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 term “health equity” means different things to different people. It’s about access to medical care — but not only access to medical care. It’s about race, ethnicity, and gender; income, wealth, and class; and even geography — but not only those things. And it’s about how historical and institutional racism, manifested in things like over-policing and contaminated drinking water, can inflict health problems years and even generations later.

In a live taping on Sept. 6 at the Texas Tribune Festival, special guests Carol Alvarado, the Texas state Senate’s Democratic leader, and Ann Barnes, president and CEO of the Episcopal Health Foundation, along with KFF Health News’ Southern bureau chief Sabriya Rice and Midwest correspondent Cara Anthony, joined KFF Health News’ chief Washington correspondent, Julie Rovner, to discuss all that health equity encompasses and how current inequities can most effectively be addressed.

Anthony also previewed “Silence in Sikeston,” a four-part podcast and documentary debuting this month exploring how a history of lynching and racism continues to negatively affect the health of one rural community in Missouri.

Panelists

Carol Alvarado
Texas state senator (D-Houston)

Cara Anthony
Midwest correspondent, KFF Health News

Ann Barnes
President and CEO, Episcopal Health Foundation

Sabriya Rice
Southern bureau chief, KFF Health News

Also mentioned on this week’s podcast, from KFF Health News’ “Systemic Sickness” project:

• “A Teen’s Murder, Mold in the Walls: Unfulfilled Promises Haunt Public Housing,” by Fred Clasen-Kelly and Renuka Rayasam.
• “Med Schools Face a New Obstacle in the Push To Train More Black Doctors,” by Lauren Sausser.
• “‘I Feel Dismissed’: People Experiencing Colorism Say Health System Fails Them,” by Chaseedaw Giles.
• “As Record Heat Sweeps the US, Some People Must Choose Between Food and Energy Bills,” by Melba Newsome.
• “Black Hospitals Vanished in the U.S. Decades Ago. Some Communities Have Paid a Price,” by Lauren Sausser.

click to open the transcript

Transcript: Live from Austin, Examining Health Equity

[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 usually I’m joined by some of the best and smartest health reporters in Washington. But today we have a special episode for you all about health equity taped before a live audience at the Texas Tribune Festival on Sept. 6, 2024. I hope you enjoy it. We’ll be back with our regular panel and all the news on Sept. 12. So here we go.

I am pleased to be joined on this panel by two of my KFF Health News colleagues, Southern bureau chief Sabriya Rice, who’s right here next to me, and Midwest correspondent Cara Anthony, down at the end. We are also honored to be joined by two guests with a lot of combined expertise on this issue, [Texas] Senate Democratic leader Carol Alvarado, who represents the 6th District of Texas, which includes parts of Houston, and Dr. Ann Barnes, president and CEO of the Episcopal Health Foundation, also based in Houston.

We’re going to talk amongst ourselves for the next, I don’t know, 40 minutes or so. Then we will go to you in the audience for your questions. So go ahead and be thinking. I have to say I am personally really excited about this episode because health equity is something I think about a lot, but I’ve never been able to accurately define, even for myself. I know it’s about race and ethnicity and gender, but it’s not just about race and ethnicity and gender. It’s about income and wealth and class, but it’s not just about income and wealth and class. It’s about geography, but not just about geography. And it’s about medical care, but not just about medical care. So I want to kick off this discussion by asking each of you how you define health equity. And why don’t we just sort of go down the row? So we’ll start with you, Sabriya.

Sabriya Rice: Really great question and it gave me a lot of things to think about. And I want to start with a little anecdote from something that happened yesterday evening. I was having a conversation with a group of visitors from South Africa who work for an investigative news site there called The Daily Maverick, and my colleague, Aneri Pattani, who’s also a KFF Health News reporter. We were explaining some of the things about the U.S. health care system and just some basic stuff like how a lot of people can’t afford to just go for preventive care, how you may or may not have access to care in your neighborhood, and what that means in terms of your health outcomes.

And in the middle, they paused us and were like, “Wait a minute, wait a minute. This doesn’t make any sense. We have these things in South Africa.” It’s something you hear regularly from other people who are visiting here and they’re like, “But you’re like the wealthiest country in the world. How do you not have these things?” And I was thinking about that and thinking of, in terms of your question. So, for me, I think of health equity as just creating the opportunity for everyone to be able to achieve their optimal health no matter their background. And I think that’s something we could really work on in the U.S.

Ann Barnes: Great.When I think about health equity, I share a similar definition where folks have a just and fair opportunity to live their healthiest lives. And this is largely from the Robert Wood Johnson Foundation’s definition of health equity. But coupled with that is the requirement to dismantle barriers to health. And so we have to remember that that is part of the equation, not just dreaming that we all have optimal health, but thinking about how we’re going to eliminate the barriers, especially for populations that are most vulnerable.

Carol Alvarado: I think about accessibility and affordability. And if you don’t have those two things in health care, then you create this environment of the haves and the have-nots, those who can afford to have health insurance and those who can’t. Maybe it’s because of their job, their social economic status. And I also think that we have to take partisanship and politics out of health care. I mean, when did that become such a divisive issue that really reached the height during the Obamacare debate and the many, many times to repeal it? And I know we’re going to dive into this a little bit more, but health care and access should never be political.

Cara Anthony: When I think about health equity, I agree with all of the panelists here today, but I’m also thinking about the future and the next generation. I’m a single mom. I have a 7-year-old daughter, and I think about how is she going to be able to live a longer and healthier life than previous generations. I’m going back home tomorrow and one of the first things that I’m going to do is sign my daughter up for a swim lesson, right? That’s health equity because I’m also signing up for a lesson as well. Why? Because I never learned to swim. It’s about each generation doing better. And why didn’t I learn to swim? Because my parents were born in 1948 in the South and did not have access to swimming pools. So it’s those daily practical applications that I think about when I think about health equity. So yeah.

Rovner: Sen. Alvarado and Dr. Barnes, I want to talk about Texas a little bit since, obviously, we’re sitting here. Texas is, we try not to think about just insurance when we talk about health equity, although it’s a big deal, and in Texas it’s still a big deal as opposed to a lot of other states. What impact does Texas’ failure to, so far at least, expand Medicaid have on health equity in this state?

Barnes: Well, we know that health care and access to health care is critically important to health. It accounts for 20% of a person’s health, and nonmedical drivers account for the other 80%. But 20% is important. We still have the highest rate of uninsured. So that means that there are parts of our community that can’t get the preventive care that they need, that can’t talk to people who might connect them to social services to support their nonmedical needs. And so the larger conversation is about increasing health coverage overall in Texas. And certainly expansion of Medicaid is one piece of that. About 5 million people are uninsured right now in our state, and so we’ve got a lot of ground to cover. Affordable Care Act is one way, Medicaid expansion is another. And so a lot of work to do, for sure.

Alvarado: And I’ll pick up where you left off. Medicaid expansion has been, believe it or not, a hot political hot potato here in Texas. I’ve been filing, along with many of my colleagues, bills every session since 2009, maybe. We can’t get hearings. And no one really gives you a good explanation why. They’ll have things that really don’t make a lot of sense that there are too many strings attached. Well, somehow 40 other states don’t have that problem.

And we’ve seen that the cost that we’re leaving on the table, millions of dollars. I think the last number I saw was 2023, maybe $11 billion just there on the table; other states are utilizing it. And then here in Texas, it’s kind of complicated. I’ll just give you the elevator speech on that. But they kept the Medicaid enrollment going during the pandemic, and then afterwards they did this winding, what they called winding down, and almost 2 million people were left without Medicaid. And a good portion of that are children, and a good portion of those children are Black and brown kids who are already living in environments where they don’t have access to green space or grocery stores, fresh fruits and vegetables. So you pile all of that together and that’s why we are in this place of many uninsured, almost twice the number of the national rate, which is at 8[%]. We’re at 17[%]. Yeah, everything’s bigger in Texas especially the number of uninsured.

Rovner: So, Dr. Barnes, I want you to talk about what it is that your foundation does. I find it fascinating that even though you would think that you’re all about medical care, you’re really not all about medical care, right?

Barnes: No, that’s right. So we are committed to promoting equity by addressing health and not just health care. And so we use our resources in partnership with community members and organizations and change-makers to address factors that occur outside of the clinical setting and the doctor’s office. And representative [Sen.] Alvarado listed so many of them: housing, food security, employment, education. All of these are critically important to health. And so we use our resources to help address those needs because we know that that will set people up for a healthy life and not just a sick life that ends them up in clinical care at the very tail end of their illness. One of the things I wanted to share, I’m a physician by training, in internal medicine and primary care, and my patients taught me so much when I saw them and I prescribed medicines for diabetes or high blood pressure. It was the stories about their lives outside of the clinic that really helped me understand what was impacting their health, which is why I got into this space of health and not just the clinical side.

Rovner: Cara, you’re about to debut a project that you’ve been working on for four years that has to do with exactly this, with sort of the nonmedical implications of other things and the lack of health equity. So why don’t you tell us a little bit about it?

Anthony: Yeah, so coming up next week, we’re going to premiere a new podcast, and also it’s a documentary film, called “Silence in Sikeston.” It focuses on police violence and police killings, but looking at them not as crime stories, but more as a public health threat. Also looking at the lynchings of yesterday as a public health threat. Maybe people didn’t use those terms back then, but certainly we recognize them as such now.

And so I hope everyone checks this out because it really talks about how racism and chronic stress are linked. And so oftentimes it can weigh not only on your mental health — anxiety, depression, you can become suicidal because of these things — but also you can have physical health effects as well, higher rates of high blood pressure, cancer, et cetera. And so I’ve been traveling for the last four years to Sikeston, Missouri. It’s a small community in rural Missouri where there was a man who was lynched there in 1942. His name was Cleo Wright. This is America’s first federally investigated lynching, the first time the FBI decided to look at lynching as a federal crime. They came to Sikeston, Missouri. But the story has never really been told and not in this way, not looking at it as a public health story, because as public health reporters we’re tasked with looking at what makes a community sick, what’s harming a community, and sometimes that can be something like lynching, something like police killings. And so we’re looking at that head-on and talking about the health impacts there.

Rovner: And Sabriya, obviously this is a big project that we’ve been working on, but we’ve been working on a lot of other health equity stories that you’re sort of in charge of. So why don’t you tell us about some of those?

Rice: Yeah, certainly. And it’s a great parallel to the work that Cara’s been doing. I came to KFF in 2022, and my charge was to start up a Southern bureau and look at the health equity disparities that happen across the South. So my team ranges from Texas to Florida up until North Carolina, and we meet weekly and have conversations. And one thing I was constantly hearing from the reporters — I’m not a policy expert and I’m not a statistician, but I’m a people person and I listen to people — and my reporters were saying over and over again, “Yeah, we spoke to this expert about Medicaid expansion, but they were like, ‘Yeah, we could do that, but it’s not going to stop the root of the problem, which is racism.’”

“Yeah, we wrote about maternal mortality or infant mortality, but still at the root of this is racism.” So that term kept coming up. And so we decided this year to take a look at systemic racism in the health care system, and our series is called “Systemic Sickness,” and it looks at some of the things that Cara talked about, including policing, but we also look at redlining or the history of redlining, of public housing challenges. We’re looking modern-day, like attacks on diversity, equity, and inclusion programs in education, specifically the field of medicine. So that’s the nature of our project that we have for this year. And it’s been just a real fascinating experience.

Rovner: I think I’ve heard this come up a couple of times in the panels we’ve had this morning about some of the other issues that really impact this in a bigger way than many people think. And I think housing is definitely one of those. You talked about redlining. A lot of this is historic racism and literal redlining: “You cannot live here. If you live here, you cannot get a mortgage.” There’s been a lot of that. How significant, I assume, the problem is here in Texas?

Barnes: Yeah, it is significant in a lot of those racist structures. We continue to experience the aftereffects of those. Even today, those neighborhoods are still under-resourced, and that includes, like you mentioned, grocery stores, safe spaces to play, green spaces, good transportation options. And so those old and, I suppose, acceptable forms of structural racism that were enacted are still playing out today in the health of people.

Alvarado: It’s very important. And housing doesn’t get a lot of attention. It’s not a very glamorous or sexy issue, but I’m glad to hear presidential candidate Kamala Harris, she talked about housing and what she would like to see to build more affordable housing, or I guess we’re calling it “workforce housing” now. And then our state comptroller, Glenn Hegar, recognizing how many people we have moving to Texas all the time. And to accommodate that, we’d need about 300,000 new units or housing. So people don’t have a place to lie their head that’s comfortable and a place to cook meals. And then if they don’t have those safety nets, then their last concern is probably, “Oh, am I getting my workout in today?” Or “Am I eating enough fruits and vegetables?” when they’re in survival mode.

Rice: And I’ll piggyback on what representative [Sen.] Alvarado said. It’s hard for people to see how this kind of plays out in real time. And two of our reporters on the Southern team just recently looked at a community in Savannah, Georgia, called Yamacraw Village. It’s a public housing community that started around World War II. And historically, at that time, the residents were white. Disinvestment happened within this community over the years and the population of the community changed.

So now it’s a predominantly Black and Latino community, but what you see is a large amount of disinvestment. People can’t get things fixed, so you’re living in very unhealthy housing, when you do have housing. There’s no playgrounds, there’s no green space, there’s an extreme amount of violence. But one man told our reporters, “The walls sweat like working men.” This person moved into this community and got vouchers to be able to live there and immediately developed asthma and has been taking medication even years after he left the community. So when you think about how the system is harming people, these communities are there and they’re not being invested in. Instead, people are given things like Section 8, if they can get the vouchers, and then if you can find affordable living that will take your Section 8 voucher. So it’s a really big problem. And housing is often not talked about as a public health crisis.

Barnes: Absolutely. And not just the place that you lay your head, but high-quality housing, not substandard that actually can impact your health.

Rovner: One of the things we’ve seen, I guess in the last couple of years, are these extraordinarily hot summers. And I know the government has always helped underwrite heating assistance in the winter, but apparently air-conditioning assistance is not considered of the same importance. I just read Phoenix has been 100 degrees every day for the last hundred days. I know that here in Texas you’ve had some pretty extended heat waves. I mean, how big an issue is heat as a public health and equity issue?

Alvarado: It’s a big problem, and especially when we’ve had things like power outages, storms that we had very close to one another. We had the derecho in May and then we had followed by the Hurricane Beryl, and that was tough. I mean, people were out of power anywhere from a couple of days to 10 days, and for some, it’s life or death, especially if they have medical equipment that they have to be hooked up to. We’re going to be tackling some of those issues in this session, but our city does a good job in our county of opening cooling centers so that people have a place to go and retreat and charge their devices. But the weather is getting much more turbulent. The summers are getting hotter, the hurricane season is more active. And until people realize that there’s a reason all this is happening and people don’t want to talk about it or put policy forth that addresses what’s taking place in our environment. So they go hand in hand.

Barnes: One of the other things, as we talk about communities where there isn’t investment, is that there are these heat islands, and typically they are where people are low-income communities of color where simple things like trees being planted that could cool the temperature in the area, these neighborhoods don’t have those amenities. So there are efforts in Texas and in Houston to try to green up some of those communities, but it requires investment and attention and acknowledging that we have these disparities across the community.

Rovner: Yeah, there was a study, I think it was in Baltimore a couple of years ago, where the temperature differential was like 15 degrees. I mean, it would be 85 in the suburbs and it would be 100 in some of these sort of concrete jungles downtown where the buildings hold onto the heat. And, of course, those are places where people live and often can’t afford their utilities, and obviously their utility bills would be higher because it’s going to cost more to cool those places.

Barnes: And as representative [Sen.] Alvarado mentioned, heat, when you have chronic conditions, so the elderly in particular, these are the communities that have the greatest burden of those conditions. And so it’s particularly alarming. That need is there and we really have to pay attention to it.

Rice: One of the things we just looked at in a story was this idea of energy poverty. And one interesting factoid that I learned from that that I was unaware of myself is the idea that many of our federal policies tend to focus on cold weather and that this idea, in federal and state, so for example in North Carolina where the story was centered, there are requirements that apartments and other kind of housing that they mandate that you have heat in the winter. It’s not the same for AC in the summer, and that’s probably something that should be looked at.

Rovner: I want to talk about women. When we talk about health equity differences between men and women, where one of the first places we saw before the Affordable Care Act, insurers were allowed to charge women more simply because they were women and they lived longer and had more health expenses associated with being pregnant and having children. That was eliminated. But, obviously, there are still a lot of inequities between men and women and it’s there. I know that they’re exacerbated by race, but it’s not purely race. I mean, how big an issue is this still? Obviously, reproductive health in general, abortion in specific, is the central health issue in this year’s campaigns. So where does it fall in the pantheon of health equity?

Alvarado: I think if we had more women elected to office, definitely in Texas and in statewide positions, that things like Medicaid would pass, expansion of Medicaid. And it does matter who is at the table, who is making the decisions. And this happened just on one side of the aisle, but just 12-month postpartum for women, so that they can take advantage of Medicaid, and it finally got done. But that’s the only piece that we’ve been able to do. And they were two women, Democrat and Republican, Toni Rose and Sen. Huffman, who led that effort. And I just know if we had more women in the right places, that issues like health care wouldn’t be so partisan and divisive.

Barnes: Yeah, I was going to say the same thing. We finally got 12 months of coverage postpartum, and it’s really unfortunate that we have to piecemeal the care that women need. I think about the fact that we expect good pregnancy outcomes when someone hasn’t had care until they’re pregnant, and up until recently, only eight weeks after they were pregnant. And so yeah, there are a lot of disparities, and for many women being pregnant is their ticket to Medicaid. And so it just perpetuates this fragmented continuum of health, and women are falling out of it regularly.

Alvarado: And especially with women of color, 64% of Latinas and 62% of African American women will at some point be on Medicaid.

Anthony: I just want to chime in here too. You talk about reproductive rights. I considered, Julie, writing a personal essay about, at the time I was 35, I went on … I’m only 37 now, but as a Black woman in the U.S., going on birth control for the first time in my life. Now, I mentioned I’m a single mom, so that wasn’t always my story, but I think we’re in an era of progress and education that is still really, really important. So I just wanted to share that.

Rovner: So I want to talk a little bit about the actual inequities within medical care. One thing, Stat News has a wonderful story that’s part of a series they’re starting this week on algorithms that are embedded into care — when doctors make a diagnosis and then the algorithm comes up and shows all the things you should consider in deciding what kind of treatment. And a lot of these now have: Is the patient Black? And some of them, I think, were originally, I assume most of them, were originally born out of some sort of thought that there’s a differential in risk depending on skin color, but obviously a lot of them … have been completely overturned by science and yet they’re still there. What impact does embedded racism in medicine, in general, have on health equity?

Barnes: Yeah, specific to that, in particular, what it resulted in is individuals who had evidence of risk, because they were Black there was a higher threshold that had to be crossed before they got additional testing or additional treatment, which means that there are populations of people who didn’t get timely care because of those embedded algorithms. One of the other things, there’s not an overriding body — I guess CMS could be that overriding body — but right now no one is standing up saying, “Absolutely you cannot use race-based algorithms.” And so it’s really up to individual health systems. States could implement penalties if you use them, but right now it’s up to an individual institution, and it takes a lot to undo an algorithm and change an electronic medical record. But we are at the threshold, I think, of that beginning to happen.

Anthony: And it’s such a common issue. I spent the last few years looking particularly at kidney disease testing, and if you put a Black person’s kidney on a table and you put a white person’s kidney on the table, you would not be able to tell the difference. People really need to understand that race and biology are not the same, but for years, I mean decades, people have mixed this up and it has delayed care from people who are not getting the treatment that they need.

We wrote a story a couple of years ago about a Black man who needed a kidney, a white woman read the story and decided to donate a kidney to him, but that’s not everybody’s case. I can only write about so many patients that are in that same scenario. And so there’s still a lot of work that needs to be done, but progress is being made. The hospital in particular that we were looking at in St. Louis, they’ve made some policy changes since we published that particular article, but we still have a long way to go. I can’t say that enough. Race and biology are not the same.

Rovner: I mentioned at the top geography, and we talk about people who are grouped together because they have to be, but it’s also about where people decide to live, in rural versus urban. I mean, how can we look population-wide and try to even out, I mean, we talk constantly about the closures of rural hospitals and the difficulty of getting care in far-flung areas, and obviously Texas has a lot of far-flung areas, I know. That is another issue that sort of plays into this whole thing, right?

Alvarado: Oh, absolutely. And one of the arguments, again, this all keeps going back to Medicaid expansion, but you’re talking to my colleagues on the other side of the aisle, I said, your districts, some of your rural districts are suffering the most. Hospitals have shut down. They have to drive to the next big city. It might be Houston or Dallas or San Antonio, but it has, I think, disproportionately hurt rural areas. And until folks want to own that, embrace that, and try to fix it, we’re going to continue to be in this place and probably the gap will widen even more.

Rice: And I’d say we saw this kind of play out in Georgia this week. I live in Atlanta, and there was the unfortunate school shooting incident that happened there. And the community that that school is in had no hospital in that area. So the closest place would’ve been 40 miles away in either direction to Athens, Georgia, which is about 40 miles from the Barrow County and then Atlanta. So even in an incident like that, just coordinating to get people treatment in a major incident is just another example of why we need to do something, right? It’s not just Black communities or Hispanic communities. I think it’s all of us and any given moment may need access to care. And if you think about it, in light of that, 40 miles is no easy feat on Atlanta highways in rush-hour traffic or even being airlifted, it’s still a distance and you have a small window of time to save a life.

Barnes: And there’s been specific conversations in Texas about access to maternal health care in rural communities. And so again, the distance that someone would have to drive is hard for many of us to imagine, especially in a time of crisis.

Rovner: One of the other continuing issues when we talk about health equity is the desire of people to be treated by people who look like them or people who have similar backgrounds to them. That’s obviously been an issue for years that the medical community has been trying to deal with. I want to ask specifically what impact the Supreme Court’s decision banning affirmative action is going to have on the future of the medical workforce and the few strides that have been made to get more people of color, not just into medical school, but into practice.

Rice: I’d say that was pretty immediate, and especially in some of our Southern states, given the history. But I think there were immediate bans on DEI programs or dismantling of those at schools across the South. I can think of Alabama, Mississippi, Texas, even Georgia introduced a bill. It didn’t pass, but I think we saw that happen pretty immediately. And the doctors that at least reporters on my team have spoken to have said, even in their programs, they can’t even say, “We’re trying to increase the number of Black doctors or Hispanic doctors or Native American doctors.” You can’t target those groups to come to special programs, to have access to visitations to schools or that sort of thing. You can’t even say it. So they’re having to kind of circumvent how they reach people to increase the low numbers of doctors of these ethnic groups.

Alvarado: I think we’ve only begun to see the consequences that have taken place because of that. When you mentioned the medical center, we have people that come from all over the world and having physicians that they can relate to or just speaking the language, 48% of people from Houston speak other languages other than English at home. So Houston is known for being very international, very diverse, and it’s only going to continue to grow. So having the language barrier also contributes to many other issues regarding your health. But having that comfort with someone that understands your background, may understand your challenges, that’s important. And I don’t think that the people who were coming up with DEI legislation here in Texas and, those things don’t cross their mind because they’re shortsighted. They’re trying to check a box or get that “A-plus” on their whatever scorecard by whatever group in their party.

Rovner: But people think, well, a doctor is a doctor is a doctor. Why does it matter if that doctor, if you’re able to relate to that doctor, how important is it really to have a medical community that looks like the community it’s serving?

Barnes: Yeah, I would say it’s a huge trust issue. I remember having patients in my practice, African American patients, and there was a wonderful trust that we had with one another. And then I would refer them to a specialist who didn’t look like them, and they would ask me questions, “Do you really think they’re going to do the procedure that they said?” And I was just thinking, “Oh my gosh, I am taking for granted that someone would trust me.” And when we think about how we make recommendations to patients, if the trust isn’t there, why would they listen to what you had to say? And then that will, of course, put you at a disadvantage from a health perspective. And in terms of eliminating affirmative action, I don’t know the medical school data, but a lot of higher education institutions are already reporting lower numbers in their incoming classes. And that certainly is going to be the same in medical schools, nursing schools, PA schools.

Rovner: I did have in my notes that medical schools are freaked out by this.

Anthony: And it’s really …

Barnes: Absolutely.

