abortion medication by mail. We also have a separate study this week that found infant mortality in states with abortion bans are rising, perhaps due to less available medical care in some of those states, as well as more fetuses with deadly anomalies being carried to term. But I have to wonder what these numbers will prompt from the anti-abortion side. Are they going to double down on efforts to impose some sort of nationwide restrictions or bans if Republicans regain control of the White House and Congress? And how are they going to address the rising infant mortality numbers? Victoria, are you hearing anything from the anti-abortion side? I’ve heard kind of not a lot. I’ve been surprised at how much I have not heard. 

Knight: Yeah, I mean I think this has been an interesting election for them because I think Trump has said different things throughout this election cycle on his stance on abortion and being — taking credit for appointing the Supreme Court justices who overturned Roe, but then at the same time being, like, it’s a states issue. And I’ve seen some reporting on that a lot of these groups are frustrated with Trump, but they kind of are sticking with him for the moment because they’re, like, this is the guy we have. 

So I think that perhaps they will put more pressure, depending on what the makeup of Congress is, and I think it’s important to remember it really depends on the majorities, this upcoming Congress, what will that look like? So if there is a Republican sweep, how many senators will be there? How many Republican senators? Also in the House, it may not be a huge majority either. And as we talked about earlier in this episode, there are some Republicans that are trying to walk the line more and be more moderate on abortion. And will they want to vote for a national abortion ban? That seems doubtful to me. And, for now, the filibuster is still in place in the Senate, so you still need 60 votes to pass anything. So, I think that they’re being quiet for now, but I think, depending on what Congress looks like, they could up their ante later. 

Cohrs Zhang: Again, I think Congress just has no appetite really to talk about these things, and I don’t expect that to change, especially, like you said, with narrow majorities. And I just think that the cost-benefit, maybe we’re going to see new leadership in the Senate Republican party too, and I think a lot of that could shape how much appetite they have to pick a fight on this. So yeah, just a lot of unknowns at this point. 

Rovner: And, as we’ve discussed before, if Trump is elected, he can do a lot from the executive branch that wouldn’t require Congress, and I completely agree with Rachel: I think Congress does not have a whole lot of appetite for this. 

Knight: Right. 

Rovner: Possibly on either side. 

Knight: And I think one more thing also interesting to point out is that the current House speaker, Mike Johnson, is very anti-abortion. Throughout his congressional career and even his career as a state lawmaker, he’s always been very anti-abortion, but he’s been in power now over a year, at least a year, and he has done, really, nothing on this. And he has a slim majority, but also I think you see that, yeah, as Rachel said, there’s just not an appetite for it, so … 

Rovner: He doesn’t have the votes. 

Knight: Yeah, exactly. He doesn’t have the votes, but he’s staunchly anti-abortion, has done really nothing, so. 

Rovner: Well, Sarah, you have a story on the revived lawsuit challenging the FDA over its rules for the abortion pill mifepristone. This is my chance to say I told you so, when the Supreme Court ruled that the original plaintiffs in this case did not have standing to sue. We said at the time: not over. Not over, right? 

Karlin-Smith: Yeah, three states are trying to revive that case in the court in Texas, where it originated. And it’s not particularly a surprise, like you said, the Supreme Court didn’t totally throw out the case. They said, “You guys don’t have standing,” that the doctors’ group that filed suit there. One of the interesting things now, given the timing, is as this case moves forward and if Trump wins the election, it’s not really clear to me whether his FDA and his Justice Department and so forth would actually want to defend this case or whether they would just, again, use the powers they have and push FDA to go back to the older restrictions around mifepristone’s availability. And basically make it … 

Rovner: We’re no longer talking about pulling it from the market right now? We’re just talking about the changes that were made in 2016 that makes it more easily available? 

Karlin-Smith: Right, so they sort of … 

Rovner: Is that a fair way to put it? 

Karlin-Smith: That’s like one change, which by the time we got to the Supreme Court, we were largely arguing about this as well, but they had initially started to just — by trying to get it off the market entirely. But now we’re basically arguing about changes that have made it easier to take later in pregnancy, so up to 10 weeks, and just made it easier to access. So you can now get it via telehealth and via mail and so forth, which has been really important given some of the state-specific bans on abortion. And it’s why abortion pills have become a really much more popular method for abortion. So a lot of legal experts don’t actually think these three states have standing either, or have jurisdiction, certainly in this court. However, I think they also acknowledge there’s a good chance this case proceeds and proceeds very similarly to how it did before, if for no other reason than the judges involved in the past have been willing to let these states be heard in their courtroom. 

Rovner: Yeah, it is in the 5th Circuit land of mostly Republican anti-abortion judges. 

Karlin-Smith: Right. So there’s a good chance, again, barring this sort of scenario where Trump administration comes in and just says, “We’re not going to defend this. We’re going to revert to the old restrictions anyway.” But under a Democratic administration, they could end up back all the way at the Supreme Court having to defend mifepristone’s newer availability as well. 

And the other thing that there’s been a number of mifepristone cases around the country, but there’s one that’s very similar in the 9th Circuit, where judges have basically ruled that the entire, what’s known as a REMS [risk evaluation and mitigation strategy], these restrictions related to mifepristone should actually be removed altogether. And they, actually, in some ways, want to make it more easily accessible. So whenever you have a circuits … but you also know that the Supreme Court is likely to take things up against. So yeah, I think the big thing is if people thought that last June’s Supreme Court ruling was kind of like Eh, it’s over, mifepristone is here to stay, that was just sort of the first round of many fights in access and availability of that in the courts. 

Rovner: Could a Trump administration just say, “The FDA should never have approved this drug,” and pull it from the market? Or does somebody have to file a petition for that to happen? 

Karlin-Smith: Ooh, that’s a good, tough question. I mean, there are very formal processes that go around withdrawing a drug. I think it would be challenging because at least the generic companies that manufacture the drug still want to be manufacturing it at this point. And I would imagine there would be quite a process FDA would have to go through, particularly to try and declare it no longer safe and effective to be marketed. And you, again, to raise strange history, I think if you looked at all the documents in science, because you have FDA scientists who over the years have declared it’s safe and effective and said, “Actually, as we’ve got more use with this, we realize you can actually give it to more women at different parts of pregnancy, and it’s safer than we thought. We don’t need to monitor a woman at a doctor’s office while she takes it.” So I think it would be challenging. I certainly wouldn’t put it past them trying this. 

But it does get to, I think, what’s been worrying about this mifepristone case to begin with for just people outside of the abortion space, but who follow FDA and the drug industry, which is this lack of certainty you start to lose when politicians come in and start trying to undermine the scientific drug-approval process and using politics instead, and their whims, to shift what is available or not available, because, obviously, it undermines FDA’s authority. 

And for the drug industry, I mean, a big thing they dislike is certainty, right? You’re investing millions, maybe even billions, of dollars to bring a drug to market. You want some confidence that if it’s successful and FDA says yes, it’s going to stay there unless some new, real, true safety event happens, which it does occasionally happen, but for the most part, you don’t want a new president to come into office or a new member of the Congress to flip and all of a sudden you have a drug that they’ve decided to challenge. So it’s an abortion case that’s always had these broader undertones of just confidence and trust and certainty around our scientific agencies in the U.S. 

Rovner: Yet another space we will continue to watch. All right, that is this week’s news. Now we’ll play my interview with KFF’s Tricia Neuman, and then we’ll come back and do our extra credits. 

I am so pleased to welcome to the podcast Tricia Newman, who’s KFF’s senior vice president and executive director of KFF’s Program on Medicare Policy, and senior adviser to the president, and the person I always turn to first when I have a question about Medicare and have done so for more than three decades. Tricia, welcome back to “What the Health?” 

Tricia Neuman: Hi, Julie. Thanks for having me back. 

Rovner: So, as anybody who watches over-the-air or cable TV knows, it’s Medicare open enrollment right now until Dec. 7. What should people in Medicare or people helping people in Medicare know about changes coming for 2025? 

Neuman: This is the time for people to really compare coverage options. What we’ve seen in our own research is that most people don’t compare options during the open enrollment period, but plans change, people’s needs change, and this is a great moment. People have between now until Dec. 7, as you said. The important thing to do is figure out what is actually most important to either yourself or the person you’re helping. 

Some people really need certain drugs covered by their plan, and so that might be the go-to question. Other people care very much about being able to see certain doctors or hospitals. So, for them, it’s a question of do they want to be in traditional Medicare, where they can see virtually any doctor and go to any hospital? Or if they want to be in a Medicare Advantage plan for a variety of reasons, the question is, are the doctors that they care most about covered by their plan? 

Rovner: There are big changes coming next year both for prescription drugs and for Medicare Advantage, right? 

Neuman: Absolutely. I mean, Medicare Advantage plans also cover prescription drugs, and what the big thing people need to know there is there’s a new out-of-pocket limit that’s coming. There’s not really much you have to do in order to get; it’s a Medicare benefit. So that’s really a huge change and it really is a change that helps people who take very expensive medications. I mean, I can tell you how helpful it would be to some family members of mine. I have a family member who is taking a drug, she had a Part D plan, and it was costing her $13,000 a year for this particular drug for her cancer treatment. With the new $2,000 out-of-pocket cap, her costs would drop from $13,000 to $2,000. Keep in mind that half of all people on Medicare live on an income of $36,000 or less, so this is a big deal. And not everybody is going to need this benefit in any given year, but over time, you never know. And so it’s a big change that will be helpful to people who take expensive medications. 

Rovner: Over the spring and summer, it looked like, because of this $2,000 cap, Part D plans were going to raise their premiums dramatically. That mostly didn’t happen. Why not? 

Neuman: The administration, the government put in place what they call a demonstration or a model, and essentially what it did is it limited premium increases. So no Part D plan will have a premium increase greater than $35 between 2024 and 2025. 

Rovner: … of $35 a month. 

Neuman: … of $35-a-month increase. Now that said, some will increase by $35, some will decrease. There are going to be changes, and that’s an important thing for people to keep an eye on as they consider their drug coverage for next year. 

Rovner: There are Republicans in Congress who say that what the administration did was sort of unfairly politically tinkering with Medicare, but this isn’t the first time this kind of thing has been put into place, right? 

Neuman: That’s absolutely true. I mean, I would agree that there was some concern that people in Medicare would see big increases in their drug premiums, and that was part of the concern that motivated the administration. But that was also a concern that motivated prior administrations. In fact, right after the drug benefit went into effect, and that was under the Bush administration, there were similar demonstrations that took effect. And at the time, nobody really complained because the main issue was protecting people from higher premiums. 

Rovner: But now everything is more political. 

Well, regular listeners to the podcast know that Medicare Advantage has become not just more popular among beneficiaries, but also much more controversial. Some companies are even using artificial intelligence to deny benefits and micromanaging doctors and other health care providers. Has the cost-benefit analysis for Medicare Advantage shifted over the past few years? 

Neuman: I think the focus on Medicare Advantage has changed. The way people are thinking about it is changing. Medicare Advantage is quite popular among people because plans, for a variety of reasons related to their payments, are able to offer extra benefits, and they are appealing. I mean, dental, vision, hearing. Now, the latest thing is “flex cards,” which is just kind of offering money for people to sign up for a plan. So it’s really appealing, particularly for people with fixed incomes. But the medical community has sort of surfaced and started raising concerns about what these prior authorizations and other cost-management tools mean for them and for their patients. 

So hospitals, for example, have expressed concerns about delayed payments. Doctors are now talking about prior authorization hassles. We recently did a study that documented 46 million prior-authorization requests, close to 2 million requests per enrollee. That’s a hassle for doctors. It also can delay or lead to no care for beneficiaries when it’s been prescribed by their doctor. It could, of course, limit inappropriate care, not necessary care, but I think the medical community now sees that Medicare Advantage is a big part of their patient profile and has some concerns. 

We’ve also been reading stories about some medical groups that are saying that we’re not going to take any more Medicare Advantage patients. So I think there’s a little bit more of an eye toward, gee, this has gotten really big. We know it’s really popular, but it might require a closer look. 

Rovner: Speaking of which, I mean, Medicare hasn’t really been a big campaign issue in 2024 when maybe it should have been. It doesn’t seem that safe to leave a program of its size and importance on autopilot, which is kind of what former President Trump is promising. What do we know about what Vice President Harris would do for Medicare if she were elected and what former President Trump would do if he was elected? 

Neuman: We actually know very little about what former President Trump would do. 

Rovner: He says he wouldn’t touch it. 

Neuman: He said he wouldn’t touch it. He said he’s concerned about drug costs, but we’re not really sure what more he would do there. He was for a proposal called Most Favored Nation, but he’s now withdrawn support for that. So it’s hard to know whether he would implement anything new or scale back what has already become the law of the land. For example, it’s not clear what he would do about government negotiations and whether or not there would be sufficient pressure in his caucus to scale back that pretty popular proposal that was included in the Inflation Reduction Act. 

Vice President Harris has talked about strengthening Medicare and improving the solvency, mostly through revenues on higher-income people. So that is one major proposal she has with regard to solvency. She has recently put out a proposal that would add a home care benefit to Medicare. This responds to a huge issue that you and I have talked about, that a lot of families across the country have talked about where people are really struggling to care for a family member. Family members are dropping out of the workforce in order to care for somebody because they cannot afford to get help at home. Medicare really does not currently provide a home care benefit except under limited circumstances. So this is recognizing a huge issue for families that are, it’s an economic issue if people, mostly women, have to step out of the workforce. It’s also an issue if you just cannot afford or you’re paying huge amounts for people to come into your home to help a parent, grandparent, spouse who’s unable to care for themselves. So that’s a big initiative on her part that would be funded primarily out of expanding Medicare’s ability to negotiate drugs. 

Rovner: So neither candidate is talking about solvency issues with Medicare, though, and that’s a long-term issue that somebody’s going to need to address, right? 

Neuman: Yes, that is absolutely true. It is an issue that is not going away. We have more and more people aging onto Medicare and the people who are on Medicare are getting older. And as people grow older, they tend to be more expensive. So this is not an imminent concern, but it is an issue that policymakers will have to deal with one way or the other in the years to come. 

Rovner: Well, we will keep talking about it. Tricia Neuman, thank you so much. 

Neuman: And thank you for having me, Julie. 

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it; we will put the links in our show notes, on your phone or other mobile device. Victoria, why don’t you go first this week? 

Knight: Sure. My extra credit is a story on NPR, it’s called “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year.” It was on Weekend Edition, and it is by Rosemary Westwood and Jack Jenkins, basically detailing that in the past, the Catholic Church and bishops have been really big in the anti-abortion movement and that has also translated to donating a lot of money to anti-abortion campaigns. But this year, they’re kind of seeing almost a historic low in how little they’re donating to anti-abortion campaigns. And they didn’t really have a clear answer of what the reason for that was, except that maybe they’re just acknowledging the reality of the situation. When you look at particularly the ballot measures in states and how popular those have been — we’ve seen since 2022 that the ballot measures, even in more conservative-leaning states, that protect abortion access, and those vary depending on the state, what they look like, they’ve been really, really popular. And they really have been really overwhelmingly approved, even if there’s Republicans running on the same ballot with them and that people are voting for. People still really support abortion rights mostly. 

So that seems to be the reason — they didn’t really have a clear reason, but it was an interesting marker in the trend of just kind of following where abortion rights are going, as well as where the Catholic Church is moving as well. It seems to be becoming somewhat more progressive over time. 

Rovner: I was fascinated by this story, which I just heard on the radio as I was driving, because the Catholic Church is the originator of the right-to-life movement in the United States. And for a long time, it was almost exclusively the Catholic Church that was pushing this, and now it seems to have moved sort of into other places. So this is sort of the exclamation point on that, that it’s broadened and changed, but it’s no longer being driven as much by the Catholic Church as it used to be. Rachel, why don’t you go next? 

Cohrs Zhang: Sure. So my piece is in The Atlantic, and the headline is “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch. And I just love this story because it’s a look back on this policy that seemed like a good idea at the time, where these really wealthy benefactors are donating to elite, often elite medical schools to make tuition free. And the whole idea was that more doctors will go into primary care if they don’t have debt, and it might open medical school to a more diverse cohort of students. And the opposite has almost happened, where they’re not seeing any more doctors going into primary care and their student body has actually gotten more wealthy than it was before. So I mean, it’s just a great check-in, because I feel like so often we’re just looking forward with the news that we don’t take a moment to question whether some of these policies or stories that we’ve covered, how they’ve worked out a couple of years later. So, I thought it was a great look back. 

Rovner: Yes, in health care, so many things go in, we try things with so much promise, and sometimes they don’t work. So it’s good to notice when they don’t work. Sarah? 

Karlin-Smith: I took a look at a Vanity Fair piece by Katherine Eban: “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health.” And it’s a fascinating deep dive to the challenges the U.S. has faced in containing what is, right now at least, mostly just an epidemic in animals, but certainly has public health folks worried about the potential for a human spillover pandemic, if not properly contained. And it’s just a really great story that shows you all of the tensions, and how it has a lot of these flashbacks to early days of covid, where you had different parts of the government with different responsibilities, not quite working together well, and not quite knowing how to play together well. Because you have the USDA in this case, which in many ways has the economics of farmers and the dairy industry in mind more than perhaps broader health concerns. You have FDA, which regulates milk; CDC, which comes in and does the human health; and then you have states, which don’t necessarily always have to answer to everything the federal government would like them to be doing here. 

And the biggest, I think, crisis we face now is just we don’t have a lot of data. We don’t have enough information to truly know the scope of this outbreak. And without knowing that, I think you risk something bad happening before we are on top of it. And that’s really what people are really concerned about now, particularly with seasonal flu season coming up, is if you mix this virus and a human being with seasonal flu or even in an animal, you could develop an even more dangerous virus. So, it’s a warning to everybody in the public health space that this is something we need to be paying attention to because, obviously, the best thing to do is contain it and tamp it out and not have to deal with a much larger human pandemic. 

Rovner: Yes, that would be nice. Something else to keep us awake at night. 

My story this week is from NBC News, it’s called “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks. She got a hold of the intake forms of a pregnancy center in Idaho, which included not just the typical medical questions, but also questions about religious and financial status. And one asking, “What decision would the father like you to make, regarding the outcome of your pregnancy?” The answers, which are not protected by HIPAA, because crisis pregnancy centers are not technically medical providers, allow the staff to score whether a patient is “abortion-vulnerable,” which would lead them to try to talk her out of ending the pregnancy. 

It also includes a story of one patient who was strung along so long waiting for test results from this crisis pregnancy center that she ended up needing a second-trimester abortion. It’s quite the look at what goes on behind the scenes at some of these centers, and I strongly recommend it. 

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

Karlin-Smith: A little bit on X, a little bit on Bluesky, at @SarahKarlin or @sarahkarlin-smith. 

Rovner: Rachel? 

Cohrs Zhang: I’m on X @rachelcohrs and also spending some time on LinkedIn, so feel free to follow me there. 

Rovner: Great. Victoria? 

Knight: I am @victoriaregisk still on X. I am trying to post more on LinkedIn, too. 

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

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

As part of a media blitz aimed at women voters, Vice President Kamala Harris this week rolled out a plan for Medicare to provide in-home long-term care services. It’s popular, particularly for families struggling to care for both young children and older relatives, but its enormous expense has prevented similar plans from being implemented for decades.

Meanwhile, President Joe Biden called out former President Donald Trump by name for having “led the onslaught of lies” about the federal efforts to help people affected by hurricanes Helene and Milton. Even some Republican officials say the misinformation about hurricane relief efforts is threatening public health.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's stories.

Shefali Luthra
The 19th

@shefalil

Read Shefali's stories.

