KFF Health News' 'What the Health?': Congress Kicks the (Budget) Can Down the Road. Again.
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Congress narrowly avoided a federal government shutdown for the second time in as many months, as House Democrats provided the needed votes for new House Republican Speaker Mike Johnson to avoid his first legislative catastrophe of his brief tenure. But funding the federal government won’t get any easier when the latest temporary patches expire in early 2024. It seems House Republicans have not yet accepted that they cannot accomplish the steep spending cuts they want as long as the Senate and the White House are controlled by Democrats.
Meanwhile, a pair of investigations unveiled this week underscored the difficulty of obtaining needed long-term care for seniors. One, from KFF Health News and The New York Times, chronicles the financial toll on families for people who need help for activities of daily living. The other, from Stat, details how some insurance companies are using artificial intelligence algorithms to deny needed rehabilitation care for Medicare patients.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.
Panelists
Rachel Cohrs
Stat News
Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- Congress passed a two-part continuing resolution this week that will prevent the federal government from shutting down when the current CR expires Nov. 18 at 12:01 a.m. The new measure extends some current spending levels, including funding for the FDA, through Jan. 19. The rest of federal agencies, including most of the Department of Health and Human Services, are extended to Feb. 2.
- House Speaker Mike Johnson (R-La.) has said he wants to use the next two months to finish work on individual appropriations bills, none of which have passed both the House and Senate so far. The problem: They would deeply cut many popular federal programs. They also are full of changes to abortion restrictions and transgender policies, highlighting the split between the GOP caucus’ far-right wing and its more moderate members.
- In the wake of abortion rights successes in passing abortion rights ballot initiatives, new efforts are taking shape in Ohio and Michigan among state lawmakers who are arguing that when Dobbs turned this decision back to states, it meant to the state legislatures — not to the courts or voters. Most experts agree the approach is unlikely to prevail. Still, it highlights continuing efforts to change the rules surrounding this polarized issue.
- Sen. Tim Scott (R-S.C.) — who was the only remaining Republican presidential candidate pushing for a national, 15-week abortion ban — suspended his campaign last week. He, along with former Vice President Mike Pence, who bowed out of the race at the end of October, were the field’s strongest anti-abortion candidates. This seems to suggest that the 15-week ban is not drawing voter support, even among Republicans. Meanwhile, former President Donald Trump, the GOP’s front-runner by miles, continues to be willing to play both sides of the abortion debate.
- Amid increasing concern about the use of artificial intelligence in health care, a California class-action lawsuit charges that UnitedHealth Group is using algorithms to deny rehabilitation care to enrollees in its Medicare Advantage program. The suit comes in the wake of an investigation by Stat into insurer requirements that case managers hew to the AI estimates of how long the company would pay for rehabilitation care, regardless of the patient’s actual medical situation.
- More than 10 million people have lost Medicaid coverage since states began reviewing eligibility earlier in the year. Advocates for Medicaid patients worry that the Biden administration has not done enough to ensure that people who are still eligible for the program — particularly children — are not mistakenly terminated.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “How Lawmakers in Texas and Florida Undermine Covid Vaccination Efforts,” by Amy Maxmen.
Alice Miranda Ollstein: The New York Times’ “They Wanted to Get Sober. They Got a Nightmare Instead,” by Jack Healy.
Rachel Cohrs: Stat’s “UnitedHealth Pushed Employees to Follow an Algorithm to Cut Off Medicare Patients’ Rehab Care,” by Casey Ross and Bob Herman.
Joanne Kenen: ProPublica’s “Mississippi Jailed More Than 800 People Awaiting Psychiatric Treatment in a Year. Just One Jail Meets State Standards,” by Isabelle Taft, Mississippi Today.
Also mentioned in this week’s episode:
- KFF Health News’ “Facing Financial Ruin as Costs Soar for Elder Care,” by Reed Abelson, The New York Times, and Jordan Rau.