Anthony: And what you’re talking about, and I’ve written a lot about this topic, and just to name it, we’re talking about “culturally competent care,” and culturally competent care is really, really hard to find because the numbers are low, because there has been a shift. But I think the conversation is also shifting towards culturally humble care or cultural humility in health care. So even if I can’t find a doctor who looks like me, I need someone who’s culturally humble to say, “You know what? I don’t understand everything that you’re going through as a Black woman raising a child in America, but I can admit that, I can say that out loud, and I can maybe direct you towards someone who can be more helpful. Or maybe we could just have a really candid conversation about that.” And so I just want to give people the terminology that I think could be useful if you want to learn more.

Rice: We also just did a story looking at colorism in the U.S. and the impact that that has on people. Interviewed a woman, for example, who had been bleaching her skin for all of these years, had these side effects from that, but clinicians weren’t catching it. They didn’t know to look for specific things. So there were mental health challenges there because of feeling unhappy being in her own body, but there were also manifestations on her physical health because the chemicals that she was introducing were causing harm. So I think that kind of cultural competence, someone that looked like her and could relate to her background might be like, “Wait a minute, is this what’s happening here?” And that’s what happened in the case of that particular patient.

Rovner: So at our session this morning on why does care cost so much? My colleague Noam Levey talked about something he calls a culture of greed in health care, it does seem as if every aspect of the system is or has been monetized. I mean, it really is all about the money. How does that impact health equity? I mean, you could think that if the incentives were in the right place, it might be able to help.

Alvarado: And it drives up the cost of insurance too. I mean, if you’ve ever had a loved one in the hospital, they don’t want you to bring your medications from home. So you have to take what they have there. And it is the same thing, but it’s very expensive. You can buy a bottle of Advil for 5, 6 bucks; each pill is about that much, and then it drives up cost of insurance, and it has an economic impact that trickles down to the consumer.

Barnes: And then it becomes a barrier. So if you are paying out-of-pocket and things are incredibly expensive and you also have to buy food and pay your rent, you may forgo or delay care, which again is going to leave you in a worse situation from a health standpoint and just perpetuate the disparities.

Rovner: Now we have managed-care companies who serve not just most of the Medicare population, but most of the Medicaid population, who get paid for presumably the incentive there was, you’re going to take care of these people and we’re going to pay you, and the more people you can find to take care of, the more we’re going to pay you. And in theory, they have adequate networks where people can actually find care, which is not always the case with Medicaid. It’s hard to find providers who will take Medicaid. I’ve started seeing ads for managed-care companies for people who are eligible for both Medicare and Medicaid, the “dual eligibles.” They don’t call them that, but it’s like, “Wow, I’m looking at TV ads for dual eligibles.” Somebody must be making some amount of money off of these people. Is anything good coming from it?

Alvarado: I mean, the pharmaceutical companies are raking it in pretty good. And in some countries you can’t even have direct promotion for pharmaceuticals from the pharmaceutical company to the consumer.

Rovner: Most other countries.

Alvarado: Yeah, except I mean every commercial. I mean, you pick your drug, what is it, Skyrizi or Cialis, whatever. I mean, it’s out there.

Rovner: Yes, we all know the names of the drugs now.

Alvarado: Something for everybody.

Rovner: I’m going turn it over to questions in a minute, but before I do, I don’t want this to be a complete downer. So I would like each of you to talk about something that you’ve seen in the last year or two that’s made you optimistic about being able to at least address the issue of health equity.

Rice: I mean, the fact that we’re having these conversations more, I think, is something that brings optimism, for me. I don’t remember my family having these conversations as a kid. It was just like, “Well, this is just the way it is. Or “This is how the system is.” And I think it’s positive that we’re having conversations not just about how the system is currently, but about changing it, as Cara mentioned, for the next generation.

Barnes: As a philanthropy, I can talk about some specific investments that we’ve made that have allowed community health workers to work with women throughout their pregnancy period. And so in a small way, for those women, we have increased the opportunity for them to have a healthy outcome. But we’ve also done some policy work. We were part of a large coalition of folks pushing for 12 months of Medicaid coverage postpartum. And those system-level changes affect millions of Texans. And so again, we felt that was really an important way to change the health equity equation.

Alvarado: And thank you for your work on that. Many of us on my side of the aisle have been filing those bills to get it extended to 12 months. But again, everything goes back to politics. They weren’t going to let somebody in the minority party carry it. And at that point, you don’t care who gets the credit, just get it done. Or as we say in Texas, “Git-er-done” and take care of folks. But another thing that we’ve been talking about on our side of the aisle was the tampon tax, the pink tax, and wow, all of a sudden my colleagues on the other side thought, “Oh, that’s a good idea.” And so anyway, we didn’t get to carry it. They passed it, OK, it’s done. So we’ve got to play this game, dance this dance here, and we’ll do it. The most important thing is to make things accessible and affordable to people.

And one of the other things too, we didn’t get to talk about this much, but when you talk about the environment and health impacts, my district has so many concrete batch plants. And so we are seeing more people become aware of particulate matter and the negative impact that these facilities have. And they’re almost all, I’d say 99% all, located in African American and Latino neighborhoods. And Harris County has the largest number of concrete batch plants in any other county in Texas. And a third of those concrete batch plants are walking distance to schools and to day cares. We have more work to do in this area, but at least now the public is holding people accountable and we’re putting more pressure on the agencies that regulate these facilities.

Anthony: We often think about data and there’s negativity associated with that. But one thing that I’ve learned, particularly in the last four years, is that there’s good data too. There’s change that is happening, right? I mentioned early on in our conversation about the swim lesson with my daughter, and that’s progress, right? There’s institutional change happening as well. We talk about the algorithms and the issues there, but we know that there are institutions that have said, “Yes, this is a mistake.” I have concerns, and this is another conversation about what’s going to happen with AI. But I think that there are positive ways to look at that as well. So change is happening, and we have to think about also moving forward, and we want to tell those stories too.

Rovner: All right, well, I’m going to turn it over to the audience now. I see we already have someone waiting to ask a question. Please, before you ask your question, tell us who you are and where you’re from and please make it a question. Go ahead.

Abimisola: Hi, my name is Abimisola. I am from Nigeria, but I live in Austin, Texas. My question is about education. I feel like a big part of access and equity is education. So what are we doing to let people know that there are some services that are available to help them access the care that they need? I imagine that as, I guess, working through the pandemic, health literacy is not really a thing in the public. And so what are we doing to let people know that some of these services exist? And then also on the cultural humility end of things, what are we doing to make sure that providers are aware of this gap and how can they be helpful in their own way to make sure that equitable care does exist when people come in?

Barnes: So I think that we are at a moment of awakening when it comes to recognizing that you need trusted messengers in communities to actually engage in conversations about navigating health care systems or engaging in preventive health measures. Community health workers are really starting to have their day, and there is recent legislation that will actually allow them to be reimbursed for case management services related to their care of pregnant women. And so we are in a moment, that same legislation will also cover doulas and their case management services. But I think to your point, education, health literacy, having someone you trust who can walk you through that process is so critically important and those caregivers are finally getting the recognition that they deserve and being elevated and reimbursed. And so I think that that is a great step.

Linda Jackson: Hello, thank you for the information that you’ve provided. So I’m Linda Jackson and I’m with Huston-Tillotson University, which is a historically Black university a few miles from here. And I want to talk about the speed. One thing that happened again during the coronavirus is that because the university had systems in place, for example, the university was able to move from on-campus, on-ground, to online almost immediately with all of those funds and programs that were available. We’re in that same situation now with what we’re experiencing now, we have an increase in the number of students who want to attend college, an increase in our enrollment. We are a pipeline for the health industry, for some of the issues that we have to deal with, but the issue is that we can move quickly, but to get to all of those entities that are out there that can provide the funding that’s needed.

We have students we turned away who are waiting to get into college, and they’re interested in computer science and they’re interested in the health care industry and they’re interested in all those fields, but it’s the speed. We are here waiting, but the speed for which all of those resources have to come into place. And for example, we had entities who came to us with a doula program, with a doula idea, and we offer a certificate in the doula program to ensure that there are more doulas to provide that culturally sensitive care. And so my question is we’re here. We’re waiting. The resources need to come faster. And so I guess that’s a statement as opposed to a question.

Rovner: But thank you for raising the topic.

Barnes: I will just say, well, first off, my mother and my aunt are both graduates of Huston-Tillotson. So very excited to have you here. I think connecting the industries that need the workforce with the institutions who can provide the training is a key connection that we haven’t figured out how to do well because that’s where your resources would come to be able to support students getting trained to then fill the jobs where we have needs in the health care setting.

Rovner: And this is not just a health equity issue, this is the entire health system writ large.

Barnes: Absolutely.

Rovner: The difficulties with matching workforce needs with patient needs.

Robert Lilly: Good afternoon. Thank you very much for this lively conversation. My name is Robert Lilly. I am a criminal justice participatory defense organizer with Grassroots Leadership, and I’m also justice-impacted, formerly incarcerated, 54 years old with 21 years of my life spent in some institution or another. I want to just comment or not comment, but inquire from the two points that were made about equity. You mentioned that you wanted to, equity was about optimal health, no matter the background of the individual and also to eliminate barriers, especially for populations that are most vulnerable.

Texas has over 110 prisons, 135,000 people currently incarcerated, 600,000 every year exiting the system. Medicaid expansion is a challenge in Texas. My question before you is, in this era of mass incarceration, what options do we have? If policy can’t fix this problem, what other options exist? With the creative minds that you have, the thoughtful insights that you’re gaining from your research and reflection, how can you advise us to move, if our legislature won’t move? Do we depend on them alone to solve these problems, or is there an alternative route that supersedes them? And the last thing I’ll ask is how much of what we’re experiencing today, and we know America’s been historically racist, but how much of what we experiencing is a backlash to George Floyd?

Rovner: Oh, excellent question. Somebody want to take him on?

Anthony: I really think about if policy can’t do it, what can? And that’s where I think about for me, often it’s the institution of the Black family and starting young, what conversations do we need to have with our children as we move forward? That’s one thing that I, in particular, think about because I really think it comes down to literacy, education, being made aware, and also thinking about what can we do as individuals? But it really requires institutional change. I don’t want to act like that’s not at the core of the issue, but really want to talk about our future a lot and think about our future a lot. And so I think it starts at a really young age.

Rice: I wish we could tackle the whole iceberg all at once and just tear the whole thing down and start over. But the reality is we have to chip at it. And I think as we continue to do that, I think it starts to dismantle. And I don’t know that that offers much hope, but I think it’s kind of where we’re at and what we have to do is to keep moving because we wouldn’t have had this progress without that kind of fight.

Rovner: But … go ahead.

Rice: And vote.

Carley Deardorff: Hi, y’all. My name is Carley Deardorff, born and raised in Texas. I have lived in Texas my whole life, except I ran away to Spain for a little bit. Born in Lubbock, been in Austin for about 15 years now. I want to say one, thank you so much for your question previously. My question involves both formerly incarcerated but also aging. So aging parents, aging families. My partner and I were both raised by single moms, and so the outcomes for them, health-wise and also financially in terms of retirement and things like that are very, very slim. And so now in this next phase of life, navigating equity and health outcomes for them, it’s really scary because I don’t know. So before I cry, what do y’all have as opportunities and resources as you help someone age, and what that can look like in the space of life?

Barnes: So, thank you for being so vulnerable in talking about how incredibly challenging navigating the health care system and the systems that address nonmedical factors are for individuals. I don’t have an easy answer. There are organizations, and some that we have funded, that provide navigation services so that folks who know how to walk their way through these complicated systems can be helpful and maybe we can talk offline after we’re done. Again, they rely on trusted messengers in the communities who know what’s going on in the environment and then can actually help with the complicated side of things as well. And I think that’s probably the best bet for traversing something that doesn’t have to be as complicated as it is, but it is what it is at this point.

Meer Jumani: Do we have time for one more?

Barnes: We do.

Jumani: Perfect.

Rovner: Go ahead.

Jumani: So Meer Jumani, I work as a public health policy adviser to Commissioner Adrian Garcia, Harris County, Precinct 2. Sen. Alvarado’s District and Precinct 2 overlap a ton, but Precinct 2 has approximately 1.1 million constituents, of which 65% are Hispanic. We also have some of the most vast health disparities ranging from the highest mortality rate to the lowest home ownership rate. We touched on that amongst others, and despite launching programs ranging from free community-based clinics to lead abatement programs, we see a trend that these are most underutilized by the most vulnerable populations. So my question is, can you speak to what measures can be taken or what folks are not doing to change the mindset of these populations from a curative mindset to a preventative mindset?

Rice: I think it’s, as you mentioned before, trust, right? Those community navigators and making sure they’re out there giving voice to the community and sharing what resources are there. During covid, there was a community in northeast Georgia with a large immigrant population, and they actually ended up having some of the lowest rates of covid for the state because of those community navigators. They really hit the ground and it was kind of amazing what they did, going door to door if they had to, having weekly events and having conversations, making screenings accessible to everyone, and having navigators that spoke various different languages. I think those kind of things continue to help with that kind of outreach.

Anthony: I totally agree. And acknowledging painful history too. I think we have to realize who is tasked to do the fixing, and are we really giving agency and empowering those that need help the most? I’m thinking about particularly in Sikeston, Missouri, where the police chief tried to institute a program where people were to come, particularly Black residents in town. He wanted to have meetings with them and have conversations, but it just didn’t take off. But part of the reason why is because the level of mistrust, but also some acknowledgment of the history of racial violence that had gone on in the past in that community that people were still trying to heal from today. So I think that there’s so much work that has to be done in institutions. One of the first steps that they can take is acknowledging painful history as a way to move forward because we have to acknowledge our pain to have some joy too.

Rovner: I think that’s a wonderful place to leave it. I want to thank our panel so much and thank you to the audience for your great questions.

I hasten to add, if you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d always appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our technical guru back in Washington, D.C., Francis Ying, and our editor, Emmarie Huetteman. And thanks to the kind folks here at TribFest for helping us put this all together. We’ll be back in D.C. with our regular panel and all the news on Sept. 12. Until then, everyone, be healthy.

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Christina Kashiwada was traveling for work during the summer of 2018 when she noticed a small, itchy lump in her left breast.

She thought little of it at first. She did routine self-checks and kept up with medical appointments. But a relative urged her to get a mammogram. She took the advice and learned she had stage 3 breast cancer, a revelation that stunned her.

“I’m 36 years old, right?” said Kashiwada, a civil engineer in Sacramento, California. “No one’s thinking about cancer.”

About 11,000 Asian American and Pacific Islander women were diagnosed with breast cancer in 2021 and about 1,500 died. The latest federal data shows the rate of new breast cancer diagnoses in Asian American and Pacific Islander women — a group that once had relatively low rates of diagnosis — is rising much faster than that of many other racial and ethnic groups. The trend is especially sharp among young women such as Kashiwada.

About 55 of every 100,000 Asian American and Pacific Islander women under 50 were diagnosed with breast cancer in 2021, surpassing the rate for Black and Hispanic women and on par with the rate for white women, according to age-adjusted data from the National Institutes of Health. (Hispanic people can be of any race or combination of races but are grouped separately in this data.)

The rate of new breast cancer cases among Asian American and Pacific Islander women under 50 grew by about 52% from 2000 through 2021. Rates for AAPI women 50 to 64 grew 33% and rates for AAPI women 65 and older grew by 43% during that period. By comparison, the rate for women of all ages, races, and ethnicities grew by 3%.

Researchers have picked up on this trend and are racing to find out why it is occuring within this ethnically diverse group. They suspect the answer is complex, ranging from cultural shifts to pressure-filled lifestyles — yet they concede it remains a mystery and difficult for patients and their families to discuss because of cultural differences.

Helen Chew, director of the Clinical Breast Cancer Program at UC Davis Health, said the Asian American diaspora is so broad and diverse that simple explanations for the increase in breast cancer aren’t obvious.

“It’s a real trend,” Chew said, adding that “it is just difficult to tease out exactly why it is. Is it because we’re seeing an influx of people who have less access to care? Is it because of many things culturally where they may not want to come in if they see something on their breast?”

There’s urgency to solve this mystery because it’s costing lives. While women in most ethnic and racial groups are experiencing sharp declines in breast cancer death rates, about 12 of every 100,000 Asian American and Pacific Islander women of any age died from breast cancer in 2023, essentially the same death rate as in 2000, according to age-adjusted, provisional data from the Centers for Disease Control and Prevention. The breast cancer death rate among all women during that period dropped 30%.

The CDC does not break out breast cancer death rates for many different groups of Asian American women, such as those of Chinese or Korean descent. It has, though, begun distinguishing between Asian American women and Pacific Islander women.

Nearly 9,000 Asian American women died from breast cancer from 2018 through 2023, compared with about 500 Native Hawaiian and Pacific Islander women. However, breast cancer death rates were 116% higher among Native Hawaiian and Pacific Islander women than among Asian American women during that period.

Rates of pancreatic, thyroid, colon, and endometrial cancer, along with non-Hodgkin lymphoma rates, have also recently risen significantly among Asian American and Pacific Islander women under 50, NIH data show. Yet breast cancer is much more common among young AAPI women than any of those other types of cancer — especially concerning because young women are more likely to face more aggressive forms of the disease, with high mortality rates.

“We’re seeing somewhere almost around a 4% per-year increase,” said Scarlett Gomez, a professor and epidemiologist at the University of California-San Francisco’s Helen Diller Family Comprehensive Cancer Center. “We’re seeing even more than the 4% per-year increase in Asian/Pacific Islander women less than age 50.”

Gomez is a lead investigator on a large study exploring the causes of cancer in Asian Americans. She said there is not yet enough research to know what is causing the recent spike in breast cancer. The answer may involve multiple risk factors over a long period of time.

“One of the hypotheses that we're exploring there is the role of stress,” she said. “We're asking all sorts of questions about different sources of stress, different coping styles throughout the lifetime.”

It’s likely not just that there’s more screening. “We looked at trends by stage at diagnosis and we are seeing similar rates of increase across all stages of disease,” Gomez said.

Veronica Setiawan, a professor and epidemiologist at the Keck School of Medicine of the University of Southern California, said the trend may be related to Asian immigrants adopting some lifestyles that put them at higher risk. Setiawan is a breast cancer survivor who was diagnosed a few years ago at the age of 49.

“Asian women, American women, they become more westernized so they have their puberty younger now — having earlier age at [the first menstrual cycle] is associated with increased risk,” said Setiawan, who is working with Gomez on the cancer study. “Maybe giving birth later, we delay childbearing, we don't breastfeed — those are all associated with breast cancer risks.”

Moon Chen, a professor at the University of California-Davis and an expert on cancer health disparities, added that only a tiny fraction of NIH funding is devoted to researching cancer among Asian Americans.

Whatever its cause, the trend has created years of anguish for many patients.

Kashiwada underwent a mastectomy following her breast cancer diagnosis. During surgery, doctors at UC Davis Health discovered the cancer had spread to lymph nodes in her underarm. She underwent eight rounds of chemotherapy and 20 sessions of radiation treatment.

Throughout her treatments, Kashiwada kept her ordeal a secret from her grandmother, who had helped raise her. Her grandmother never knew about the diagnosis. “I didn't want her to worry about me or add stress to her,” Kashiwada said. “She just would probably never sleep if she knew that was happening. It was very important to me to protect her.”

Kashiwada moved in with her parents. Her mom took a leave from work to help take care of her.

Kashiwada’s two young children, who were 3 and 6 at the time, stayed with their dad so she could focus on her recovery.

“The kids would come over after school,” she said. “My dad would pick them up and bring them over to see me almost every day while their dad was at work.”

Kashiwada spent months regaining strength after the radiation treatments. She returned to work but with a doctor’s instruction to avoid lifting heavy objects.

Kashiwada had her final reconstructive surgery a few weeks before covid lockdowns began in 2020. But her treatment was not finished.

Her doctors had told her that estrogen fed her cancer, so they gave her medicine to put her through early menopause. The treatment was not as effective as they had hoped. Her doctor performed surgery in 2021 to remove her ovaries.

More recently, she was diagnosed with osteopenia and will start injections to stop bone loss.

Kashiwada said she has moved past many of the negative emotions she felt about her illness and wants other young women, including Asian American women like her, to be aware of their elevated risk.

“No matter how healthy you think you are, or you're exercising, or whatever you're doing, eating well, which is all the things I was doing — I would say it does not make you invincible or immune,” she said. “Not to say that you should be afraid of everything, but just be very in tune with your body and what your body's telling you.”

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Supplemental support comes from the Asian American Journalists Association-Los Angeles through The California Endowment.

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

The conventions are over, and the general-election campaign is officially on. While reproductive health is sure to play a key role in the race between Vice President Kamala Harris and former President Donald Trump, it’s less clear what role other health issues will play.

Meanwhile, Medicare recently announced negotiated prices of the first 10 drugs selected under the 2022 Inflation Reduction Act. The announcement is boosting attention to what was already a major pocketbook issue for both Republicans and Democrats.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Politico and Johns Hopkins University’s schools of nursing and public health, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.

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

• The Democratic National Convention highlighted reproductive rights issues as never before, with a parade of public officials and private citizens recounting some of their most personal, painful memories of needing abortion care. But abortion rights activists remain concerned that Harris has not promised to push beyond codifying the rights established under Roe v. Wade, which they believe allows too many barriers to care.
• As reproductive rights have taken center stage in her campaign, Harris has been less forthcoming about her other health policy plans so far. In her career, she has embraced fights against anticompetitive behavior by insurers and hospitals and in drug pricing.
• Would former President Donald Trump make Robert Kennedy Jr. his next health secretary? Even many Republicans would consider his elevation a bridge too far. Polls show Trump stands to gain from Kennedy’s departure from the presidential race, but likely only slightly more than Harris.
• In other national health news, abortion access will be on the ballot this fall in Arizona and Montana, and the federal government recently announced the first drug prices secured under Medicare’s new drug-negotiation program.

Also this week, Rovner interviews KFF Health News’ Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment about a woman who fought back after being charged for two surgeries despite undergoing only one. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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

Julie Rovner: The New York Times’ “Hot Summer Threatens Efficacy of Mail-Order Medications,” by Emily Baumgaertner.

Joanne Kenen: The Milwaukee Journal Sentinel’s “Who Is Gus Walz and What Is a Non-Verbal Learning Disorder?” by Natalie Eilbert. 

Alice Miranda Ollstein: The Wall Street Journal’s “The Fight Against DEI Programs Shifts to Medical Care,” by Theo Francis and Melanie Evans.  

Shefali Luthra: The Washington Post’s “Weight-Loss Drugs Are a Hot Commodity. But Not in Low-Income Neighborhoods,” by Ariana Eunjung Cha. 

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Transcript: Let the General Election Commence

KFF Health News’ ‘What the Health?’Episode Title: ‘Let the General Election Commence’Episode Number: 361Published: Aug. 23, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, Aug. 23, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So here we go. Today we are joined via teleconference by Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: Shefali Luthra of The 19th.

Shefali Luthra: Good morning.

Rovner: And Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month,” about a woman who got two bills for the same surgery and refused to back down. But first, this week’s news. So, now both conventions are over. Labor Day is just over a week away. And I think it’s safe to declare the general election campaign officially on. What did we learn from the just-completed Democratic [National] Convention, other than that Beyoncé didn’t show up?

Luthra: I think the obvious thing we learned is there is a lot of abortion for Democrats to talk about and very little abortion Republicans would like to. I did the fun brain exercise of going back through old Democratic conventions to see how much abortion came up. It might be interesting to note that in 2012, for instance, [the former president of Planned Parenthood] Cecile Richards spoke, never mentioned abortion.

A Planned Parenthood patient came and didn’t talk about abortion, talked about endometriosis care. And I think that really underscores what a shift we have seen in the party from treating abortion as an issue for the base, but not one that got center stage very often. And that shifted a bit in 2016, but is really very different now.

We had abortion every night, and that is just such a marked contrast from the RNC, where Republicans went to great lengths to avoid the topic because Democrats are largely on the winning side of this issue and Republicans are not.

Rovner: I’ve watched every Democratic convention since 1984. I have to say, I’m still trying to wrap my brain around the idea of all of these, and not just women, but men and [Sen.] Tammy Duckworth talking about IVF and women who had various difficulties with pregnancy. Usually, it would be tucked into a section of one night, but every single night we had people getting up and telling their individual stories. I was kind of surprised. Alice, you wanted to add something?

Ollstein: Yeah. We also wrote about how the breadth of the kinds of abortion stories being told has also changed. There’s been frustration on the left for a while that only these medical emergency cases have been lifted up.

Rovner: The good abortions.

Ollstein: Exactly. So there’s a fear that that further stigmatizes people who just had an abortion because they simply didn’t want to be pregnant, which is the majority of cases. These really awful medical emergencies are the minority, even though they are happening, and people do want those stories told. But I think it was notable that the head of Planned Parenthood talked about a case that was simply someone who didn’t want to be pregnant and the lengths she had to go through to get an abortion.