Among the takeaways from this week’s episode:

• Vice President Kamala Harris’ plan to expand Medicare to cover more long-term care is popular but not new, and in the past has proved prohibitively expensive.
• Former President Donald Trump has abandoned support for a drug price policy he pursued during his first term. The idea, which would lower drug prices in the U.S. to their levels in other industrialized countries, is vehemently opposed by the drug industry, raising the question of whether Trump is softening his hard line on the issue.
• Abortion continues to be the biggest health policy issue of 2024, as Republican candidates — in what seems to be a replay of 2022 — try to distance themselves from their support of abortion bans and other limits. Voters continue to favor reproductive rights, which creates a brand problem for the GOP. Trump’s going back and forth on his abortion positions is an exception to the tack other candidates have taken.
• The Supreme Court returned from its summer break and immediately declined to hear two abortion-related cases. One case pits Texas’ near-total abortion ban against a federal law that requires emergency abortions to be performed in certain cases. The other challenges a ruling earlier this year from the Alabama Supreme Court finding that embryos frozen for in vitro fertilization have the same legal rights as born humans.
• The 2024 KFF annual employer health benefits survey, released this week, showed a roughly 7% increase in premiums, with average family premiums now topping $25,000 per year. And that’s with most employers not covering two popular but expensive medical interventions: GLP-1 drugs for weight loss and IVF.

Also this week, excerpts from a KFF lunch with “Shark Tank” panelist and generic drug discounter Mark Cuban, who has been consulting with the Harris campaign about health care issues.

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

Julie Rovner: KFF Health News’ “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly.

Shefali Luthra: The 19th’s “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” by Mel Leonor Barclay.

Jessie Hellmann: The Assembly’s “Helene Left Some NC Elder-Care Homes Without Power,” by Carli Brosseau.

Joanne Kenen: The New York Times’ “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It,” by Kate Morgan.

Also mentioned on this week’s podcast:

• The New York Times’ “Biden Accuses Trump of ‘Outright Lies’ About Hurricane Response,” by Michael D. Shear.
• The Miami Herald’s “Florida Threatens To Prosecute TV Stations Over Abortion Ad. FCC Head Calls It ‘Dangerous,’” by Claire Healy and Ana Ceballos.
• KFF’s “2024 Employer Health Benefits Survey.”

Click to open the Transcript

Transcript: Yet Another Promise for Long-Term Care Coverage

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

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

Today we are joined via teleconference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Jesse Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

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

Joanne Kenen: Hi everybody. 

Rovner: Later in this episode, we’ll have some excerpts from the Newsmaker lunch we had here at KFF this week with Mark Cuban — “Shark Tank” star, part-owner of the Dallas Mavericks NBA team, and, for the purposes of our discussion, co-founder of the industry-disrupting pharmaceutical company Cost Plus Drugs. But first, this week’s news. 

We’re going to start this week with Vice President [Kamala] Harris, who’s been making the media rounds on women-focused podcasts and TV shows like “The View.” To go along with that, she’s released a proposal to expand Medicare to include home-based long-term care, to be paid for in part by expanding the number of drugs whose price Medicare can negotiate. Sounds simple and really popular. Why has no one else ever proposed something like that? she asks, knowing full well the answer. Joanne, tell us! 

Kenen: As the one full-fledged member of the sandwich generation here, who has lived the experience of being a family caregiver while raising children and working full time, long-term care is the unfulfillable, extremely expensive, but incredibly important missing link in our health care system. We do not have a system for long-term care, and people do not realize that. Many people think Medicare will, in fact, cover it, where Medicare covers it in a very limited, short-term basis. So the estimates of what families spend both in terms of lost work hours and what they put out-of-pockets is in, I think it’s something like $400 billion. It’s extraordinarily high. But the reason it’s been hard to fix is it’s extraordinarily expensive. And although Harris put out a plan to pay for this, that plan is going to have to be vetted by economists and budget scorers and skeptical Republicans. And probably some skeptical Democrats. It’s really expensive. It’s really hard to do. Julie has covered this for years, too. It’s just— 

Rovner: I would say this is where I get to say one of my favorite things, which is that I started covering health care in 1986, and in 1986 my first big feature was: Why don’t we have a long-term care policy in this country? Thirty-eight years later, and we still don’t, and not that people have not tried. There, in fact, was a long-term-care-in-the-home piece of the Affordable Care Act that passed Congress, and HHS [the Department of Health and Human Services] discovered that they could not implement it in the way it was written, because only the people who would’ve needed it would’ve signed up for it. It would’ve been too expensive. And there it went. So this is the continuing promise of something that everybody agrees that we need and nobody has ever been able to figure out how to do. Shefali, I see you nodding here. 

Luthra: I mean, I’m just thinking again about the pay-fors in here, which are largely the savings from Medicare negotiating drug prices. And what Harris says in her plan is that they’re going to get more savings by expanding the list of drugs that get lower prices. But that also feels very politically suspect when we have already heard congressional Republicans say that they would like to weaken some of those drug negotiation price provisions. And we also know that Democrats, even if they win the presidency, are not likely to have Congress. It really takes me back to 2020, when we are just talking about ideas that Democrats would love to do if they had full power of Congress, while all of us in Washington kind of know that that is just not going to happen. 

Rovner: Yes, I love that one of the pay-fors for this is cutting Medicare fraud. It’s like, where have we heard that before? Oh, yes. In every Medicare proposal for the last 45 years. 

Kenen: And it also involves closing some kind of international tax loopholes, and that also sounds easy on paper, and nothing with taxes is ever easy. The Democrats probably are not going to have the Senate. Nobody really knows about the House. It looks like the Democrats may have a narrow edge in that, but we’re going to have more years of gridlock unless something really changes politically, like something extraordinary changes politically. The Republicans are not going to give a President Harris, if she is in fact President Harris, her wish list on a golden platter. On the other hand there’s need for this. 

Rovner: But in fairness, this is what the campaign is for. 

Kenen: Right. There is a need for something on long-term care. 

Rovner: And everybody’s complaining: Well, what would she do? What would she do if she was elected? Well, here’s something she said she would do if she could, if she was elected. Well, meanwhile, former President [Donald] Trump has apparently abandoned a proposal that he made during his first term to require drugmakers to lower their prices for Medicare to no more than they charge in other developed countries where their prices are government-regulated. Is Trump going soft on the drug industry? Trump has been, what, the Republican, I think, who’s been most hostile towards the drug industry until now. 

Hellmann: I would say maybe. I think the “most favored nation” proposal is something that the pharmaceutical industry has feared even more than the Democrats’ Medicare negotiation program. And it’s something that Trump really pursued in his first term but wasn’t able to get done. In such a tight race, I think he’s really worried about angering pharmaceutical companies, especially after they were just kind of dealt this loss with Medicare price negotiation. And if he does win reelection, he’s going to be kind of limited in his ability to weaken that program. It’s going to be hard to repeal it. It’s extremely popular, and he may be able to weaken it. 

Rovner: “It” meaning price negotiation, not the “most favored nations” prices. 

Hellmann: Yeah. It’s going to be really hard to repeal that, and he may be able to weaken it through the negotiation process with drug companies. It’s definitely an interesting turn. 

Rovner: Joanne, you want to add something? 

Kenen: Trump rhetorically was very harsh on the drug companies right around the time of his inauguration. I think it was the week before, if I remember correctly. Said a lot of very tough stuff on drugs. Put out a list of something like dozens of potential steps. The drug companies have lots of allies in both parties, and more in one than the other, but they have allies on the Hill, and nothing revolutionary happened on drug pricing under Trump. 

Rovner: And his HHS secretary was a former drug company executive. 

Kenen: Yes, Eli Lilly. So we also pointed out here that former President Trump is not consistent in policy proposals. He says one thing, and then he says another thing, and it’s very hard to know where he’s going to come down. So Trump and drug pricing is an open question. 

Rovner: Yes, we will see. All right, well, moving on. Drug prices and Medicare aside, the biggest health issue of Campaign 2024 continues to be abortion and other reproductive health issues. And it’s not just Trump trying to back away from his anti-abortion record. We’ve had a spate of stories over the past week or so of Republicans running for the House, the Senate, and governorships who are trying to literally reinvent themselves as, if not actually supportive of abortion rights, at least anti abortion bans. And that includes Republicans who have not just voted for and advocated for bans but who have been outspokenly supportive of the anti-abortion effort, people like North Carolina Republican gubernatorial candidate Mark Robinson, New Hampshire Republican gubernatorial candidate and former U.S. Senator Kelly Ayotte, along with former Michigan Republican representative and now Senate candidate Mike Rogers. Donald Trump has gotten away repeatedly, as Joanne just said, with changing his positions, even on hot-button issues like abortion. Are these candidates going to be able to get away with doing the same thing, Shefali? 

Luthra: I think it’s just so much tougher when your name is not Donald Trump. And that’s because we know from focus group after focus group, and survey after survey, that voters kind of give Trump more leeway on abortion. Especially independent voters will look at him and say, Well, I don’t think he actually opposes abortion, because I’m sure he’s paid for them. And they don’t have that same grace that they give to Republican lawmakers and Republican candidates, because the party has a bad brand on abortion at large, and Trump is seen as this kind of maverick figure. But voters know that Republicans have a history of opposing abortion, of supporting restrictions. 

When you look at surveys, when you talk to voters, what they say is, Well, I don’t trust Republicans to represent my interests on this issue, because they largely support access. And one thing that I do think is really interesting is, once again, what we’re seeing is kind of a repeat of the 2022 elections when we saw some very brazen efforts by Republican candidates for the House and Senate try and scrub references to abortion and to fetal personhood from their websites. And it didn’t work, because people have eyes and people have memories, and, also, campaigns have access to the internet archive and are able to show people that, even a few weeks ago, Republican candidates were saying something very different from what they are saying now. I don’t think Mark Robinson can really escape from his relatively recent and very public comments about abortion. 

Rovner: Well, on the other hand, there’s some things that don’t change. Republican vice presidential candidate JD Vance told RealClearPolitics last week that if Trump is elected again, their administration would cut off funding to Planned Parenthood because, he said, and I quote, “We don’t think that taxpayers should fund late-term abortions.” Notwithstanding, of course, that even before the overturn of Roe, less than half of all Planned Parenthoods even performed abortions and almost none of those who did perform them later in pregnancy. Is it fair to say that Vance’s anti-abortion slip is showing? 

Luthra: I think it might be. And I will say, Julie, when I saw that he said that, I could hear you in my head just yelling about the Hyde Amendment, because we know that Planned Parenthood does not use taxpayer money to pay for abortions. But we also know that JD Vance has seen that he and his ticket are kind of in a tough corner talking about abortion. He has said many times, We need to rebrand — he’s very honest about that, at least — and trying to focus instead on this nonmedical term of “late term” abortions. 

It’s a gamble. It’s hoping that voters will be more sympathetic to that because they’ll think, Oh, well, that sounds very extreme. And they’re trying to shift back who is seen as credible and who is not, by focusing on something that historically was less popular. But again, it’s again tricky because when we look at the polling, voters’ understanding of abortion has shifted and they are now more likely to understand that when you have an abortion later in pregnancy, it is often for very medically complex reasons. And someone very high-profile who recently said that is Melania Trump in her new memoir, talking about how she supports abortion at all stages of pregnancy because often these are very heart-wrenching cases and not sort of the murder that Republicans have tried to characterize them as. 

Rovner: I think you’re right. I think this is the continuation of the 2022 campaign, except that we’ve had so many more women come forward. We’ve seen actual cases. It used to be anti-abortion forces would say, Oh, well, this never happened. I mean, these are wrenching, awful things that happened to a lot of these patients with pregnancy complications late in pregnancy. And it is, I know, because I’ve talked to them. It’s very hard to get them to talk publicly, because then they get trolled. Why should they step forward? 

Well, now we’ve seen a lot of these women stepping forward. So we now see a public that knows that this happens, because they’re hearing from the people that it’s happened to and they’re hearing from their doctors. I do know also from the polling that there are people who are going to vote in these 10 states where abortion is on the ballot. Many of them are going to vote for abortion access and then turn around and vote for Republicans who support restrictions, because they’re Republicans. It may or may not be their most important issue, but I still think it’s a big question mark where that happens and how it shakes out. Joanne, did you want to add something? 

Kenen: You’re seeing two competing things at the same time. You have a number of Republicans trying to moderate their stance or at least sound like they’re moderating their stance. At the same time, you also have the whole, where the Republican Party is on abortion has shifted to the right. They are talking about personhood at the moment of conception, the embryo — which is, scientifically put, a small ball of cells still at that point — that they actually have the same legal rights as any other post-birth person. 

So that’s become a fairly common view in the Republican Party, as opposed to something that just five or six years ago was seen as the fringe. And Trump is going around saying that Democrats allow babies to be executed after birth, which is not true. And they’re particularly saying this is true in Minnesota because of [Gov.] Tim Walz, and some voters must believe it, right? Because they keep saying it. So you have this trend that Shefali just described and that you’ve described, Julie, about this sort of attempting to win back trust, as Vance said. And it sounded more moderate, and at the same time as you’re hearing this rhetoric about personhood and execution. So I don’t think the Republicans have yet solved their own whiplash post-Roe. 

Rovner: Meanwhile, the abortion debate is getting mired in the free-speech debate. In Florida, Republican governor Ron DeSantis is threatening legal action against TV stations airing an ad in support of the ballot measure that would overturn the state’s six-week abortion ban. That has in turn triggered a rebuke from the head of the Federal Communications Commission warning that political speech is still protected here in the United States. Shefali, this is really kind of out there, isn’t it? 

Luthra: It’s just so fascinating, and it’s really part of a bigger effort by Ron DeSantis to try and leverage anything that he can politically or, frankly, in his capacity as head of the state to try and weaken the campaign for the ballot measure. They have used the health department in other ways to try and send out material suggesting that the campaign’s talking points, which are largely focused on the futility of exceptions to the abortion ban, they’re trying to argue that that is misinformation, and that’s not true. And they’re using the state health department to make that argument, which is something we don’t really see very often, because usually health departments are supposed to be nonpartisan. And what I will say is, in this case, at least to your point, Julie, the FCC has weighed in and said: You can’t do this. You can’t stop a TV station from airing a political ad that was bought and paid for. And the ads haven’t stopped showing at this point. I just heard from family yesterday in Florida who are seeing the ads in question on their TV, and it’s still— 

Rovner: And I will post a link to the ad just so you can see it. It’s about a woman who’s pregnant and had cancer and needed cancer treatment and needed to terminate the pregnancy in order to get the cancer treatment. It said that the exception would not allow her to, which the state says isn’t true and which is clearly one of these things that is debatable. That’s why we’re having a political debate. 

Luthra: Exactly. And one thing that I think is worth adding in here is, I mean, this really intense effort from Governor DeSantis and his administration comes at a time when already this ballot measure faces probably the toughest fight of any abortion rights measure. And we have seen abortion rights win again and again at the ballot, but in Florida you need 60% to pass. And if you look across the country at every abortion rights measure that has been voted on since Roe v. Wade was overturned, only two have cleared 60, and they are in California and they are in Vermont. So these more conservative-leaning states, and Florida is one of them, it’s just, it’s really, really hard to see how you get to that number. And we even saw this week there’s polling that suggests that the campaign has a lot of work to do if they’re hoping to clear that threshold. 

Rovner: And, of course, now they have two hurricanes to deal with, which we will deal with in a few minutes. But first, the Supreme Court is back in session here in Washington, and even though there’s no big abortion case on its official docket as of now this term, the court quickly declined to hear two cases on its first day back, one involving whether the abortion ban in Texas can override the federal emergency treatment law that’s supposed to guarantee abortion access in medical emergencies threatening the pregnant woman’s life or health. The court also declined to overrule the Alabama Supreme Court’s ruling that frozen embryos can be considered legally as unborn children. That’s what Joanne was just talking about. Where do these two decisions leave us? Neither one actually resolved either of these questions, right? 

Luthra: I mean, the EMTALA [Emergency Medical Treatment and Labor Act] question is still ongoing, not because of the Texas case but because of the Idaho case that is asking very similar questions that we’ve talked about previously on this podcast. And the end of last term, the court kicked that back down to the lower courts to continue making its way through. We anticipate it will eventually come back to the Supreme Court. So this is a question that we will, in fact, be hearing on at some point. 

Rovner: Although, the irony here is that in Idaho, the ban is on hold because there was a court stay. And in Texas, the ban is not on hold, even though we’re talking about exactly the same question: Does the federal law overrule the state’s ban? 

Luthra: And what that kind of highlights — right? — is just how much access to abortion, even under states with similar laws or legislatures, really does depend on so many factors, including what circuit court you fall into or the makeup of your state Supreme Court and how judges are appointed or whether they are elected. There is just so much at play that makes access so variable. And I think the other thing that one could speculate that maybe the court didn’t want headlines around reproductive health so soon into an election, but it’s not as if this is an issue that they’re going to be avoiding in the medium- or long-term future. These are questions that are just too pressing, and they will be coming back to the Supreme Court in some form. 

Rovner: Yes, I would say in the IVF [in vitro fertilization] case, they simply basically said, Go away for now. Right? 

Luthra: Yeah. And, I mean, right now in Alabama, people are largely able to get IVF because of the state law that was passed, even if it didn’t touch the substance of that state court’s ruling. This is something, for now, people can sort of think is maybe uninterrupted, even as we all know that the ideological and political groundwork is being laid for a much longer and more intense fight over this. 

Rovner: Well, remember back last week when we predicted that the judge’s decision overturning Georgia’s six-week ban was unlikely to be the last word? Well, sure enough, the Georgia Supreme Court this week overturned the immediate overturning of the ban, which officially went back into effect on Monday. Like these other cases, this one continues, right? 

Luthra: Yes, this continues. The Georgia case continued for a while, and it just sort of underscores again what we’ve been talking about, just how much access really changes back and forth. And I was talking to an abortion clinic provider who has clinics in North Carolina and Georgia. She literally found out about the decision both times and changed her plans for the next day because I texted her asking her for comment. And providers and patients are being tasked with keeping up with so much. And it’s just very, very difficult, because Georgia also has a 24-hour waiting period for abortions, which means that every time the decision around access has changed — and we know it very well could change again as this case progresses — people will have to scramble very quickly. And in Georgia, they have also been trying to do that on top of navigating the fallout of a hurricane. 

Rovner: Yeah. And as we pointed out a couple of weeks ago when the court overturned the North Dakota ban, there are no abortion providers left in North Dakota. Now that there’s no ban, it’s only in theory that abortion is now once again allowed in North Dakota. Well, before we leave abortion for this week, we have two new studies showing how abortion bans are impacting the health care workforce. In one survey, more than half of oncologists, cancer doctors, who were completing their fellowships, so people ready to go into practice, said they would consider the impact of abortion restrictions in their decisions about where to set up their practice. And a third said abortion restrictions hindered their ability to provide care. 

Meanwhile, a survey of OBGYNs in Texas by the consulting group Manatt Health found “a significant majority of practicing OB/GYN physicians … believe that the Texas abortion laws have inhibited their ability to provide highest-quality and medically necessary care to their patients,” and that many have already made or are considering making changes to their practice that would “reduce the availability of OB/GYN care in the state.” What’s the anti-abortion reaction to this growing body of evidence that abortion bans are having deleterious effects on the availability of other kinds of health care, too? I mean, I was particularly taken by the oncologists, the idea that you might not be able to get cancer care because cancer doctors are worried about treating pregnant women with cancer. 

Luthra: They’re blaming the doctors. And we saw this in Texas when the Zurawski case was argued and women patients and doctors in the state said that they had not been able to get essential, lifesaving medical care because of the state’s abortion ban and lack of clarity around what was actually permitted. And the state argued, and we have heard this talking point again and again, that actually the doctors are just not willing to do the hard work of practicing medicine and trying to interpret, Well, obviously this qualifies. That’s something we’ve seen in the Florida arguments. They say: Our exceptions are so clear, and if you aren’t able to navigate these exceptions, well, that’s your problem, because you are being risk-averse, and patients should really take this up with their doctors, who are just irresponsible. 