- JAMA Internal Medicine’s “Excess Death Rates for Republican and Democratic Registered Voters in Florida and Ohio During the COVID-19 Pandemic,” by Jacob Wallace, et al.
Click to open the transcript
Transcript: Congress Kicks the (Budget) Can Down the Road. Again.
[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, Nov. 16, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go.
We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Rachel Cohrs of Stat News.
Rachel Cohrs: Hi, everybody.
Rovner: And Joanne Kenen of the Johns Hopkins University and Politico Magazine.
Joanne Kenen: Hi everyone.
Rovner: No interview this week, but more than enough news, so we will get right to it. So the federal government is not going to shut down when the current continuing spending resolution expires at 12:01 a.m. Saturday. In basically a rerun of what happened at the end of September, new House Speaker Mike Johnson ended up having to turn to Democrats to pass another CR. This one extends a bunch of federal programs until Jan.19 and the rest of them until Feb. 2. Most of HHS [the Department of Health and Human Services] is in the latter category, but the FDA, because it’s funded through the Department of Agriculture, its spending bill would be in the group that’s funded only through Jan. 19. Don’t worry if you don’t remember that.
The stated goal here is to use the next two months, minus what’s likely to be a sizable Christmas break, to finish work on the individual appropriation bills, of which exactly zero of 12 have passed both the House and Senate and been sent to the president. Meanwhile, in just the last week, House Republicans have been unable to pass any of the individual appropriations they have brought to the floor and a few haven’t been able to even get to the floor. Yesterday, Republican leaders pulled the plug on the rest of the week’s floor schedule, literally in the middle of a series of votes on the HHS spending bill. So Democrats are not going to bail them out on these individual bills the way they have on the relatively clean continuing resolutions because the individual bills include very deep spending cuts and lots of abortion and transgender and other culture wars riders. So what exactly do they think is going to change between now and the next deadline?
Ollstein: Well, there’s been a lot of chatter about how cranky members of Congress have gotten because they worked 10 weeks in a row. Most of us work 10 weeks in a row without destroying each other, but there it is. And so there’s the hope that when they come back …
Rovner: Yes, there were threats of physical violence this week.
Ollstein: And allegedly some actual physical violence. Most of us work 10 weeks in a row without assaulting our colleagues, but we are not members of Congress. So the idea is they could take some time to cool off and come back and be more collaborative, but really this is a problem the Republican Caucus has not been able to solve. You have dissent on the right of the caucus and the sort of more moderate left or more left side of the caucus. You have moderate members who are worried about getting reelected in districts that voted for [President Joe] Biden who are not wanting to vote for these spending bills that are full of anti-trans and anti-abortion provisions, which you could easily picture that being used against them in campaign ads. And then you have folks on the far right in the Freedom Caucus who are sort of tanking these individual bills to protest the overall trajectory of spending and the overall process. So this is not going away anytime soon. And, like you said, Democrats are not bailing them out here.
Cohrs: One other point I wanted to make, sorry, Julie, on the deadlines is that for people who are interested in health policy and PBM [pharmacy benefit manager] reform and DSH [Medicaid’s Disproportionate Share Hospital] cuts, all of those. Those all have a Jan. 19 deadline. So those will come with the first round. So I think for the people out there who are worried about those policies, community health centers, extenders, that will happen with the first deadline even though the full Labor, HHS preparations aren’t until the second one.
Rovner: Yeah, these continuing resolutions do carry some of these extraneous, what we like to call “extender,” provisions that would otherwise have expired. And so they’ll keep them going for another couple of months and keep lobbyists busy wringing their hands and keep all of our inboxes full of emails of people warning of terrible things that will happen if these programs aren’t continued. But I want to go back to the underlying problem here, though, is that first of all, the conservative Republicans say they want to put the budget on a different trajectory. Well, discretionary spending, which is what we’re talking about here with the 12 spending bills, is a tiny portion of what makes up the budget and the budget deficit. So even if they were to cut all of these programs as dramatically as they like, they wouldn’t have much of an impact on the overall budget. I’m sort of mystified that people don’t keep pointing that out.