I think we’re still mostly seeing the more politically palatable, sympathetic stories of sexual assault and medical emergencies, but I think you’re starting to see the discourse broaden a little bit more. It’s still not what a lot of activists want, but it’s widening. It’s opening the door a little bit more to those different stories.

Rovner: And certainly having [Kamala] Harris at the top of the ticket rather than Biden, I mean, she’s been the point person of this administration on reproductive health even before Roe v. Wade got overturned.

Ollstein: Right. And I think it’s been interesting to see the policy versus politics side of this, where politically she’s seen as such a stronger ally on abortion rights, and her messaging is much more aggressive than [President Joe] Biden’s, a lot more specific. But when it comes to the policy, she’s exactly where Biden was. She says, “I want to restore Roe v. Wade,” where a lot of activists say that’s not enough. Roe v. Wade left a lot of people out in the cold who couldn’t get an abortion that they wanted later in pregnancy, or they ran into all these restrictions earlier in pregnancy that were allowed under Roe. And so I think we’re going to see that tension going forward of the messaging is more along the lines of what the progressive activists want, but the policy isn’t.

Luthra: And to build on Alice’s point, I mean, a lot of the speakers we had this week are speakers who would’ve been there for a Biden campaign as well. Amanda Zurawski was a very effective Biden surrogate. She is now a Harris surrogate.

And I think what’s really important for us to remember as we look not just to November, but to potentially January and beyond, is that what Harris is campaigning on, what Biden tried to campaign on, although he struggled to say the words, is something that probably isn’t going to happen because they’re talking about signing a law to codify Roe’s protections and they in all likelihood won’t have the votes to do so.

Rovner: Yes. And they either have to get rid of the filibuster in the Senate or they have to have 60 votes, neither of which seems probable. And as I have pointed out many times, the Democrats have never had enough votes to codify Roe v. Wade. There’s never actually been a basically pro-choice Congress. The House has never been pro-choice until Trump was president, when obviously there was nothing they could do.

It’s not that Congress didn’t want to, or the Democrats in Congress didn’t want to or didn’t try, they never had the votes. For years and years and years, I would say, there were a significant number of Republicans who were pro-abortion rights and a significant, even larger number of Democrats who were anti-abortion. It’s only in the last decade that it’s become absolutely partisan, that basically each party has kicked out the ones on the other side. Joanne, you wanted to add something?

Kenen: Remember that the very last snag that almost pulled down the Affordable Care Act at zero hour, or zero minus, after zero hour, was anti-abortion Democrats. And that was massaged out and they cut a deal and they put in language and they got it through. But no, the phenomenon Julie’s talking about was that the dynamics have changed because of the polarization.

I mean, it wasn’t just abortion; there were centrists in both parties, and they’re pretty much gone. The other thing that struck me last night is there was rape victims and victims of traffic and abuse speaking both within the context of abortion. I mean, that was a mesmerizing presentation by a really courageous young woman.

And then there were other episodes about sexual violence against women, a nod to Biden a couple of times, who actually wrote the original Violence Against Women Act in ’94, part of the crime bill, but also in terms of liberal Democrats or progressives who … “prosecutor” isn’t their favorite title. But because they tied these themes together or at least link them or they were there in a basket together of her as a protector of victims of trafficking, rape, and abuse, starting when she was in high school with her friend.

So I thought that that was another thing that we would not have spoken about. You did not have young women talking about being raped by their stepfather and impregnated at age 12.

Rovner: So aside from reproductive rights, which was obviously a headline of this convention, it’s almost impossible to discern what a second Trump administration might mean for health because Trump has been literally all over the place on most health issues. And he may or may not hire back the former staffers who compiled Project 2025.

But we don’t really know what a Harris administration would mean either. There is still no policy section on the official Harris for President website. One thing we do seem to know is that she seems to have backed away from her support for “Medicare for All,” which she kind of ran on in 2019.

Luthra: Sort of.

Rovner: Yeah, kind of, sort of. What else do we know about what she would do on health care other than on reproductive health, where she’s been quite clear?

Ollstein: So the focus on the policies that have been rolled out so far have been cost of living and going after price-gouging. She also has a history, as California attorney general, of using antitrust and those kinds of legal tools to go after monopolistic practices in health care. In California, she did that on the insurance front and the hospital front and the drug pricing front. So there is an expectation that that would be a focus. But again, they have not disclosed to us what the plans are.

Kenen: I mean, one of the immediate things, and I watched a fair amount of the convention and none of us absorbed every word, but I don’t think I heard a single mention of it was the extension of the ACA subsidies, which expire next year. I mean, if they mentioned it, it was in passing by somebody. So you didn’t really hear too much ACA, right? You hear that wonderful line from President [Barack] Obama when he said the Affordable Care Act, and then he said that aside: “Now that it’s popular, they don’t call it Obamacare anymore.”

But you didn’t hear a lot of ACA discussion. You heard a lot of drug price and you heard a lot of some vague Medicare, mostly in the context of drug prices. But there wasn’t a segment of one night devoted to the health policy. So I mean, I think we can assume she’s pretty much going to be Biden-like. I would be surprised if she didn’t fight to preserve the subsidies.

The Medicare drug stuff is in law now and going ahead. I think Julie wants to come back to that, but I don’t think we know what’s different. And I don’t know what, in that to-do list, I don’t think she articulated the priorities, although I would imagine she’ll start talking about the subsidies because the Republicans are probably going to oppose that. But no, it wasn’t a big focus. It was like sprinkles on an ice cream cone instead of serving a sundae.

Rovner: It’s hard to remember that just four years ago in 2020, there was this huge fight about the future of health care. Do we want to go to Medicare for All? What do we want to do about the ACA? Biden was actually the most conservative, I think, of the Democratic candidates when it came to health care.

Kenen: And then he expanded things way more than people expected him to.

Rovner: Yes, that’s true. I was going to say, but the other thing that jumped out at me is how many liberals, [Rep.] Alexandria Ocasio-Cortez, talking like a moderate basically, I mean, giving this big speech. It feels like the left wing of the Democratic Party, at least on health care, has figured out that it’s better to be pragmatic and get something done, which apparently the right wing of the Republican Party has not figured out.

Luthra: Well, part of what happened, right, is, I mean, the left lost in 2020. Joe Biden won. He became president. And there’s this real interesting effort that we saw this week to try and recapture the energy of 2008, 2012, the Obama era, and that wasn’t a Medicare-for-All-type time. That was much more vibes and pragmatism, which is what we are seeing now.

Kenen: The other thing is that the progressives, more centrist, more moderate, whatever you call the mainstream bring, they kissed and made up. I mean, [Sen.] Bernie Sanders became an incredible backer of Biden. I mean, they fought on the original Bring [Build] Back Better. That became the watered-down Inflation Reduction [Act]. They had some policy differences and some of which were stark.

But basically, Bernie Sanders became this bulwark for it, helped create party unity, helped move it ahead, supported Biden when he was thinking about staying in the race. So I think that Bernie’s support of Biden, who did do an awful lot of things on the progressive agenda; he did expand health care, although not through single-payer, but through expanded ACA. He did do a lot on climate. He did do a lot of things they cared about, and the party is less divided. We don’t know how long that’ll last. We had, not just unusual, but unprecedented last two months. So these things like Medicare for All versus strengthening the ACA, they’ll bubble up again, but they’re not going to divide the party in the next seven weeks, eight weeks, whatever we’re out: 77 days. Do the math, 10 weeks.

Rovner: Seventy-some days. In other political news, third-party candidate and anti-vax crusader Robert F. Kennedy Jr. is going to drop out of the race later today and perhaps endorse Donald Trump. The rumor is he’s hoping to win a position in a second Trump administration, if there is one, possibly even secretary of Health and Human Services. What would that look like? A lot of odd faces from our panelists here.

Ollstein: I’m always skeptical. There’s also talk about Elon Musk getting a Cabinet job. I’m always skeptical of these incredibly wealthy individuals — who, currently, as private citizens, can basically do whatever they want — I have a hard time imagining them wanting to submit to the constrictures and the oversight of being in the Cabinet. I would be surprised. I think that it sounds good to have that power, but to actually have to do that job, I think, would not be appealing to such people. But I could be surprised.

Rovner: We did have Steve Mnuchin as secretary of the Treasury, and he seemed to have a pretty good time doing it.

Ollstein: I guess so, but I think his background was maybe a little more suited to that. I don’t know.

Kenen: Mnuchin, you’ve also had Democrats who appoint Wall Street types. Rubin being one of several, at least.

Rovner: We tend to have billionaires at the Treasury Department.

Kenen: The idea of Bobby Kennedy running HHS, I think even many Republicans who support Trump would find a bridge too far. And remember they want … if you look at the part of the Republican Party that really equate … their priority is anti-abortion, that’s it for them. There’s some on the right who talked about — I’m pretty sure this is in 2025, but at least it’s out there — change it to the Department of Life.

There’s a faction within the Republican Party who sees HHS as the way of driving an anti-abortion agenda. What’s left of abortion, right? It has oversight over the NIH [National Institutes of Health] and FDA [Food and Drug Administration] and CDC [Centers for Disease Control and Prevention], et cetera. You can’t say that Trump won’t do something because he is a very unpredictable person. So, who knows what Donald Trump would do? I don’t think it’s all that likely that Bobby Kennedy gets HHS.

But I do think that in order to get the endorsement that Trump wants, he’d have to promise him something in the health realm — whether it’s a special adviser for vaccine safety, who knows what it would be? But something that makes him feel like he got something in exchange for the support.

Rovner: I do wonder what the support would mean politically to have prominent anti-vaxxer. If Trump is out trying to capture swing voters, this doesn’t seem necessarily a way to appeal to suburban moms.

Kenen: Remember the vaccine commission to study vaccine safety? And it was Bobby Kennedy who came out of a meeting with Trump and said it was going to happen, that he was going to be the chair of it. The commission didn’t happen, and Bobby Kennedy didn’t chair it. So we already know that this goes back, what, eight years now. So there’s going to be a tit-for-tat. That’s politics. Whether the tat is HHS secretary, I’m skeptical. But again, I’d never say anything isn’t possible in Washington.

Rovner: If nothing else, this year has shown us that …

Kenen: I think it’s extremely unlikely.

Luthra: To your point about who Bobby Kennedy appeals to, the polls tell us that everyone who supports him, by and large, would vote for Trump if he dropped out. So I mean, that’s obviously why this would happen. It’s because it is a net gain for Trump and his calculus is probably that it would outweigh the losses he might get from having someone with a strong anti-vax bent on his side. I think that’s a pretty obvious, to me at least, gain for him rather than loss, especially given how close the race is.

Rovner: While we are on the subject of national politics and abortion, former President Trump this week said in an interview with CBS that he would not enforce the Comstock Act to basically impose a national abortion ban, reiterating that he wants to leave it to the states to decide what they want to do. Alice, it’s fair to say this did not go over very well with the anti-abortion base, right?

Ollstein: That’s right. It’s interesting. I reached out to lots of different folks in the anti-abortion movement to get their take, and I expected at least some of them to say, “Oh, Trump’s just saying that. He doesn’t really mean it. He’ll still do it anyways.” None of them said that. They all completely took him seriously and said that they were extremely upset about this. I mean, it’s also not happening in a vacuum.

They were already upset about the RNC [Republican National Convention] platform having some anti-abortion language being taken out of it. There is still some anti-abortion language in there. Folks should remember him declining to endorse a national abortion ban. Him refusing to say how he plans to vote in Florida’s referendum on abortion coming up. So this is one more thing that they’re upset about. And they told me that they think it could really cost him some votes and enthusiasm from the base.

He’s having trouble winning over these moderate swing voters. If that’s true, then he needs every vote on the more religious right/conservative wing of things. And they’re saying, look, most people are probably going to vote for him anyways because they don’t want Kamala Harris to be president. But will they volunteer? Will they tell a friend? Will they go knock on doors? Begrudgingly voting for someone versus being enthusiastic difference.

Rovner: I think it’s fair to say that it was the anti-abortion right that basically got him over the finish line in 2016 when he put out that list of potential Supreme Court nominees and signed a now-infamous letter that Marjorie Dannenfelser of the SBA [Susan B. Anthony Pro-Life America] list put together. Then the anti-abortion movement put a lot of money into door-knocking and getting out the vote. And obviously, as we all remember, it was just a few thousand votes in a couple of states that made him president.

So I was a little bit surprised that he was that definitive — although as we said 14 times already this morning — he often says one thing and does another, or says one thing and says another thing later, right.

Kenen: In the same day!

Rovner: Or in the same conversation sometimes. I was interested to see Kamala Harris in her speech refer to the Comstock Act without doing it by name. I thought that was artfully done.

Ollstein: Yeah, and several other speakers did talk about it by name, which is interesting because I think earlier this year there was this attitude among Democrats and some abortion rights leaders that there should not be a lot of talk about the Comstock Act because they didn’t want to give the right ideas. But I think now it’s pretty clear that the right doesn’t need to be given ideas. They already had these ideas. And so there’s a lot more open talk about it.

And just this piece of Project 2025, along with all of the focus on Project 2025 in general, just really seemed to resonate with voters in a really unusual way. And no matter how much Trump tries to disavow it or distance himself from it, it doesn’t seem like people are convinced, because these are very close allies of Trump who worked for him, who are likely to work for him in the future, who are the authors of this.

Rovner: And who put together this whole list of people who could work in a second administration. It’s basically the second Trump term all ready to go. It’s hard to imagine where he would then find a list of people to populate his agencies if not turning to the list that was put together by Project 2025.

So Trump says, as we’ve mentioned, that he wants voters in each state to decide how to regulate abortion. And that’s pretty much what he’s getting. Since we last talked, several states have finalized abortion rights ballot questions. But some have come with a couple of twists. Alice, where are we on the state ballot measure checklist?

Ollstein: It’s been a crazy couple of weeks. So we have Arizona and Montana certified for the ballot. Those are two huge states that also have major Senate races. Arizona is a presidential swing state. Montana, arguably not. But these are states that are going to get a blitz of ads and campaign attention. I think there is an expectation that the abortion measures on the ballot will benefit the Democratic candidates.

I would caution people to be skeptical about this. We’ve done analyses of the abortion ballot measures that have been on the ballot in the past couple of years in other states, and they did not always benefit the Democratic candidates who shared the ballot. Of course, this is a presidential year. It could be totally different.

At the same time, the big news this week was that a Arkansas Supreme Court ruling means that their abortion rights ballot measure will almost certainly not be on the ballot in November. And there’s a lot of consternation about that. The dissenting justices accused the majority of making up rules out of whole cloth and treating different ballot measures differently based on the content.

So basically there was a medical marijuana ballot measure and the sponsors of it wrote a brief saying, “Hey, we made the same alleged paperwork error that the abortion rights folks are accused of making, yet ours was certified for the ballot and theirs wasn’t. What gives?” So there are accusations of the conservative officials of Arkansas making these rulings to prevent a vote on abortion rights in that state. So they could try again in 2026. They are weighing their options right now.

Rovner: So abortion issues are not just bubbling among voters and in the elections. We now have a series of lawsuits with patients accusing hospitals that deny them emergency care of violating the Emergency Medical Treatment and Active Labor Act. Some may remember this was also the subject of a Supreme Court case this term. For those who have forgotten, Shefali, what happened with that Supreme Court case? Where are we with EMTALA?

Luthra: Great question, Julie. We are waiting, as ever, and we will be waiting for a long time because the Supreme Court after taking up that case said, “Actually, never mind. We were wrong to take this case up now. It should go back to the lower courts and continue to progress.” And what that means is uncertainty. It does mean that EMTALA’s protections exist for now in Idaho. They do not exist in Texas, where there is a related corresponding case going through the courts as well.

But regardless, EMTALA’s protections are quite meaningful for providers compared to not having them. But they are still pretty vague and pretty limited in terms of how abortion can come up in pregnancy. And that’s why we are still seeing patients filing these complaints saying, “My rights were violated. I did not get this emergency care I needed until it was very late.” But the problem there is that: A, EMTALA is retroactive.

So these complaints only come up when people know to file them; when they have perhaps already suffered medical consequences such as losing a fallopian tube, as two women in Texas both reported experiencing. You know, serious implications for their future fertility. And the other thing that’s important to note is that complaints are one step, but enforcement is another one.

And we haven’t seen a ton of hospitals being penalized by the federal government for not giving people care in these medical emergencies. And so if you’re a hospital, the dilemma is complicated, but in some ways not. Because if you provide care for someone and you find yourself in violation of state law, that’s a felony, potentially. But if you are going against EMTALA, well, maybe it’ll be reported, maybe it won’t be. Maybe you’ll be fined or penalized by the federal government, but maybe you won’t be. And that creates a real challenge for patients in particular because they are once again caught in a situation where they need emergency medical care, and the incentives are against hospitals providing it.

Ollstein: The Biden administration has not been transparent on how many complaints have been filed, how many hospitals they’ve investigated, what measures they’ve taken to make hospitals correct their behavior, whether they’ve come into compliance or not, whether they are getting these penalties, including losing Medicare status, which is one of the most severe penalties possible.

We just don’t know. And so they say they’re making this big focus on EMTALA enforcement, but we are not really seeing the evidence of that. And the only way we even know anything is happening is when the patients themselves are choosing to disclose it, either to advocacy groups or the media.

Rovner: Or the Democratic National Convention, where we saw several of these stories. It is a continuing theme as we go forward. Well, moving on. While we were celebrating the 50th anniversary of ERISA [Employee Retirement Income Security Act] here on “What the Health?” last week — and if you did not hear that special episode, I highly recommend it — the Biden administration unveiled negotiated prices for the first 10 drugs chosen under the new authority granted by the Inflation Reduction Act.

It’s hard to tell how much better the prices that they got are because so much of the information remains proprietary. But Joanne, what’s the reaction been, both in the drug industry and larger in the political realm?

Kenen: The drug industry obviously doesn’t like it. This is only 10 drugs this year, but it’ll be more in the future. Look, I’m not so sure how well that message has gotten through yet. The Medicare drugs came under what ended up being called the Inflation Reduction Act. There’s several measures in it. There’s protection for everybody in Medicare, how much you spend on drugs in a year, it’s $2,000. That’s it. Which is a big difference from what some of the out-of-pocket vulnerabilities people had in the past.

When you look at the polls or you look at interviews with undecided voters, you wonder who’s paying attention other than us? The Democrats have wanted this for more than 20 years. Twenty years is a conservative estimate. I mean, it was part of the fight over what became the Medicare Modernization Act in 2003.

They fought for it every year. They lost every year. They finally got it through. So the idea of having Medicare negotiating drug prices is a huge victory for the Democrats. Ten drugs, not a big deal for the industry, but they know something changed. They will fight every opportunity for a lawsuit or a lobbying campaign or blocking a new regulation or the next round of negotiations.

This is going to be probably just like these annual fights we have about physician pay. This’ll be an annual fight about how much can PhRMA punch back. That would assume that a Democrat wins and that these policies don’t get rescinded. It’s a big deal. It’s not a big deal for individual pocketbooks yet, but it’s a big, big deal on the balance of power between PhRMA, which is so powerful, and the federal government, which pays for these drugs.

Rovner: I’m reminded of a sentence I wrote about the Medicare Catastrophic Coverage Act, which was passed and repealed much at the behest of the drug industry because it had what would’ve been the first Medicare outpatient drug benefit ever. And I wrote, the drug industry fought this tooth and nail because they were concerned that if Medicare started covering drugs, they would want to have some say in how much they cost. That was, I think, 1989.

Kenen: Right.

Rovner: And here we are, however many years later it is.

Kenen: It’s really hard to take away a benefit, as the Republicans learned when they spent all that energy trying and failing to repeal the ACA. Once people have a benefit, it’s hard to say, “Whoops! No more.” However, that doesn’t mean there’s not fights about technical matters or how the regulations are worded or how deep discounts are or what other things they could get in exchange that make up for the losses on this.

I mean, PhRMA is really a huge lobby, hugely influential, and sympathetic in some ways because they do create a pro … — unlike something like tobacco — they do create products that saves our lives, right? And their argument, innovation, and those arguments resonate with people. But I don’t really see this turning back. I don’t think any of us can predict how PhRMA will regain some of the influence that it did lose in this battle.

It’s certainly not permanent defeat of PhRMA. I mean, PhRMA is powerful. PhRMA has allies in both parties. But this was a huge victory for the Democrats. They got something after 20-plus years.

Rovner: Well, finally this week, earlier this spring we talked at some length about the Biden administration’s Federal Trade Commission proposal to ban noncompete clauses, which in health care often applied to even the lowest-level jobs. It was supposed to take effect Sept. 4, but a federal district court judge in Texas has ruled in favor of the U.S. Chamber of Commerce that the agency lacks the authority to implement such a sweeping rule.

And the appeals court there in the 5th Circuit is notoriously conservative and unlikely to overturn that lower-court decision even if Vice President Harris wins and becomes president. Are we just going to continue to see every agency effort blocked by some Trump-appointed judge in Texas? That seems to be what’s happening now.

Ollstein: I mean, I think especially with the recent Supreme Court rulings on Chevron, I think we’re just … I mean, that plus the makeup of the judiciary means that executive power is just a lot more curtailed than it used to be. Theoretically, that should apply to both parties to whoever is president, but we have seen courts be very politicized and treat different things differently. So I think that it will be a special challenge for a Democratic or progressive administration to push those policies going forward.

Rovner: And of course in Texas, as we have pointed out on many occasions, there are all these single-judge districts, where if you file in certain places you know which judge you’re going to get. I mean, it’s the ultimate in judge shopping.

Luthra: I was just thinking about [U.S. District Judge] Reed O’Connor and [U.S. District Judge] Matthew Kacsmaryk, two names that listeners know well.

Rovner: Yes, that’s right. And this was a third judge, by the way. This was neither Reed O’Connor nor Matthew Kacsmaryk in this case.

Ollstein: But a secret third thing.

Rovner: A secret, a secret third thing.

Kenen: I mean, what Alice just referred to as the Supreme Court reducing the power of the regulators, and they said Congress has to pass the laws. You’re not going to get something this sweeping through Congress. But could you end up getting bits of it written into legislation about hospital personnel or doctors or things like that? I can see nibbles added in certain fields. And also you’re going to see some of it at the state level. I’m pretty sure Maryland has passed some kind of a noncompete.

Rovner: Yeah, there are states that have their own noncompete laws.

Kenen: I think they’ll go at it piecemeal. They may not be able to do anything that huge, all noncompetes, but by profession, or sector by sector, I think they may try to keep nibbling away at it. But the effort that we saw is gone.

Rovner: I mean, just to broaden it out, obviously this was something that the Biden administration has relied on the power of the FTC, the Federal Trade Commission, something that the Biden administration has highlighted. It’s something that I think Vice President Harris is relying on going forward. So this is probably not a good sign for wanting to make policy in this way.

See, nods all around. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Tony Leys, and then we will come back and do our extra credits.

I am so pleased to welcome to the podcast my KFF Health News colleague Tony Leys, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” Tony, welcome back to “What the Health?”

Tony Leys: Hi, Julie.

Rovner: So tell us about this month’s patient: who she is, where she’s from, and what kind of medical care she got.

Leys: The patient is Jamie Holmes, who lives in Washington state. In 2019, she went to a surgical center to have her fallopian tubes tied. While she was on her anesthesia, the surgeon noticed early signs of endometriosis, a common condition in which fibrous tissue grows in and around the uterus. The surgeon took care of that secondary issue. Holmes said he later told her the whole operation was done within the allotted time for the original surgery, which was about an hour.

Rovner: As one who’s had and knows a lot of people who’ve had endometriosis, it is extremely painful and very difficult to treat. So medically, at least this story seems to have a happy ending, a doctor who was on his toes spotted an impending problem and took care of it on the spot. But then, as we say, the bill came.

Leys: The bill came. The surgery center billed her for two separate operations, $4,810 each.

Rovner: So even though she only went under anesthesia once and simply had two different things done to her at the time.

Leys: Right. And the surgery center is the place that does the support work for the operation. And there was just one operation.

Rovner: So obviously she figured this must be a mistake and complained. What happened?

Leys: She thought once she explained what really happened, they would go, “Oh,” and they would fix it. But that didn’t work. And after adjustments and the insurance payment for the one operation, they said that she still owed the surgery center $2,605, and she said, “Nope.”

Rovner: This was in 2019. So obviously things have happened since then.

Leys: Right. The bill was turned over to a collections agency, which wound up suing Holmes last year for about $3,800, including interest and fees.