Rovner: Yes, this is obviously an issue that’s going to continue. Well, moving on. The cost of health care continues to grow, which is not really news, but this week we have more hard evidence, courtesy of my KFF colleagues via the annual 2024 Employer Health Benefit Survey, which finds the average family premium rose 7% this year to $25,572, with workers contributing an average of $6,296 towards that cost. And that’s with a distinct minority of firms covering two very popular but very expensive medical interventions, GLP-1 [glucagon-like peptide-1] drugs for obesity and IVF, which we’ve just been talking about. Anything else in this survey jump out at anybody? 

Hellmann: I mean, that’s just a massive amount of money. And the employer is really paying the majority of that, but that doesn’t mean it doesn’t have an impact on people. That means it’s going to limit how much your wages go up. And something I thought of when I read this study is these lawsuits that we’re beginning to see, accusing employers of not doing enough to make sure that they’re limiting health care costs. They’re not playing enough of a role in what their benefits look like. They’re kind of outsourcing this to consultants. And so when you look at this data and you see $25,000 they’re spending per year per family on health care premiums, you wonder, what are they doing? 

Health care, yes, it’s obviously very expensive, but you just kind of question, what role are employers actually playing in trying to drive down health care costs? Are they just taking what they get from consultants? And another thing that kind of stood out to me from this is, I think it’s said in there, employers are having a hard time lately of passing these costs on to employees, which is really interesting. It’s because of the tight labor market. But obviously health care is still very expensive for employees — $6,000 a year in premiums for family coverage is not a small amount of money. So employers are just continuing to absorb that, and it does really impact everyone. 

Rovner: It’s funny. Before the Affordable Care Act, it was employers who were sort of driving the, You must do something about the cost of health care, because inflation was so fast. And then, of course, we saw health care inflation, at least, slow down for several years. Now it’s picking up again. Are we going to see employers sort of getting back into this jumping up and down and saying, “We’ve got to do something about health care costs”? 

Hellmann: I feel like we are seeing more of that. You’re beginning to hear more from employers about it. I don’t know. It’s just such a hard issue to solve, and I’ve seen more and more interest from Congress about this, but they really struggle to regulate the commercial market. So … 

Rovner: Yes, as we talk about at length every week. But it’s still important, and they will still go for it. Well, finally, this week in health misinformation. Let us talk about hurricanes — the public health misinformation that’s being spread both about Hurricane Helene that hit the Southeast two weeks ago, and Hurricane Milton that’s exiting Florida even as we are taping this morning. President [Joe] Biden addressed the press yesterday from the White House, calling out former President Trump by name along with Georgia Republican congresswoman Marjorie Taylor Greene for spreading deliberate misinformation that’s not just undermining efforts at storm relief but actually putting people in more danger. Now, I remember Hurricane Katrina and all the criticism that was heaped, mostly deservedly, on George W. Bush and his administration, but I don’t remember deliberate misinformation like this. I mean, Joanne, have you ever seen anything like this? You lived in Florida for a while. 

Kenen: I went through Andrew, and there’s always a certain — there’s confusion and chaos after a big storm. But there’s a difference between stuff being wrong that can be corrected and stuff being intentionally said that then in this sort of divided, suspicious, two-realities world we’re now living in, that’s being repeated and perpetuated and amplified. It damages public health. It damages people economically trying to recover from this disastrous storm or in some cases storms. I don’t know how many people actually believe that Marjorie Taylor asserted that the Democrats are controlling the weather and sending storms to suppress Republican voters. She still has a following, right? But other things … 

Rovner: She still gets reelected. 

Kenen: … being told that if you go to FEMA [the Federal Emergency Management Agency] for help, your property will be confiscated and taken away from you. I mean, that’s all over the place, and it’s not true. Even a number of Republican lawmakers in the affected states have been on social media and making statements on local TV and whatever, saying: This is not true. Please, FEMA is there to help you. Let’s get through this. Stop the lies. A number of Republicans have actually been quite blunt about the misinformation coming from their colleagues and urging their constituents to seek and take the help that’s available. 

This is the public health crisis. We don’t know how many people have been killed. I don’t think we have an accurate total final count from Helene, and we sure don’t have from Milton. I mean, the people did seem to take this storm seriously and evacuated, but it also spawned something like three dozen tornadoes in places where people hadn’t been told, there’s normally no need to evacuate. There’s flooding. It’s a devastating storm. So when people are flooding, power outages, electricity, hard to get access to health care, you can’t refrigerate your insulin. All these— 

Rovner: Toxic floodwaters, I mean, the one thing … 

Kenen: Toxic, yeah. 

Rovner: … we know about hurricanes is that they’re more dangerous in the aftermath than during the actual storm in terms of public health. 

Kenen: Right. This is a life-threatening public health emergency to really millions of people. And misinformation, not just getting something wrong and then trying to correct it, but intentional disinformation, is something we haven’t seen before in a natural disaster. And we’re only going to have more natural disasters. And it was really — I mean, Julie, you already pointed this out — but it was really unusual how precise Biden was yesterday in calling out Trump by name, and I believe at two different times yesterday. So I heard one, but I think I read about what I think was the second one really saying, laying it at his feet that this is harming people. 

Rovner: Yeah, like I said, I remember Katrina vividly, and that was obviously a really devastating storm. I do also remember Democrats and Republicans, even while they were criticizing the federal government reaction to it, not spreading things that were obviously untrue. All right. Well, that is the news for this week. Now we will play a segment from our Newsmaker interview with Mark Cuban, and then we will be back with our extra credits. 

On Tuesday, October 8th, Mark Cuban met with a group of reporters for a Newsmaker lunch at KFF’s offices in Washington, D.C. Cuban, a billionaire best known as a panelist on the ABC TV show “Shark Tank,” has taken an interest in health policy in the past several years. He’s been consulting with the campaign of Vice President Harris, although he says he’s definitely not interested in a government post if she wins. Cuban started out talking about how, as he sees it, the biggest problem with drug prices in the U.S. is that no one knows what anyone else is paying. 

Mark Cuban: I mean, when I talk to corporations and I’ve tried to explain to them how they’re getting ripped off, the biggest of the biggest said, Well, so-and-so PBM [pharmacy benefit manager] is passing through all of their rebates to us. 

And I’m like: Does that include the subsidiary in Scotland or Japan? Is that where the other one is? 

I don’t know. 

And it doesn’t. By definition, you’re passing through all the rebates with the company you contracted with, but they’re not passing through all the rebates that they get or that they’re keeping in their subsidiary. And so, yeah, I truly, truly believe from there everybody can argue about the best way. Where do you use artificial intelligence? Where do you do this? What’s the EHR [electronic health record? What’s this? We can all argue about best practices there. But without a foundation of information that’s available to everybody, the market’s not efficient and there’s no place to go. 

Rovner: He says his online generic drug marketplace, costplusdrugs.com, is already addressing that problem. 

Cuban: The crazy thing about costplusdrugs.com, the greatest impact we had wasn’t the markup we chose or the way we approach it. It’s publishing our price list. That changed the game more than anything. So when you saw the FTC [Federal Trade Commission] go after the PBMs, they used a lot of our pricing for all the non-insulin stuff. When you saw these articles written by the Times and others, or even better yet, there was research from Vanderbilt, I think it was, that says nine oncology drugs, if they were purchased by Medicare through Cost Plus, would save $3.6 billion. These 15, whatever drugs would save six-point-whatever billion. All because we published our price list, people are starting to realize that things are really out of whack. And so that’s why I put the emphasis on transparency, because whether it’s inside of government or inside companies that self-insure, in particular, they’re going to be able to see. The number one rule of health care contracts, particularly PBM contracts, is you can’t talk about PBM contracts. 

Rovner: Cuban also says that more transparency can address problems in the rest of the health care system, not just for drug prices. Here’s how he responded to a question I asked describing his next big plan for health care. 

We’ve had, obviously, issues with the system being run by the government not very efficiently and being run by the private sector not very efficiently. 

Cuban: Very efficiently, yeah. 

Rovner: And right now we seem to have this sort of working at cross-purposes. If you could design a system from the ground up, which would you let do it? The government or— 

Cuban: I don’t think that’s really the issue. I think the issue is a lack of transparency. And you see that in any organization. The more communication and the more the culture is open and transparent, the more people hold each other responsible. And I think you get fiefdoms in private industry and you get fiefdoms in government, as well, because they know that if no one can see the results of their work, it doesn’t matter. I can say my deal was the best and I did the best and our outcomes are the best, but there’s no way to question it. And so talking to the Harris campaign, it’s like if you introduce transparency, even to the point of requiring PBMs and insurers to publish their contracts publicly, then you start to introduce an efficient market. And once you have an efficient market, then people are better able to make decisions and then you can hold them more accountable. 

And I think that’s going to spill over beyond pharm. We’re working on — it’s not a company — but we’re working on something called Cost Plus Wellness, where we’re eating our own dog food. And it’s not a company that’s going to be a for-profit or even a nonprofit, for that matter, just for the lives that I cover for my companies, that we self-insure. We’re doing direct contracting with providers, and we’re going to publish those contracts. And part and parcel to that is going through the — and I apologize if I’m stumbling here. I haven’t slept in two days, so bear with me. But going through the hierarchy of care and following the money, if you think about when we talk to CFOs and CEOs of providers, one of the things that was stunning to me that I never imagined is the relationship between deductibles for self-insured companies and payers, and the risk associated with collecting those deductibles to providers. 

And I think people don’t really realize the connection there. So whoever does Ann’s care [KFF Chief Communications Officer Ann DeFabio, who was present] — well, Kaiser’s a little bit different, but let’s just say you’re employed at The Washington Post or whoever and you have a $2,500 deductible. And something happens. Your kid breaks their leg and goes to the hospital, and you’re out of market, and it’s out of network. Well, whatever hospital you go to there, you might give your insurance card, but you’re responsible for that first $2,500. And that provider, depending on where it’s located, might have collection — bad debt, rather — of 50% or more. 

So what does that mean in terms of how they have to set their pricing? Obviously, that pricing goes up. So there’s literally a relationship between, particularly on pharmacy, if my company takes a bigger rebate, which in turn means I have a higher deductible because there’s less responsibility for the PBM-slash-insurance company. My higher deductible also means that my sickest employees are the ones paying that deductible, because they’re the ones that have to use it. And my older employees who have ongoing health issues and have chronic illnesses and need medication, they’re paying higher copays. But when they have to go to the hospital with that same deductible, because I took more of a rebate, the hospital is taking more of a credit risk for me. That’s insane. That makes absolutely no sense. 

And so what I’ve said is as part of our wellness program and what we’re doing to — Project Alpo is what we call it, eating our own dog food. What I’ve said is, we’ve gone to the providers and said: Look, we know you’re taking this deductible risk. We’ll pay you cash to eliminate that. But wait, there’s more. We also know that when you go through a typical insurer, even if it’s a self-insured employer using that insurer and you’re just using the insurance company not for insurance services but as a TPA [third-party administrator], the TPA still plays games with the provider, and they underpay them all the time. 

And so what happens as a result of the underpayment is that provider has to have offices and offices full of administrative assistants and lawyers, and they have to not only pay for those people, but they have the associated overhead and burden and the time. And then talking to them, to a big hospital system, they said that’s about 2% of their revenue. So because of that, that’s 2%. Then, wait, there’s more. You have the pre-ops, and you have the TPAs who fight you on the pre-ops. But the downstream economic impacts are enormous because, first, the doctor has to ask for the pre-op. That’s eating doctor’s time, and so they see fewer patients. And then not only does the doctor have to deal with them, they go to HR at the company who self-insures and says, Wait, my employee can’t come to work, because their child is sick, and you won’t approve this process or, whatever, this procedure, because it has to go through this pre-op. 

Or if it’s on medications, it’s you want to go through the step-up process or you want to go through a different utilization because you get more rebates. All these pieces are intertwined, and we don’t look at it holistically. And so what we’re saying with Cost Plus Wellness is, we’re going to do this all in a cash basis. We’re going to trust doctors so that we’re not going to go through a pre-op. Now we’ll trust but verify. So as we go through our population and we look at all of our claims, because we’ll own all of our claims, we’re going to look to see if there are repetitive issues with somebody who’s just trying to —there’s lots of back surgeries or there’s lots of this or there’s lots of that — to see if somebody’s abusing us. And because there’s no deductible, we pay it, and we pay it right when the procedure happens or right when the medication is prescribed. Because of all that, we want Medicare pricing. Nobody’s saying no. And in some cases I’m getting lower than Medicare pricing for primary care stuff. 

Rovner: OK, we are back. Now it’s time for our extra credits. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We will include the links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week. 

Kenen: There was a fascinating story in The New York Times by Kate Morgan. The headline was “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It.” So I knew nothing about this, and it was so interesting. Placentas have amazing healing properties for wound care, burns, infections, pain control, regenerating skin tissue, just many, many things. And it’s been well known for years, and it’s not widely used. This is a story specifically about a really severe burn victim in a gas explosion and how her face was totally restored. We don’t use this, partly because placenta — every childbirth, there’s a placenta. There are lots of them around. There’s I think three and a half million births a year, or that’s the estimate I read in the Times. One of the reasons they weren’t being used is, during the AIDS crisis, there was some development toward using them, and then the AIDS crisis, there was a fear of contamination and spreading the virus, and it stopped decades later. 

We have a lot more ways of detecting, controlling, figuring out whether something’s contaminated by AIDS or whether a patient has been exposed. It is being used again on a limited basis after C-sections, but it seems to have pretty astonishing — think about all the wound care for just diabetes. I’m not a scientist, but I just looked at the story and said, it seems like a lot of people could be healed quicker and more safely and earlier if this was developed. They’re thrown away now. They’re sent to hospital waste incinerators and biohazard waste. They’re garbage, and they’re actually medicine. 

Rovner: Definitely a scientist’s cool story. Shefali. 

Luthra: My story is from my brilliant colleague Mel Leonor Barclay. The headline is “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” and as part of this really tremendous series that she has running this week, looking at how Latinas as a much more influential and growingly influential voter group could shape gun violence, abortion rights, and housing. And in this story, which I really love, she went to Arizona and spent time talking to folks on all sides of the issue to better understand how Latinas are affected by abortion rights and also how they’ll be voting on this. 

And she really challenges the narrative that has existed for so long, which is that Latinas are largely Catholic, largely more conservative on abortion. And she finds something much more complex, which is that actually polls really show that a large share of Latina voters in Arizona and similar states support abortion rights and will be voting in favor of measures like the Arizona constitutional amendment. But at the same time, there are real divides within the community, and people talk about their faith in a different way and how it connects their stance on abortion. They talk about their relationships with family in different ways, and I think it just underscores how rarely Latina voters are treated with real nuance and care and thoughtfulness when talking about something as complex as abortion and abortion politics. And I really love the way that she approaches this piece. 

Rovner: It was a super-interesting story. Jesse. 

Hellmann: My story is from The Assembly. It’s an outlet in North Carolina. It’s called “Helene Left Some North Carolina Elder-Care Homes Without Power.” Some assisted living facilities have been without power and water since the hurricane hit. Several facilities had to evacuate residents, and the story just kind of gets into how North Carolina has more lax rules around emergency preparedness. While they do require nursing homes be prepared to provide backup power, the same requirements don’t apply to assisted living facilities. And it’s because there’s been industry pushback against that because of the cost. But as we see some more of these extreme weather events, it seems like something has to be done. We cannot just allow vulnerable people living in these facilities to go hours and hours without power and water. And I saw that there was a facility where they evacuated dozens of people who had dementia, and that’s just something that’s really upsetting and traumatizing for people. 

Rovner: Yeah, once again, now we are seeing these extreme weather events in places that, unlike Florida and Texas, are not set up and used to extreme weather events. And it is something I think that a lot of people are starting to think about. Well, my story this week is from our KFF Health News public health project called Health Beat, and it’s called “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly. And it’s one of those stories you never really think about until it’s pointed out that in areas, particularly those that had been redlined, in particular, the lack of safety infrastructure that most of us take for granted — crosswalks, sidewalks, traffic lights are not really there. And that’s a public health crisis of its own, and it’s one that rarely gets addressed, and it’s a really infuriating but a really good story. 

All right, that is our show. Next week, for my birthday, we’re doing a live election preview show here at KFF in D.C., because I have a slightly warped idea of fun. And you’re all invited to join us. I will put a link to the RSVP in the show notes. I am promised there will be cake. 

As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Stephanie Stapleton. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me for the moment at X. I’m @jrovner. Joanne, where are you? 

Kenen: @JoanneKenen sometimes on Twitter and @joannekenen1 on Threads.

Rovner: Jessie.

Hellmann: @jessiehellmann on Twitter.

Rovner: Shefali.

Luthra: @shefalil on Twitter.

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

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Most employers have little idea what the pharmacy benefit managers they hire do with the money they exchange for the medications used by their employees, according to a KFF survey released Wednesday morning.

In KFF’s latest employer health benefits survey, company officials were asked how much of the rebates collected from drugmakers by pharmacy benefit managers, or PBMs, is returned to them. In recent years, the pharmaceutical industry has tried to deflect criticism of high drug prices by saying much of that income is siphoned off by the PBMs, companies that manage patients’ drug benefits on behalf of employers and health plans.

PBM leaders say they save companies and patients billions of dollars annually by obtaining rebates from drugmakers that they pass along to employers. Drugmakers, meanwhile, say they raise their list prices so high in order to afford the rebates that PBMs demand in exchange for placing the drugs on formularies that make them available to patients.

Leaders of the three largest PBMs — CVS Caremark, Optum RX and Express Scripts — all testified in Congress in July that 95% to 98% of the rebates they collect from drugmakers flow to employers.

For KFF’s survey of 2,142 randomly selected companies, officials from those with 500 or more employees were asked how much of the rebates negotiated by PBMs returned to the company as savings. About 19% said they received most of the rebates, 27% said some, and 16% said little. Thirty-seven percent of the respondents didn’t know.

While a larger percentage of officials from the largest companies said they got most or some of the rebates, the answers — and their contrast with the testimony of PBM leaders — reflect the confusion or ignorance of employers about what their drug benefit managers do, said survey leader Gary Claxton, a senior vice president at KFF, a health information nonprofit that includes KFF Health News.

“I don’t think they can ever know all the ways the money moves around because there are so many layers, between the wholesalers and the pharmacies and the manufacturers,” he said.

Critics say big PBMs — which are parts of conglomerates that include pharmacies, providers, and insurers — may conceal the size of their rebates by conducting negotiations through corporate-controlled rebate aggregators, or group purchasers, mostly based overseas in tax havens, that siphon off a percentage of the cash before it goes on the PBMs’ books.

PBMs also make money by encouraging or requiring patients to use affiliated specialty pharmacies, by skimping on payments to other pharmacies, and by collecting extra cash from drug companies through the federal 340B drug pricing program, which is aimed at lowering drug costs for low-income patients, said Antonio Ciaccia, CEO of 46brooklyn Research.

The KFF survey indicates how little employers understand the PBMs and their pricing policies. “Employers are generally frustrated by the lack of transparency into all the prices out there,” Claxton said. “They can’t actually know what’s true.”

Billionaire Mark Cuban started a company to undercut the PBMs by selling pharmaceuticals with transparent pricing policies. He tells Fortune 500 executives he meets, “You’re getting ripped off, you’re losing money because it’s not your core competency to understand how your PBM and health insurance contracts work,” Cuban told KFF Health News in an interview Tuesday.

Ciaccia, who has conducted PBM investigations for several states, said employers are not equipped to understand the behavior of the PBMs and often are surprised at how unregulated the PBM business is.