Ollstein: Well, and they’re also cutting things that won’t save money. I mean, they wanted to cut things like IRS enforcement, which would lose money because then the IRS wouldn’t be going after wealthy tax cheats and recouping that government spending. And so some of this is ideological. They’re going after health care programs that support LGBT people, for instance, and that doesn’t save that much money. But there’s been a lot of speeches from Republicans railing against the substance of the programs and calling them “woke” and inappropriate and such. And so, yes, some of this is fiscal, but a lot of it is also ideological.
Kenen: Yeah, it’s a relatively small portion of federal dollars, but a relatively large portion of culture war.
Rovner: Yes, I think that is a very good way to put it because, of course, it’s a place where they can put culture war things because they have to come up every year. But yeah, I think that’s why we end up fighting over this. All right, well this fight has been put off until 2024, although it’ll be the first thing when we get back.
Kenen: Yeah. And nothing’s really going to change except maybe cooler heads prevail. Anyone see any cooler heads around there? They may come back a little bit more personally tolerant when they’ve had some time off over the holidays. But the basic ideological and political alignment and the loggerheads, it’s like the only thing that changes between November, December, and January is it’s colder here then.
Rovner: Yeah, that’s exactly correct. Yeah. The far right of the House Republican Caucus is going to have to realize that there is a Senate and there is a president and they all get a say in what these final bills look like too. So they can’t just dictate we’re going to make all these cuts and, if not, we’re going to close down the government, unless that’s what they decide to do.
Kenen: But I think they skipped that session in their orientation.
Rovner: Yeah. Apparently.
Kenen: They’re not finding, “OK, where’s the compromise? What do we really, really, really want? And what are we willing to trade that for?” They’re not doing that. If you give and take, everybody gets some victory, and you have to identify what victory you can get that satisfies you. But there’s no sign of any kind of realistic grasp that this is divided government.
Rovner: Right. And they yet to figure that out. All right, well let us turn to abortion, where there is always news. We are going to start in Ohio, where last week voters, by a pretty healthy margin, approved a ballot measure to enshrine abortion rights in the state constitution. Now, though, some anti-abortion lawmakers in Ohio say, “Never mind, we can overrule that.” Really, Alice?
Ollstein: So there are efforts going on in both Ohio and Michigan to block, undo, undermine what voters voted for in these referenda and, based on talking to sources, it seems like neither of these really have legs. They’re sort of seen as just messaging. But I think that even the attempt to try to undermine or undo what voters overwhelmingly approved is telling and interesting. And, of course, it builds on all of the attempts leading up to the votes that we saw from these same forces to try to change the rules, make it more difficult. So I think when state legislatures around the country come back into session in January, we’re going to be watching closely to see if they pass things that aim to block these votes. So definitely something to keep an eye on.
Rovner: I did see that this speaker of the Ohio House has poured at least some cold water on this effort. The argument had been from some of these lawmakers that because the Supreme Court gave this decision back to the states, that means only state legislatures and not the courts and not the voters directly. Am I interpreting that right?
Kenen: Yeah, the speaker was pretty firm. He said … what did he say? It was “Schoolhouse Rock”? He basically said that the voters, they matter.
Rovner: Yeah.
Ollstein: And what’s interesting is that the court that they want to cut out of this in Ohio is very conservative. And so this isn’t like, “Oh, we want to block these liberal activist judges from weighing in here.” This is “We want to keep this solely in the hands of the legislature and not have, really, courts have a role in it at all,” although the courts are very conservative and tilt in the anti-abortion direction anyway, which I think is notable.