Rovner: Now, to be clear, Jamie says she doesn’t object to paying extra for the extra service that she got. What she does object to is being charged as if it was two separate surgical procedures. So what happened next?

Leys: I mean, she joked that it was as if she went to a fast-food restaurant and ordered a value meal, ended up with one extra order of fries and then got charged for two full meals. The collections agency went to court. They asked for a summary judgment, which could have allowed the collection agency to garnish Holmes’ wages.

But she went to a couple of court hearings and explained her side, and the judge ruled last February that he wasn’t going to grant summary judgment to the collection agency. And if it really wanted to pursue the matter, it would have to go to trial. And she has not heard from them since then.

Rovner: Because presumably it would cost them more to go to trial than it would to collect her … however many couple of thousand dollars they say she still owes, right?

Leys: That could certainly be the explanation. We don’t know.

Rovner: So what’s a takeaway here?

Leys: The takeaway is if you get a bill that’s totally bogus, don’t necessarily pay it. Don’t be afraid to fight it. And if someone sues you, don’t be afraid to go to court and tell your side of it.

Rovner: Yeah, because I mean, that’s mostly what happens is that these collection agencies go to court, nobody shows up on the other side, and they get to start garnishing wages, right?

Leys: Exactly. That’s probably what would’ve happened here.

Rovner: She didn’t even have to hire a lawyer. She just showed up and told her side of the story.

Leys: And her take on it is she could have arranged to pay it. It’s not a huge, huge amount of money. But she just wasn’t going to do it. So she stood her ground.

Rovner: And as we pointed out, she was willing to pay for the extra order of fries. She just wasn’t willing to pay for an entire second meal that she didn’t get.

Leys: Right. I mean, she told me, “I didn’t get the extra burger and drink and a toy.”

Rovner: There we go. So basically fight back if you have a problem, and don’t be afraid to fight back.

Leys: Exactly.

Rovner: Tony Leys, thank you so much.

Leys: Thanks, Julie.

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

Ollstein: Sure. So I had an interesting piece from The Wall Street Journal by Theo Francis and Melanie Evans called “The Fight Against DEI Programs Shifts to Medical Care.” So we’ve seen this growing effort from conservative activists to go after so-called DEI [diversity, equity, and inclusion] programs, to go after affirmative action, to go after a lot of various programs in government and in the private sector that take race into account when allocating resources.

And so now this is coming to health care where you have a lot of major players. This story is about a complaint filed against the Cleveland Clinic. But throughout health care, you have efforts to say, OK, certain racial groups and other demographics have higher risk and are less likely to get treatment for various diseases. This one is about strokes, but it applies in many areas of health care. And so they have created these targeted programs to try to help those populations because they are at higher risk and have been historically marginalized and denied care. And now those efforts are coming under attack. And so it’s unclear. So this is a federal complaint, and so the federal government would have to agree with it and take action. I don’t think that’s super likely from the Biden administration to crack down on a minority health care program. But this could be yet another thing people should keep in mind regarding the stakes of the election because a conservative administration could very well take a different approach.

Rovner: Shefali.

Luthra: My story is from The Washington Post. It is by Ariana Eunjung Cha, and the headline is “Weight-Loss Drugs Are a Hot Commodity. But Not in Low-Income Neighborhoods.” I think this is a really smart framing and it gets at something that folks have been worried about for a long time, which is that we have these revolutionary drugs like Ozempic and Wegovy. They show massive improvements for people with diabetes, for people with obesity. And they are so expensive and often not covered by Medicaid. Or if you are uninsured, you cannot get them. And what this story gets at really …

Rovner: If you’re insured, you can’t get them in a lot of cases.

Luthra: It’s true. What I love about this story is it sets us in place. It takes us to Atlanta and helps us see in the different parts of the city, based on income, on access to all sorts of other, to use the jargon, race, social determinants of health, obesity and diabetes are already very unequal diseases. They hit people differently because of access to safe places to exercise, walkable streets, affordable groceries, time to cook, all of that. And then you add on it another layer, which is this drug that can be very helpful is just out of reach for people who are already at higher risk because of systemic inequalities. The story also gets into some of the more social challenges that you might see from a drug like Ozempic. People saying, “Well, I know that rich people get that drug, but how do I know they would be giving the same thing to me? How do I know that the side effects will not be really damaging down the line because these drugs are so new?” And what it speaks to, in a way that I think we’re seeing a lot more journalism do very intelligently, is that there are going to be very real challenges — economic and cultural and social and political — to helping these drugs have the impact that they were touted as potentially able to have.

Rovner: Indeed. Joanne.

Kenen: Well, after that amazing moment with Gus Walz and his dad on the convention floor, I looked up the quick 24-hour coverage of what was going to best explain what a nonverbal learning disorder is and a little bit about who Gus Walz is. And Natalie Eilbert of The Milwaukee Journal Sentinel did a nice piece [“Who Is Gus Walz and What Is a Non-Verbal Learning Disorder?”]

Nothing I read yesterday answered every question I had about this particular processing disorder, but this was a good one and it explained what kind of things kids with these kinds of issues have trouble comprehending, and also what kind of things they’re really good at. This is not a learning disability. You can be really, really smart and still have a learning disability.

There’s actually an acronym, as there always is, which is GTLD: gifted and talented and learning disabled. Much of the country responded really warmly, as we all saw, and some of the country did not. But in terms of just what is this disorder and how does it affect your ability to communicate, which is part of what it is, understanding language cues, Natalie Eilbert did a good job.

Rovner: And no matter what you can be proud of your dad, particularly when he’s just been nominated to run for vice president. All right, my extra credit this week is from The New York Times. It’s called “Hot Summer Threatens Efficacy of Mail-Order Medications.” And it’s something I’ve been thinking about for a while because packages get subjected to major extremes of temperature in both the summer and the winter.

Indeed, now we have studies that show particularly that heat can degrade the efficacy and safety of some medications. One new study that embedded data-logging thermometers in packages found that those packages spent more than two-thirds of their transit time outside the recommended temperature range.

While the FDA has very strict temperature guidelines for shipping and storing medications between manufacturers and wholesalers and pharmacies, once it leaves the pharmacy it’s apparently up to each state to regulate. Just one more unexpected consequence of climate change.

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

Luthra: I am on the former Twitter platform @shefalil.

Rovner: Alice?

Ollstein: On X @aliceollstein.

Rovner: Joanne?

Kenen: On X @JoanneKenen and on Threads @JoanneKenen1.

Rovner: Before we go, a quick note about our schedule. We are taking next week off. I’m going to the beach. The week after that, we’ll have a very special show from The Texas Tribune TribFest in Austin. We’ll be back with our regular panel and all the news we might’ve missed on Sept. 12. Until then, be healthy.

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A federal lawsuit in Texas against Planned Parenthood has a web of ties to conservative activist Leonard Leo, whose decades-long effort to steer the U.S. court system to the right overturned Roe v. Wade, yielding the biggest rollback of reproductive health access in half a century.

Brought by an anonymous whistleblower and later joined by Texas Attorney General Ken Paxton, the suit alleges the Planned Parenthood Federation of America and three Planned Parenthood affiliates defrauded the Texas and Louisiana Medicaid programs by collecting $17 million for services provided while it fought state efforts to remove it as an approved provider.

The suit claims violations of the False Claims Act, an obscure but powerful law protecting the government from fraud, and seeks $1.8 billion in penalties from Planned Parenthood, according to a motion that lawyers for the whistleblower filed in federal court in 2023.

The lawsuit builds on efforts over years by the religious right and politicians who oppose abortion to deliver blows to Planned Parenthood — which provides sexual and reproductive health care at nearly 600 sites nationwide — now bolstered by Leo’s work reshaping the American judiciary.

Anti-abortion groups and their allies secured a generational victory in 2022 when the Supreme Court overturned Roe v. Wade, which ended the constitutional right to abortion and paved the way for bans or severe restrictions in 20 states. The court challenge in Texas demonstrates how the forces behind the end of Roe threaten access to other health and family planning services.

The Planned Parenthood clinics being sued do not provide abortions. They are in Texas and Louisiana, which banned nearly all abortions, respectively, in 2021 and 2022.

Leo, an anti-abortion Catholic, is connected to the key players in the Texas lawsuit — the whistleblower plaintiff, an attorney general, and the judge — according to a KFF Health News review of tax records, court documents from multiple lawsuits, statements to lawmakers, and website archives.

Leo provided legal counsel to the anti-abortion group at its center, and he has financial and other connections to Paxton.

They filed the case in federal court in Amarillo, Texas, where Matthew Kacsmaryk is the only judge. He is a longtime member of the Federalist Society, the conservative legal juggernaut for which Leo has worked for over 25 years in various capacities and currently serves as co-chair.

Kacsmaryk’s rulings have curtailed access to reproductive health since the Senate confirmed him in 2019. He suspended the FDA’s approval of mifepristone, a drug used in medication abortion, propelling the issue to the Supreme Court, which ultimately threw out the case. In another case, Kacsmaryk ruled to limit young people’s access to birth control through a federal family planning program.

Leo did not respond to questions for this article and a spokesperson declined to comment. Through a court spokesperson, Kacsmaryk declined to comment for this article.

The anonymous whistleblower in 2021 accused the Planned Parenthood Federation of America and Planned Parenthood affiliates of defrauding the Medicaid programs of Texas and Louisiana. Paxton, who has repeatedly acted to thwart abortion rights and joined the case in 2022, alleges in the lawsuit that clinics received payments they weren’t entitled to from Texas Medicaid from early 2017 to early 2021 as the state was pushing to end Planned Parenthood’s status as a Medicaid provider. Louisiana and the Department of Justice have not joined the complaint.

The lawsuit’s origins go back a decade. The anonymous whistleblower, between 2013 and 2015, “conducted an undercover investigation to determine whether Planned Parenthood’s fetal tissue procurement practices were continuing, and if they were legal and/or ethical,” according to the whistleblower’s complaint filed in 2021.

The explanation mimics how the Center for Medical Progress, a California-based anti-abortion group founded by activist David Daleiden in 2013, has publicly described its work. “The Human Capital project is a 30-month-long investigative journalism study by The Center for Medical Progress, documenting how Planned Parenthood sells the body parts of aborted babies,” the group states on its website.

In a November 2022 court order, Kacsmaryk said the private party initiating the lawsuit is “the president of CMP,” the title Daleiden held at that time, according to a Center for Medical Progress tax filing.

The Center for Medical Progress and Daleiden did not respond to requests for comment.

By law, federal funds can’t pay for abortions unless the pregnancy threatens the life of a woman or is the result of rape or incest, but the program reimburses for other care such as contraception, screenings for sexually transmitted infections, and cancer screenings. Medicaid, which provides health coverage for people with low incomes, is jointly financed by states and the federal government.

According to its 2022-23 annual report, Planned Parenthood affiliate clinics provided 9.13 million health care services to 2.05 million patients nationally in 2022. Testing and treatment for sexually transmitted infections accounted for about half of those services, contraception amounted to a quarter, and abortions constituted 4%.

Planned Parenthood Gulf Coast, which operates clinics in Texas and Louisiana, is among the branches Paxton and the whistleblower are suing. From July 2022 to June 2023, its clinics provided patients more than 86,000 tests for sexually transmitted infections, 44,000 visits for birth control, and nearly 7,000 cancer screening and prevention services, CEO Melaney Linton told KFF Health News.

“All of these services and more are at risk in this politically motivated lawsuit,” Linton said. The lawsuit’s allegations “are false. Planned Parenthood did not commit Medicaid fraud.”

Linton has said the lawsuit’s purpose is clear: “trying to shut Planned Parenthood down.”

Texas terminated Planned Parenthood’s Medicaid participation in March 2021. Until then, affiliates “were entitled to receive reimbursement” for services to Medicaid patients because their provider agreements with Texas’ Medicaid program were valid, attorneys for the Planned Parenthood clinics wrote in a February 2023 court filing in support of their motion for summary judgment.

Louisiana has not removed Planned Parenthood from its Medicaid program.

Leo served as legal counsel to the Center for Medical Progress, according to documents produced as part of a separate lawsuit Planned Parenthood filed in federal court in California against the anti-abortion group. Among those, a July 2018 document lists 25 emails Leo and Daleiden traded in June and July 2015, including in the days before the anti-abortion group released its first video.

Paxton’s ties to Leo can be traced back at least a decade to when the former state senator and rising conservative star was about to begin his first term as attorney general.

In 2014, Leo, then executive vice president of the Federalist Society, was a rare non-Texan named to Paxton’s attorney general transition advisory team. Tax filings show that the Concord Fund, one of several Leo-linked groups that spend money to influence elections and aren’t required to disclose their donors, gave $20.3 million from July 2014 through June 2023 to the Republican Attorneys General Association, the political nonprofit that works to elect Republicans as states’ top law enforcement officers. Known as RAGA, the group funneled more than $1.2 million to Paxton’s campaign over three election cycles from 2014 to 2022, Texas campaign finance records show.

Texas government officials knew the state was reimbursing Planned Parenthood clinics for medical services from 2017 to 2021, which renders the state’s argument that clinics violated the False Claims Act “without merit,” said Jacob Elberg, a professor at Seton Hall Law School and an expert in health care fraud.

The law is intended for situations “where essentially someone submits a claim for payment or keeps money that they’re not entitled to where they have information that the government doesn’t have,” Elberg said. “And they essentially know that if the government knew the truth, the government wouldn’t pay them or would be demanding money back.”

But with Planned Parenthood, “everything involved here happened out in the open,” Elberg said. “They were submitting bills and the government knew what was going on and was paying those bills.”

The plaintiffs’ arguments are a “tortured use” of the False Claims Act, said Sarah Saldaña, a former U.S. attorney for the Northern District of Texas.

“Things like this, which have these obvious political overtones, tend to undermine further the view of the public of the judicial courts system,” Saldaña said.

The office of the attorney general did not respond to requests for comment.

Anti-abortion groups support the Paxton lawsuit even though abortion is essentially outlawed in the Lone Star State. Planned Parenthood “is still a pro-abortion organization,” said John Seago, president of Texas Right to Life. Even though Planned Parenthood provides other care, “all of those services are tainted by their pro-abortion mindset,” he said.

“Planned Parenthood is a danger to Texans. We wish that Planned Parenthood didn’t have a single location within our state,” Seago said. “Whenever the state pays Planned Parenthood to do something, even if it’s a good service, we are building up their brand and giving them more reach into our Texas communities.”

Roughly three dozen Planned Parenthood clinics in Texas continue to provide non-abortion services like birth control and STI screenings. The $1.8 billion the whistleblower is seeking is equivalent to nearly 90% of Planned Parenthood’s annual revenue, according to its most recent annual report.

The Campaign Against Planned Parenthood

The Center for Medical Progress was little known in 2015 when it began releasing videos containing explosive allegations that Planned Parenthood was illegally selling tissue from aborted fetuses, which Planned Parenthood denies.

The group and Daleiden had ties to powerful anti-abortion organizations. They include Live Action, where Daleiden worked before creating the Center for Medical Progress, and Operation Rescue, the Kansas-based group that staged demonstrations against George Tiller’s abortion clinic in that state before a gunman killed the physician in 2009.

“The evidence I am gathering deeply implicates Planned Parenthood affiliates across the country in multiple felonies and can trigger severe legal and financial consequences for PP and their associates, while providing new justifications for state defunding efforts and turning public opinion against Planned Parenthood and abortion,” Daleiden wrote in a May 2013 email produced as part of the litigation Planned Parenthood brought in California. The subject line: “Meeting to Take Down PP.”

Texas tried to remove Planned Parenthood clinics from its Medicaid program following the center’s release of the undercover videos, a move that was part of a larger political firestorm. Roughly a dozen states launched investigations into the reproductive health provider, and Republicans in Congress renewed calls to strip Planned Parenthood of government funding.

Paxton made his feelings clear about abortion as he pursued an investigation of Planned Parenthood in Texas. During a July 29, 2015, legislative hearing, he said “the true abomination in all of this is the institution of abortion.”

“We are rightfully horrified by what we’ve seen on these videos,” Paxton said. “However these videos also serve as a larger reminder that, as a society, we’ve turned a blind eye to the gruesome horrors that occur in abortion clinics across America every single day. They remind us that this industry as a whole has lost the perspective of humanity.”

Planned Parenthood denied selling fetal tissue and other claims in the videos, some of which contained graphic footage. It said the videos were “deceptive” and heavily edited to be misleading. A grand jury in Texas cleared Planned Parenthood of wrongdoing.

Daleiden worked on the center’s “Human Capital Project” for years, receiving advice from Leo and his associates, according to the Center for Medical Progress’ website, and Daleiden’s email correspondence and other documents produced as part of the separate lawsuit in federal court in California.

The July 2018 document filed as part of the litigation in California describes emails between Leo and Daleiden as “providing legal communication with counsel regarding legal planning” and “for counsel to provide legal advice regarding investigative journalism methods and the legality of fetal tissue procurement practices,” among other descriptions. Daleiden sent one email to Leo “regarding legal planning” on July 13, 2015, the day before the Center for Medical Progress released its first video.

A November 2018 letter from the Center for Medical Progress’ lawyers stated “CMP was receiving legal advice” from Leo, as well as other conservative lawyers and organizations. Lawyers representing the center and Daleiden in a December 2018 legal filing said Leo “provided legal advice on how to ensure successful prosecutions of the criminal actors which CMP identified.”

In its defense, Planned Parenthood has said it billed the Texas Medicaid program for reimbursement for “lawfully provided” services from February 2017 to March 2021 as a participating Medicaid provider in the state.

In 2015 and 2017, federal courts in Louisiana and Texas blocked those states from terminating Planned Parenthood’s Medicaid provider agreements. Judge John deGravelles of the U.S. District Court for the Middle District of Louisiana said the state was prohibited “from suspending Medicaid payments to [Planned Parenthood Gulf Coast] for services rendered to Medicaid beneficiaries.”

The 5th Circuit Court of Appeals in November 2020 vacated the Texas and Louisiana injunctions, but the court never weighed in on clawing back Medicaid funds that had been paid to clinics. Texas terminated Planned Parenthood in March 2021, following a state court ruling.

Texas and the whistleblower argue that, once the court injunctions were lifted, Planned Parenthood’s termination from each state’s Medicaid program became effective years earlier — 2015 in Louisiana and 2017 in Texas — due to the dates that state officials gave clinics final notice.

Planned Parenthood has argued that it is under no obligation to return payments received while injunctions were in place. Kacsmaryk disagrees. In a recently unsealed summary judgment order in the case, the judge wrote that Planned Parenthood clinics “had an obligation to repay the government payments they received as a matter of law.”

The order was unsealed after attorneys for the Reporters Committee for Freedom of the Press intervened. The committee argued the public has a presumptive and constitutional right to access judicial records, and that Kacsmaryk’s stated concerns — which included the tainting of a potential jury pool or jeopardizing the safety of those involved in the lawsuit — didn’t justify keeping the document secret.

Kacsmaryk’s brief justification for sealing the document, contained in the order itself, “was very thin,” said Katie Townsend, legal director for the Reporters Committee for Freedom of the Press.

She said his decision to seal such an important document was “highly unusual” and “very troubling.”

“Those orders are almost always completely public,” she said.

What Paxton Gains

Paxton has publicly toyed with the idea of pursuing federal office, and former President Donald Trump has said he’d consider him for U.S. attorney general should Trump return to the White House.

For Republicans in Texas, there are political benefits to going after Planned Parenthood, said Mark Jones, a political scientist at Rice University in Houston. “Doing anything punitive against Planned Parenthood and anything that would reduce the ability of Planned Parenthood to be active and effective in Texas is going to be greeted with near-universal consensus within the Republican primary electorate,” Jones said. “There’s no downside to it.”

The Republican Attorneys General Association, which can accept unlimited political donations that it distributes to candidates, is a Paxton supporter. Campaign finance records show it gave more than $730,000 to Paxton’s attorney general campaigns in 2014 and 2018.

Tax filings show that the Marble Freedom Trust, a political nonprofit where Leo serves as trustee and chair, gave the Concord Fund $100.9 million from May 2020 through April 2023. During the 2022 election cycle, the Concord Fund gave $6.5 million to RAGA, which then contributed $500,000 to Paxton’s campaign. It was tied as the highest contribution to the Texas attorney general, matched by a $500,000 contribution from a political action committee backed by conservative Texas billionaires, according to Transparency USA, a nonprofit that tracks spending in state politics.

RAGA has praised Leo’s role, calling him its “greatest champion.”

“Leonard Leo has helped shape the trajectory of RAGA and the conservative legal movement more than anyone else. As RAGA’s greatest champion, Leonard Leo reimagined the role of the state attorney general and promoted men and women dedicated to the persistence of the rule of law and the original meaning of the Constitution,” reads a RAGA website post from 2019 that has since been deleted.

“You want access to Leo because Leo gives you access to money,” said Chris Toth, former executive director of the National Association of Attorneys General.

In many conservative states like Texas, Toth said, “the issue is worrying about getting primaried. And that is where playing nice with Leonard Leo and the Concord Fund come in because if you’re on their side, basically, you’re going to have no problem getting reelected.”

The Concord Fund gave $4 million to RAGA between July 1, 2022, and June 30, 2023, four times what it gave the prior fiscal year.

Abortion rights supporters have warned that they anticipate ongoing reproductive health battles in Texas and beyond, with access to contraception, fertility services, and other types of care under threat.

As an example, some point to the Griswold v. Connecticut decision from 1965, in which the Supreme Court legalized the use of contraception among married couples. The high court ruled that a state law violated a constitutional right to privacy, a rationale that was central to Roe v. Wade eight years later.

In a 2017 speech at the Acton Institute, a conservative think tank, Leo criticized Griswold as a decision amounting to “the creation of rights found nowhere in the text or structure of the Constitution.”

The Planned Parenthood lawsuit in Texas is expected to go to trial, potentially this year. The central question is whether Planned Parenthood knowingly withheld money owed to the government.

All the while the public is expressing greater uncertainty about rights once considered constitutionally guaranteed. In a KFF poll conducted in February, 1 in 5 adults said the right to use contraception is threatened and likely to be overturned.

Fewer than half of adults considered it to be secure.

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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Enfrenta los desafíos de ser una estudiante de primer año de secundaria, aunque también está emocionada de reencontrarse con sus amigos y volver a bailar y a jugar voleibol. Incluso podría unirse al equipo de lucha libre para ganarse el respeto en la escuela.

Pero el pasado sigue presente.

En una reunión del 4 de julio, un amigo de la familia llevó auriculares que amortiguan el ruido, por si los fuegos artificiales eran demasiado para ella. A principios del verano, Gabriella tuvo dificultades para ver la colección de armas de un pariente, especialmente las pistolas. Y comenzó a hiperventilar cuando vio la herida en el dedo de un amigo de la familia que se había cortado accidentalmente: la vista de la sangre le recordó a Lisa Lopez-Galván, quien murió por una herida de bala afuera de Union Station, la única fatalidad ese día.

Su madre, Bridget Barton, dijo que Gabriella ha tenido una actitud más dura desde el desfile. “Ha perdido algo de suavidad, algo de dulzura”, observó.

Los niños son particularmente vulnerables al estrés de la violencia con armas de fuego, y 10 de las 24 que sufrieron heridas de bala en el desfile del 14 de febrero tenían menos de 18 años. Muchos más niños como Gabriella experimentaron el trauma de primera mano. Enfrentan miedo, ira, problemas de sueño e hipersensibilidad a las multitudes y los ruidos.

Una adolescente de 15 años que recibió disparos en la mandíbula y el hombro prácticamente dejó la escuela por un tiempo, y los ataques de pánico diarios también le impidieron asistir a la escuela de verano.

Un niño de 11 años que recibió un disparo describió sentirse enojado en la escuela por razones que no podía explicar. Una niña de 5 años que estaba sobre los hombros de su padre cuando le dispararon entra en pánico cada vez que su papá se siente enfermo, temiendo que le hayan disparado de nuevo.

“No es la misma niña. Quiero decir, definitivamente no lo es”, dijo Erika Nelson, madre de Mireya, de 15 años, quien tiene cicatrices en la mandíbula y la cara. “Nunca sabes cuándo va a estallar. Nunca sabes. Podrías decir algo o alguien podría mencionar algo que le recuerde ese día”.

En 2020, las armas superaron a los accidentes automovilísticos como la principal causa de muerte de niños, pero un número mucho mayor sufren heridas de balas y sobreviven. La investigación sugiere que los niños sufren lesiones por armas de fuego no fatales entre dos y cuatro veces más a menudo de lo que son asesinados con armas.