“You’d assume that employers want to pay less, that they would want to pay more attention,” he said. “But what I’ve learned is they are often underequipped, underresourced, and oftentimes not understanding the severity of the lack of oversight and accountability.”

Employers may assume the PBMs are acting in their best interest, but they don’t have a legal obligation to do so.

Prices can be all over the map, even those charged by the same PBM, Ciaccia said. In a Medicaid study he recently conducted, a PBM was billing employers anywhere from $2,000 to $8,000 for a month’s worth of imatinib, a cancer drug that can be bought as a generic for as little as $30.

PBM contracts often guarantee discounts of certain percentage points for generics and brand-name drugs. But the contracts then contain five pages of exclusions, and “no employer will know what they mean,” Ciaccia said. “That person doesn’t have enough information to have an informed opinion.”

The KFF survey found that companies’ annual premiums for coverage of individual employees had increased from an average of $7,739 in 2021 to $8,951 this year, and $22,221 to $25,572 for families. Among employers’ greatest concerns was how to cover increasingly popular weight loss drugs that list at $2,000 a month or more.

Only 18% of respondents said their companies covered drugs such as Wegovy for weight loss. The largest group of employers offering such coverage — 28% — was those with 5,000 or more employees.

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

When it comes to health care, this year’s presidential campaign is increasingly a matter of which candidate voters choose to believe. Democrats, led by Vice President Kamala Harris, say Republicans want to further restrict reproductive rights and repeal the Affordable Care Act, pointing to their previous actions and claims. Meanwhile, Republicans, led by former President Donald Trump, insist they have no such plans.

Meanwhile, with open enrollment approaching for Medicare, the Biden administration dodges a political bullet, avoiding a sharp spike next year in Medicare prescription drug plan premiums.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Anna Edney of Bloomberg News.

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna'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:

• This week, Sen. JD Vance of Ohio muddled his ticket’s stances on health policy during the vice presidential debate, including by downplaying the possibility of a national abortion ban. And Melania Trump, the former president’s wife, spoke out in support of abortion rights. Their comments seem designed to soothe voter concerns that former President Donald Trump could take actions to further block abortion access.
• Vance raised eyebrows with his debate-night claim that Trump “salvaged” the Affordable Care Act — when, in fact, the former president vowed to repeal the law and championed the GOP’s efforts to deliver on that promise. Meanwhile, Trump deflected questions from AARP about his plans for Medicare, replying, “What we have to do is make our country successful again.”
• On the Democratic side, Vice President Kamala Harris is campaigning on health, in particular by pushing out new ads highlighting the benefits of the ACA and Trump’s efforts to restrict abortion. Polls show health is a winning issue for Democrats and that the ACA is popular, especially its protections for those with preexisting conditions.
• Also in the news, the Centers for Medicare & Medicaid Services reported a slight dip in average Medicare drug plan premiums for next year. Coming in an annual report — out shortly before Election Day — it looks as though government subsidies cushioned changes to the system, sparing seniors from potentially paying in premiums what they may save under the new $2,000 annual out-of-pocket drug cost cap, for instance.
• And in abortion news, a judge struck down Georgia’s six-week abortion ban — but many providers have already left the state. And a new California law protects coverage for in vitro fertilization, including for LGBTQ+ couples.

Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month,” about a teen athlete whose needed surgery lacked a billing code. Do you have a confusing or outrageous medical bill you want to share? Tell us about it.

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

Julie Rovner: KFF Health News’ “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” by Ronnie Cohen.

Anna Edney: Bloomberg News’ “A Free Drug Experiment Bypasses the US Health System’s Secret Fees,” by John Tozzi.

Alice Miranda Ollstein: The Wall Street Journal’s “Hospitals Hit With IV Fluid Shortage After Hurricane Helene,” by Joseph Walker and Peter Loftus.

Sandhya Raman: The Asheville Citizen Times’ “Without Water After Helene, Residents at Asheville Public Housing Complex Fear for Their Health,” by Jacob Biba.

Also mentioned on this week’s podcast:

• SisterSong v. State of Georgia: Superior Court of Fulton County decision.

Click to open the transcript

Transcript: The Health of the Campaign

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

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

Rovner: Today we are joined via teleconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Sandhya Raman of CQ Roll Call. 

Raman: Hello, everyone. 

Rovner: And Anna Edney of Bloomberg News. 

Anna Edney: Hi there. 

Rovner: Later in this episode, we’ll have my “Bill of the Month” interview with my KFF Health News colleague Lauren Sausser. This month’s patient is a high school athlete whose problem got fixed, but his bill did not. But first, the news. 

We’re going to start this week with the campaign. It is October. I don’t know how that happened. On Tuesday, vice-presidential candidates Senator JD Vance of Ohio and Governor Tim Walz of Minnesota held their first and only debate. It felt very Midwestern nice, with Walz playing his usual Aw shucks self and Vance trying very hard to seem, for want of a better word, likable. Did we learn anything new from either candidate? 

Edney: I don’t think I heard anything new, no — not that I can remember. 

Rovner: I know, obviously, they exchanged some views on abortion. Vance tried very hard to distance himself from his own hard-line views on the subject, including denying that he’d ever supported a national abortion ban, which he did, by the way. Meanwhile, during the debate, former President [Donald] Trump announced on social media that he would veto a national abortion ban, something he’d not said in those exact words before. Alice, you’ve got a pretty provocative story out this week suggesting that this all might actually be working on a skeptical public. Is it? 

Ollstein: Yes. This has been a theme I’ve been tracking for a little bit. It was part of the reporting I was doing in Michigan a couple weeks ago. One, what I thought was interesting about that night was Trump and Vance have been talking past each other on abortion and contradicting each other, and now … 

Rovner: Oh, yeah. 

Ollstein: … it finally seems that they are on the same page, in terms of trying to convince the public: Nothing to see here. We won’t do a national ban. Don’t worry about it. Democrats and abortion rights groups are running around screaming: They’re lying. Look at their record. Look at what their allies have proposed in things like Project 2025. But the Republican message on this front does seem to be working. Polls show that even people who care about abortion rights and support abortion rights in some of these key battleground states still plan to vote for Trump. It’s a continuation of a pattern we’ve seen over the past few years where a decent chunk of people vote for these state ballot initiatives to protect abortion but then also vote for anti-abortion politicians. 

Voters contain multitudes. We don’t know exactly if it’s because they are not worried that Trump and Vance will pursue national restrictions. We don’t know if it’s because just other issues are more important to them. But I think it’s really worth keeping an eye on in terms of a pattern. And KFF has done some really interesting polling showing that people in states where the ballot initiatives have already passed sort of view it as, Oh, we took care of that, it’s settled, and they don’t see the urgency and the threat of a national ban in the way that Democrats and abortion rights groups want them to. 

Rovner: Which we’ll talk about separately in a minute. In late breaking news, Melania Trump this week came out and said that she supports abortion rights. Is this part of the continuing muddle where everybody can see what it is that they want to see, or is this going to have any impact at all? 

Ollstein: Can I say one more thing about the debate first? 

Rovner: Sure. 

Ollstein: OK. So what really struck me about what Vance said about abortion at the debate is he really portrayed two arguments that I’ve seen sort of trickle up from the grass roots of the anti-abortion movement. So one, there were some semantics quibbles around what is a ban. There’s really been an effort in the anti-abortion movement to say that only a total ban throughout pregnancy with no exceptions, only that they call a ban. Everything else, they don’t consider it a ban. 

Rovner: It’s a national standard. 

Ollstein: Yeah, minimum standard, federal standard. There’s a lot of different words they use — “limit,” “restriction.” But what they’re describing is what others call a ban. It’s not a different policy, and so we saw that on full display on the debate stage. We also saw this argument sort of that these government programs and funding and support are the answer to abortion, so, basically, promoting the idea that with enough child care supports and health care supports, fewer people would have abortions — which the data is mixed on that, I will say, from the U.S. and from other countries. But financial hardship is just one of many reasons people have abortions, so that would impact some people and not others. It also goes against a lot of the sort of traditional small-government, cut-government-spending Republican ethos, and so it is this really interesting sort of pro-natalist direction that some of the party wants to go in and some of the activist movement wants to go in. But there’s definitely some tension around that. And, of course, we’ve seen Republicans vote against those programs and funding at the state and federal level. 

Rovner: Things like paid family leave have been a Democratic priority much, much longer than it’s been a Republican priority, if it ever was and if it is now. 

Ollstein: But it’s interesting that he was promoting that to sort of show a kinder, gentler face to the anti-abortion movement, which has been a trend we’ve been seeing. 

Rovner: Yes. Yes, not just from JD Vance but from lots of Republicans on the anti-abortion side. And Melania— 

Ollstein: Sorry, back to Melania. 

Rovner: Is there any impact from this? 

Edney: Oh, it’s certainly worked for the Trump campaign to muddy the waters on any subject. If you think about immigration, certainly that worked before, and I think you can see where they’re realizing that. And they are coming together, like Alice mentioned, with JD Vance and Trump talking on the same page now a bit better but using sort of a, I don’t want to say “underling,” but like a second … 

Rovner: A surrogate. 

Edney: Yeah, a surrogate, a secondary character to say, I support abortion rights. And she has Trump’s ear, and that could really be a solid salve to a lot of people. 

Rovner: I was fascinated because she’s been pretty much invisible all year. I think this is the first time we have actually heard her voice, the first time I have heard her voice in 2024. 

Raman: I would add that it’s not unprecedented for a first lady on the Republican side to come out in favor of abortion rights. I think what makes it so interesting is, A, how close we are to the election and that we are actively in a campaign. When we look at the remarks that Laura Bush made several years ago, it was after [former President George W.] Bush had left office for a few years. And so this, I think, is just what really makes it, if the book is going to come out about a month or so before the election that … 

Rovner: Melania’s book. 

Raman: Yeah, Melania’s book, yes. 

Rovner: So yes, we will see. All right. Well, abortion was not the only health issue that came up during the debate. So did the Affordable Care Act. JD Vance went as far to claim that Donald Trump is actually the one that saved the Affordable Care Act. That’s not exactly how I remember things happening. You’re shaking your head. 

Raman: I think this was one of the most striking parts of the debate for me, just because he made several comments about how this was a bipartisan process and Trump was trying to salvage the ACA. And for those of us that were reporting in 2017, he was kind of ringleading the effort to repeal and replace the Affordable Care Act. And I guess there were just numerous claims within the few statements he made that were just all incorrect. He was talking about how Trump had divided risk pools, and that was not something that happened. I think that we assume that he was referring to the reinsurance waivers, but those were also created under the Obama administration, so it wasn’t like a Trump invention. We just had some approved under Trump. And he’d mentioned that enrollment was reaching record heights. Health enrollment grew more under the Biden administration than it did under Trump. 

Rovner: Yeah, I went back and actually looked up those numbers because I was so, like, “What are you talking about?” Actually, it was the moderator question: Didn’t enrollment go up during the Trump administration? No, it went down every year. 

Ollstein: The number of uninsured went up, in fact, during the Trump administration. 

Rovner: That’s right. 

Ollstein: But, I mean, this is, again, part of a long pattern. Trump has routinely taken credit for things that were the decisions of other administrations, both before and after him. 

Rovner: And things that he tried to do and failed to do. 

Ollstein: Right. 

Rovner: Like lowering drug prices. 

Ollstein: Right. Right, right, right. Exactly. Exactly. Like Anna said, there was very little new that was revealed in this exchange. 

Rovner: Well, elsewhere on the campaign trail, the Harris campaign is working hard to elevate health care as an issue, including rolling out not just a 60-second ad warning of what repealing the Affordable Care Act could mean, but also issuing a 43-page white paper theorizing what Trump and Vance are likely to have in mind with their, quote, “concepts” of a health care plan based on what they’ve said and done in the past. They must be seeing something in the polls suggesting this could have some legs, don’t you think? I’m a little surprised, because everybody keeps saying: Not a health care election. This is not a health care election. But I don’t know. The Harris campaign sure keeps behaving like it might be. 

Raman: Hammering in on the preexisting conditions and protecting those, just because that is such a popular part of the ACA across the board, is probably a good strategy for them, just because that is something that is not the most wonky with that and that people can understand in a campaign ad and kind of distill down. 

Edney: Yeah, that was what I was thinking as well, is it’s a popular issue for, certainly, to be talking about, but also just the idea that he’s talking about it in a way that people think, Oh, we don’t have to worry. And Alice has made this point on abortion before. There’s a lot that he can do through executive order and things like that, and did do like taking away money for the navigators and things to help people enroll. So even if they don’t think it’s maybe going to be about health care fully, it makes sense to try to counter some of that. And you can’t do that on a debate stage most of the time, not in an effective way, but certainly putting out this paper, I mean, it did get some press and things like that, and if you really wanted to go read it, you could. 

Rovner: Even I didn’t want to read all 43 pages. 

Edney: Yeah. 

Rovner: Well, as Anna previewed, the AARP released what’s normally a pretty routine interview with both candidates about issues important to Americans over age 50, things like Medicare, Social Security, and caregiving. But I think it’s fair to say that, at least, former President Trump’s answers were anything but routine. Asked how he would protect Medicare from cuts and improve the program, he said, and I quote: “What we have to do is make our country successful again. This has to do with Medicare and Social Security and other things. We have to let our country become successful, make our country successful again, and we’ll be able to do that.” How do you even respond to things like that? Or is this campaign now so completely divorced from the issues that literally nothing matters? 

Edney: Well, I kind of noticed a trend in between that answer and one JD Vance gave when he was talking about abortion, and he said: We just need to make women trust us. They need to trust us again. We need to make them trust us. I was like, I don’t understand how that even connects. But also, how are you going to do that? And I think that this is the same thing. You’re just saying these words over and over again in relation. So in somebody’s mind, Medicare and success is Trump’s word, and trust and abortion as JD Vance’s thing, and you’re connecting these in their minds. And I was seeing this as a trend. It just felt familiar to me after listening to the vice-presidential debate. They’re not going to talk about any policy or anything, but repeating these words over and over again like you were listening to morning affirmations or something was going to really get that through in a voter’s mind is maybe what they’re going for. 

Rovner: And I have to say, I mean, when candidates start to talk about actual policy ideas, it gets really wonky really fast. Sort of going back to the debate, JD Vance was talking about visas and immigration, and I think it’s an app that he was talking about. I know this stuff pretty well. I had no idea what he was talking about. I mean, maybe it does work better when Trump says, I’m not going to cut Medicare or Social Security, and leave it at that. 

Ollstein: Well, right, because when you talk specific policies, that opens it up to critique. And when you just talk total platitudes, then it’s harder to pick apart and criticize, even though it’s clearly not an answer to the questions they’re asking. And it was even a little bit funny to me for the AARP interview, because I believe they sent in written responses, and so they had the ability— 

Rovner: I think they also talked on the phone. 

Ollstein: Oh, OK. 

Rovner: So I think it was a little bit of both. 

Ollstein: Right. Right, right, right. It wasn’t the sort of live televised interview. They could have looked up — it was an open-book test. 

Rovner: It was. 

Ollstein: And yet all of the responses from Trump were just like, We’re going to do something and it’s going to be great and awesome and it’ll fix everything, and it was completely devoid of policy specifics, which again may be smarter politically than actually saying what you plan to do, which as we’ve seen in Project 2025, generates a lot of backlash. But it is also a little bit dangerous to go into the election not knowing the specifics of what someone wants to do on health care. 

Rovner: Yeah, I know. I find when I listen to some of these focus groups with undecided voters, we want to know what exactly they’re going to do, except they don’t really want to know what exactly they’re going to do. They think they do, but it appears that that is not necessarily the case. One thing that we know does matter, at least to people on Medicare, is the premiums they pay for their coverage. And unfortunately, for every administration, that announcement comes just weeks before Election Day every year. So this year, the Biden administration was worried about big jumps in premiums for Medicare Part D drug coverage, mostly thanks to the new caps on spending that will save consumers money but will cost insurers more. That didn’t happen, though. And in fact, average premiums will actually fall slightly next year. 

Now, I’m not sure I understand exactly what the administration did to avoid this, but they used existing demonstration authority to boost payments to insurers. And, not surprisingly, Republicans are pretty furious. On the other hand, Republicans used pretty much this same authority to avoid Medicare premium spikes in the past. Anna, is this just political manipulation or good governing, or a little bit of both? 

Edney: Yeah, it is certainly very timely and probably necessary also because the IRA, the Inflation Reduction Act, kept the seniors’ out-of-pocket pay at $2,000 a year. And so that was going to skyrocket premiums, and they did not want to face that, particularly in an election year. And as you mentioned, this all happens around that time. And so they did this demonstration, and I have read a few things trying to figure out exactly what it does, and I can’t. 

Rovner: So it’s not just me. It’s complicated. 

Edney: It’s not just you. It’s really complicated, and it has to do with payments that usually come at the end that insurers are now going to get upfront. And that’s the best I can tell you. But they’ll be getting some subsidies upfront, and it’s to try to spread these premium increases to help mitigate those so that seniors don’t have to then pay on that end instead of for their drugs out-of-pocket. So I think that they need to do something. I mean, already, the premiums were able to go up. I think it’s $35 a month, and some plans did elect to do that and others have them staying even. And you even have some with them going down a little bit. So I guess the moral of the story is for consumers to shop around this year, certainly. 

Rovner: That’s right, and we will talk more about Medicare open enrollment, which opens in a couple of weeks, because it’s October, and all of these things happen at once. Moving back to abortion, a judge in Georgia struck down, at least for now, the state’s six-week abortion ban, quoting from “The Handmaid’s Tale” about how the law requires women to serve as human incubators. And I’ll put a link to the decision, because that’s quite the decision. But Alice, this is far from the last word on this, right? 

Ollstein: Yes. It’s just so fascinating what a slow burn these lawsuits are. I mean, this, the one in North Dakota recently that restored access, these just sort of simmer under the radar for months or even years, and then a decision can have a major impact. And so access has been restored in some of these states. Some interesting things that came to mind were, one, it could be reversed again and pingpong back and forth, and all of that is very challenging for doctors and patients to manage. 

But also — and I’m thinking more of North Dakota, because Georgia is sort of a medical powerhouse with a lot of providers and hospitals and facilities and stuff — but in North Dakota, the state’s only abortion clinic moved out of state, and they do not plan to move back as a result of this decision. This isn’t a switch you can flip back and forth. And so when access is restored on paper in the law, that doesn’t mean it’s going to be restored in practice. You need doctors willing to work in these states and provide the procedure. And even with the court rulings, they may not feel comfortable doing so, or the logistics are just too daunting to move back. So I would urge people to keep that in mind. 

Rovner: Yeah, and the state’s already said that it’s going to appeal to the next-higher court. So we will see this continue, but I think it was definitely worth mentioning. We’ve talked a lot this year about women experiencing pregnancy complications not being able to get care in states with abortion bans and restrictions. Well, it’s happening in states where abortion is supposed to be widely available, too. 

In California, the state’s attorney general filed suit this week against a Catholic hospital in the rural northern part of the state that refused to terminate the doomed pregnancy of a woman carrying twins after her water broke at 15 weeks, because they said one of the twins still had a heartbeat. She eventually was driven to the only other hospital within a hundred miles of the labor and delivery unit, where she did get the care that she needed, although she was hemorrhaging, but not until after a nurse at the Catholic hospital gave her a bucket of towels, quote, “in case something happens in the car.” Meanwhile, the labor and delivery unit at the hospital she was taken to is itself scheduled to close. Are women starting to get the idea that this is about more than just selective abortions and that no matter where they live, that being pregnant could be more dangerous than it has been in the past? 

Raman: I was going to say this is something that abortion rights advocates have been saying for years now, that it’s not just abortion, that they point to things like the whole ordeal that we’ve been having with IVF [in vitro fertilization] and birth control and so many other things. Even in the last couple years, people trying to get other medications that have nothing to do with pregnancy and not being able to get those because they might have an effect or cause miscarriage or things like that. So I think in one way, yes. But at the same time, when you look at something like what we saw happen with the two deaths in Georgia, right? The messaging from the anti-abortion crowd has been that this was not because of the abortion ban but because of the regulations that allowed these people to get a medication abortion and that’s what’s driving the death. 

So we think that, in some ways, there’s certain camps that are just going to be focused on a different side of how the emergency might not be related to abortion at all, or the branding is that this is not an abortion in certain cases versus an abortion, it’s just semantics. So I don’t know how many minds it’s changing at this point. 

Ollstein: Like Sandhya said, the awareness that this is not just for so-called elective abortions. Obviously, that term is disputed and there’s gray area of what that means. I think the overwhelming focus in messaging — from Democrats, anyway — has been about these wanted pregnancies that suffer medical complications and people can’t get care, and so the spillover effect on miscarriage care. But I think the piece that’s new that this could emphasize is that it’s not a strict red-state-blue-state divide, that Catholic hospitals and other facilities in states with protections, like California — it could happen there, too. So I think that’s what this case may be contributing in a new way to people’s understanding. 

Rovner: And, of course, this was happening long before Dobbs — I mean, with Catholic hospitals, particularly Catholic hospitals in areas where there are not a lot of hospitals, denying care according to Catholic teachings and women having basically no place, at least nearby, to go. So I think people are seeing it in a new light now that it seems to be happening in many, many places at the same time. Well, while we are visiting California, Governor Gavin Newsom this week signed legislation requiring large group health insurance plans to cover IVF and other fertility treatments starting next year. California is far from the first state to do this. I think it’s now up to over a dozen. But it’s by far the most populous state to do this. Do we expect to see more of this, particularly given, as you were saying, Sandhya, the attention that IVF is suddenly getting? 

Raman: I think we could. We’ve had a lot of states do different variations of those so far, and they haven’t necessarily been blue versus red. I think one thing that was interesting about the California law in particular was that it included LGBTQ people within the infertility definition, which we’ve been having IVF laws for over 20 years at this point and I don’t know that that has been necessarily there in other ones. So I would be watching for more things like that and seeing how widespread that would be in some of the bills coming up in the next legislative cycle. 

Rovner: Yes, and another issue that I suspect will continue to simmer beyond this election. Well, finally this week, two big business-of-health-related stories: Over the summer, we talked about how the CEO of Steward Health Care, which is a chain of hospitals bought out by private equity and basically run into bankruptcy, refused to show up to testify before the Senate Health, Education, Labor and Pensions Committee. Well, in the last two weeks, the committee, followed by the full Senate, voted to hold CEO Ralph de la Torre in criminal contempt. And as of last week, he is now ex-CEO Ralph de la Torre, and now he is suing the Senate over that contempt vote. If nothing else, I guess this raises the stakes in Congress to continue to look at the impact of private equity in health care? 

Edney: Yeah, I think it’s interesting, because when you look at [Sen.] Bernie Sanders calling in pharmaceutical CEOs, they typically show up and they take their hits and they go home. And in this case, it probably kind of heightens that idea that private equity is the evil person. And I’m not saying everyone thinks pharma is not, but they do understand Washington. And there’s a chance that a lot of New York–focused, Wall Street–focused private equity folks may not get that quite in the same way or just may not view it as important. But now, that may be changing. 

Rovner: I was surprised by how bipartisan this was. 

Edney: Yeah. 

Rovner: I mean, beating up on pharma tends to be a Democratic thing, but this was bipartisan in the committee and bipartisan in the Senate. I mean, it’s also important to remember that Steward Health Care is a chain of hospitals in a whole bunch of states, so there are a lot of senators who are seeing hospitals in, now, dire straits through this whole private equity thing, who I imagine are not very happy about it. And their constituents are not very happy about it. But I think the bipartisanship of it is what sort of stuck out to me. 

Raman: I was just going to say hospitals are such a big employer for so many districts that I think that, but I would say this was the first time in 50 years they’ve sent a contemptor to the DOJ [Department of Justice]. And especially doing that in a unanimous fashion is just very striking to me, and I’m curious if DOJ kind of goes forth and does, takes penalty and action with it. 

Rovner: Yeah, this is a real under-the-radar story that I think could explode in a big way at some point. Well, the other big, evolving business story this week involves Medicare Advantage, the private sector alternative that gives enrollees extra benefits and makes insurance shareholders rich, mostly at taxpayer expense. Well, the party is, if not ending, then at least slowly closing down. Humana’s stock price dropped dramatically this week after the company reported the new way Medicare officials are calculating quality scores from Medicare Advantage. They get stars. The more stars, the better. The new way that Humana appears to be getting its stars could effectively deprive it of its entire operating profit. 

In separate news, UnitedHealthcare is suing Medicare over its Medicare Advantage payments in one of those single-judge conservative districts in Texas, of course. Democrats have been working to at least somewhat rein in these excess payments to Medicare Advantage for the past, I don’t know, two decades or so, but I assume this will all likely be reversed if Trump wins. And Medicare Advantage has been a troublesome issue because it’s really popular with beneficiaries, but it’s really expensive, because it’s really popular, because they get extra money, and some of that extra money goes to give extra benefits. Talk about things that are hard to explain to people. It’s great that you get all these extra benefits, but it’s costing the government more than it should. 

Edney: Yeah. 

Raman: I guess I do wonder if people, how much attention they’re paying. Are they going to switch plans if it’s dropping that many stars? If you’re on a Humana plan and a huge number of them got demoted to a lower rating, the next time you’re looking for a plan, are you going to switch to something else? And how often people are doing that and just if that would move the needle, because it’s just a longer process than overnight. 

Rovner: Although, I think it isn’t just that people have to switch. If people stay in those plans with fewer stars, the company gets less money. 

Raman: Yeah. 

Rovner: Because they get bonuses when people are in the, quote-unquote, “higher quality” plan. So even if their four-star plan is now a three-star plan and they stay in it, the company’s going to lose money, which I think is why the stock price took such a quick and dramatic bath. 

Edney: Yeah, I was surprised. It’s such a seemingly wonky issue, but it did really hit Humana very hard in the stock price. Technically, I think — correct me if I’m wrong — the stars aren’t even out yet. This is people doing searches to see if they can find some of them that have been changed at all, and so they’re coming out soon, but Humana particularly is very Medicare-focused out of all of the insurers. They rely on that for a large part of their revenue, so it is a big deal for them. I don’t know how much, but certainly Wall Street was. And as you mentioned with Trump, the Republicans typically really have supported Medicare Advantage because it is private insurers offering this instead of being just government-run Medicare. So that could have an effect. 

It’s hard to tell why their stars went down currently. With UnitedHealth, you at least get a little insight. They’re suing because, last year, their star rating went down for some plans, they said, because of one bad customer service phone call. So someone from Medicare calls and does a test thing, and UnitedHealth says they didn’t ask the right question, so the person never got a chance to answer it correctly, and then their star ratings went down. So, it does feel like it could happen at any point for any reason, so I don’t know how conducive that is, how much that actually plays into people who might have a Humana plan that think, “Oh, I haven’t had any issues, so why would I change?” 

Rovner: Yeah. All these under-the-hood things, as you point out, we have all looked at and don’t quite understand is worth billions and billions and billions of dollars. It’s one of the reasons why health care is so expensive and such a big part of the economy. All right. Well, we will continue to watch that space, too. That is the news for the week. Now we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back with our extra credits. 

I am pleased to welcome to the podcast my KFF Health News colleague Lauren Sausser, who reported and wrote the latest KFF Health News “Bill of the Month.” Lauren, thanks for joining us. 

Lauren Sausser: Thanks for having me. 

Rovner: So tell us about this month’s patient, who he is, and what kind of medical care he needed. 

Sausser: This month’s patient is a young man named Preston Nafz. He’s 17. He’s a senior in high school. He lives in Hoover, Alabama, which is right outside of Birmingham. And he played youth sports his whole life and recently is focused on lacrosse, but like many kids in this country, he has sort of cycled through a bunch of different sports, and ended up injured last year. 

Rovner: And what happened? 

Sausser: He had really debilitating pain in his hip, and the pain was progressive. And, obviously, they tried some treatments on one end of the spectrum, but it kept growing worse and worse. And at one point last year, he ended up limping off of the lacrosse field. He couldn’t do really simple things like turning over in bed or getting in and out of a car. These things were really painful for him. So he ended up as a patient at a sports medicine clinic, and providers at that clinic recommended surgery. 

Rovner: And to cut to the chase, the story, at least medically, has a happy ending, right? The surgery worked? He’s better? 

Sausser: Yes, the surgery worked. He ended up getting something late last year, a procedure called a sports hernia repair, which is a little bit of a misnomer because he didn’t actually have a hernia. But it’s kind of a catchall phrase that orthopedic surgeons use to talk about a procedure to relieve this type of pain that he was having in his pelvis, groin area. And the recovery was longer than he was anticipating, but yes, it medically does have a happy ending. He was able to play lacrosse again, although the last time I spoke to him, he had another sports-related injury. But the sports hernia repair did do what it was supposed to do, so that’s the good news. 

Rovner: So it sounded like it should have been routine. Kid growing up, gets hurt playing sports, family has health insurance, goes to sports medicine, doctor fixes problem. Except for the bill, right? 

Sausser: Yeah. So the interesting thing about this story, and this is really why we pursued it, is because there is no CPT [Current Procedural Terminology] code for a sports hernia repair. CPT codes, your listeners are probably familiar with, but they’re the medical codes that providers and insurers use to figure out how things get paid for. And it can become more complicated when there’s no code for a procedure, which was the case here. So Preston’s dad was told before the surgery that he was going to have to pay upfront because his insurance company, which was Blue Cross Blue Shield of Alabama, likely wasn’t going to pay for it. 

Rovner: And how much was it upfront? 

Sausser: It was just over $7,000. So the surgery itself was $6,000. There was, I think, almost $500 for anesthesia, a little over $600 for the facility fee. And Preston’s dad paid for it on a few different credit cards. 

Rovner: So kid has the surgery, is in rehab, and Dad is now trying to recoup this money that he has paid for upfront. And what happened then? 

Sausser: Yeah. Before the surgery even happened, Preston’s dad tried to call his insurance company and say: Can I get this covered? My son’s doctor says this is medically necessary. And initially, he got good news. His insurer said: It sounds like this is something that should be covered. If this is something that’s medically necessary, your insurance plan generally covers those things. As the date of the surgery grew closer and closer, he found that the people he was talking to at the insurance company weren’t being as definitive with their answers. And so before the surgery, he got a no. He said he got a no from his insurer saying that they were not going to cover this. Now, on the back end of the surgery, after he’d paid the bill with those credit cards, he tried to appeal that decision by filing a lot of paperwork. And he did end up getting a few hundred dollars reimbursed, but when the insurer sent him that check, it was unclear exactly what they were covering. And, obviously, that didn’t come close to the $7,000-plus that they had paid for it. 

Rovner: So that’s what eventually happened with the bill, right? He ended up getting stuck with almost all of it? 

Sausser: Yeah. 

Rovner: Is there anything he could have done differently that might’ve helped this get reimbursed? 

Sausser: That’s the tricky thing about this story, because they did do almost everything right. But it’s almost a cautionary tale for people who are faced with this prospect in the future. So if your provider is recommending something that doesn’t have a CPT code, it is going to be harder to get reimbursed from your insurer. You should assume that. That’s not to say it’s impossible, but it’s going to take more work on your end. It’s going to take more paperwork, it may take more work on your doctor’s end, and you should be prepared to get some pushback, if that makes sense. 

Rovner: And has he just sort of written this off? 

Sausser: I mean, he paid off the surgery using the credit cards. And the last I spoke to this family, they were still getting some confusing communication from their insurer. I don’t know that they’ve gotten the final, final no yet. I think that he still is invested in getting reimbursed if he can. But at this point, we’re approaching almost the one-year anniversary of the surgery, so it’s looking less likely. 

Rovner: Well, we will keep following it. Lauren Sausser, thank you so much. 

Sausser: Thanks for having me. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We’ll include links to all these stories in our show notes on your phone or other mobile device. We have two hurricane-related extra credits this week. Sandhya, why don’t you go first? 

Raman: My extra credit this week is called “Without Water After Helene: Residents at Asheville Public Housing Complex Fear for Their Health,” and it is from the Asheville [North Carolina] Citizen Times, by Jacob Biba. And the story just looks at the residents of a specific complex in Asheville that have been hit really hard by the hurricane. And, when this was written, they’d been without water for two days and it might not come back for weeks, and just some of the public health impacts they were facing. One person couldn’t clean their nebulizer or their tracheostomy tube. Others were worrying about sanitation from not being able to flush toilets. I think it’s a good one to check out. 

Rovner: Yeah. We think about so many things with hurricanes. We think about being without power. We don’t tend to think about being without water. Alice, you have a related story. 

Ollstein: Yeah, and this is more of a supply chain story but really shows that these hurricanes and natural disasters can have really widespread impacts outside the region that they’re in. And so this is from The Wall Street Journal. It’s called “Hospitals Hit With IV Fluid Shortage After Hurricane Helene.” It’s by Joseph Walker and Peter Loftus, and it’s about a facility in North Carolina that produces, like I said, IV bag fluids that hospitals around the country depend on. And yeah, we’ve talked before about just how vulnerable our medical supply chains are and we don’t spread the risk around maybe as much as we need to in this age of climate instability. And so, yeah, hospitals, they’re not rationing the fluids, but they are taking steps to conserve. And so they’re thinking, OK, certain patients can take fluids orally instead of intravenously in order to conserve. And so that’s happening now. Hopefully, it doesn’t become rationing down the road. But, yeah, with the long recovery the region is expecting, it’s a bit scary. 

Rovner: Anna. 

Edney: I did one from a colleague of mine at Bloomberg, John Tozzi. It’s “A Free Drug Experiment Bypasses the US Health System’s Secret Fees.” So he looked at this Blue Shield of California plan that is deciding to just bypass the pharmacy benefit managers and go directly to a drugmaker to get a biosimilar of Humira, the rheumatoid arthritis and many other ailments drug. And they’re going to be getting it for $525 a month for this drug that a lot of the PBMs are offering for more than a thousand dollars. And so the PBMs mentioned to him, We give rebates, and it’s less than a thousand dollars. But they didn’t say if it was as low as $525. And Blue Shield of California seems to think that this is a really good deal and that they’re basically going to give it for free just to show that it can reach Americans affordably. And so I thought it was a good look at this plan and at maybe a trend, I don’t know, that plans might start going outside of the PBM network. 

Rovner: We shall see. Well, I chose a story from KFF Health News this week from Ronnie Cohen, and it’s called “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” and it’s a really thoughtful piece about how to best protest things you disagree with. In this case, some doctors want medical groups to move professional conferences out of states with abortion bans, in order to exert financial pressure and to make a point. But there are those who worry that that amounts to punishing the victims and that it won’t do much anyway, frankly, unless you’re the Super Bowl or the baseball All-Star Game. It’s not like your conference is going to make or break some city’s annual budget. But it’s a microcosm of a bigger debate that’s going on in medicine that I’ve been covering. How do doctors balance their duty to serve patients with their duty to themselves and their own families? There are obviously pregnant medical professionals who do not wish to travel to states with abortion bans lest something bad happens. It’s a struggle that is obviously going to continue. It’s a really interesting story. 

OK. That is our show. Before we go this week, it is October and we want your scariest Halloween haikus. The winner will get their haiku illustrated by our award-winning in-house artists, and I will read it on the podcast that we tape on Halloween. We will have a link to the entry page in our show notes. 

As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me at X. I’m @jrovner. Sandhya? 

Raman: @SandhyaWrites. 

Rovner: Anna? 

Edney: @annaedney. 

Rovner: Alice. 

Ollstein: @AliceOllstein. 

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

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

A unanimous Supreme Court turned back a challenge to the FDA’s approval and rules for the abortion pill mifepristone, finding that the anti-abortion doctor group that sued lacked standing to do so. But abortion foes have other ways they intend to curtail availability of the pill, which is commonly used in medication abortions, which now make up nearly two-thirds of abortions in the U.S.

Meanwhile, the Biden administration is proposing regulations that would bar credit agencies from including medical debt on individual credit reports. And former President Donald Trump, signaling that drug prices remain a potent campaign issue, attempts to take credit for the $35-a-month cap on insulin for Medicare beneficiaries — which was backed and signed into law by Biden.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Rachana Pradhan of KFF Health News, and Emmarie Huetteman of KFF Health News.

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna's stories.

Emmarie Huetteman
KFF Health News

@emmarieDC

Read Emmarie's stories.

Rachana Pradhan
KFF Health News

@rachanadpradhan

Read Rachana's stories.

Among the takeaways from this week’s episode:

• All nine Supreme Court justices on June 13 rejected a challenge to the abortion pill mifepristone, ruling the plaintiffs did not have standing to sue. But that may not be the last word: The decision leaves open the possibility that different plaintiffs — including three states already part of the case — could raise a similar challenge in the future, and that the court could then vote to block access to the pill.
• As the presidential race heats up, President Joe Biden and former President Donald Trump are angling for health care voters. The Biden administration this week proposed eliminating all medical debt from Americans’ credit scores, which would expand on the previous, voluntary move by the major credit agencies to erase from credit reports medical bills under $500. Meanwhile, Trump continues to court vaccine skeptics and wrongly claimed credit for Medicare’s $35 monthly cap on insulin — enacted under a law backed and signed by Biden.
• Problems are compounding at the pharmacy counter. Pharmacists and drugmakers are reporting the highest numbers of drug shortages in more than 20 years. And independent pharmacists in particular say they are struggling to keep drugs on the shelves, pointing to a recent Biden administration policy change that reduces costs for seniors — but also cash flow for pharmacies.
• And the Southern Baptist Convention, the nation’s largest branch of Protestantism, voted this week to restrict the use of in vitro fertilization. As evidenced by recent flip-flopping stances on abortion, Republican candidates are feeling pressed to satisfy a wide range of perspectives within even their own party.

Also this week, Rovner interviews KFF president and CEO Drew Altman about KFF’s new “Health Policy 101” primer. You can learn more about it here.

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

Julie Rovner: HuffPost’s “How America’s Mental Health Crisis Became This Family’s Worst Nightmare,” by Jonathan Cohn.

Anna Edney: Stat News’ “Four Tops Singer’s Lawsuit Says He Visited ER for Chest Pain, Ended Up in Straitjacket,” by Tara Bannow.

Rachana Pradhan: The New York Times’ “Abortion Groups Say Tech Companies Suppress Posts and Accounts,” by Emily Schmall and Sapna Maheshwari.

Emmarie Huetteman: CBS News’ “As FDA Urges Crackdown on Bird Flu in Raw Milk, Some States Say Their Hands Are Tied,” by Alexander Tin.

Also mentioned on this week’s podcast:

• Bloomberg News’ “Dozens of CVS Generic Drug Recalls Expose Link to Tainted Factories,” by Anna Edney and Peter Robison.
• KFF Health News’ “Biden Plan To Save Medicare Patients Money on Drugs Risks Empty Shelves, Pharmacists Say,” by Susan Jaffe.
• KFF Health News’ “More States Legalize Sales of Unpasteurized Milk, Despite Public Health Warnings,” by Tony Leys.

click to open the transcript

Transcript: SCOTUS Rejects Abortion Pill Challenge — For Now

KFF Health News’ ‘What the Health?’ Episode Title: ‘SCOTUS Rejects Abortion Pill Challenge — For Now’Episode Number: 351Published: June 13, 2024

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

Mila Atmos: The future of America is in your hands. This is not a movie trailer and it’s not a political ad, but it is a call to action. I’m Mila Atmos and I’m passionate about unlocking the power of everyday citizens. On our podcast “Future Hindsight,” we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, June 13, at 10:30 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go.