Científicos dicen que los efectos a largo plazo de la violencia armada en los niños se investigan poco y son mal comprendidos. Pero el daño es generalizado. Investigadores de Harvard y del Hospital General de Massachusetts encontraron que durante el primer año después de una lesión por arma de fuego, los sobrevivientes infantiles experimentaron un aumento del 117% en trastornos del dolor, del 68% en afecciones psiquiátricas y del 144% en adicciones. Los efectos en la salud mental se extienden a madres, padres y hermanos.

Para muchos afectados por el tiroteo en Kansas City, Missouri, los desencadenantes comenzaron de inmediato.

“Me enojo fácilmente”

A solo 10 días que Samuel Arellano fuera baleado en el desfile, fue a otro gran evento deportivo.

Samuel fue invitado a un partido de baloncesto masculino de la Universidad de Kansas en el Allen Fieldhouse en Lawrence. Durante un descanso del partido, con una cámara de video apuntando a Samuel y a sus padres, Jalen Wilson, ex estrella de KU, apareció en la pantalla y se dirigió a él directamente.

“Escuché tu historia”, dijo Wilson, que ahora juega en la NBA, desde la pantalla gigante. “Estoy muy agradecido de que estés aquí hoy, y es una bendición que podamos tenerte para brindarte el amor y apoyo que realmente mereces”.

Wilson pidió a los 16,000 fans presentes que se pusieran de pie y aplaudieran a Samuel. Mientras la multitud aplaudía y un locutor exclamaba que era un “joven valiente”, Samuel miró a sus padres, luego al suelo, sonriendo tímidamente.

Pero minutos después, cuando el partido se reanudó, Samuel comenzó a llorar y tuvo que salir del auditorio con su madre, Abigail.

“Cuando se puso bastante ruidoso, fue cuando comenzó a desmoronarse de nuevo”, dijo su padre, Antonio. “Así que ella tuvo que salir con él por un momento. Así que cualquier lugar ruidoso, si es demasiado fuerte, lo afecta”.

Samuel, que cumplió 11 años en marzo, fue baleado a la altura de las costillas en su lado derecho. Ahora, la cicatriz en su espalda es apenas perceptible, pero los efectos persistentes del tiroteo son evidentes. Está viendo a un terapeuta, al igual que su padre, aunque a Abigail le ha resultado difícil encontrar uno que hable español y aún no ha tenido una cita.

En las primeras semanas luego del tiroteo, Samuel tuvo problemas para dormir y a menudo se metía en la cama con su madre y su padre. Solía tener buenas notas, pero eso se volvió más difícil, dijo Abigail. Su personalidad ha cambiado, algo que a veces se ha manifestado en la escuela.

“Me enojo fácilmente”, dijo Samuel. “Nunca he sido así antes, pero si me dicen que me siente, me enojo. No sé por qué”.

Los niños traumatizados a menudo tienen dificultades para expresar emociones y pueden tener arrebatos de ira, según Michelle Johnson-Motoyama, profesora de trabajo social en la Universidad Estatal de Ohio.

“Estoy segura que para ese niño hay una sensación de tremenda injusticia por lo que sucedió”, dijo Johnson-Motoyama.

Especialmente justo después del tiroteo, Samuel tenía ataques de pánico y comenzaba a sudar, contó Antonio. Los terapeutas les dijeron que eso era normal. Pero los padres también lo mantuvieron alejado de su teléfono por un tiempo: había demasiado sobre el tiroteo en las noticias y en internet.

Abigail, que trabaja en un concesionaria de automóviles con Antonio, está ansiosa por ver a su hijo cambiar, por su sufrimiento y tristeza. También está preocupada por sus tres hijas, una de 16 años y gemelas de 13. Su padre, Victor Salas, que estaba con Samuel en el desfile, también estaba devastado después de los hechos.

“Estoy llorando y llorando y llorando por lo que pasó”, dijo Salas en español cuatro días después del desfile. “Porque fue un caos. Eso no significa que las familias no amen a su familia, pero todos huyeron para salvar sus propias vidas. Salvé la vida de mis nietos, pero ¿qué pasa con el resto de la gente? No estamos preparados”.

En el lado positivo, Samuel se sintió muy apoyado por la comunidad en Kansas City, Kansas. Muchas personas de su escuela se acercaron en los primeros días para visitarlo, amigos e incluso un ex conductor de autobús, que estaba llorando. Tiene una “habitación llena de dulces”, dijo Abigail, en su mayoría Skittles, su favorito.

En su cumpleaños, recibió una pelota de fútbol americano autografiada por Patrick Mahomes, mariscal de campo de los Kansas City Chiefs. Lo hizo llorar, algo que ocurre con bastante frecuencia, dijo su padre.

“Hay días buenos y malos, días más normales y fáciles, y luego hay días en los que la familia tiene que estar un poco más atenta y apoyarlo”, dijo Abigail en español. “Siempre ha sido extrovertido y hablador como su madre, pero eso ha cambiado desde el desfile”.

El 4 de julio, disparador de una semana

El 4 de julio fue particularmente angustiante para muchos de los jóvenes sobrevivientes y para sus familias. ¿Deberían comprar fuegos artificiales? ¿Querrían celebrar? ¿Por qué todos los petardos que explotan en el vecindario suenan como disparos?

Este año, Gabriella, de 14 años, necesitó la ayuda de su padrastro, Jason Barton, para encender sus fuegos artificiales, algo que normalmente hace con entusiasmo. En el desfile, como muchas personas, la familia Barton primero confundió el sonido de los disparos con fuegos artificiales.

Y Erika Nelson, madre soltera de Belton, Missouri, temía incluso mencionar la celebración a Mireya, quien siempre ha amado el Día de la Independencia. Eventualmente, Mireya dijo que no quería fuegos artificiales grandes este año y que solo quería que su madre los encendiera.

“Cualquier pequeño desencadenante, quiero decir, podría ser un ligero chasquido, y ella se tensaba”, dijo Erika Nelson.

Patty Davis, gerente de programas para el cuidado informado sobre el trauma en el hospital Children’s Mercy en Kansas City, dijo que incluso clientes suyos que estuvieron en el desfile pero no resultaron heridos todavía se estremecen ante los sonidos de sirenas u otros ruidos fuertes. Es una respuesta poderosa a la violencia armada en general, no solo al desfile.

“No es una respuesta exagerada”, dijo Davis. “De hecho, es muy natural para los jóvenes, y no tan jóvenes, que han experimentado algo similar o han presenciado violencia con armas de fuego”.

“No se trata de un trauma accidental, sino de un trauma perpetrado con fines violentos, que puede provocar un mayor nivel de ansiedad en las personas que lo viven, que se preguntan si volverá a suceder. ¿Y qué tan seguras están?”, agregó.

Reviviendo el instante

Los ruidos extraños, las luces brillantes y las multitudes pueden tomar desprevenidos a los niños y a sus padres.

En junio, Mireya Nelson estaba esperando a su hermana mayor después de un recital, con la esperanza de ver a un muchacho. Su madre quería ir, pero Mireya la hizo callar. “De repente, se escuchó un estruendo muy fuerte”, dijo Erika. “Se agachó y luego se levantó de un salto. Dijo: ‘¡Dios mío, me estaban disparando otra vez!’”. Mireya lo dijo tan fuerte que la gente se quedó mirando, así que fue el turno de Erika de hacerla callar y tratar de calmarla. “Le dije: ‘Mireya, está bien. Estás bien. Se les cayó una mesa. Solo están sacando cosas. Fue un accidente’”, explicó Erika.

Pasaron unos minutos hasta que el shock se disipó y más tarde Mireya se rió de la situación, pero Erika siempre está atenta.

La tristeza inicial de su hija (que veía películas durante horas y lloraba todo el tiempo) se ha transformado en descaro. Medio año después, Mireya bromea sobre el tiroteo, lo que destroza a su madre. Pero tal vez eso sea parte del proceso de sanación, dijo Erika.

Antes del 4 de julio, Mireya fue a Worlds of Fun, un gran parque de diversiones, y la pasó bien. Se sintió bien porque había guardias de seguridad por todas partes. También disfrutó de una visita a la oficina local del FBI con una amiga que estaba con ella el día del tiroteo.

Pero cuando alguien le sugirió ir al ballet, Mireya lo descartó rápidamente: está cerca de Union Station, el lugar del tiroteo. Ya no quiere ir al centro. Erika dijo que ha habido muchas citas médicas y dificultades económicas, y que su mayor frustración como madre es no poder arreglar las cosas para su hija.

“Tienen que seguir su propio camino, su propio proceso de curación. No puedo sacudirla, como diciéndole: ‘Vuelve a ser tú misma’”, dijo Erika. “Podría llevar meses, años. ¿Quién sabe? Podría ser el resto de su vida. Pero espero que pueda superarlo un poco”.

Piel de gallina en medio del calor sofocante

James Lemons notó un cambio en su hija de 5 años, Kensley, que estaba sobre sus hombros cuando le dispararon en el desfile.

Antes del tiroteo, Kensley era extrovertida y comprometida, dijo James, pero ahora está retraída, como si estuviera dentro de una burbuja y se hubiera desconectado de la gente.

A Kensley, las grandes multitudes y los policías le recuerdan al desfile. Ambos estuvieron presentes en una graduación de secundaria a la que asistió la familia este verano, y Kensley solo quería irse. James la llevó a un campo de fútbol vacío, donde, dijo, se le puso la piel de gallina y se quejó de tener frío a pesar del calor sofocante.

La hora de dormir es un problema particular para la familia Lemons. Kensley ha estado durmiendo con sus padres. Otro hijo, Jaxson, de 10 años, ha tenido pesadillas. Una noche, soñó que el tirador se acercaba a su padre y lo hacía tropezar, dijo Brandie Lemons, la madrastra de Jaxson.

Los niños más pequeños como Kensley expuestos a la violencia con armas de fuego tienen más probabilidades de desarrollar un trastorno de estrés postraumático que los niños mayores, según Johnson-Motoyama, de la Universidad Estatal de Ohio.

Davis, del Children’s Mercy en Kansas City, dijo que los niños cuyos cerebros no están completamente desarrollados pueden tener dificultades para dormir y comprender que están seguros en sus hogares por la noche.

James le compró a la familia un nuevo cachorro, un bulldog americano que ya pesa 32 libras, para ayudarlos a sentirse protegidos. “Busqué el pedigrí”, dijo, “Son muy protectores. Muy cariñosos”.

En busca de una salida

Para desahogarse después del tiroteo, Gabriella comenzó a boxear. Su madre, Bridget, dijo que le devolvió algo de la confianza y el control que había bajado después del desfile. “Me gusta golpear a la gente, no de una manera mala, lo juro”, dijo Gabriella en abril mientras moldeaba un protector bucal a sus dientes antes de irse a entrenar.

Sin embargo, desde entonces ha dejado de boxear, por lo que el dinero puede destinarse a un viaje a Puerto Rico con su clase de español. Están pagando $153 al mes durante 21 meses para cubrir el viaje. Las clases de boxeo costaban $60 al mes.

Bridget pensaba que el boxeo era una buena salida para la ira que le quedaba, pero a finales de julio Gabriella no estaba segura de si todavía tenía el impulso para contraatacar de esa manera. “El pasado es el pasado, pero todos vamos a pasar por cosas. ¿Tiene sentido?”, preguntó Gabriella.

“Estás bien en general, pero todavía tienes desencadenantes. ¿Es eso lo que quieres decir?”, preguntó su madre. “Sí”, respondió.

Después del tiroteo, Mireya Nelson probó las clases en línea, que no funcionaron bien. Los primeros días de la escuela de verano, Mireya tenía un ataque de pánico todos los días en el auto y su madre la llevaba de vuelta a casa.

Mireya quiere regresar a la escuela secundaria este otoño, y Erika es cautelosa. “Sabes, si vuelvo a la escuela, existe la posibilidad de que me disparen, porque en la mayoría de las escuelas hoy en día hay tiroteos”, recordó Erika que dijo su hija. “Y yo digo: ‘Bueno, no podemos pensar así. Nunca se sabe lo que va a pasar’”.

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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Six months after Gabriella Magers-Darger’s legs were burned by sparks from a ricocheted bullet at the Kansas City Chiefs Super Bowl parade in February, the 14-year-old is ready to leave the past behind.

She is dreading the pitfalls of being a high school freshman, even as she looks forward to being back with friends and at color guard, dance, and volleyball. She might even join the wrestling team to get some respect at school.

But the past remains ever present.

At a July Fourth gathering, a family friend brought noise-canceling headphones in case the fireworks became too much. Earlier in the summer Gabriella had a hard time viewing a relative’s gun collection, the handguns in particular. And she hyperventilated when she saw a family friend’s finger after it was sliced by accident — the sight of blood reminds her of seeing a fatally wounded Lisa Lopez-Galvan minutes after she was shot outside Union Station, the only person killed that day.

Her mom, Bridget Barton, said Gabriella has had a chip on her shoulder since the parade.

“She’s lost some softness to her, some gentleness to her,” Barton said.

Children are particularly vulnerable to the stresses of gun violence, and 10 of 24 people injured by bullets at the Feb. 14 parade were under 18 years old. Countless more children like Gabriella experienced the trauma firsthand. They’ve endured fear, anger, sleep problems, and hypersensitivity to crowds and noises.

A 15-year-old girl who was shot through the jaw and shoulder effectively dropped out of school for a time and daily panic attacks kept her from summer school, too. An 11-year-old boy shot in the side described feeling angry at school for reasons he couldn’t explain. A 5-year-old girl who was on her father’s shoulders when he was hit by gunfire panics each time her dad feels sick, fearing he has been shot again.

“She’s not the same kid. I mean, she’s definitely not,” said Erika Nelson, mother of the 15-year-old, Mireya, who has scars on her jaw and face. “You never know when she’s going to snap. You never know. You might say something or someone might bring up something that reminds her of that day.”

Guns overtook motor vehicle accidents as the leading cause of death for children in 2020, but a far higher number of kids are hit by gunfire and survive. Research suggests that kids sustain nonfatal firearm injuries anywhere from two to four times more often than they are killed by guns.

Scientists say the long-term effects of gun violence on kids are little researched and poorly understood. But the harm is pervasive. Harvard and Massachusetts General Hospital researchers found that during the first year after a firearm injury, child survivors experienced a 117% increase in pain disorders, a 68% increase in psychiatric disorders, and a 144% increase in substance use disorders. The mental health effects spill over — to mothers, fathers, siblings.

For many affected by the shooting in Kansas City, Missouri, the triggers began right away.

‘I Get Mad Easily’

Just 10 days after Samuel Arellano was shot at the parade, he attended another big sporting event.

Samuel was invited to attend a University of Kansas men’s basketball game at Allen Fieldhouse in Lawrence. During a break in the game, with a video camera pointed at Samuel and his parents, former KU star Jalen Wilson appeared on the scoreboard and addressed him directly.

“I heard about your story,” Wilson, who now plays in the NBA, said on the big screen. “I’m so very thankful that you are here today and it is a blessing that we can have you to give you the love and support you truly deserve.”

Wilson asked the 16,000 fans in attendance to stand and give Samuel a round of applause. As the crowd clapped and an announcer bellowed about him being a “brave young man,” Samuel looked at his parents, then down at his feet, smiling shyly.

But minutes later when the game resumed, Samuel started to cry and had to leave the auditorium with his mom, Abigail.

“When it got pretty loud, that’s when he started breaking up again,” his dad, Antonio, said. “So she had to step out with him for a minute. So any loud places, if it’s too loud, it’s affecting him.”

Samuel, who turned 11 in March, was shot in the ribs on his right side. The scar on his back is barely noticeable now, but lingering effects from the parade shooting are obvious. He is seeing a therapist — as is his father, though Abigail has had a tough time finding a Spanish-speaking one and still hasn’t had an appointment.

Samuel had trouble sleeping in the first weeks after the shooting and often crawled in bed with his mom and dad. He used to get good grades, but that became more difficult, Abigail said. His personality has changed, which sometimes has shown up at school.

“I get mad easily,” Samuel said. “I [have] never been like this before but like, if they tell me to sit down, I get mad. I don’t know why.”

Traumatized children often have difficulty expressing emotions and may be given to outbursts of anger, according to Michelle Johnson-Motoyama, a professor of social work at Ohio State University.

“I’m sure for that child there is a sense of tremendous injustice about what happened,” Johnson-Motoyama said.

Especially right after the shooting, Samuel had panic attacks, Antonio said, and he’d break out in a sweat. Therapists told them that was normal. But the parents also kept him off his phone for a while, as there was so much about the shooting on the news and online.

Abigail, who works at a car dealership with Antonio, is anxious about seeing her son change, his suffering and sadness. She is also concerned for her three daughters, a 16-year-old and 13-year-old twins. Her father, Victor Salas, who was with Samuel at the parade, was also reeling in its aftermath.

“I’m crying and crying and crying about what happened,” Salas said in Spanish four days after the parade. “Because it was chaos. It doesn’t mean that families don’t love their family, but everyone took off to save their own lives. I saved my grandchildren’s lives, but what happens to the rest of the people? We’re not prepared.”

On the good side, Samuel felt very supported by the community in Kansas City, Kansas. Many people from his school stopped by in the first few days to visit, including friends and even a former bus driver, who was in tears. He has a “room full of candy,” Abigail said, mostly Skittles, his favorite.

An autographed football from Kansas City Chiefs quarterback Patrick Mahomes arrived on his birthday. It made him cry, his father said, which happens pretty often.

“There are good and bad days, days that are more normal and easier, and then there are days where the family has to be a little bit more aware and supportive,” Abigail said in Spanish. “He’s always been outgoing and talkative like his mom, but that has changed since the parade.”

Fourth of July a Weeklong Trigger

The Fourth of July was particularly harrowing for many of the young survivors and their families. Should they buy fireworks? Will they want to celebrate? And why do all the firecrackers going off in the neighborhood sound like gunshots?

Fourteen-year-old Gabriella needed help from her stepfather, Jason Barton, to light her fireworks this year, something she is ordinarily enthusiastic about doing herself. At the parade, like many people, the Barton family initially mistook the sound of gunfire for fireworks.

And Erika Nelson, a single mom in Belton, Missouri, feared even bringing up the holiday with Mireya, who has always loved Independence Day. Eventually Mireya said she didn’t want any big fireworks this year and wanted only her mom to set theirs off.

“Just any little trigger — I mean, it could be a light crackle — and she just clenched,” Erika Nelson said.

Patty Davis, a program manager for trauma-informed care at Children’s Mercy hospital in Kansas City, said even her clients who were at the parade but were not injured still flinch at the sounds of sirens or other loud noises. It’s a powerful response to gun violence, she said.

“So not just an accidental trauma,” she said, “but a trauma that was perpetrated for violent purposes, which can cause an increased level of anxiety for persons around that to wonder if it’s going to happen again. And how safe are they?”

Reliving Getting Shot

Random sounds, bright lights, and crowds can catch the kids and their parents off guard. In June, Mireya Nelson was waiting for her older sister after a dance recital, hoping to see a boy she knew give a flower to a girl everyone said he had a crush on. Her mom wanted to go, but Mireya shushed her.

“Then all of a sudden, there was a loud boom,” Erika said. “She dropped low to the ground. And then she jumped back up. She goes, ‘Oh my God, I was getting shot again!’”

Mireya said it so loudly people were staring, so it was Erika’s turn to shush her and try to soothe her.

“I was like, ‘Mireya, it’s OK. You’re all right. They dropped a table. They’re just moving stuff out. It was an accident,’” Erika said.

It took a few minutes for the shock to wear off and Mireya later giggled about it, but Erika is always on watch.

Her daughter’s early sadness — she watched movies for hours, crying throughout — has since changed to a cheekiness. Half a year later, Mireya will joke about the shooting, which tears her mother up. But maybe that is part of the healing process, Erika says.

Before the Fourth of July, Mireya went to Worlds of Fun, a large amusement park, and had a good time. She felt OK because there were security guards everywhere. She also enjoyed a visit to the local FBI office with a friend who was with her the day of the shooting. But when someone suggested a trip to the ballet, Mireya squashed it quickly — it’s near Union Station, the site of the shooting. She doesn’t want to go downtown anymore.

Erika said the doctor appointments and financial strains have been a lot to juggle and that her biggest frustration as a parent is that she’s not able to fix things for her daughter.

“They have to go their own way, their own process of healing. I can’t shake her, like, ‘Get back to yourself,’” Erika said. “It could take months, years. Who knows? It could be the rest of her life. But I hope that she can overcome a little bit of it.”

Goose Bumps in the Sweltering Heat

James Lemons noticed a change in his 5-year-old daughter, Kensley, who was on his shoulders when he was shot at the parade. Before the shooting Kensley was outgoing and engaged, James said, but now she is withdrawn, like she has closed off her bubble and disconnected from people.

Large crowds and police officers remind Kensley of the parade. Both were present at a high school graduation the family attended this summer, prompting Kensley to ask repeatedly to leave. James took her to an empty football field, where, he said, she broke out in goose bumps and complained of being cold despite the sweltering heat.

Bedtime is a particular problem for the Lemons family. Kensley has been sleeping with her parents. Another child, 10-year-old Jaxson, has had bad dreams. One night, he dreamt that the shooter was coming near his dad and he tripped him, said Brandie Lemons, Jaxson’s stepmom.

Younger children like Kensley exposed to gun violence are more likely to develop post-traumatic stress disorder than older children, according to Ohio State’s Johnson-Motoyama.

Davis, of Children’s Mercy in Kansas City, said children whose brains are not fully developed can have a hard time sleeping and understanding that they are safe in their homes at night.

James got the family a new puppy — an American bulldog that already weighs 32 pounds — to help them feel protected.

“I looked up the pedigree,” he said, “They’re real protective. They’re real loving.”

Searching for an Outlet to Let Off Steam

Gabriella took up boxing after the shooting. Her mother, Bridget, said it restored some of her confidence and control that dimmed after the parade.

“I like beating people up — not in a mean way, I swear,” Gabriella said in April as she molded a mouthguard to her teeth before leaving for training.

She has since stopped boxing, however, so the money can instead go toward a trip to Puerto Rico with her Spanish class. They’re paying $153 a month for 21 months to cover the trip. Boxing classes were $60 a month.

Bridget thought boxing was a good outlet for leftover anger, but by the end of July Gabriella wasn’t sure if she still had the drive to fight back that way.

“The past is the past but we’re still gonna all, like, go through stuff. Does that make sense?” Gabriella asked.

“You’re mostly OK but you still have triggers. Is that what you mean?” her mother asked.

“Yeah,” she replied.

After the shooting, Mireya Nelson tried online classes, which didn’t work well. The first few days of summer school, Mireya had a panic attack every day in the car and her mother took her home.

Mireya wants to return to high school this fall, and Erika is wary.

“You know, if I do go back to school, there’s a chance at school of being shot, because most schools nowadays get shot up,” Erika recalled her daughter saying. “And I’m like, ‘Well, we can’t think like that. You never know what’s gonna happen.’”

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Gavin Newsom to support food makers’ nightmare scenario — a first-in-the-nation law banning certain food additives in the state, which was signed into law last year.

Wagner is best known for his co-ownership of Magnolia Pictures alongside his longtime business partner Mark Cuban. But now, he told STAT in an extended interview, he’s dedicating himself to fighting food makers and their industrial creations, ultra-processed foods.

“I want people angry,” said Wagner, who is worth an estimated $1.9 billion. “This is an indictment of the food companies that have tainted our food supply, and now we wake up 50, 60 years later with a nation that is unhealthy.”

Continue to STAT+ to read the full story…

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.

Minnesota Gov. Tim Walz is Vice President Kamala Harris’ choice of running mate. Walz — also a former U.S. congressman, high school teacher, and member of the National Guard — has a folksy, Midwestern affect and a liberal record. He has signed bills expanding abortion rights and medical care for transgender people as governor and represented a swing district in the House of Representatives.

Meanwhile, the number of abortions taking place in the U.S. since the overturn of Roe v. Wade continued to rise into early this year, according to a new study. That is frustrating abortion opponents, who are seeking more ways to bring the numbers down, even if it means barring pregnant women from traveling to other states.

This week’s panelists are Julie Rovner of KFF Health News, Sandhya Raman of CQ Roll Call, and Shefali Luthra of The 19th.