We are joined today via video conference by Anna Edney of Bloomberg News.

Anna Edney: Hi there.

Rovner: Rachana Pradhan of KFF Health News.

Rachana Pradhan: Hello.

Rovner: And Emmarie Huetteman, also of KFF Health News.

Emmarie Huetteman: Good morning.

Rovner: Later in this episode we’ll have my interview with KFF President and CEO Drew Altman, who I honestly can’t believe hasn’t been on the podcast before. He is here to talk about “Health Policy 101,” which is KFF’s all-new, all-in-one introductory guide to health policy. But first, this week’s news.

So, as we tape, we have breaking news from the Supreme Court about that case challenging the abortion pill mifepristone. And you know how we always say you can’t predict what the court is going to do by listening to the oral arguments? Well, occasionally you can, and this was one of those times the court watchers were correct. The justices ruled unanimously that the anti-abortion doctors who brought the suit against the pill lack standing to sue. So the suit has been dismissed, wrote Justice [Brett] Kavanaugh, who wrote the unanimous opinion for the court: “A plaintiff’s desire to make a drug less available for others does not establish standing to sue.” So, might anybody have standing? Have we not maybe heard the end of this case?

Edney: Yeah, I think certainly there could be someone else who could decide to do that. I mean, just quickly looking around when this came out, it seems like maybe state AGs [attorneys general] could take this up, so it doesn’t seem like it’s the last of it. I also quickly saw a statement from Sen. [Bill] Cassidy, a Republican, who mentioned this wasn’t a ruling on the merits exactly of the case, but just that these doctors don’t have standing. So it does seem like there would be efforts to bring it back.

Rovner: This is not going to be the last challenge to the abortion pill.

Edney: Yeah.

Pradhan: Just looking in my inbox this morning after the decision, I mean it’s clear the anti-abortion groups are really not done yet. So I think there’s going to be a lot of pressure, of course, from them. It is an election year, so they’re trying to get, notch wins as far as races go, but also to get various AGs to keep going on this.

Rovner: And if you listen to last week’s podcast, there are three AGs who are already part of this case, so they may take it back with the district court judge in Texas. We shall see. Anyway, more Supreme Court decisions to come.

But moving on to campaign 2024 because, and this seems impossible, the first presidential debate is just two weeks away.President [Joe] Biden is still struggling to convince the public that he’s doing things that they support. Along those lines, this week the administration proposed rules that would ban medical debt from being included in calculating people’s credit scores. I thought that had happened already. What would this do that hasn’t already been done?

Huetteman: Well, last year the big credit agencies volunteered to cut medical debt that’s below $500 from people’s credit reports. Of course, there’s a lot of evidence that shows that that’s not really the way that people get hurt with their credit scores, they get hurt when they have big medical bills. So this addresses a major concern that a lot of Americans have with paying for health care in the United States.

I oversee our “Bill of the Month” project with NPR and I can say that a lot of Americans will pay their medical bills without question, even for fear of harm to their credit score, even if they think that their bill might be wrong. Also, it’s worth noting also that researchers have found that medical debt does not accurately predict whether an individual is credit-worthy, actually, which is unlike other kinds of debt that you’d find on credit scores.

Rovner: So yeah, not paying your car payment suggests what you might or might not be able to do with a mortgage or a credit card. But not paying your surprise medical bill, maybe not so much?

Huetteman: Yes, exactly. Really, we can all end up in the emergency room with a big bill. You don’t get a big bill just because you have trouble meeting your credit card bills or you have trouble meeting your car payments, for example.

Rovner: We’ll see if this one resonates with the public because a lot of the things that the administration has done have not. Meanwhile, President [Donald] Trump, who presided over one of the most rapid and successful vaccine development projects ever, for the covid vaccine, now seems to be moving more firmly into the anti-vax camp, and it’s not just apparently anti-covid vaccine. Trump said at a rally last month that he would strip federal funding from schools with vaccine mandates — any vaccines apparently, like measles and mumps and polio — and he says he would do it by executive order. No legislation required. This feels like it could have some pretty major consequences if he followed through on this. Anna, I see you nodding. You have a toddler.

Edney: Right, right. I was just thinking about that going into kindergarten, what that could mean, and there’s just so many … I mean, even kids don’t have to get chickenpox nowadays. That seems like a really great thing. I don’t know. I mean, I had chickenpox. I think that it could take us backwards, obviously, into a time that we’re seeing pockets of as measles crops up in certain places and things like that. I’d be curious. What I don’t know is how much federal funding supports a lot of these schools. I know there’s state funding, county funding, how much that’s actually taking away if it would change the minds of certain ones. But I guess if you’re in maybe a state that doesn’t like vaccines in the first place, it’s a free-for-all to go ahead and do that.

Pradhan: One of the questions I have, too, is through the CDC [Centers for Disease Control and Prevention] we have the Vaccines for Children Program, which provides free immunizations to children for a lot of these infectious diseases, for children who are either uninsured or underinsured or low-income. And so that’s been a really long-standing program and I’m very curious as to whether they would try to maybe reduce or eliminate a bunch of the vaccines that are provided through that, which obviously could affect a significant number of children nationwide.

Rovner: Yeah, it’s funny, the anti-vax movement has been around for, I don’t know, 20, 25 years; whenever that Lancet piece that later got rescinded came out that connected vaccines to autism. It seems it’s getting a boost and, yes, that’s an intended pun right now. I guess covid, and the doubts about covid, is pushing onto these other vaccines, too.

Edney: I think that we’ve certainly seen that. Before covid, at least my understanding of a lot of the concerns around the behavioral issues and autism linked to vaccines or things like that was more of the left-wing, maybe crunchier people who were seeing it as not wanting to put, in their words, poison in their bodies. But now we’re seeing this also right-wing opposition to it, and I think that’s certainly linked to covid. Any mandate at this point from the government is pushed back against more so than before.

Rovner: Well, we have lots of news this week on drugs and drug prices. Anna, you have quite the story about how trying to save money by buying generic might not always be the best move? As I describe it: the scary story of the week. Tell us about it.

Edney: Yes. Yeah, thank you. Yeah, I did this data dive looking into store-brand medication. So when you go into CVS or Walgreens, for example, you can see the Tylenol brand name there, but next to it you’ve got one that looks a lot like it, but it’s got CVS Health or Walgreens on the name and it costs usually a few dollars less. What I found is that of those store brands, CVS has a lot more recalls than the rest, even though they’re selling these same store-brand drugs. So they have two to three times more recalls than Walgreens and Walmart. And what’s happening is they are more often going to shady contract manufacturers to make their generic products that they’re selling over the counter. I found one that was making kids’ medication with contaminated water. And then the really disturbing one that was nasal sprays for babies on the same machines that this company was using to make pesticides. And just wrote about a whole litany of these kinds of companies that CVS is hiring at a higher rate than the other two — Walgreens and Walmart — that I was able to do the data dive on.

And interestingly, these store brands have a loophole, so they’re not responsible for the quality of those medications, even though their name’s on it. They can just walk away and say, “Well, we put it on the shelves. We agree with that, but it’s up to these companies that are making it to verify the quality.” And so, that’s usually not how this works. Even if there’s contract manufacturers, which a lot of drugmakers use, they usually have to also verify the quality. But store brands are considered just distributors, and so there’s this separation of who even owns the responsibility for this drug.

Pradhan: Yeah, I think a collective reaction reading this. I know, how many people did I text your story to Anna, saying, “Yikes! … FYI.”

Rovner: So on the one hand, you get what you pay for. On the other hand, price is not the only problem that we find with drugs. A new study from the University of Utah Drug Information Service just found that pharmacists are reporting the largest number of drugs in shortage since the turn of the century. And my colleague Susan Jaffe has a story on how some shortages are being exacerbated at the pharmacy level by a new Medicare rule that was intended to lower prices for patients at the counter.

Anna, how close are we to the point where the drug distribution system is just going to collapse in on itself? It does not seem to be working very well.

Edney: Yeah, it does feel that way because I always think of that example of the long balloon and when you squeeze it at one end the other end gets bigger. Because when you’re trying to help patients at the counter, somebody’s taking that hit, that money isn’t just appearing out of thin air in their pockets. So the pharmacists are saying — and particularly smaller pharmacies, but also some of the bigger ones — are saying the way that these drugs are now being reimbursed, how that’s working under this new effort, is they don’t have as much cash on hand, so they’re having trouble getting these big brand-name drugs. It was a really interesting story that Susan wrote. Just shows that you can’t fix one end of it, you need to fix the whole thing somehow. I don’t know how you do that.

And shortages are another issue just of other kinds, whether it’s quality issues or whether it’s the demand is growing for a lot of these drugs, and depending even on the time of year. So I think we’re all seeing it just appear to be disintegrating and hoping that there’s just no tragedy or big disaster where we really need to rely on it.

Rovner: Yeah, like, you know, another pandemic.

Edney: Exactly.

Rovner: There’s also some good news on the drug front. An FDA [Food and Drug Administration] advisory committee this week recommended approval for yet another potential Alzheimer’s drug, donanemab, I think I’m pronouncing that right. I guess we’ll learn more as we go on. The drug appears to have better evidence that it actually slows the progression of the disease without the risks of Aduhelm, the controversial drug approved by the FDA that’s been discontinued by its manufacturer. This would be the second promising drug to be approved following Leqembi last year. When we first started talking about Aduhelm — what was that, two years ago — we talked about how it could break Medicare financially because so many people would be eligible for such an expensive drug. So now we’re looking at maybe having two drugs like this and I don’t hear people talking about the potential costs anymore.

Is there a reason why or are we just worried about other things?

Edney: Well, I think there’s a benefit that they seem to have proven more than Aduhelm. But there’s also still a risk of brain swelling and bleeding, and that I’m sure would factor into someone’s decision of whether they want to try this. So maybe people aren’t exactly flocking in the same way to want to get these drugs. As they’re used more, maybe that changes and we see more of “Can you spot the swelling? Can you stop it?” And things like that. But I think that there just seems to be a lot of questions around them. Also, Aduhelm was the biggest one, which obviously Medicare didn’t cover, and then they’re not even trying to sell anymore. But I think that there’s just always questions about how they’re tested, how much benefit really there is. Is a few months worth that risk that you could have a major brain issue?

Rovner: While we are on the subject of drugs and drug prices, we have “This Week in Misinformation” from former President Trump, who as we all know, likes to take credit for things that are not his and deflect blame from things that are. Now in a post on his Truth Social platform, he says that he is the one who lowered insulin copayments to $35 a month, and that President Biden “had nothing to do with it.” Yes, the Trump administration did offer a voluntary $35 copayment program for Medicare Part D plans, but it was limited. It was time-limited and not all the plans adopted it. President Biden actually didn’t do the $35 copay either, but he did propose and sign the law that Congress passed that did it. It was part of the Inflation Reduction Act. Ironically, President Biden didn’t get all he wanted either. The intent was to limit insulin copayments for all patients, but so far, it’s only for those on Medicare. I would guess that Trump is saying this to try to neutralize one of the few issues that maybe is getting through to the public about something that President Biden did.

Pradhan: Well, I mean, I think even during President Trump’s first term, I mean lowering drug prices, he made it very clear that that was something that was important to him. He certainly wasn’t following the traditional or older Republican Party’s friendliness to the pharmaceutical industry. I mean, he was openly antagonizing them a lot, and so it’s certainly something that I think he understands resonates with people. And it’s a pocketbook issue similar to what’s going on on medical debt that we talked about earlier, right? These new regulations that are being proposed — they may not be finalized, we’ll have to see about that because of the timing — but these are things that are, I think at the end of the day, of course, are very relatable to people. Unlike, perhaps, abortion is a big campaign issue, but it’s not necessarily going to resonate with people in the same way and certainly not potentially men and women in the same way. But I think that there’s much more broad-based understanding of having to pay a lot for medications and potentially not being able to afford it. Obviously, insulin is probably the best poster child for a lot of reasons for that. So no surprise he wants to take credit for it, and also perhaps that it’s not really what happened, so …

Rovner: If nothing else, I think it signals that drug prices are still going to be a big issue in this campaign.

Pradhan: For sure. And I mean Joe Biden has made it very clear. I mean the Inflation Reduction Act of course included other measures to lower people’s out-of-pocket costs for drugs, which he’s very eagerly touting on the trail right now to shore up support.

Rovner: Let’s move on from drugs to abortion via the FDA spending bill on Capitol Hill this week. The annual appropriations bills are starting to move in House committees, which is notable itself because this is when they are supposed to start moving if they’re going to get done by Oct. 1, the start of the next fiscal year. We haven’t seen that in a long time. So last year Republicans got hung up because they wanted their leaders to attach all manner of policy riders to the spending bills, most of them aimed at abortion, which can’t get through the Senate. Well in a big shift, Republicans appear to be backing off of that, and the current version of the bill that funds the Department of Agriculture, as well as the FDA, does not include language trying to ban or further restrict the abortion pill mifepristone. Of course, that could still change, but my impression is that the new [House] Appropriations chairman, [Rep.] Tom Cole, who’s very much a pragmatist, wants to get his bills signed into law.

Pradhan: I do wonder, though, if because of the Supreme Court decision that just came out today, whether that will change the calculation, or at the very least, the pressure that he is under to include something in the FDA bill. But as you know, there’s plenty of time for abortion riders to make it in or out. I feel like this is, it’s like Groundhog Day. Usually something related to abortion policy will upend various pieces of legislation. So I’ll be curious to be on the lookout for that, whether it changes anything.

Rovner: Anna, were you surprised that they left it out, at least at the start?

Edney: Yeah, I think you’re just what we’ve seen with all of the rancor around abortion and abortion-related issues, I guess a little surprised. But also maybe it makes sense in just the sense that there are Republicans who are struggling with that issue and don’t want to have to keep talking about it or voting on it in the same way.

Rovner: Well, that leads right to my next subject, which is that the Senate is voting this afternoon, after we tape, on a bill that would guarantee access to IVF. Republicans are expected to block it as they did last week on the bill to guarantee access to contraception. But as of Wednesday, it’s going to be harder for Republicans to say they’re voting against the bill because no one is threatening to block IVF. That’s because the influential Southern Baptist Convention, one of the nation’s largest evangelical groups, voted, if not to ban IVF, at least to restrict the number of embryos that can be created and ban their destruction, which doctors say would make the treatments more expensive and less successful. It sounds like the rift among conservatives over contraception and IVF is a long way from getting settled here.

Huetteman: That certainly seems to be true. It’s also worth noting that there are a lot of influential members of Congress who are Baptist, of course, including House Speaker Mike Johnson. And I was refreshing my memory of the religious background of the current Congress with a Pew report: They say 67 members of this Congress are Baptist. Of course, Southern Baptist is the largest piece of that. And 148 are Catholic, which of course is another denomination that opposes IVF as well. So that’s a pretty big constituency that has their churches telling them that they oppose IVF and should, too.

Rovner: Yeah, everybody says they’re not coming for contraception, they’re not coming for IVF. I think we’re going to see a very spirited and continued debate over both of those things.

Well, speaking of the rift over reproductive health, former President Trump is struggling to please both sides and not really succeeding at it. He made a video address last week to the evangelical group, The Danbury Institute, which is a conservative subset of the aforementioned Southern Baptist Convention, in which former President Trump didn’t use the word abortion and skirted the issue. That prompted some grumbling from some of the attendees, reported Politico. Even as Democrats called him an anti-abortion radical for even speaking to the group, which has labeled abortion “child sacrifice.”

So far, Trump has gotten away with telling audiences what they want to hear, even if he contradicts himself regularly. But I feel like abortion is maybe the one issue where that’s not going to work.

Pradhan: Well, I think the struggle really is even if people are more forgiving of him saying different things, it puts a lot of down-ballot candidates in a really difficult position. And I know, Julie, you’d wanted to talk about this, but Republican candidates for U.S. Senate, I mean just how they have to thread the needle, and I don’t know that voters will be as forgiving about changes in their position. So I think they say it’s like, it’s not just about you. It’s like when two people get married, they’re like, “It’s not just about the two of you. It’s like your whole family.” This is like the family is your party and everyone down-ballot who has to now figure out what the best message is, and as we’ve seen, they’ve really struggled with “We’ve shifted now from being many candidates and Republican officeholders supporting basically near-total abortion bans, if not very early gestational limits, to the 15-week ban being a consensus position.” And now saying, well, Trump’s saying he’s not going to sign a national abortion ban, so let’s leave it to the states. I mean, it keeps changing, and I think obviously underscores the difficulty that they’re all having with this. So I don’t think it helps for him to be saying inconsistent things all the time because then these other candidates for office really struggle, I think, with explaining their positions also.

Rovner: So as I say every week, I’ve been covering abortion for a very long time, and before Roe [v. Wade] was overturned the general political rule is you could change positions on abortion once. If you were anti-abortion you could become pro-choice, and we’ve seen that among a lot of Democrats, Sen. [Bob] Casey in Pennsylvania, sort of a notable example. And if you supported abortion rights, you could become anti-abortion, which Trump kind of did when he was running the first time. Others have also as, there are … and again we’re seeing this more among Republicans, but not exclusively.

But people who try to change back usually get hammered. And as I say, Trump has violated every political rule about everything. So not counting him, I’m wondering about, as you say, Rachana, some of these Senate candidates, some of these down-ballot candidates who are struggling to really rationalize their current positions with maybe what they’d said before is something I think that bears watching over the next couple of months.

Huetteman: Absolutely. And we’re seeing candidates who will change their tone within weeks of saying something or practically days at this point. They’re really banking on our attention being pretty low as a public.

Rovner: Yeah. Although they may be right about that part.

Pradhan: Yeah, that’s true. And there’s a lot of time between now and November, but I think even the … just all the things, even this week of course, between now and November is an eternity. But we just talked about the Southern Baptist Convention stance on IVF. Of course, usually when these things happen, it prompts a lot of questions to lawmakers about whether they support that decision or not, whether they agree with it. And I think these court decisions … the Supreme Court, of course, will be out by the end of June, and so right now it might be fresh on people’s minds. But it’s hard to know whether September or October is the dominant or very prominent campaign issue in the same way.

Rovner: At the same time, we have a long way to go and a short way to go, so we will actually all be watching.

All right, well that is the news for this week. Now we will play my interview with Drew Altman and then we will come back and do our extra credits.

I am pleased to welcome to the podcast Drew Altman, president and CEO of KFF, and of course my boss. But lest you think that this is going to be a suck-up interview, you will see in a moment it’s also a shameless self-promotion interview. Drew, thank you so much for joining us.

Drew Altman: It’s great to be on “What the Health?” Thank you.

Rovner: I asked you here to talk about KFF’s new “Health Policy 101” project which launched last month, as a resource to help teach the basics of health policy. I know this is something you’ve been thinking about for a while. Tell us what the idea was and who’s the target audience here.

Altman: Well, since the Bronze Era, when I started KFF, faculty and students found their way to our stuff and they found it useful. It might’ve been a fact sheet about Medicaid or a policy brief about Medicare or a bunch of charts that we produced. But they’ve had to hunt and peck to find what they wanted and someone would find something on Medicaid or Medicare or the ACA [Affordable Care Act] or health care costs or women’s health policy or international comparisons or whatever it was. And for a very long time, I have wanted to organize our material about health policy for their world so that it was easy to find. It was one stop, and you could find all the basic materials that you wanted on the core stuff about health policy as a service to faculty and students interested in health policy because we don’t just analyze it and poll about it and report on it. We have a deep commitment. We really care about health policy and health policy education.