Panelists

Shefali Luthra
The 19th

@shefalil

Read Shefali's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Walz has been active on health issues, including capping insulin prices, codifying access to abortion and gender-affirming care, and supporting veterans’ health, as well as challenging hospital consolidation efforts. In fact, the similarities between him and Harris highlight unity among Democrats on key health issues.
• Meanwhile, the GOP vice presidential nominee, Sen. JD Vance of Ohio, said in an interview that reforming the Affordable Care Act would still be on the table if Trump were reelected, though he did not elaborate. The lack of specificity in the GOP’s plans leaves a lot unknown about what a second Trump administration would do with health policy.
• A recent report shows the number of abortions continued to rise amid restrictions. How? Telehealth is a major reason for the trend. And a separate report shows hundreds of millions in taxpayer dollars have been funneled to crisis pregnancy centers since the overturn of Roe v. Wade, reflecting an effort in conservative state legislatures to steer funding to centers that discourage abortion.
• And Congress has departed for its August recess without funding the federal government, again. Those eyeing other must-pass legislation, such as extended telehealth flexibilities and pharmacy benefit manager reform, are banking on the lame-duck session after the election.

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

Julie Rovner: JAMA Internal Medicine’s “Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons,” by Emily Lupton Lupez; Steffie Woolhandler; David U. Himmelstein; et al.

Shefali Luthra: KFF Health News’ “Inside Project 2025: Former Trump Official Outlines Hard Right Turn Against Abortion,” by Stephanie Armour.

Sandhya Raman: The War Horse’s “‘I Had a Body Part Repossessed’: Post-9/11 Amputee Vets Say VA Care Is Failing Them,” by Hope Hodge Seck.

Also mentioned on this week’s podcast:

• ProPublica’s “Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant To Help Needy Families, But No One Knows if It Works,” by Cassandra Jaramillo, Jeremy Kohler, and Sophie Chou, ProPublica, and Jessica Kegu, CBS News.
• Vox’s “Free Medical School Won’t Solve the Doctor Shortage,” by Dylan Scott.
• Stat’s “How UnitedHealth Turned a Questionable Artery-Screening Program Into a Gold Mine,” by Casey Ross, Lizzy Lawrence, Bob Herman, and Tara Bannow.
• The Wall Street Journal’s “The One-Hour Nurse Visits That Let Insurers Collect $15 Billion From Medicare,” by Anna Wilde Mathews, Christopher Weaver, Tom McGinty, and Mark Maremont.

click to open the transcript

Transcript: The Walz Record

KFF Health News’ ‘What the Health?’ Episode Title: ‘The Walz Record’Episode Number: 359Published: Aug. 8, 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, Aug. 8, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this, so here we go.

We are joined today via videoconference by Sandhya Raman of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: And Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: No interview this week, but plenty of news for a hot summer week so we will get right to it. So for the second time in three weeks, we have a new vice-presidential nominee to talk about. Newly minted Democratic nominee Vice President Kamala Harris has chosen former congressman and current Minnesota Gov. Tim Walz to be her running mate. What do we know about Walz’s record on health care?

Raman: We know a lot. I think it’s easier to draw from his record compared to JD Vance, who was only elected for the first time in 2022. Tim Walz has had six terms in the House. He’s on his second term as governor. And from that you can see what his priorities are, how he’s drawn from his personal experience and the things that he’s been doing that are very in line with what either Biden and Harris or just Harris have done. When we had Biden, we hear a lot of talk about capping insulin costs, and that’s something that Walz signed a Minnesota bill for a few years ago. And he’s also been very active in reproductive health issues. He signed a couple abortion-related laws last year. That’s been a key focus of the Harris and Biden-Harris campaigns. He’s been active in talking about IVF and how his family has used that, also pretty in line with that.

Rovner: I love that he had a daughter using IVF, whose name is Hope.

Raman: Yeah, yeah.

Rovner: Very Midwestern.

Raman: Yes, and I think he’s also been pretty active on some of the veterans’ issues as a former member of the Army National Guard for several years. And just some of the education and health issues as a former teacher. And he signed legislation related to gender-affirming care as governor. So I think we have a pretty good idea of the types of things that he’d be interested in if they were elected.

Luthra: And I think what’s striking as well is how in line he seems to be on so many policy fronts to what we know the vice president and, frankly, what we know about the other people who were in contention for the vice-presidential nomination. And what I think that tells us is how unified a lot of the party is right now on health care and health policy issues in general. I was pretty struck by how quickly we got reactions from both pro-abortion rights groups and anti-abortion rights groups. As soon as the news came, SBA [Susan B. Anthony] Pro-Life America, one of the biggest anti-abortion groups, is quick to say this is the most pro-abortion ticket in history. They might be right.

Rovner: I was going to say it’s probably true.

Luthra: Yeah. And they could have said that about any Harris, et cetera, ticket, whether that was Walz, whether that was [Pennsylvania Gov. Josh] Shapiro, whether that was someone else from her reported list of finalists. And at the same time, what we saw from abortion rights advocates is they’re equally thrilled about this because they look at Walz as an ally. They look at the work that was done in Minnesota around getting rid of abortion bans; codifying abortion rights in the state constitution; limiting requirements like the 24-hour waiting period: That is gone in the state. And passing a shield law.

All of that underscores that he’s very in line with the vice president. I think what’s worth asking ourselves is how much does that matter when we have someone like Kamala Harris who is very interested in these issues. And in a way, we know far less about JD Vance. But whatever we could find out about him probably matters a lot more because Donald Trump has never shown much interest in health care or health policy. So if we did get a Trump-Vance ticket, it feels like there is a real possibility we’d have a lot more Vance influence in this area as opposed to Walz in a Harris-Walz administration.

Rovner: Which we’ll get to in a second. Just something that jumped out at me when I was researching this is that there’d been much made about the fact that Harris is the first presidential candidate who’s actually visited an abortion clinic. Well, so has Walz. So we’ve now got a presidential candidate and a vice-presidential candidate who have visited an abortion clinic. And I’m thinking even 15, 20 years ago on a Democratic ticket, how much the world has changed since the fall of Roe [v. Wade], that that never would’ve been something that anybody would’ve wanted to advertise. I think it speaks volumes as to really how big reproductive health is going to be going forward in this campaign.

Raman: They went together when they visited a clinic together in St. Paul [Minnesota] earlier. So I think that speaks to it, too, that it is a very important issue for both of them and that it is definitely going to be something the other side is going to really seize on and a point of distinction.

Rovner: Meanwhile, as Shefali alluded to, the Republicans continue to bob and weave on health care issues. Republican vice presidential nominee JD Vance told the news site Notice earlier this week that the ACA [Affordable Care Act] is indeed on the agenda for a second Trump administration, although he didn’t say exactly how. “I think we’re definitely going to have to fix the health care problem in this country,” was his exact quote. Any hints to what that might entail?

Raman: Honestly, no. I think that everything that we’ve heard so far has really just put multiple things up on the table without giving any specifics. Is the ACA repeal-and-replace still on the table? It depends on do we have a majority, do we have a minority, in Congress? And what would that even entail given that we had the whole thing in 2017 where it didn’t work out for them? And Trump has hinted back and forth and not been very clear, so we’re still not sure without more clarity from them.

Rovner: The rest of what JD Vance said was “Obamacare is still too expensive and a lot of people can’t afford it, and if they can’t afford it, they don’t get high-quality care, and we’re going to give them high-quality care.” And my thought was, that would be great. How on earth do you plan to make Obamacare less expensive and care higher quality? That seems like a rather tall order, but a great goal.

Luthra: And realistically, right? We don’t have, as Sandhya pointed out, a real record for JD Vance to look at. We do have a record for Donald Trump, but we don’t have statements of principle or value that we can really attribute to him. We don’t know what he really would do because we don’t know what he believes in. And that, I think, is why we put so much attention in the press. And why we’ve seen Democrats put so much attention on what Republican think tanks are talking about. And what the people who would staff those administrations would say. That is why something like Project 2025 merits so much scrutiny because those are the people who will be in power in institutions of government and potentially interpreting these kinds of vague sentences into actual policy that touches our lives.

Rovner: We don’t know very much of what Donald Trump really thinks about health care because he wants it that way. He wants to keep all of his options open. But one of the things that we do know is that he’s repeatedly promised not to touch Social Security or Medicare, the so-called third rails of American politics. He has specifically declined, however, to include Medicaid on that list of things that he won’t touch. And now we’re reading various proposals — as you mentioned, from Project 2025 to the Paragon Institute, which is run by a former Trump official — that are proposing various ways to scale back Medicaid, particularly federal Medicaid spending, possibly dramatically. Did they not learn from the 2017 repeal-and-replace fight that Medicaid, now that it covers like 90 million people, is kind of pretty popular?

Raman: I think that even after that, we’ve had so many times that we’ve seen in that administration trying to modify the ways that they can with Medicaid. We had the try to push for block grant proposals multiple times. We’ve had the work requirements try to come to fruition in multiple states before being struck down by the courts. And those things are still pretty popular if you look at the documents put out by a lot of these think tanks as something that could be brought up again. Including pulling back on expansion as a way that they see as really reducing federal spending, especially as they’re trying to reduce the national debt and just bring down costs in general.

Rovner: Pulling back on the federal match for expansion, more to the point.

Raman: Because Medicaid expansion is largely funded by the federal government. And so I think those are things that we could see given the history and the people that are working in those places and their connections to the former administration.

Luthra: And I do think it’s worth noting that Trump has said right now that he would not want to touch Social Security or Medicare. I think we can also put a few grains of salt, maybe some more salt, in there, because that is also what he said when he ran for president in 2016. And again, that isn’t really what he was as committed to as president. It was: What does [House Speaker] Paul Ryan want to do? What will I be willing to negotiate on? And with Trump in particular, there is such a distinction between knowing what is politically pragmatic to say in a campaign versus what is on the table as an administration, that I just think that it is incumbent on all of us to not take that with too much credibility, just in this very specific case.

Rovner: And also Social Security and Medicare sometimes need touching, saying that you’re not going to touch, leaving them on autopilot, is not a very responsible public policy. You actually do have to get under the hood occasionally and do things to these programs. But before we get to that, I want to talk a little bit more about abortion. This week, the Society of Family Planning, which is tracking the number of abortions around the U.S. in the wake of the Dobbs [v. Jackson Women’s Health Organization] ruling, reported that the volume of abortions continues to increase despite complete bans in 14 states and near-bans in several others. Shefali, how is this happening? Why is the number of abortions going up? One would think it would be going down.

Luthra: I think these numbers are really striking. They show a continuation of a trend, which is largely this increase in telehealth. More people getting abortion through, in some cases, shield law provision, living in states like Texas and getting pills mailed to them from doctors in New York. Or the fact that it is simply easier to get an abortion if you live in a state with abortion protections because telehealth is much more available right now. The numbers also do show more in-clinic care because people are traveling and overcoming great distances to get abortion.

One thing that I think is really important and that the authors had noted when this came out was these go through March. And on May 1, Florida’s abortion ban took effect, and that is one of the biggest abortion bans that we have seen since the Dobbs decision. And I think it will be really interesting to see whether the trend that we have been observing for quite some time — this steady increase and, in particular, growth of telehealth and continued travel — if that remains possible and viable when you lose a state with as many clinics and as many people as Florida had had.

Rovner: I saw Stephen Miller, the Trump adviser, on TV last night talking about “There will be no national abortion ban under Donald Trump,” which is a whole other discussion. But these numbers, and continuing to go up, must be making the anti-abortion movement crazy.

Luthra: They are losing their minds. They are deeply frustrated on two levels. They’re very concerned that people are finding ways to travel. That is not something they hoped for. And they are very concerned about telehealth in particular. And what they keep saying is they want to find some kind of legal strategy to challenge the shield law provision, but they haven’t quite figured out how. There is real talk in Texas among some of the anti-abortion activists. They’re trying to see is there a way we could pass legislation in a future session to perhaps ban internet providers from showing the websites that allow you to order medication abortion.

Something like that. All of this would be fought through the courts. All of this would be heavily litigated. But it is their No. 1 priority because it is an existential threat to abortion bans. Obviously, they are waiting to see what happens in the presidential election because if you do have an administration that is willing to restrict the ability to mail mifepristone through rehabilitating the Comstock Act — not passing a national abortion ban, but using older laws on the books — then that does some of the job for them and could very significantly put a dent in or even halt this trend.

Rovner: Well, speaking of the abortion pill, we’re seeing pressure campaigns from both sides now aimed at some of the big corporations, including Costco and Walmart, that could start selling the abortion pill in their brick-and-mortar pharmacies. This is something that the Food and Drug Administration, at least, started to make easier earlier in the Biden administration. Now we have institutional investors from blue states pushing companies to carry the drug to make it more available, or else they will divest their very large stock holdings. While we have institutional investors that represent anti-abortion groups, like the American Family Association, who are threatening to divest if the companies do start selling the abortion pills, I would not like to be on the board of any one of these big corporations right now. This seems like a rather uncomfortable place for them to be.

Luthra: Yeah, and none of this is surprising. Alice Ollstein, regular contributor to this podcast, broke a really great story, gosh, a year and a half ago now, when we saw that even CVS and Walgreens, for a time, didn’t want to distribute mifepristone in states where abortion was legal, but there were threats of litigation from attorneys general. And that has changed. The story points out that we have CVS and Walgreens carrying these pills and distributing them. But a lot of people do get medication from Costco. A lot of people do get medication from Walmart. What we’ll see is that this is just another way in which the fight over abortion, which has real meaning for so many people, just continues to play out in the corporate sector. It is something that has been true since Dobbs happened. It is just another sign of how much people care about this and the money behind it and the chaotic nature of banning a procedure in some states and heavily stigmatizing it even in others.

Rovner: The ripple effect of the Dobbs decision. I really do think the Supreme Court had no great appreciation for just how far into other facets of American life this was going to spread, which it definitely is. Well, even as abortions are going up, states with abortion bans are spending increasing amounts of taxpayer money on anti-abortion crisis pregnancy centers that try to talk pregnant people out of terminating their pregnancies. This is flying under the radar, I feel like. We’ve seen these crisis pregnancy centers have been around for a very long time, but what we haven’t seen is the amount of money that states are now saying, “Well see, we care about pregnant women, even though we’re banning abortion, because we’re giving all this money to these crisis pregnancy centers.”

Luthra: And I was pretty struck by just how much money we have seen states put into these centers since the Dobbs decision. The report that you highlight, Julie, found that it was almost $500 million across all these states has gone in since 2022. That’s almost half a billion dollars going into these centers. And you’re right that they do fly, in some ways, under the radar. And part of that is because it is very hard to know how they spend that money. They have very, very little accountability built in place. They are not regulated the way that health care systems are. That also means if you’re a patient and you go there for seeking health care, you are not protected by HIPAA necessarily. And you often will get “care” that can be inaccurate or misleading because, fundamentally, these institutions exist to try and deter people from getting abortions, from … staying pregnant and having children.

I do think that we will see more and more of this happen, and in some ways Republicans have been very overt about that. This was the focus of the March for Life. We saw a bunch of bills in Congress that Republicans put forth talking very specifically about federal funding for anti-abortion centers. This was the biggest trend we saw in statehouses this year when it came to abortion, was passing bills that would add more funding to anti-abortion centers. It’s one area where they feel like the political consequences are far less than bans because bans are unpopular and people don’t fully understand and know what these are. And so they’re not going to get as upset with you when they hear, “Oh, you put more money into these places that are supposed to help pregnant people.” Even though the reality is we don’t actually have any metrics or data that show that they do, and we do have a lot of journalism that shows that they mislead people.

Rovner: Yeah. I will put the link back to the good investigation that ProPublica did that we talked about a couple of weeks ago about how all the money in Texas is impossible to track, basically. All right, well, the Senate last week followed the House’s lead and recessed until early September, which leaves them just a few legislative days when they get back to either finish up all 12 of the regular spending bills — spoiler, that is not going to happen — or else pass some sort-of continuing resolution to keep the government open after the Oct. 1 start of fiscal 2025. Sandhya, they went into this — we’ve said this before — with so much optimism from the Republicans: “We’re going to get these all done before Oct. 1.” Where are we?

Raman: So, at this point, we’ve gotten some work done, but it’s very unlikely we would have things done before the end of September. So the House was on track initially to vote on the House floor on their Labor HHS [Health and Human Services] spending bill, but it got derailed after there were some issues with another bill, the energy-water bill, and after they’d fallen short on their legislative branch spending bill, they recessed early.

Rovner: We should point out that while “Labor-H” is always hard to pass, those other ones tend not to be … those are ones that usually go through.

Raman: Yeah, Labor H generally is done near the end of the whole slate just because it is notoriously one of the trickier ones to get all the agreement on. And it is the biggest nondefense spending bill. So it takes longer, and so less far along on the progress with that, and we’re in August recess, both chambers are out. We won’t see any progress until September. Before the Senate left, they did advance their spending bill on the committee level. That went a lot differently than the House’s markup. So we had three people opposed, but everyone else was pretty much in agreement. A lot less eventful. It wasn’t focused on amendment debate and it was bipartisan, which is a big thing.

So we will see it when they come back, if they gravitate a little bit more towards this, if they’re shifting a little bit in between the two bills. But I think another thing to keep in mind is they have so little time this year to get so much done. They have so much recess this year for the election that it really puts a crunch on their timeline. And then there are certain people advocating that if this person wins, if that person wins, should we do a shorter-term plan spending bill so that we can get our priorities in if this party’s in control, this party has more control. So it’s a difficult situation.

Rovner: Yeah. Here we are basically heading into the home stretch for the spending bills with a gigantic question mark. As usual. Every year they say, “This won’t happen next year.” Every year this happens next year. Well, meanwhile, this is our midyear reminder that Congress also has to pass a bunch of other bills to do things like preventing some pretty big cuts to Medicare physician pay, to keep community health centers and safety-net hospitals up and running, and they have to do all this by the end of the year. I assume we’re still looking at a postelection, lame-duck session to try to wrap everything together.

Raman: I think that’s what we’re looking at. The big priority is going to be to get the government funded. And I think. as with previous years, will we get some of these other things tacked onto there? Will we get extension of telehealth flexibilities or some of the PBM [pharmacy benefit manager] reform or some of the other things that we’ve been discussing at the committee level and hoping to get across the finish line? But it’s really difficult, I think, to get some of those things done until we have this broader package. And I think it’s important that some of the times when we get the broader package, it can help pay for other of the programs that we’ve been considering at the committee level.

Rovner: That was just what I was going to say. The PBM reform, in particular, saves money. Gee, you can prevent the physician pay cut and fund community health centers.

Raman: Yeah. So I think a lot of it will depend on how quickly they’re able to get to an agreement. And if you look at the differences between the House and the Senate bills, it’s billions of dollars. I think just on health spending, it was like almost a $16 billion difference in the top line number between the bills. So getting to some sort of middle ground is going to take some time to get there.

Rovner: Well, before we leave the Hill for the rest of the summer, the Senate Health, Education, Labor, and Pensions Committee, where Democrats and Republicans have not always seen eye to eye under Chairman Bernie Sanders, actually came together last month to open an investigation into, and issue a subpoena to, the CEO of Steward Health Care. You may remember we talked about Steward back in May. It’s a Dallas-based, physician-owned hospital group that was sold to a private equity firm, which promptly sold the real estate the hospitals were sitting on, forcing them to then pay rent. Then the private equity group basically cashed out. And now the hospitals are floundering financially, which is threatening patient care in several states. This is the first time the committee has issued a subpoena since 1981. I did not know that before this week. And it’s kind of a big deal. This is the first, I think, I feel like, big investigation, at least among this committee, about the consequences of private equity in health care.

Raman: Yeah, I would say that, and especially because this is bipartisan. And I think there have been so many bipartisan issues over the past couple of years that it has been difficult to get the chairman and the ranking member to see eye to eye on or to prioritize in the same order. And so I really do think it is a big deal to be able to issue that subpoena and have the CEO come in in September.

Rovner: Yeah, this will be interesting. [Sen.] Bernie Sanders made a big point of dragging up some of the drug company CEOs who said pretty much what we expected them to say. But this is a little bit of a different situation and there’s a bunch of senators from both parties who have hospitals in their states that are now being threatened by the bankruptcy of Steward Health Care, so we’ll see how that goes. Speaking of profiteering in health care, we have two really excellent stories this week on pretty much the same subject: Stat News as part of its continuing investigation into the way UnitedHealthcare is squeezing extra money out of the Medicare program, particularly the Medicare Advantage program, has a piece on the use of a questionable test that’s used to diagnose peripheral artery disease, which can dramatically increase the Medicare Advantage payment for a patient who has it, just kind of coincidentally.

Along similar lines, The Wall Street Journal has a story looking at how not just United, but other major Medicare Advantage insurers, including Humana and Aetna, are using the same test, often provided during a “free home visit” by a nurse practitioner, and scoring those very same extra Medicare Advantage payments. Now, I’m old enough to remember when the biggest knock on Medicare Advantage was that, because it had fixed payments, it gave insurers an incentive to skimp on care. So we had lots of patients who couldn’t get care that they needed. Now that the payments are risk-adjusted, there’s an incentive for insurers to give too much care, or at least to suggest that patients need more care than they do; like that maybe they have peripheral artery disease when they don’t, really. Are there any suggestions floating around how to fix this? Shefali, you were alluding to this, that Medicare Advantage, in particular, can be a little bit of a sinkhole for federal funds.

Luthra: I think this is something that we have struggled with for a long time, right. And I think I was always thrilled to see a Bob Herman byline and we get another one on this Stat story. And one thing that he has written about so compellingly is that the sheer power that health care providers have. And I think we just can’t really ignore the role that they play then in being able to get all of this federal money into their system for things that we don’t necessarily need. And that’s not an easy thing to address politically because people like their hospitals. And even when you hear from lawmakers who want to talk about better regulation of hospitals, they really only talk about for-profit hospitals. Even though if you were to go to a for-profit or not-for-profit, you might see some similarities in how they approach what they bill for. And this is something that we haven’t figured out a good solution to because of how our politics work. But I’m really grateful that we get more reporting like this that helps remind us just how skewed the incentives are in our system.

Rovner: Yeah, it’s hard to blame them. These are for-profit companies that have shareholders, and their job is to figure out how to make money for their shareholders. And they do it extremely well. But the money that they’re making is coming from U.S. taxpayers, and there are patients who are caught in the middle. It’s been a thorny issue. This has been what we’ve been fighting about with Medicare for Medicare’s entire 59 years of its existence. So that will continue while we try to figure out everything else, like making this year’s budget work. Finally this week, we reported in July how Michael Bloomberg gave his alma mater, Johns Hopkins University, another billion dollars that will, among other things, eliminate medical school tuition for most of its student body. We pointed out at the time that the schools that have gone tuition-free have not actually succeeded either in getting more students to go into primary care.

There’s the concern that if you have a lot of debt, you’re going to want to go into a specialty to pay it off. Nor has it enabled more students of color to become doctors. So now Bloomberg is making his philanthropy a little bit more direct. He’s giving a combined $600 million to the four historically Black colleges and universities that have their own medical schools, including Howard [University] here in D.C., in hopes of more directly addressing equity issues that go along with patients not being able to get culturally sensitive care. HBCUs educate the vast majority of the nation’s Black doctors, so is this finally a step in the right direction with the medical education and health equity?

Raman: I would argue it is. Like you said, if you look at the data, the American Association of Medical Colleges [Association of American Medical Colleges] said half of Black doctors graduate from one of these schools. And that could really increase some of the uptake of preventative care and trust in medicine in the Black community who, I think they’ve done some polling, that are more comfortable a lot of times with other Black doctors. And I think that another point was the money is also starting another medical school to increase that pipeline as well. And that is another big thing where it’s broadening the pipeline, but also just really feeding into these goals, should be big over time.

Rovner: A continuing effort, I think there. All right, well, that is the news for this week. 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. Sandhya, you got yours picked first this week. Why don’t you tell us about your extra credit?

Raman: So I chose, “‘I Had a Body Part Repossessed’: Post-9/11 Amputee Vets Say VA Care Is Failing Them.” And it’s by Hope Hodge Seck at The War Horse. And it is just a really excellent piece looking at some of the concerns that amputee vets have been having and what the shortcomings are in the care from the VA [U.S. Department of Veterans Affairs], not having bills paid for some of the prosthetics or just delays in receiving them. And one interesting issue that was brought up there is that VA care for post-9/11 amputee veterans doesn’t take into account some of the needs for that population. They’re very different from maybe the needs of senior veterans. And it goes into more about how Capitol Hill is hearing some of these concerns. But read the story and learn more.

Rovner: Shefali?

Luthra: This is from KFF Health News. It is by Stephanie Armour. It is on a topic we discussed earlier on this podcast. The headline is “Inside Project 2025: Former Trump Official Outlines Hard Right Turn Against Abortion.” And what I love about this piece is it does a great job going into detail about the reproductive health ideas and agenda that is outlined in Project 2025. But I also really love that it ties that to the people who are involved in Trump World. Right? And it talks about who are the people who wrote this. Roger Severino, obviously a huge name, very anti-abortion, was involved in Trump’s HHS when he was president last time, and …

Rovner: Did the Office for Civil Rights.