Rovner: You said those are the main topics covered. I assume that other topics could be added in the future? I mean, I could see a chapter on AI and health care.

Altman: Yes, and we’re starting with an introduction for me. There’s a chapter by Larry Levitt about challenges ahead. There’s a chapter by somebody named Julie Rovner on Congress and the agencies, who also wrote a book about all of that stuff, which is still available, folks.

Rovner: It desperately needs updating. So I’m pleased to be contributing to this.

Altman: But this is just the first year. And there were 13 chapters on the issues that I ticked off a moment ago and many more issues. And we’re starting the process of adding chapters. So the next chapter will probably be on LGBTQ issues, and then, though it’s not exactly the same thing as health policy, by popular demand, we will have a chapter on the basics of public health and what is the public health system, and spending on public health.

And I will admit, some of this also has origins in my own personal experience because before I was in government or in the nonprofit world or started and ran KFF, I was an academic at MIT [Massachusetts Institute of Technology] and I was fine when it came to big thoughts. And there I was and I’d written a book about health cost regulation. But what I didn’t know much about was how stuff really worked and the basics. And if I really needed to understand what was happening with regulation of private health insurance or the Medicaid program or the Medicare program, I didn’t really have any place to go to get basic information about the history of the program, or the details of the program, or a few charts that would give me the facts that I needed, or what are the current challenges. And when it really sunk in was when I left MIT and I went to work in what is now CMS [Centers for Medicare & Medicaid Services] and then was called the HCFA [Health Care Financing Administration], and boy on the first day did I realize what I did not know. It was only when I entered the real world of health policy that I understood how much I had to learn. So I wanted to bridge the two worlds a little bit by making available this basic “Health Policy 101.”

Rovner: I confess, I’m a little bit jealous that this hadn’t existed when I started to learn health policy because, like you, I had to ferret it all out, although thankfully KFF was there through most of it and I was able to find most of it along the way.

Altman: Exactly, and I think there’ll be other audiences for this because if you’re working on the Hill — but you don’t work full time on health — if you’re working in an association, if you’re working anywhere in the health care system, there’s lots of times when you really just need to understand. I just read about an 1115 waiver. What is that? Or what really is the difference between traditional Medicare and the Medicare Advantage plan? How is it that you get your drugs covered in the Medicare program? It seems to be lots of different ways. And just I’m confused. How does this actually work?

I’ll admit to you, also, I personally have an ulterior motive in all of this. And my ulterior motive is that it is my feeling now, and this has been a slowly creeping problem, that there isn’t enough what I would call health policy in health policy education. So that over time it has become more about what is fashionable now, which is delivery and quality and value.

And I won’t name names, but I spent a couple of days advising a health policy center at a renowned medical school about their curriculum in what they called health policy. And the draft of it had nothing in it that I recognized as health policy. Some of this is understandable. It’s because if you’re faculty with a disciplinary base — economics, political science, sociology, whatever — there’s no reason you would know a lot about what we recognize as the core of health policy. There has been a serious decline in faith in government, in young people taking jobs in certainly the federal government, but a little bit in state government as well. So the jobs now are all in the health care industry, they’re in tech, they’re in consulting firms. And so I think there’s just less of an incentive to learn a lot about Medicare, Medicaid, the ACA, the federal agencies, because you’re not going to go work in the federal agencies, at least as frequently as students did in my time. And so just to be blunt about it, I am, in my mind, trying to get more health policy back into health policy education.

Rovner: Well, as you know, I endorse that fully because that’s what we’re trying to do, too. One more question since I have you. I’ve been thinking about this a lot. When I started covering health policy shortly after you left HCFA, the big issue was people without insurance. And then throughout the early 2000s the big issue was spiraling costs. I feel like now the big issue is people who simply cannot navigate the system. The system has become so byzantine and complicated that, well, now there’s a “South Park” about it. I mean, it’s really to get even minor things dealt with is a major undertaking. I mean, what do you see as the biggest issue in policy for the next five or 10 years?

Altman: Well, I think the big issue for health care people used to be access to care. Now only about 8% of the population is uninsured. The big issue now is affordability, in my mind, and the struggles Americans are having paying their health care bills. It is an especially acute problem, virtually a crisis, for people with severe illnesses or people who are chronically ill. Fifty[%], 60% of those people really struggle to pay their medical bills. The crisis or the problem that isn’t discussed enough — because it isn’t a single problem it rears its head in so many ways — is the one you’re talking about: that is the complexity of the health care system. Just the sheer complexity of it; how difficult it is to navigate and to use for people who have insurance or don’t have insurance. Larry Levitt and I wrote a piece in JAMA about this, and we, all of us at KFF, are trying to focus more attention on that problem. Need to do more work on that problem and the many parts of it. It’s partly why we set up an entire program a couple of years ago on consumer and patient protection, where we intend to focus more on just this issue of the complexity of the system makes it hard to make it work for people. But especially for patients who are people who encounter the system because they need it.

Rovner: Well, we will both continue to try to keep explaining it as it keeps getting more byzantine. Drew Altman, thank you so much for joining us.

Altman: Thank you, Julie, very much.

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

Huetteman: Sure. My story comes from CBS [News]. The headline is “As FDA Urges Crackdown on Bird Flu in Raw Milk, Some States Say Their Hands Are Tied.” So the story says that there are three more states that have had their first reported cases of bird flu in the last month. And two of them don’t really have a way to conduct increased oversight of dairy cows and the industry that seems to be particularly having problems here. Wyoming and Iowa are those two states. Basically, these are states where raw milk is unregulated, so there’s no way for them to implement surveillance and restrictions on raw milk that might protect people from the fact that pasteurization appears to kill bird flu. But you don’t have pasteurization with raw milk, of course, that’s the definition.

Actually, this leads me to an extra, extra credit. KFF Health News’ Tony Leys wrote about the raw milk change in Iowa last year, and he was reporting on how Iowa only just changed their law, allowing legal sales of raw milk. And his story, among other things, pointed out that pasteurization helped rein in many serious illnesses in the past, including tuberculosis, typhoid, and scarlet fever. So unfortunately, this is a public health issue that’s been going on for a century or more, and we’ve got a method to deal with this, but not if you’re drinking raw milk. So that’s my story this week.

Rovner: Now people are going to drink raw milk and not get childhood vaccines. We’ll see how that goes. Sorry. Anna, you go next.

Edney: Yeah, mine is from Stat and it’s “Four Tops Singer’s Lawsuit Says He Visited ER for Chest Pain, Ended Up in Straitjacket.” It’s really scary, and maybe not totally surprising, unfortunately, that this is how an older Black man was treated when he went to the hospital. But this is Alexander Morris, a member of the Motown group The Four Tops. These are in the Rock & Roll Hall of Fame, The Four Tops, and he had chest pain and problems breathing and went to the hospital in Detroit and was immediately just assumed he was mentally ill, and he ended up quickly in a straitjacket. So he is suing this hospital. And I think he brought up in this article he’d seen people talk about driving while Black or walking while Black, and he essentially had become sick while Black. And he was able to prove he was a famous person and they took him out of the straitjacket. But how many other people haven’t had that ability, and just been assumed, because of the color of their skin, to not be having a serious health issue? So I think it’s worth a read.

Rovner: Yeah, it was quite a story. Rachana.

Pradhan: This week, I will take a story from The New York Times that is headlined “Abortion Groups Say Tech Companies Suppress Posts and Accounts.” It is basically an examination of how TikTok, Instagram, and others, how they moderate/remove content about abortion. What’s interesting about this is, so this is being told from the perspective of individuals who support access to abortion services. And it recounts some examples of Instagram suspending one group, it was called Mayday Health, which provides information about abortion pill access. There’s a telemedicine abortion service called Hey Jane, where TikTok briefly suspended them. What I thought was really interesting about this is anti-abortion groups have said for longer, actually, that technology companies have suppressed or censored information about crisis pregnancy centers, for example, that designed to dissuade women from having abortions. But I think it’s concerns about, broadly speaking, just what the policies are of some of these social media companies and how they decide what information is acceptable or not. And it details these examples of, again, women who support abortion access or posting TikToks that maybe spell abortion phonetically. Like “tion” is, instead of T-I-O-N, it’s S-H-U-N. Or they’ll put a zero instead of an O, and so it doesn’t get flagged in the same way. So yeah, definitely an interesting read.

Rovner: The fraughtness of social media moderation on this issue and many others. Well, my extra credit this week is from my fellow Michigan fan and sometime podcast guest Jonathan Cohn of HuffPost, and it’s called “How America’s Mental Health Crisis Became This Family’s Worst Nightmare.” And it’s basically the story of the entire mental health system in the United States over the last century, as told through the eyes of one middle-class American family, about one patient whose trip through the system came to a tragic end. Even if you think you know about this country’s failure to adequately treat people with mental illness, even if you do know about this country’s failures on mental health, you really do need to read this story. It is that good.

All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our doing-double-duty editor this week, Emmarie Huetteman. As always, you can email us your comments or questions. We’re whatthehealth, all one word, @kff.org. Or you can still find me at X, I’m @jrovner. Anna?

Edney: @annaedney.

Rovner: Rachana?

Pradhan: I’m @rachanadpradhan on X.

Rovner: Emmarie?

Huetteman: I’m lurking on X @EmmarieDC.

Rovner: We will be back in your feed next week. Actually, we’ll be coming to you from Aspen next week. But until then, be healthy.

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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 national abortion landscape was shaken again this week as Florida’s six-week abortion ban took effect. That leaves North Carolina and Virginia as the lone Southern states where abortion remains widely available. Clinics in those states already were overflowing with patients from across the region.

Meanwhile, in a wide-ranging interview with Time magazine, former President Donald Trump took credit for appointing the Supreme Court justices who overturned Roe v. Wade, but he steadfastly refused to say what he might do on the abortion issue if he is returned to office.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Alice Miranda Ollstein of Politico, and Rachana Pradhan of KFF Health News.

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Sarah Karlin-Smith
Pink Sheet

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Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Rachana Pradhan
KFF Health News

@rachanadpradhan

Read Rachana's stories.

Among the takeaways from this week’s episode:

• Florida’s new, six-week abortion ban is a big deal for the entire South, as the state had been an abortion haven for patients as other states cut access to the procedure. Some clinics in North Carolina and southern Virginia are considering expansions to their waiting and recovery rooms to accommodate patients who now must travel there for care. This also means, though, that those traveling patients could make waits even longer for local patients, including many who rely on the clinics for non-abortion services.
• Passage of a bill to repeal Arizona’s near-total abortion ban nonetheless leaves the state’s patients and providers with plenty of uncertainty — including whether the ban will temporarily take effect anyway. Plus, voters in Arizona, as well as those in Florida, will have an opportunity in November to weigh in on whether the procedure should be available in their state.
• The FDA’s decision that laboratory-developed tests must be subject to the same regulatory scrutiny as medical devices comes as the tests have become more prevalent — and as concerns have grown amid high-profile examples of problems occurring because they evaded federal review. (See: Theranos.) There’s a reasonable chance the FDA will be sued over whether it has the authority to make these changes without congressional action.
• Also, the Biden administration has quietly decided to shelve a potential ban on menthol cigarettes. The issue raised tensions over its links between health and criminal justice, and it ultimately appears to have run into electoral-year headwinds that prompted the administration to put it aside rather than risk alienating Black voters.
• In drug news, the Federal Trade Commission is challenging what it sees as “junk” patents that make it tougher for generics to come to market, and another court ruling delivers bad news for the pharmaceutical industry’s fight against Medicare drug negotiations.

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 “A Doctor at Cigna Said Her Bosses Pressured Her To Review Patients’ Cases Too Quickly. Cigna Threatened To Fire Her,” by Patrick Rucker, The Capitol Forum, and David Armstrong, ProPublica.

Alice Miranda Ollstein: The Associated Press’ “Dozens of Deaths Reveal Risks of Injecting Sedatives Into People Restrained by Police,” by Ryan J. Foley, Carla K. Johnson, and Shelby Lum.

Sarah Karlin-Smith: The Atlantic’s “America’s Infectious-Disease Barometer Is Off,” by Katherine J. Wu.

Rachana Pradhan: The Wall Street Journal’s “Millions of American Kids Are Caregivers Now: ‘The Hardest Part Is That I’m Only 17,” by Clare Ansberry.

Also mentioned on this week’s podcast:

• Time’s “How Far Trump Would Go,” by Eric Cortellessa.
• NPR’s “Why Is a 6-Week Abortion Ban Nearly a Total Ban? It’s About How We Date a Pregnancy,” by Selena Simmons-Duffin.
• NPR’s “’Sicko’s’ Peeno Sees Few Gains in Health Insurance,” by Julie Rovner.
• CNN’s “Walmart Will Close All of Its Health Care Clinics,” by Nathaniel Meyersohn.

Click to open the Transcript

Transcript: Abortion Access Changing Again in Florida and Arizona

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

Mila Atmos: The future of America is in your hands. This is not a movie trailer, and it’s not a political ad, but it is a call-to-action. I’m Mila Atmos, and I’m passionate about unlocking the power of everyday citizens. On our podcast “Future Hindsight,” we take big ideas about civic life and democracy, and turn them into action items for you and me. Every Thursday, we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 2, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go.

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

Alice Miranda Ollstein: Hello.

Rovner: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: And my KFF Health News colleague Rachana Pradhan.

Rachana Pradhan: Hello.

Rovner: No interview this week, but more than enough news to make up for it, so we will dig right in. We will start, again, with abortion. On Wednesday, Florida’s six-week abortion ban took effect. Alice, what does this mean for people seeking abortions in Florida, and what’s the spillover to other states?

Ollstein: Yeah, this is a really huge deal not only because Florida is so populous, but because Florida, somewhat ironically given its leadership, has been a real abortion haven since Roe vs. Wade was overturned. A lot of its surrounding states had near-total bans go into effect right away. Florida has had a 15-week ban for a while, but that has still allowed for a lot of abortions to take place, and so a lot of people have been coming to Florida from Alabama, Louisiana, those surrounding states for abortions. Now, Florida’s six-week ban is taking effect and that means that a lot of the patients that had been going there will now need to go elsewhere, and a lot of Floridians will have to travel out of state.

And so there are concerns about whether the closest clinics they can get to, in North Carolina and southern Virginia, will have the capacity to handle that patient overload. I talked to some clinics that are trying to staff up. They’re even thinking about physical changes to their clinics, like building bigger waiting rooms and recovery rooms. This is going to cause a real crunch, in terms of health care provision. That is set to not only affect abortion, but with these clinics overwhelmed, that takes up appointments for people seeking other services as well. My colleagues and I have been talking to people in the sending states, like Alabama, who worry that the low-income patients they serve who were barely able to make it to Florida will not be able to make it even further. Then, we’ve talked to providers in the receiving states, like Virginia, who are worried that there just are simply not enough appointments to handle the tens of thousands of people who had been getting abortions in Florida up to this point.

Rovner: Of course, what ends up happening is that, if people have to wait longer, it pushes those abortions into later types of abortions, which are more complicated and more dangerous and more expensive.

Ollstein: Yes. While the rate of complication is low, the later in pregnancy you go, it does get higher. That’s another consideration as well.

I will flag, though, that restrictions on abortion pills in North Carolina, which is now one of the states set to receive a lot of people, those did get a little bit loosened by a court ruling this week so people will not have to have a mandatory in-person follow-up appointment for abortion pills like they used to have to have. That could help some patients who are traveling in from out of state, but a lot of restrictions remain, and it’ll be tough for a lot of folks to navigate.

Rovner: While we think of that, well there’s at least, you can get abortions up to six weeks, my friend Selena Simmons-Duffin over at NPR had a really good explainer about why six weeks isn’t really six weeks, because of the way that we measure pregnancy, that six weeks is really two weeks. It really is a very, very small window in which people will be able to get abortions in Florida. It’s not quite a full ban, but it is quite close to it.

Well, speaking of full bans, after several false starts, the Arizona Senate Wednesday voted to repeal the 1864 abortion ban that its Supreme Court ruled could take effect. The Democratic governor is expected to sign it. Where does that leave abortion law in the very swing state of Arizona? It’s kind of a muddle, isn’t it?

Ollstein: It is. The basics are that a 15-week ban is already in place and will continue to be in place once this repeal takes effect. What we don’t know is whether the total ban from before Arizona was even a state will take effect temporarily, because of the weird timing of the court’s implementation of that old ban, and the new repeal bill that just passed that the governor is expected to sign very soon. The total ban could go into effect, at least for a little bit over the summer. Planned Parenthood is positioning the court to not let that happen, to stay the implementation until the repeal bill can take effect. All of this is very much in flux. Of course, as we’ve seen in so many states, that leads to patients and providers just being very scared, and not knowing what’s legal and what’s not, and folks being unable to access care that may, in fact, be legal because of that. Of course, this is all in the context of Arizona, as well as Florida, being poised to vote directly on abortion access this fall. If the total ban does go into effect temporarily, it’s sure to pour fuel on that fire and really rile people up ahead of that vote.

Rovner: Yeah, I was going to mention that. Well, now that we’re talking about politics. This week, we heard a little bit more about how former President Trump wants to handle the abortion issue, via a long sit-down interview with Time magazine. I will link to that interview in the show notes. The biggest “news” he made was to suggest that he’d have an announcement soon about his views on the abortion pill. But he said that would come in the next two weeks, the interview was of course more than two weeks ago. They did a follow-up two weeks later and he still said it was coming. In the follow-up interview, he said it would be next week, which this has already passed. Do we really expect Trump to say something about this, or was that just him deflecting, as we know he is wont to do?

Pradhan: Well, I’m sure that he’s getting pressure to say something, because as people have noted now quite widely, regardless of individual state laws, there are certainly conservatives that are pushing for him and his future administration to ban the mailing of abortion pills using the Comstock Act from the 1800s, which would basically annihilate access to that form of terminating pregnancies.

Rovner: There are also some who want him to just repeal the FDA approval, right?

Ollstein: Right. Of course, the Biden administration has made it easier for folks to get access to those, to mifepristone, in particular, one of two pills that are used in medication abortion. But yeah, will it be two weeks? I think he obviously knows that this is a potential political liability for him, so whether he’ll say something, I’m sure he will get competing advice as to whether it’s a good idea to say something at all, so we’ll have to see.

Rovner: Well, speaking of Trump deflecting, he seemed to be pretty disciplined about the rest of the abortion questions — and there were a lot of abortion questions in that interview — insisting that, while he takes credit for appointing the justices who made the majority to overturn Roe, everything else is now up to the state. But by refusing to oppose some pretty-out-there suggestions of what states might do, Trump has now opened himself up to apparently accepting some fairly unpopular things, like tracking women’s menstrual periods. Lest you think that’s an overstatement, the Missouri state health director testified at a hearing last week that he kept a spreadsheet to track the periods of women who went to Planned Parenthood, which, according to The Kansas City Star, “helped to identify patients who had undergone failed abortions.” Yet, none of these things ever seem to stick to Trump. Is any of this going to matter in the long run? He’s clearly trying to walk this line between not angering his very anti-abortion base and not seeming to side too much with them, lest he anger a majority of the rest of the people he needs to vote for him.

Ollstein: Well, he’s also not been consistent in saying it’s totally up to states, whatever states want to do is fine. He’s repeatedly criticized Florida’s six-week ban. He refused to say how he would vote on the referendum to override it. He has criticized the Arizona ruling to implement the 1864 ban. This isn’t a pure “whatever states do is fine” stance, this is “whatever states do, unless it’s something really unpopular, in which case I oppose it.” That is a tough line to walk. The Biden administration and the Biden campaign have really seized on this and are trying to say, “OK, if you are going to have a leave-it-to-states stance, then we’re going to try to hang on you every single thing states do, whether it’s the legislature, or a court, or whatever, and say you own all of this.” That’s what’s playing out right now.