Luthra: Exactly, which has huge implications for abortion policy and reproductive health policy. And I think that Stephanie does a really great job of getting into the political back and forth that has emerged over Project 2025, in which Trump himself has tried to distance himself from the document, from what it outlines and what it says. But that doesn’t really stand up to scrutiny when we look at the authors because it is largely people who have worked for Trump, have advised him, and are likely to have influential roles coming forward. There’s also some ties between JD Vance and the folks at [The] Heritage [Foundation] and Project 2025 that really solidifies the notion that this is something that could be very influential in dictating what our country would look like under a Trump-Vance presidency. And I appreciate Stephanie’s work in clarifying what it says.

Rovner: Yeah, it’s a really good story. Well, my extra credit this week is a study in JAMA Internal Medicine. It’s from the Cambridge [Health] Alliance at Harvard and is called “Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons.” And it looks at something that I didn’t even know existed: copays required in prisons for prison inmates in order to obtain medical care. The study found, not surprisingly, that copays can be equal to more than a week’s wage for some inmates, who often make just pennies an hour for the work that they do behind bars. And that many inmates end up going without needed care because they can’t afford said copays.

It’s pretty eye-opening and I hope it gets some attention. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions; we’re at whatthehealth@kff.org. Or you can still find me at X, I’m @jrovner. Sandhya?

Raman: @SandhyaWrites.

Rovner: Shefali?

Luthra: @shefalil.

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

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Brotes de covid-19, paperas y varicela. Agua contaminada, comida con moho y conductos de aire que despiden polvo negro.

Estas amenazas a la salud se han documentado dentro de las instalaciones de detención de inmigrantes administradas de manera privada en California a través de demandas, auditorías federales y estatales, y quejas presentadas por los mismos detenidos.

Pero los oficiales de salud pública locales que inspeccionan de manera rutinaria las cárceles del condado y las prisiones estatales dicen que no tienen autoridad bajo la ley estatal para inspeccionar los centros de detención operados por compañías privadas, incluidos los seis centros federales de inmigración en California.

La senadora estatal María Elena Durazo (demócrata de Los Ángeles) quiere zanjar esa laguna legal con una legislación que permitiría a los oficiales de salud de los condados realizar inspecciones en las instalaciones si lo considerasen necesario.

Durazo dijo que muchos detenidos viven en condiciones infrahumanas, y que las enfermedades contagiosas que se propagan en estas instalaciones podrían representar un riesgo para las comunidades circundantes.

“Desafortunadamente, a nuestros detenidos se los trata como si no fueran seres humanos”, dijo. “No queremos excusas. Queremos que los funcionarios estatales y de  salud pública entren siempre que fuera necesario”.

No está claro cuánta autoridad tendrían los oficiales de salud locales para implementar cambios, pero expertos en salud pública dicen que podrían actuar como observadores independientes para documentar violaciones que de otro modo el público no conocería.

El Senado estatal aprobó el proyecto de ley, SB 1132, por unanimidad a finales de mayo. Ahora está bajo consideración en la Asamblea estatal.

La inmigración está regulada por el gobierno federal. GEO Group, el contratista privado de prisiones más grande del país, opera los centros federales de California, ubicados en cuatro condados. En conjunto, pueden albergar hasta 6,500 personas en espera de deportación o audiencias de inmigración.

Durante su campaña en 2020, el presidente Joe Biden prometió poner fin a la detención de inmigrantes con fines de lucro. Pero más del 90% de las aproximadamente 30,000 personas detenidas por la agencia de Inmigración y Control de Aduanas de Estados Unidos (ICE) en un día cualquiera permanecen en instalaciones privadas, según un análisis de 2023 de la Unión Americana de Libertades Civiles.

Miembros del Congreso en ambas cámaras han presentado legislaciones para eliminar gradualmente los centros de detención privados, mientras que otros legisladores, incluidos al menos dos en julio, han pedido investigaciones sobre la atención médica y de salud mental deficientes, y las muertes.

En 2023, legisladores en el estado de Washington aprobaron una ley para imponer supervisión estatal de las instalaciones de detención privadas, pero el GEO Group demandó, y la medida está atascada en los tribunales. Los legisladores de California han intentado repetidamente regular estas instalaciones, con resultados mixtos.

En 2019, el gobernador de California, el demócrata Gavin Newsom, firmó una medida que prohíbe que las prisiones y centros de detención privados operen en California. Pero luego un tribunal federal declaró la ley inconstitucional en lo que respecta a los centros de detención de inmigrantes, diciendo que interfería con las funciones federales.

En 2021, los legisladores estatales aprobaron un proyecto de ley que exige que los centros de detención privados cumplan con las órdenes de salud pública estatales y locales, y las regulaciones de seguridad y salud de los trabajadores.

Esa medida se adoptó en el apogeo de la pandemia de covid-19, cuando el virus arrasaba con las instalaciones de detención donde las personas estaban hacinadas en dormitorios sin, o con poca, protección contra los virus transmitidos por aire.

Por ejemplo, en el Centro de Detención de Otay Mesa, en San Diego, un brote al comienzo de la pandemia infectó a más de 300 miembros del personal y a detenidos.

La Asociación de Oficiales de Salud de California, que representa a los oficiales de salud pública de los 61 departamentos de salud locales del estado, apoya la legislación de Durazo.

“Estas investigaciones desempeñan un papel fundamental en la identificación y abordaje de preocupaciones de salud e higiene dentro de estas instalaciones, mitigando así los riesgos para los detenidos, el personal y las comunidades circundantes”, indica una carta de Kat DeBurgh, directora ejecutiva de la asociación.

Bajo la medida, los oficiales de salud pública determinarían si las instalaciones están cumpliendo con las reglas ambientales, como garantizar una ventilación adecuada, y ofrecer atención básica de salud mental y física, tratamiento de emergencia y alimentos preparados de manera segura.

A diferencia de las instalaciones correccionales públicas, que los oficiales de salud locales inspeccionan cada año, los centros de detención privados serían inspeccionados a necesidad, según lo determine el oficial de salud.

Christopher Ferreira, vocero de GEO Group, y Richard Beam, vocero de ICE, se negaron a comentar sobre la medida.

Georges Benjamin, director ejecutivo de la Asociación Americana de Salud Pública, dijo que los oficiales de salud pública están bien posicionados para inspeccionar estas instalaciones porque entienden cómo hacer que los espacios confinados sean más seguros para grandes poblaciones.

Aunque probablemente no puedan obligar a los centros de detención a cumplir con sus recomendaciones, sus informes podrían proporcionar información valiosa para los funcionarios públicos, abogados y otros que quieran explorar opciones como litigar, dijo. “Cuando el sistema no funciona, los tribunales pueden desempeñar un papel muy importante”, agregó Benjamin.

El sistema federal que monitorea la atención médica y la transmisión de enfermedades contagiosas dentro de los centros de detención de inmigrantes está roto, dijo Annette Dekker, profesora clínica asistente de medicina de emergencia en UCLA, que estudia la atención médica en estas instalaciones.

Tradicionalmente, personal del ICE realiza las inspecciones de los centros de detención y, hasta 2022, también un auditor privado.

En un artículo publicado en junio, Dekker y otros investigadores mostraron que los funcionarios de inmigración y el auditor realizaban inspecciones con poca frecuencia —al menos una vez cada tres años— y proporcionaban poca información pública sobre las deficiencias y cómo se abordaban.

“Hay mucho daño que está ocurriendo en los centros de detención que no podemos documentar”, dijo Dekker.

ICE y el GEO Group han sido objeto de demandas y cientos de quejas que alegan condiciones deficientes dentro de las instalaciones de California desde que comenzó la pandemia. Algunas de estas demandas están pendientes, pero una parte significativa de las quejas ha sido desestimada, según una base de datos mantenida por la Unión Americana de Libertades Civiles.

Las demandas más recientes de los detenidos alegan condiciones de hacinamiento e insalubridad, negación de atención médica y de salud mental adecuadas, negligencia médica y muerte por suicidio.

La División de Seguridad y Salud Ocupacional de California multó al GEO Group con unos $100,000 en 2022 por no mantener procedimientos escritos para reducir la exposición a covid. El GEO Group ha impugnado la multa.

“He experimentado condiciones de vida realmente inhumanas”, dijo Dilmer Lovos, de 28 años, a KFF Health News por teléfono desde el centro de detención de inmigración Golden State Annex en McFarland, en el condado de Kern. Lovos ha estado detenido allí desde enero mientras espera una audiencia de inmigración.

Lovos, quien nació en El Salvador y usa los pronombres ellos/ellas, ha sido residente permanente legal durante 15 años y fue detenido por oficiales de inmigración mientras estaba en libertad condicional.

A principios de julio, Lovos y otros 58 detenidos del Golden State Annex y el Centro de Procesamiento de ICE Mesa Verde, en Bakersfield, comenzaron una huelga de hambre y laboral exigiendo el fin de las malas condiciones de vida, el confinamiento solitario y los servicios médicos y de salud mental inadecuados.

Lovos describió una habitación abarrotada, filtros de aire obstruidos, ratones y cucarachas correteando en la cocina, agua goteando del techo y detenidos con síntomas parecidos a los de la gripe que no podían acceder a medicamentos ni a una prueba de covid cuando lo pedían.

Los protocolos del ICE requieren pruebas a los detenidos con síntomas al ingresar a las instalaciones sin hospitalizaciones ni muertes por covid en la semana anterior. En las instalaciones con dos o más hospitalizaciones o muertes en la semana anterior, se evalúa a todos los detenidos durante el proceso de admisión. Después de eso, depende de los proveedores médicos de cada instalación decidir cuándo es necesaria una prueba.

Después que Lovos presentara una queja ante el GEO Group en junio, alegando negligencia médica y de salud mental, dijeron que los pusieron en confinamiento solitario durante 20 días sin un inodoro que funcionara correctamente. “Olía mi orina y heces porque no podía tirar de la cadena”.

El vocero Ferreira se negó a abordar las acusaciones de Lovos pero dijo por correo electrónico que los detenidos reciben “acceso las 24 horas del día a atención médica”, incluidos médicos, dentistas, psicólogos y derivaciones a especialistas externos.

“GEO rechaza las acusaciones infundadas que se han hecho con respecto al acceso a los servicios de salud en los Centros de Procesamiento del ICE contratados por GEO”, dijo.

Una inspección sorpresa de funcionarios federales de inmigración en abril de 2023 encontró que los empleados de Golden State Annex no respondieron dentro de las 24 horas a las quejas médicas, lo que, según el informe, podría afectar negativamente la salud de los detenidos, y no archivaron de manera adecuada sus registros médicos.

Lovos dijo que nadie ha abordado sus preocupaciones y que las condiciones solo han empeorado.

“Por favor, vengan a revisar estos lugares”, dijo Lovos en una súplica a los oficiales de salud locales.

Esta historia fue producida por KFF Health News, una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. KFF Health News edita California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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

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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.

As Vice President Kamala Harris appears poised to become the Democratic Party’s presidential nominee, health policy in general and reproductive health issues in particular are likely to have a higher profile. Harris has long been the Biden administration’s point person on abortion rights and reproductive health and was active on other health issues while serving as California’s attorney general.

Meanwhile, Congress is back for a brief session between presidential conventions, but efforts in the GOP-led House to pass the annual spending bills, due by Oct. 1, have run into the usual roadblocks over abortion-related issues.

This week’s panelists are Julie Rovner of KFF Health News, Stephanie Armour of KFF Health News, Rachel Cohrs Zhang of Stat, and Alice Miranda Ollstein of Politico.

Panelists

Stephanie Armour
KFF Health News

@StephArmour1

Read Stephanie's stories.

Rachel Cohrs Zhang
Stat News

@rachelcohrs

Read Rachel's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• President Joe Biden’s decision to drop out of the presidential race has turned attention to his likely successor on the Democratic ticket, Vice President Kamala Harris. At this late hour in the campaign, she is expected to adopt Biden’s health policies, though many anticipate she’ll take a firmer stance on restoring Roe v. Wade. And while abortion rights supporters are enthusiastic about Harris’ candidacy, opponents are eager to frame her views as extreme.
• As he transitions from incumbent candidate to outgoing president, Biden is working to frame his legacy, including on health policy. The president has expressed pride that his signature domestic achievement, the Inflation Reduction Act, took on the pharmaceutical industry, including by forcing the makers of the most expensive drugs into negotiations with Medicare. Yet, as with the Affordable Care Act’s delayed implementation and results, most Americans have yet to see the IRA’s potential effect on drug prices.
• Lawmakers continue to be hung up on federal government spending, leaving appropriations work undone as they prepare to leave for summer recess. Fights over abortion are, once again, gumming up the works.
• In abortion news, Iowa’s six-week limit is scheduled to take effect next week, causing rippling problems of abortion access throughout the region. In Louisiana, which added the two drugs used in medication abortions to its list of controlled substances, doctors are having difficulty using the pills for other indications. And doctors who oppose abortion are pushing higher-risk procedures, like cesarean sections, in lieu of pregnancy termination when the mother’s life is in danger — as states with strict bans, like Texas and Louisiana, are reporting a rise in the use of surgeries, including hysterectomies, to end pregnancies.
• The Government Accountability Office reports that many states incorrectly removed hundreds of thousands of eligible people from the Medicaid rolls during the “unwinding” of the covid-19 public health emergency’s coverage protections. The Biden administration has been reluctant to call out those states publicly in an attempt to keep the process as apolitical as possible.

Also this week, Rovner interviews Anthony Wright, the new executive director of the consumer health advocacy group Families USA. Wright spent the past two decades in California, working with, among others, now-Vice President Kamala Harris on various health issues.

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

Julie Rovner: NPR’s “A Study Finds That Dogs Can Smell Your Stress — And Make Decisions Accordingly,” by Rachel Treisman.  

Alice Miranda Ollstein: Stat’s “A Pricey Gilead HIV Drug Could Be Made for Dramatically Less Than the Company Charges,” by Ed Silverman, and Politico’s “Federal HIV Program Set To Wind Down,” by Alice Miranda Ollstein and David Lim. 

Stephanie Armour: Vox’s “Free Medical School Won’t Solve the Doctor Shortage,” by Dylan Scott.  

Rachel Cohrs Zhang: Stat’s “How UnitedHealth Harnesses Its Physician Empire To Squeeze Profits out of Patients,” by Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence. 

Also mentioned on this week’s podcast:

• States Newsroom’s “Anti-Abortion Researchers Back Riskier Procedures When Pregnancy Termination Is Needed, Experts Say,” by Sofia Resnick.
• KFF Health News’ “Louisiana Reclassifies Drugs Used in Abortions as Controlled Dangerous Substances,” by Rosemary Westwood, WWNO.
• The New York Times’ “Biden and Georgia Are Waging a Fight Over Medicaid and the Future of Obamacare,” by Noah Weiland.

click to open the transcript

Transcript: Harris in the Spotlight

KFF Health News’ ‘What the Health?’Episode Title: ‘Harris in the Spotlight’Episode Number: 357Published: July 25, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 25, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: And we welcome back to the podcast one of our original panelists, Stephanie Armour, who I am pleased to say has now officially joined us here at KFF Health News. Stephanie, so great to have you back.

Stephanie Armour: Great to be back.

Rovner: Later in this episode, we will have my interview with Anthony Wright, the new executive director of the consumer health advocacy group Families USA. Anthony previously spent two decades working on health issues in California so he’s pretty familiar with the health work of the current vice president and soon-to-be Democratic presidential nominee, Kamala Harris, and he’ll share some of that knowledge with us. But first, this week’s news.

So it’s safe to say a lot has changed since the last time we met. In fact, it may be fair to say that just about everything has changed. President Joe Biden announced he would not seek reelection after all, he endorsed his vice president, Kamala Harris, and she proceeded to all but lock up the nomination in less than 48 hours. Obviously, this will be a huge deal for the fight over abortion and reproductive health care, which we will get to in a moment. But how is this going to impact health care, in general, as a campaign issue?

Ollstein: Yeah, it’s interesting because Kamala Harris has been a public figure for a while and has held a bunch of different offices, and so we can glean some clues as to where she is on various health care issues. But she’s been a bit hard to pin down. And when my colleagues and I were talking to a lot of folks throughout the health care industry over the past week, there were a lot of question marks on their end, so we know a few things. We know that she used the powers of the AG [attorney general] office to go after monopolies and consolidation and anticompetitive practices in California.

She did that in the insurance space, in the provider space, in the drug space, and so people are expecting that she would be maybe more aggressive on that front. We know that she did co-sponsor [Sen. Bernie Sanders’] “Medicare for All” bill, but then she also introduced her own, arguably more moderate, one that preserved private health insurance. And then, of course, abortion rights. She’s been very vocal on that front, but since becoming the presumptive nominee, she hasn’t really laid out what, if anything, she would do differently than Joe Biden. So like I said, a lot of question marks.

Rovner: Stephanie, you led our coverage of Harris’ health record. What did you learn?

Armour: Well, I think a number of the people that I’ve talked with really expect that she’ll be a standard-bearer to what Biden has already done, and I think that’s probably true. I don’t think she’s going to go back stumping for Medicare for All right now, for example. What I did find really interesting is, yes, she’s very much made abortion and reproductive rights a cornerstone of her vice presidency and, I assume, will be of her campaign. But based on where abortion is polling right now, a number of the strategists I spoke to said she really needs to do something pretty major on it in order to get a real uptick in terms of galvanizing voters, just because economy and immigration are so high. They’re saying that she really needs to do something like say that she’ll bring back legislation to restore Roe v. Wade, for example, to really make a difference. So I think it’ll be interesting to see how much that can really motivate voters when there’s so much competing for interest right now.

Cohrs Zhang: Oh, there is one other issue that I wanted to bring up. And I think especially from her time in the Senate, she didn’t sit on health care committees, but she did go out of her way to take ownership over concerns about maternal mortality. She was lead Senate sponsor of the Momnibus Act, which included a whole slew of different policies and programs that could help support mothers, especially Black mothers. And I think she has continued that interest in the White House and really championed health equity, which does, again, just draw a very stark contrast. So we haven’t seen a lot of passion or interest in the traditional health policy sense from her outside of abortion, but that is one issue she really has owned.

Rovner: Yeah, I mean, it has not been part of her quote-unquote “portfolio” as vice president, anything except, as I mentioned, reproductive rights, which will obviously be the biggest change from Biden to Harris. The president, as we all know, does not even like to say the word “abortion.” She, on the other hand, has been all over the issue since well before Roe got overturned and obviously particularly since then. Alice, how are advocates on both sides of this issue reacting to this switch at the top of the ticket?

Ollstein: Yeah, honestly, it’s been this interesting convergence because the pro-abortion-rights side is really jazzed. They’ve basically all rushed to endorse her and talk about how they’ve been working with her for years and really know her and trust her, and they believe she’ll be more aggressive than Biden was. But you also have the anti-abortion side being excited to have her as the villain, basically. They’ve had a hard time portraying Biden as extreme on this issue and they think they’ll have an easier time portraying Kamala Harris as extreme on abortion rights. One other thing from her record and background is her fight with the conservatives who recorded sting videos at Planned Parenthood that the anti-abortion movement still brings that up a lot. So yeah, it’ll be really interesting to see for which side this really lights a fire more because we’re hearing claims from both that it will fuel them.

Rovner: And, actually, I think it will actually fuel both sides of this. I would think that the abortion-rights groups were very — I mean everybody was pretty quick to endorse her — but the abortion-rights groups were right there right away, as were the anti-abortion groups saying she is extreme on abortion, which in some ways will fuel the abortion-right side. It’s like, “Oh good. The more the antis don’t like her, the stronger that means she is for us.” I mean, I literally could see this fueling both sides of this issue and …

Armour: Whereas you see Republicans backing away increasingly from abortion like the RNC [Republican National Committee] platform. And so it’s turning out to be still very much a hot-button issue and difficult issue for Republicans.

Rovner: So they say that the vice presidency is not very good for much, and I definitely agree with that. I mean, everybody always says, “The vice president hasn’t done anything.” Because the vice president doesn’t really have a job to do anything. Often the only time the vice president is on TV is when he or she sits behind the president at the State of the Union. But I feel like, in Harris’ case, it’s made her a much more confident and natural and comfortable campaigner. I watched her a lot when she was running for president in 2019 and 2020, and she was, to be kind, a little bit awkward; I mean she was just not one of those natural, had-that-rapport with a crowd, and I feel like that has changed a lot having watched her crisscross the country, particularly on reproductive health. Am I the only one that feels that way? I feel like people are going to see a very different vice president than they think they saw, while she was doing her due diligence as vice president.

Ollstein: Definitely, and I’ve found it interesting that it’s only been a few days since all of this went down, but I have noticed that while she has brought up abortion rights in pretty much every speech and appearance she’s given, she has not given specifics. She has not indicated if she is in the Biden camp of let’s restore Roe v. Wade, or with a lot of the rest of the movement that says Roe was never good enough, we need to aim for something much more expansive. So we didn’t know where she is on that. I mean, largely she’s been just saying, “Oh, I will stop Donald Trump from banning abortion nationally.” And using him as the foil and pledging to stop him. And so we haven’t really seen her make an affirmative case of what she would do on this front.

Rovner: Well, I think that would probably be as difficult for her as it is for the Republicans to try and figure out how far they want to go banning. Because yeah, as you mentioned, I mean, there’s a lot of the abortion-rights movement that think that restoring Roe, even if they could, is not enough because obviously under Roe, many, many types of restrictions were allowed and were in place. That is obviously not where the abortion-rights side wants to end up. And on the other side, as we’ve talked about ad nauseum, do anti-abortion forces, are they OK with state-by-state bans? Do they want a national ban? If so, what would it look like? So that will obviously continue.

Now that we have, relatively, mostly settled who’s going to be at the top of the ticket, we are once again, back to the “Who will be the VP pick?” sweepstakes. Now that we’ve finished the Republican side, we’re back to the Democratic side of the short list. We’ve all been hearing Kentucky Gov. Andy Beshear, North Carolina Gov. Roy Cooper, Arizona Sen. Mark Kelly, and Pennsylvania Gov. Josh Shapiro. They all have significant health records, but mostly on different issues. Who do you think of the people who are being mentioned would make the biggest splash on the health care scene?

Ollstein: I’ve been hearing a lot of people talk about Gov. Beshear’s record on Medicaid expansion and pushing back against work requirements, and also opposing legislation to restrict trans care. And so there’s definitely a lot there. Really, a lot of them have something there, but I’ve been hearing the most about him.

Rovner: And Mark Kelly, of course, is married to Gabrielle Giffords, who was shot at a campaign event and is now a leading voice in the gun control movement. So they all seem to have slightly different major health issues. Roy Cooper in North Carolina got North Carolina to expand Medicaid, which was a very, very, very big deal with a very, very, very Republican legislature. I’m not going to ask anybody to guess who it’s going to be because I can’t imagine that any of us have any major insight into this. Whoever it turns out to be, and I imagine we’ll know in the next week or two, we will go in and examine their health care record. One of the advantages that Vice President Harris will have on the campaign trail is she gets to campaign on the Biden administration’s record, which is fairly accomplished on the health care front without the drag of being in her 80s. Somebody remind us of all the health policies the Biden administration has gotten done. Start with the Inflation Reduction Act.

Cohrs Zhang: The name of the legislation is very general, but I think President Biden, in his goodbye speech last night, did mention the drug pricing portion of that bill. He’s described it as beating Big Pharma. And I think that’s definitely something that he talked about in his State of the Union, that he wanted to expand some of those pricing mechanisms to more people, not just people in Medicare, but people in commercial health plans, too. So I think that’s been something that he has really felt passionate about and Vice President Harris now could certainly use on the campaign trail. It’s a really popular issue and, again, not a huge policy departure, but, certainly, there’s more work to be done there on Democrats’ side.

Armour: And also I think the ACA [Affordable Care Act] extensions in terms of how many more people have been eligible for coverage is something that will definitely be part of Biden’s legacy as well. And the record-low uninsurance that we saw is something I bet that will be remembered, too.

Rovner: Yeah, I mean I’ve been personally surprised at some of the things that he’s gotten done in a Congress with virtually minuscule majority. I mean, one vote in the Senate and, when the Democrats were controlling the House, it was, what, four votes in the House. That takes, I think, a certain kind of legislator to get things passed. I know people walk around and say, “Oh, the Biden administration hasn’t done anything.” And you want to pull your hair out because that’s all we’ve spent the last six years talking about, things that have actually gotten done and not gotten done.