Rovner: I highly recommend reading the interview, because the interviewer was very skilled at trying to pin him down. He was pretty skilled at trying to evade being pinned down. Well, meanwhile, Republican attorneys general from 17 states are suing the Equal Employment Opportunity Commission from including abortion in a list of conditions that employers can’t discriminate against and must provide accommodations for, under rules implementing the Pregnant Workers Fairness Act. The new rules don’t require anyone to pay for anything, but they could require employers to provide leave or other accommodations to people seeking pregnancy-related health care. The EEOC has included abortion as pregnancy-related health care. This is yet another case that we could see making its way to the Supreme Court. Ironically, the Pregnant Workers Fairness Act was a very bipartisan bill, so there are a lot of anti-abortion groups that are extremely angry that this has been included in the regulation. This is one of those abortion-adjacent issues that tends to drag abortion in, even when it was never expected to be there. And we’re going to see more of these. We’re going to get back into the spending bills, as Congress tries to muddle its way through another session.

Pradhan: I think, when I think about this, even though there’s a regulatory battle and a legal one now, too, like in the immediate aftermath of the Dobbs [v. Jackson Women’s Health Organization] decision, when there were employers, I think about it more practically. Which is that there were employers that were saying, “We would cover expenses.” Or they would pay for people to travel out of state if that was something that they needed. I wonder how many people would actually do it, even if it exists, because that’s a whole other … Getting an abortion, or even things related to pregnancy, are incredibly private things, so I don’t know how many women would be willing to stand up and say, “Hey, I need this accommodation and you have to give it to me under federal regulations.” In a way, I think it’s notable both that the EEOC put out those regulations and that there’s litigation over it, but I wonder if it, practically speaking, just how much of an impact it would really have, just because of those privacy and practical hurdles associated with divulging information in that regard.

Rovner: As we were just talking about, somebody in Alabama, the closest place they can go to get an abortion is in North Carolina or Virginia, and go, “Hey, I need three days off so I can drive halfway across the country to get an abortion because I can’t get one here.” I see that might be an awkward conversation.

Pradhan: Just like any sensitive medical- or health-related needs, it’s not like people are rushing to tell their employers necessarily that it’s something that they’re dealing with.

Rovner: That’s true. It doesn’t have anything to do with privacy. Most people are not anxious to advertise any health-related issues that they are having. Speaking of people and their sensitive medical information, that Change Healthcare hack that we’ve been talking about since February, well the CEO of Change’s owner, UnitedHealth Group, was on Capitol Hill on Wednesday, taking incoming from both the Senate Finance Committee in the morning, and the House Energy and Commerce Committee in the afternoon. Among the other things that Andrew Witty told lawmakers was that the portal that was hacked did not have multifactor authentication and he confirmed that United paid $22 million in bitcoin to the hackers, although as we discussed last week, they might not have paid the hackers who actually had possession of the information. Nobody actually seemed to follow up on that, which I found curious. My favorite moment in the Senate hearing was when North Carolina Republican Thom Tillis offered CEO Witty a copy of the book “Hacking For Dummies.” Is anything going to result from these hearings? Other than what it seemed a lot of lawmakers getting to express their frustration in person.

Pradhan: Can I just say how incredible it is to me that a company that their net worth is almost $450 billion, one of the largest companies in the world, apparently does not know how to enforce rules on two-factor authentication, which is something I think that is very routine and commonplace among the modern industrialized workforce.

Rovner: I have it for my Facebook account!

Pradhan: Right. I think everyone, even in our newsroom, knows how to do it or has been told that this is necessary for so many things. I just find it absolutely unbelievable that the CEO of United would go to senators and say this, and think that it would be well-received, which it was not.

Rovner: I will say his body language seemed to be very apologetic. He didn’t come in guns blazing. He definitely came in thinking that, “Oh, I’m going to get kicked around, and I’m just going to have to smile and take it.” But obviously, this is still a really serious thing and a lot of members of Congress, a lot of the senators and the House members, said they’re still hearing from providers who still can’t get their claims processed, and from people who can’t get their medications because pharmacies can’t process the claims. There’s a lot of dispute about how long it’s going to take to get things back up and running. One of the interesting tidbits that I took away is that, as much of health care that goes through Change, it’s like 40% of all claims, it’s actually a minimum part of United’s health claims. United doesn’t use Change for most of its claims, which surprised me. Which is maybe why United isn’t quite as freaked out about this as a lot of others are. Is there anything Congress is going to be able to do here, other than say to their constituents, “Hey, I took your complaints right to the CEO?”

Karlin-Smith: I think there’s two things they may focus on. One is just cybersecurity risks in health care, which is broader than just these incidents. In some ways, it could be much worse, if you think about hospitals and medical equipment being hacked where there could be direct patient impacts in care because of it. The other thing is, United is such a large company and the amount of Americans impacted by this, but also the amount of different parts of health care they have expanded into, is really under scrutiny. I think it’s going to bring a light onto how big they’ve become, the amount of vertical integration in our health system, and the risks from that.

Rovner: We went through this in the ’90s. Vertical integration would make things more efficient, because everybody would have what they called aligned incentives, everybody would be working towards the same goal. Instead, we’ve seen that vertical integration has just created big, behemoth companies like United. I don’t know whether Congress will get into all of that, but at least it brought it up into their faces.

There’s lots of regulatory news this week. I want to start with the FDA, which finalized a rule basically making laboratory-developed tests medical devices that would require FDA review. Sarah, this has been a really controversial topic. What does this rule mean and why has there been such a big fight?

Karlin-Smith: This rule means that diagnostic tests that are developed, manufactured, and then actually get processed, and the results get processed at the lab, will now no longer be exempted from FDA’s medical device regulations and they’ll have to go through the process of medical devices. The idea is to basically have more oversight over them, to ensure that these tests are actually doing what they’re supposed to do, you’re getting the right results and so forth. Initially, over the years, the prevalence of these tests has grown, and what they’re used for, I think, has changed and developed where FDA is more concerned about the safety and the types of health decisions people may be making without proper oversight of the tests. One, I think, really infamous example that maybe can people use to understand this is Theranos was a company that was exempted from a lot of regulations because of being considered an LDT. The initial impact is going to be interesting because they’re actually basically exempting all already-on-the-market products. There’s also going to be some other exemptions, such as for tests that meet an unmet medical need, so I think that will have to be defined. There is a reasonable chance that there’s going to be lawsuits challenging whether FDA can do this on their own or need Congress to write new legislation. There have been battles over the years for Congress to do that. FDA, I think, has finally gotten tired of waiting for them to lead. I think initially, we’re going to see a lot of battles going forth and FDA also just has limited capacity to review some of this stuff.

Rovner: We already know that FDA has limited capacity on the medical device side. I was amused to see, oh, we’re going to make these medical devices, where there’s already a huge problem with FDA either exempting things that shouldn’t really be exempt, or just not being able to look at everything they should be looking at.

Karlin-Smith: Right. They’re going to take what they call a risk-based approach, which is a common terminology used at the FDA, I think, to focus on the things where they think there’s the most risk of something problematic happening to people’s health and safety if something goes wrong. It’s also an admission, to some extent, of something that’s not necessarily their fault, which is they only have so much budget and so many people, and that really comes down to Congress deciding they want to fix it. Now, FDA has user-fee programs and so forth, so perhaps they could convince the industry to pony up more money. But as you alluded to early on, one of the fights over this has been their different segments of companies that make these tests that have different feelings about the regulations. Because you have more traditional, medical device makers that are used to dealing with the FDA that probably feel like they have this leg up, they know how to handle a regulatory agency like FDA and get through. Then you have other companies that are smaller, and do not have that expertise, maybe don’t feel like they have the manpower and, just, money to deal with FDA. I think that’s where you get into some of these business fights that have also kept this on the sidelines for a while.

Pradhan: Well, also I wonder, hospitals also use laboratory developed tests, too, and they develop them. I feel like, and Sarah, correct me if I’m wrong, but I think previously when there was debate over whether FDA was going to do this, I think hospitals were pretty critical of any move of FDA to start regulating these more aggressively, right? Because they said for tests used for cancer detection or other health issues, I think that they were not thrilled at the idea. I don’t know that they’ve had to really deal with FDA in this regard either when it comes to devices.

Karlin-Smith: Yeah. I know one big exemption that people were looking for was whether they were going to exempt academic medical centers, and they did not. We’ll see what happens with that moving forward. But obviously, again, the older ones will have this exemption.

Rovner: Well, speaking of controversial regulations, the administration has basically decided that it’s not going to decide about the potential menthol ban that we’ve been talking about on and off. There was a statement from HHS [Department of Health and Human Services] last week that just said, “We need to look at this more.” Somebody remind us why this is so controversial. Obviously, health interests say, really, we should ban menthol, it helps a lot of people to continue smoking and it’s not good for health. Why would the administration not want to ban menthol?

Pradhan: It’s controversial because, I’ll just say, that it’s an election year and they are worried about backlash from Black voters not supporting President Biden in his reelection campaign, because they do this.

Karlin-Smith: It’s a health versus criminal justice issue, because the concern is that yes, in theory, if Black people make up the majority of people who use menthol cigarettes, you’re obviously protecting their health by not having it. But the concern has been among how this would be enforced in practice and whether it would lead to overpolicing of Black communities and people being charged or facing some kind of police brutality for what a lot of people would consider a minor crime. That’s where the tension has been. Although notably, some groups like the NAACP and stuff have been gotten on board with banning menthol. It’s an interesting thing where we’re trying to solve a policing or criminal justice problem through a health problem, rather than just solving the policing problem.

Ollstein: Like Sarah said, you have civil rights groups lined up on both sides of this fight. You have some saying that banning menthol cigarettes would be racist because they’re predominantly used by the Black population. But then you have people saying, well it’s racist to continue letting their health be harmed, and pointing out that those flavored cigarettes have been targeted in their marketing towards Black consumers, and that being a racist legacy that’s been around for a while. There’s these accusations on both sides and it seems like the politics of it are scaring the administration away a little bit.

Rovner: Well, just speaking of things that are political and that people smoke, the Drug Enforcement Administration announced its plan to downgrade the classification of marijuana, which until now has been included in the category of most dangerous drugs, like heroin and LSD, to what’s called Schedule III, which includes drugs with medicinal use that can also be abused, like Tylenol with codeine. But apparently, it could be awhile before it takes effect. This may not happen in time for this year’s election, right?

Karlin-Smith: Right. They have to release a proposed rule, you got to do comments, you got to get to the final rule. OMB [Office of Management and Budget] even. It’s supposedly at OMB now. OMB could hold it up for a while if they want to. As anybody who follows health policy in [Washington] D.C. knows, nothing moves fast here when it comes to regulations.

Rovner: Yes. A regulation that we thought was taken care of, but that actually only came out last week would protect LGBTQ+ Americans from discrimination in health care settings. This was a provision of the Affordable Care Act that the Trump administration had reversed. The Biden administration announced in 2021 that it wouldn’t enforce the Trump rules. But this is still a live issue in many courts and it’s significant to have these final regulations back on the books, yes?

Pradhan: It is. I think this is one of the ACA regulations that has ping-ponged the most, ever since the law was passed, because there have been lawsuits. I want to say it took the Obama administration years to even issue the first one, I think knowing how controversial it was. I believe it was the second, I think it was his second term and it was when there was no fear of repercussions for his reelection. Yeah, it’s been a very, very long-fought battle and I imagine this is also not the end of it. But no, it is very significant, the way that they defined the regulations.

Rovner: I confess, I was surprised when they came out because I thought it had already happened. I’m like, “Oh, we were still kicking this around.” So, now they appear to be final.

Well, finally this week, lots of news in health business. First, an update from last week. The Federal Trade Commission is challenging so-called junk patents from some pretty blockbuster drugs, charging that the patents are unfairly blocking generic competition. Sarah, what is this and why does it matter?

Karlin-Smith: FDA has what’s known as an orange book, as a part of a very complicated process set up by the 1984, I believe, Hatch-Waxman Act that was a compromise between the brand and the generic drug industries to get generic drugs to market a bit faster. FTC has been accusing companies of improperly listing patents in the orange book that shouldn’t be there, and thus making it harder to get generic products on the market. In particular, they’ve been actually going against drugs that have a device component, basically saying these components’ patents are not supposed to be in the orange book. They are basically asking the companies to delist the patents. They actually have gotten some concessions so far, from some of the other products they’ve targeted.

The idea would be this should help speed some of the generic entrants. It’s not quite as simple, because you do have lots of patents covering these drugs, so it does make it a little bit easier, but it’s not like it automatically opens the door. But it is unique and interesting that they have focused in on these targets because, typically, what are sometimes known as complex generics, are a lot harder for companies to make and get into the market because of the devices. Because for safety reasons FDA wants the devices to be very similar. If you pick up your product at the pharmacy, you have to be able to just know how to use it, really, without thinking about it, even if it’s a …

Rovner: Obviously, this covers things like inhalers and injectables.

Karlin-Smith: Right. The new weight loss drugs everybody is focused on, inhalers has been a big one as well. Things like an EpiPen, or stuff like that.

I think it’s been interesting because it does seem like FTC’s had more immediate results, I guess, than you sometimes see in Washington. [Sen.] Bernie Sanders has piggybacked on what they’re doing and targeted these companies and products in other ways, and gotten some small pricing cost concessions for consumers as well. But it will take a little bit of time for, even if patents get delisted, for generic drugmakers to actually then go through the whole rigamarole of getting cheaper products to market.

Rovner: Yes. This is part of what I call the “30 Years War,” to do something about drug prices. Before we leave drug prices, we’re still fighting in court about the Medicare drug negotiation, right? There, the drug industry continues to lose. Is that where we are?

Karlin-Smith: Correct. They have their fourth negative ruling this week. Basically, in this case, the judge ruled on two main arguments the industry was trying to push forward. One is that the drug negotiation program would constitute a takings violation under the Fifth Amendment. One of the main reasons the judge in this district in New Jersey said no is because they’re saying basically participation in Medicare and this drug price negotiation program are voluntary, the government is not forcibly taking any of your property, you don’t have to participate.

Another big ruling from this judge was that this program does not constitute First Amendment violations. What’s happening here is a regulation of conduct, not speech. One of the more amusing things in the decision to me, that I enjoyed, is the industry has argued that they’re basically being forced under this program to say, “Oh, this is … when CMS [Centers for Medicare & Medicaid Services]” … and then work out a price, that the price they work out is the maximum fair price because that’s the technical terminology used in the law, that they’re then somehow making an admission that any other price that they’ve charged has not been fair. The judge basically said, “Well, this is a public relations problem, not a constitutional problem. Nobody is telling you you can’t go out and publicly disagree with CMS about this program and about their prices that you end up having to enter into.”

It’s another blow. They have a lot of different legal arguments they’re trying out in different cases. As I said, they’ve thrown a lot of spaghetti at the wall. So far, other arguments have failed. Some of the cases are stalled on more technicalities, like the districts they’ve filed in. There was another case that was heard, an appeal was heard yesterday, in PhRMA, the main trade group’s case, where they’re trying to push on because of that. There’s going to be a lot of more action, but so far, looks good for the government.

Pradhan: When this was first rolling out, including when CMS announced the initial 10 drugs that would first be on the list, lawyers that I talked with at the time said that the arguments that the industry was making, it was a reach, to be diplomatic about it. I don’t think anyone really thought that they would be successful and it seems like that is, at least to date, that’s how it’s playing out.

Rovner: I’ll repeat, it’s a good time to be a lawyer for the drug industry, at least you’re very busy.

All right, well, finally this week, we spend so much time talking about how big health care is getting, Walmart this week announced that it’s basically getting out of the primary care business. It’s closing down its two dozen clinics and ending its telehealth programs. This feels like another case of that, “Wow, it looked so easy to make money in health care.” Until you discover that it’s not.

Pradhan: Right. I think making money in primary care, certainly that’s not where the people say, “Oh, that’s a real big cash cow, let’s go in there.” It’s other parts of the health care industry.

Karlin-Smith: One thing that struck me about a quote in a CNN article from Walmart was how they were focusing on they wanted to do this, but they found it wasn’t a sustainable business model. To me, that then just brings up the question of “Should health care be a business?” and the problems. There’s a difference between being able to operate primary care and make enough money to pay your doctors and cover all your costs, and a big company like Walmart that wants to be able to show big returns for their investors and so forth. There’s also that distinction that something that’s not attractive for a business model like that can still be viable in the U.S.

Rovner: This reminds me a lot of ways of the ill-fated Haven Healthcare, which was when Amazon and JPMorgan Chase and Berkshire Hathaway all thought they could get together because they were big, smart companies, could solve health care. They hired Atul Gawande, he was one of the biggest brains in health care, and it didn’t work out. We shall continue.

Anyway, that is the news for this week. Now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device.

Rachana, why don’t you go first this week?

Pradhan: This story that I’m going to suggest, [“Millions of American Kids Are Caregivers Now: ‘The Hardest Part Is That I’m Only 17.”] it’s in The Wall Street Journal, depressing like most health care things are. It’s about how millions of children, I think it’s over 5 million children under the age of 18, are providing care to siblings, grandparents, and parents with chronic medical needs, and how they are becoming caregivers at such young ages. In part, because it is so hard to find and afford in-home care for people. That is my extra credit.

Rovner: Right, good story. Sarah?

Karlin-Smith: I looked at a piece in The Atlantic by Katherine J. Wu, “America’s Infectious-Disease Barometer Is Off.” It’s focused on our initial response in this country to bird flu, and maybe where the focus should and shouldn’t be. It has some interesting points about repeat mistakes we seem to be making, in terms of inadequate testing, inadequate focus on the most vulnerable workers, and what we need to do to protect them in this crisis right now.

Rovner: Alice?

Ollstein: I chose [“Dozens of Deaths Reveal Risks of Injecting Sedatives Into People Restrained by Police“] an AP investigation, collaborating with Frontline, about the use of sedatives when police are arresting someone. This is supposed to be a way to safely restrain someone who’s combative, or maybe they’re on drugs, or maybe they’re having a mental health episode, and this is supposed to be a nonlethal way to detain someone. It has led to a lot of deaths, nearly 100 over the past several years. These drugs can make someone’s heart stop. The reporting shows it’s not totally clear if just the drugs themselves are what is killing people, or if it’s in combination with other drugs they might be on, or it’s because they’re being held down in a way by the cops that prevent them from breathing properly, or what. But this is a lot of deaths of people who have received these injections and is leading to discussions of whether this is a best practice. Pretty depressing stuff, but important.

Rovner: Yeah. It was something that was supposed to help and has not so much in many cases. My story this week is from ProPublica. It’s called “A Doctor at Cigna Said Her Bosses Pressured Her To Review Patients’ Cases Too Quickly. Cigna Threatened To Fire Her.” It’s by Patrick Rucker and David Armstrong. It’s about exactly what the headline says. A doctor who spent too much time reviewing potential insurance denials because she wanted to be sure the cases were being decided correctly. It’s obviously not the first story of this kind, but I chose it because it so reminded me of a story that I did in 2007, which was about a physician who worked for a managed-care company, it was Humana in that case, who was pushed to deny care and first testified to Congress about it in 1996. I honestly can’t believe that, 28 years later, we are still arguing about pretty much the exact same types of practices at insurance companies. At some point you would think we would figure out how to solve these things, but apparently not yet.

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 hanging these days?

Pradhan: I am also on X, @rachanadpradhan.

Rovner: Sarah?

Karlin-Smith: I’m at @SarahKarlin or @sarahkarlin-smith on Bluesky.

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 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.

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Mary Agnes Carey
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Tami Luhby
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Alice Miranda Ollstein
Politico

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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 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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