Cohrs Zhang: Right. Well, I mean doing things and communicating well about doing things are different issues, and I think that’s going to be Vice President Harris’ challenge over the next few months.

Rovner: Yeah, and so we’ve seen, and I think the Biden administration has prevented a lot of things from happening, which is always very hard to campaign on. It’s like, “Well, if we hadn’t done this, then this might’ve happened.” I mean, I think that’s true about the pandemic. Things could have gone much, much worse and didn’t and that’s tricky to say, “Hey, we prevented things from getting even more terrible than they were.”

Ollstein: And on the drug pricing front, I mean it just always reminds me of the Affordable Care Act where the payoff is years down the road, and so selling it to voters in the moment when they’re not feeling the effects yet is really hard. So it makes sense that people aren’t aware that they got this major legal change that’s been decades in the making over the finish line because the drugs aren’t cheaper yet for a lot of people.

Rovner: That’s true. And the caps on spending haven’t really kicked in yet. It is a lot like the Affordable Care Act, which took four years from the time of passage to the time it was fully implemented.

Well, in other news, and there is some other news, Congress is back after a break for the Republican [National] Convention, although they’re about to leave again. At the top of the House’s list was passing the spending bills that they didn’t manage to pass last year. So how’s that all going, Rachel?

Cohrs Zhang: I think they’ve just thrown in the towel this week, given up a bit. I think there’s been an attitude of just apathy on the Hill and especially on health care issues that the sense has been, “We’ll return to this in December when we all have a little bit more information about the dynamics going to the lame-duck session.” And I think that clearly has bled over into any will that remains to pass appropriations bills before August recess. I think they’re ready to get out there, ready to be on the campaign trail and put this on the back burner.

Rovner: Yeah, and in an election year, you basically have the six months leading up to the first convention and then almost nothing until they come back after the election. They were going gangbusters on some of these spending bills. They were getting them out of committee even though they were obviously not in the kind of shape that they were going to become law. We talked at some length about all of the riders and all of the funding cuts that the Republicans have put in some of these bills, but they couldn’t even get them through the floor. I mean, Alice we’re hung up on abortion, again!

Ollstein: Oh, as always. And it’s the exact same policy fights as last time. The fight’s going to happen in the ag[riculture] bill, around FDA [Food and Drug Administration] regulation of abortion pills. There’s going to be fights about the provisions helping veterans and active-duty service members access abortion, knowing that these appropriations bills are the only real legislation that has any chance of going anywhere. People are putting all of their policy priorities in as riders. And last round of this, there were anti-abortion provisions tacked onto basically every single spending bill, and almost all of them got stripped out in the end and did not become law. Obviously, they kept long-standing things like the Hyde Amendment, but they didn’t add the new restrictions Republicans wanted to add. That is likely to happen again. We’ll see. This could drag past the election potentially. So the dynamics, depending on the outcome of the election, could be really different than they are today.

Rovner: Yeah, I mean, I guess the House is going out and they won’t be back until September. It used to be there would be an August recess in an election year, and they would come back in September, and they would actually work until the beginning or even the middle of October. And even that seems to have gone away. Now, once they’re gone for the quote-unquote “August recess,” it’s like, bye-bye getting much of anything done.

Well, there’s also some more news on the abortion front: The on-again off-again, on-again, off-again, six-week abortion ban in Iowa appears to be on again, possibly to start as soon as next week. Alice, I think we’ve mentioned this before, but this is going to affect a lot more than just people in Iowa.

Ollstein: Yeah, definitely. I mean, we’re seeing a big erosion of access across the Midwest Great Plains, like that whole area, that whole swath, the Dakotas, et cetera. And there’s already a lot of pressure on Illinois as the destination and clinics there are already overwhelmed with folks coming in from all over. And so this will add to that. As we’ve seen when this has happened in other states, wait times can go up, shortages of providers needed to care for everyone. Telemedicine does relieve some of that, and there are these groups that mail abortion pills into any state regardless of restrictions. But not everyone is comfortable doing that or knows how to do that or wants to do that or can afford to do that. And so this is said to have a big impact, and we’ll have to see what happens.

Rovner: There were two other pieces about abortion that caught my eye this week, and they’re both about things that we’ve talked about before. One is the push by anti-abortion doctors to change medical practice. In Louisiana, the abortion drugs mifepristone and misoprostol, both of which are used for many more things than just abortion, are now on the state’s list of controlled substances. And then from States Newsroom, there’s a piece about how anti-abortion OB-GYNs are trying to get medically necessary abortions that happen later in pregnancy, switched instead to C-sections or having the pregnant person go through and induce labor and delivery. I’ve been covering this issue, as I like to say, for nearly 40 years. This is the most intense effort I’ve ever seen from inside the medical profession to actually change how medicine is practiced in terms of what’s considered the standard of care, both for things like — not even so much mifepristone the abortion pill, but misoprostol, which is used for a lot of things other than abortion.

Armour: Was it initially an ulcer medication?

Rovner: Yes, yes, misoprostol.

Armour: That’s what I thought. Yeah.

Rovner: Cytotec. It was for a long time one of the go-to ulcer medicine. And in fact, the only reason it stopped becoming the go-to ulcer medicine because, if you were pregnant and wanted to be, it could help end your pregnancy. It is known to have that as a side effect, but yes, it’s an ulcer medication.

Armour: Yeah, this is the first I had seen anywhere, and I could be wrong, but of a real push to try and change the management of late-term medical miscarriages to how it would actually be carried out, which was just very interesting and to see what they were recommending instead.

Rovner: ACOG, the American College of Obstetricians and Gynecologists, has put out guidelines — forever, that’s what they do — about how to handle pregnancy problems later in pregnancy. Generally using the least invasive procedure is considered the safest and, therefore, best for the patient. And that’s not necessarily having a C-section, which is major surgery, or going through labor and delivery. People forget that it’s really dangerous to be pregnant. I mean, it’s amazing that we have all of these kids and happy parents because if you go back and look in history, a lot of women used to die in childbirth. They still do. It’s obviously not as bad as it used to be, but it is not everything-goes-fine-99%-of-the-time thing that I think a lot of people think it is.

Armour: That’s right. Yeah.

Rovner: All right, well, meanwhile, before we bid Congress goodbye for the rest of the summer, the House Oversight Committee, which is usually as partisan a place as there is in this Congress, held a hearing this week on PBMs [pharmacy benefit managers] and there seems to be pretty bipartisan support that something needs to be done. Rachel, I keep asking this question: It seems that just about everybody on Capitol Hill wants to do something to rein in PBM drug price abuse, and yet no one ever does. So are we getting closer yet?

Cohrs Zhang: We are getting closer, I think, as we approach December. My understanding was that lawmakers were pretty close on a deal on PBMs back in March. But I think it was just a symptom of “Appropriations Bill Has to Move.” They want it to be clean. If they add one committee’s extra stuff, they have to let other committees add extra stuff, too, and it gets too complicated on deadline. But it’s wild to me that we’re still seeing new PBM reform bills at this point. But there’s just a huge, huge pile of bills at this point, everyone wants their name on it. And so I really do believe that we’re going to see something in December. I think the big question is how far some of these reforms will reach: whether they’ll be limited to the Medicare program or whether some of these will start to touch private insurance as well. I think that’s what the larger industry is waiting to see. But I think there’s a lot of appetite. I mean with congresswoman Cathy McMorris Rodgers retiring, she’s led a package on this issue …

Rovner: She’s chairman of the House Energy and Commerce Committee, which obviously has the main jurisdiction over this in the House.

Cohrs Zhang: Right. So if we’re thinking about legacy, getting some of these things across the finish line, it does depend how dynamics change in the lame duck. But I think there is a very good chance that we’re going to see some sort of action here.

Rovner: Congressman Jamie Raskin, at that hearing, had maybe my favorite line ever about PBMs, which is, he said, “The more I hear about this, the less I understand it.” It’s like you could put that on a T-shirt.

Ollstein: That’s great. Yeah.

Cohrs Zhang: Yes.

Rovner: The PBM debate in one sentence. All right. Finally, this week we have some Medicaid news, a new report from the GAO [Government Accountability Office] finds pretty much what we already knew: that states have been wrongly kicking eligible people off of their Medicaid coverage as they were, quote, “unwinding from the public health emergency.” According to the report, more than 400,000 people lost coverage because the state looked at the household’s eligibility instead of individual eligibility. Even though Medicaid income thresholds are much higher for many people, like children and pregnant women. So if the household wasn’t eligible, possibly, even probably, the children still were. It’s a pretty scathing report. Is anybody going to do anything about it? I mean, the GAO’s recommendation was that the administration act a little more strongly and the administration says, “We already are.”

Cohrs Zhang: Yeah, I actually had the chance to talk with a White House official about this dynamic, and just, I think there’s only so far that they’re willing to go, and I think might talk about, in a while. I think there’s been clashes between the Biden administration and conservative states, especially on Medicaid programs, and there’s really only so much influence they can exert. And I think without provoking an all-out war, I’m personally expecting them to get much more aggressive in the last six months of their administration, if they weren’t going to do it before, when they really could have potentially made a difference and really made it a calling card in some of these states. So I’m not expecting much change from the White House on this issue.

Rovner: Yeah, I remember the administration was so sensitive about this that when we were first learning about how states were cutting people off who they shouldn’t have been, the administration said, “We’re working with the states.” And we all said, “Which states?” And they said, “We’re not going to tell you.” I mean, that’s literally how sensitive it was. They would not give us the list of the states who they said were incorrectly knocking people off the roll. So yeah, clearly this has been politically sensitive for the administration, but I’m …

Armour: And the Medicaid directors, too. They really pushed back, especially initially, about not wanting it to be too adversarial. I think the administration really took that to heart. Whether that was the right call or not remains to be seen, but there was a lot of tension around that from the get-go.

Rovner: Yeah. Well, also this week, The New York Times has a deep dive into the one remaining Medicaid work requirement in the country, Georgia’s Pathways to Coverage. In case you don’t remember, this was the program that Georgia said would enroll up to 100,000 people, except, so far it’s only managed to sign up about 4,500. It feels relevant again though, because the Heritage Foundation’s Project 2025, which is now all over the campaign trail, would go even further than previous Republican efforts to rein in Medicaid by possibly imposing lifetime caps on coverage. Cutting Medicaid didn’t go very well in 2017 when the Republicans tried to repeal and replace the Affordable Care Act. What makes them think an even bigger cutback would be more popular now?

Armour: Well, the study’s authors say to me that if they’re not cutting Medicaid, which goes back to the original debate back when they were talking about …

Rovner: The Project 2025 authors.

Armour: Yes, authors. Right. And that goes back to the original debate of how do you define it? A little bit of sleight of hand. And the other thing is that would definitely bring back the Medicaid work requirements and some premiums for some, which also turned out not to be super-popular as well. So it does dive right into an issue. But it’s also an issue that conservatives have been, boy, working on for years and years now to try and get this accomplished.

Rovner: Oh yeah, block-granting Medicaid goes back decades.

Armour: Exactly. Yeah.

Rovner: And there’ve been various ways to do it. And then work requirements, obviously Alice, you were the queen of our work requirement coverage in Arkansas because they put in a work requirement and it didn’t go well. Remind us.

Ollstein: Yeah. So this is what a lot of experts and advocates predicted, which is that we know from years of data that pretty much everybody on Medicaid who can work is already working and those who aren’t working are not working because they are a student or they have to care for a relative or they have a disability or there are all these reasons. And so when these work requirements actually went into effect, just a lot of people who should have been eligible fell through the cracks. It was hard to navigate the bureaucracy of it all. And so even people who were working struggled to prove it and to get their benefits. And so people really point to that as a cautionary tale for other states. But this is something conservatives really believe in ideologically, and so I don’t expect it to be going away anytime soon.

Rovner: To swing back to where we started. I imagine we will see more talk about health care on the presidential campaign trail as we go forward.

All right, well that’s as much news for this week as we can fit in. Now we will play my interview with Families USA’s Anthony Wright, and then we’ll come back and do our extra credits.

I am so pleased to welcome to the podcast Anthony Wright, the brand-new executive director of Families USA, one of the nation’s leading consumer health advocacy groups. And a big part of why we even have the ACA. Anthony is no stranger to health care battles. He spent more than 20 years heading up the group Health Access California, where he worked on a variety of health issues, large and small, and encountered someone who is suddenly very much in the news: Vice President Kamala Harris. Anthony Wright, welcome to “What the Health?”

Anthony Wright: Thank you so much for having me. I’m a longtime listener, but first-time caller.

Rovner: Awesome. So, for those who are not familiar with Families USA, tell us about the group and tell us what your immediate priorities are.

Wright: So, Families USA has been a longtime voice for health care consumers in Congress, at the administration, working nationally for the goal of quality, affordable, equitable health care for all Americans. I’m pleased to take on that legacy and to try to uplift those goals. I’m also particularly interested in continuing to uplift and amplify the voices of patients in the public in health policy debates. It’s opaque to try to figure out how normal people engage in the federal health policy discussions so that health reforms actually matter to them. I would like families to do more to provide pathways so that they have an effective voice in those policy discussion tables. There’s so many policy debates where it’s the fight between various parts of the industry, when, in fact, the point of the health care system is patients, is the public, and they should be at the center of these discussions.

Rovner: Yes, and I’m embarrassed to admit that we spend an enormous amount of time talking about the players in the health care debate that are not patients. They are basically the people who stand to make money from it. What’s your biggest priority for this year and next?

Wright: Yeah, I want to take some of the lessons that I’ve learned over the 22 years of working in California, where we had the biggest drop of the uninsured rate of all 50 states, mostly working to implement and improve the Affordable Care Act. And I recognize that some of those lessons will have to be adopted and changed for the different context of [Washington,] D.C., or the 49 other states. But there is work that we can do, and we should do, moving forward. There are things on the plate right now. For example, in the next year, the additional affordability assistance that people have in the exchanges is set to expire. And so we can either have a system where everybody has a guarantee that their premiums are capped at 8.5% of their income or less on a sliding scale, or we can let those enhanced tax credits expire and to have premiums go up by hundreds, or for many people, thousands of dollars literally in the next year or so.

So that’s a very important thing that will be on the ballot this fall, along with a number of other issues and we want to highlight that. But frankly, I’m also interested in the work around expanding coverage, including in those 10 states that haven’t expanded Medicaid yet. In California, we’ve done a lot of work on health equity dealing with racial and ethnic disparities and just meeting the specific needs of specific communities. That was an imperative in California with the diversity and the size and scale of that state. But there’s more we can do both in California, but nationally, with regard to that. And then I think there’s more to work on costs with regard to just how darn expensive health care is and how do we fix the market failures that lead to, not just high, but irrational and inflated health prices.

Rovner: So obviously a big part of what you will or won’t be able to do next year depends on who occupies the White House and who controls Congress. You’re from California and so is Vice President Harris. Tell us about her record on health care.

Wright: Yeah, she actually has a significant record, mostly from her time as attorney general of California. She didn’t have much of a portfolio as district attorney, but when she did become the attorney general — attorney generals have choices about where they focus their time and she made a point to focus more on health care and start an evolution of the attorney general being more involved in health care issues — on issues like reviewing mergers of hospitals and putting conditions to make sure that emergency rooms stayed open, that hospitals continued their commitments to charity care. She worked on broader issues of consolidation, for example, joining the [U.S.] Justice Department in opposing the merger of Anthem and Cigna.

And she took on, whether it’s the insurers or the drug companies or the hospital chains, on issues of pricing and anticompetitive practices, whether it was Bayer and Cipro and other drug companies with regard to pay-for-delay practices, basically schemes to keep the price of drugs inflated. Or on the issue of high hospital prices. She began the investigations that led to a landmark Sutter settlement where that hospital chain paid $575 million in fines, but also agreed to a series of conditions with regard to no longer engaging in anticompetitive contracting practices. And that kind of work is something that we worked on with her, and I think is really relevant to the moment we’re in now where we really do see that consolidation is one of the major drivers of why health care prices are so high. And that kind of experience that she could talk about as she talks about health care costs broadly, medical debt, and some of the issues that are on the campaign trail today.

Rovner: So, obviously, with the exception of reproductive health, health in general has not been a big part of the campaign this year. Do you think it’s going to get bigger now that Harris is at the head of the ticket?

Wright: One of the things that I’m happy with is that, after several weeks where the conversation has much been about the campaign processes, we can maybe focus back on policy and the very real issues that are at stake. Our health care is on the ballot, whether it is reproductive health and abortion care, but also there’s a very easy leap to also talk about the threats, not just to reproductive health, but also to the Affordable Care Act, to Medicaid, to Medicare. There’s very different visions and records of the last two administrations with regard to the Affordable Care Act, whether to repeal it or build upon it, on Medicaid and whether to bolster it or to block-grant it. And even on the question of something like prescription drug negotiation, whether we took some important steps under the Inflation Reduction Act. Do we now expand that authority to cover more drugs for more discounts for more people? Or do we give up that authority to negotiate for the best possible price?

Those are very key issues that are at stake in this election. We are a nonpartisan, non-endorsing organization, but we do want to make sure that health care issues are on people’s minds, and also, frankly, policymakers to make some commitments, including on something like what I was talking about earlier with those enhanced tax credits. Again, at a time when people are screaming about affordability, but we know that they’ve been actually screaming about health care affordability for not just years but decades. And that’s a very specific, concrete thing that literally means hundreds or thousands of dollars in people’s pockets.

Rovner: So then-presidential candidate Kamala Harris was a supporter of Medicare for All in 2020 when she ran. Do you expect that that may have changed, as she’s learned how hard it is even to make incremental change? I haven’t seen anybody ask her yet what her feeling is on systemic health reform.

Wright: I mean, she had a modified proposal that I think was trying to both take seriously the question of how do we get to universal coverage while also recognizing the politics and procedural barriers that exist. And so I think there’s a practical streak of how do we get the most help to the most people and help change, frankly, the financial incentives in our system, which are right now just to get bigger, not to get better. And so I think that there’s some very practical questions on the table right now, like these tax credits, this cap on how much a percentage of your income should go for premium. That’s something that’s front of mind because it literally expires next year. So it’s something that maybe gets dealt with in a lame duck, but hopefully early in the next year, since rates need to be decided early. And so those are the immediate things.

But I do think she’s also, in her record — I’m not going to talk about what may be — but in her record, she’s been supportive of the Affordable Care Act. I mean our biggest actual engagement with then-U.S. Sen. Harris was at a time when we all thought that the Affordable Care Act was a goner. It would be repealed and replaced. She was willing to be loud and proud at our rallies, in front of a thousand people, in front of a Los Angeles public hospital, talking about the need to defend the Affordable Care Act and protections for people with preexisting conditions. And she came again in July and just at a time where we needed that forceful defense of the Affordable Care Act. She was there and we very much appreciated that. I think she would continue to do that as well as want to work to build upon that financing and framework to make additional gains forward.

Rovner: This being Washington, everybody’s favorite parlor game this week is handicapping the vice presidential sweepstakes. And who about-to-be-candidate Harris is going to choose to be her running mate. Are any of the big names in contention more or less important in terms of their health care backgrounds?

Wright: I have my credentials to talk about the Californian on the ticket. I probably have less there. I do know that some of those governors and others have their own records of trying to take the framework of the ACA and adapt it to their state. And I think that would be a useful thing to continue to move forward on the trail. I’m not in a position, again, as a non-endorsing organization, we’re focused on the issues.

Rovner: You’re agnostic about the vice presidential candidate.

Wright: You’re right, I think the point is how can we make sure that people recognize what is at stake for the health care that they depend on and, frankly, the financial piece of it. Affordability has been something that has been talked about a lot and there is no greater source of economic anxiety and insecurity than the health care bill. A hospital bill is the biggest bill that anybody will get in their entire life. So how do you deal with it? And whether it’s a conversation about medical debt and how you deal with it, or what kind of tax credits we can provide to provide some security that you don’t pay more than the percentage of your income. Or how do you deal with the root causes of the market failures in our health care system, whether it’s consolidations and mergers or anticompetitive practices. Those are the things that I think we should have a bigger conversation in this campaign cycle about.

Rovner: Hopefully we’ll be able to do this again as it happens. Anthony Wright, thank you so much.

Wright: Thank you.

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

Cohrs Zhang: Sure. There’s a lot of good health journalism out there, but I have to highlight a new project from my colleagues. Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence are looking into UnitedHealth’s business practices, and there’s been a lot of buzz about UnitedHealthcare on the Hill, and the first part of their investigation is headlined “How UnitedHealth Harnesses Its Physician Empire To Squeeze Profits out of Patients.” It focuses on the trend that UnitedHealth has been acquiring so many physician practices and looks at the incentives of what actually happens when an insurer owns a physician practice.

What pressures are they putting on? What’s the patient experience? What’s the physician experience? Their physicians on the record were telling them about their experiences: having to turn through patients; feeling pressure to make patients look sicker on paper so UnitedHealth could get more money from the federal government to pay for them. And just, I mean, the documentation here is just really superb reporting. It’s part one of a series. And I think reporting like this really helps inform Washington about how these things are actually playing out and what’s next in terms of whether action should be taken to rein these practices in.

Rovner: I feel like the behemoth that is UnitedHealthcare is going to keep a lot of health reporters busy for a very long time to come. Alice.

Ollstein: Yeah. So there’s been a lot of news on the PrEP front recently. That’s the drug that prevents transmission of HIV. And so basically two steps forward, one step back. I chose this piece from Stat News [“A Pricey Gilead HIV Drug Could Be Made for Dramatically Less Than the Company Charges”], about a new form of PrEP that is an injection that you get just twice a year that has proven wildly effective in clinical trials. And so folks are really excited about that, and I think it could really make a difference because, as with birth control and as with lots of other medication, the effectiveness rate is only if you use it perfectly, which, you know, we’re humans. And humans don’t always adhere perfectly. And so something like just a couple injections a year that you could get from your doctor would go a long way towards compliance and making sure people are safe with their medications.

But my colleague and I also scooped this week that HHS [the Department of Health and Human Services] is ending one of its big PrEP distribution programs [“Federal HIV Program Set To Wind Down”]. It’s called Ready, Set, PrEP. It debuted under the Trump administration in 2019. And the reason given by HHS for it ending — which, by the way, they were very quiet about and didn’t even tell a lot of providers that it was ending — they said it was because there are all these other ways people can get PrEP now, that didn’t exist back then, like generic versions. And while that’s true, we also heard from a lot of advocates who said the program was just really flawed from the start and didn’t reach even a fraction of the people it should have reached. And so we’ll continue to dig on that front.

Rovner: Good stories. Stephanie.

Armour: Yes. I picked the story by Dylan Scott on Vox about “Free Medical School Won’t Solve the Doctor Shortage.” And it looks at Michael Bloomberg, who is donating a billion dollars to Johns Hopkins to try to pay for medical school for students there. The idea being that, “Look, there’s this doctor shortage and what can we do to help?” And what’s really interesting about the story is it goes beyond just the donation to look at the fact that it’s not really that there’s a doctor shortage, it’s that we don’t have the right kind of doctors and it’s the distribution. Where you don’t have nearly what we need when it comes to psychiatrists, for example. And there’s a real dearth of physicians in areas that are rural or in the Midwest. So I think what it raises is what resources do we want to spend and where? What other steps can we do that would really help drive doctors to where they’re most needed? So it’s a good story. It’s worth a read.

Rovner: Yeah, it is a good story. It is a continuing problem that I continue to harp on. But we now have quote-unquote “free medical school,” mostly in really urban, really expensive places.

Armour: Yes.

Rovner: New York, Los Angeles, Baltimore. That’s nice for the doctors who will now graduate without $200,000 in medical debt. But yeah, as Dylan points out, it’s not exactly solving the problem that we have. Well, I went cute this week. My extra credit this week is from NPR. It’s called “A Study Finds That Dogs Can Smell Your Stress — And Make Decisions Accordingly,” by Rachel Treisman. Now, we’ve known for a fairly long time that dogs’ sensitive noses can detect physical changes in their humans. That’s how alert dogs for epilepsy and diabetes and other ailments actually work.

But what we didn’t know until now is that if a dog smells a person’s stress, it can change the dog’s emotional reaction. It was a complicated experiment that you can read about if you want, but as somebody who competes with my dogs, and who knows how differently they act when I am nervous, this study explains a lot.

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

Ollstein: @AliceOllstein on X.

Rovner: Rachel.

Cohrs Zhang: @rachelcohrs on X.

Rovner: Stephanie.

Armour: @StephArmour1.

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

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