Rovner: We’ll definitely watch that space in the upper Midwest/Great Lakes. Well, elsewhere, in Alabama, in a story that I didn’t think got the coverage it deserved, the Justice Department is joining a case brought by an abortion fund and some former abortion providers about whether the state might be able to prosecute them for helping women travel to obtain an abortion in another state. Department of Justice says, “Of course, states can’t prevent people from traveling to other states for things that are legal in another state, but not in their state. Otherwise, very few people would be able to go to Las Vegas.” But the state attorney general has yet threatened to try to prosecute, has he not?
Ollstein: Yeah, so this is happening in a few states, but it’s sort of come to a head in Alabama in terms of treating groups that either provide material support for people to travel across state lines for an abortion or even just information, even just “Here’s a clinic that you can call in this other state.” Not even a formal referral, medical referral, but just information about where to go. The attorney general has threatened to consider that kind of a criminal conspiracy to violate Alabama’s abortion ban.
So this is an interesting test, and I think it may — like the travel bans we’ve been seeing proposed and even implemented in some cities, states, et cetera. They’re sort of trying a bunch of different things. But these are basically impossible to enforce. And so, really, what’s happening here is an attempt to undo some of the chilling effect of these laws. Right now, people are so afraid of being charged with criminal conspiracy that they’re holding off on, even providing publicly available information that’s likely protected by the First Amendment. And so they’re hoping that a court ruling saying “You do have the right to at least discuss this and even give people support to travel” will undo some of that chilling effect. And yeah, I think that’s sort of the key here.
Rovner: Yeah. Well, moving on to Texas, where a lot of these other travel bans have been tried, at least in some cities and counties, we want to go back to that case where a half a dozen women who couldn’t get care for pregnancy complications, because of the state’s abortion ban, sued. Well, now there are 22 plaintiffs in that case, including two doctors and a then-medical student who discovered her fetus’s lethal abnormalities at an 18-week scan. The Texas Supreme Court is supposed to hear this case later this month, but, Alice, this could really end up before the U.S. Supreme Court, couldn’t it? This is the concern of women who are not trying to have abortions. They were basically trying to complete pregnancies and have had things go terribly wrong. And, as you just said, doctors are afraid to treat them for fear that they’re going to be prosecuted.
Ollstein: Yeah. And so this is where state abortion bans are running up against federal protections for … you have to treat a patient who comes in who’s experiencing a medical emergency. This is the EMTALA, a federal law, and these things are in conflict. Anti-abortion groups and advocates say that they are not, and that medical care in these situations is already protected. But as we’ve seen with this chilling effect, doctors are afraid to act in these situations and they’re telling patients to go away and come back when things are more dire. And that, in some cases, in these plaintiff’s cases, has led to pretty permanent damage, damage to their future fertility, threats to their lives. And so these cases are not seeking to get rid of the abortion bans entirely, as some other lawsuits are, but they are seeking to really make clear, because it’s not clear to medical providers right now, make clear what is allowed in these really sensitive and precarious medical situations.
Rovner: Yeah, I keep hearing a lot of the anti-abortion forces saying, “Well, it’s not technically an abortion in these cases. If it’s an ectopic pregnancy or something or the woman’s water has broken early and she’s going to get septic.” And it’s like, “Except that medically, yes, they are. A termination of pregnancy is termination of pregnancy.” And that’s why the doctors are saying, “You can call this anything you want. We’re the ones who are going to get thrown in jail and lose our medical licenses.” All right. Well, before we move on, I want to talk some abortion politics. Sen. Tim Scott of South Carolina, who had been the only Republican presidential candidate strongly pushing for a federal 15-week abortion ban, suspended his campaign this week after what happened in Virginia last week, which we talked about at some length. When Republican Gov. Glenn Youngkin tried to win back the state legislature for Republicans by promising to sign his own 15-week ban and lost spectacularly. Where does that leave Republicans on abortion going into 2024? Obviously, the 15-week ban as a compromise doesn’t seem to be flying.
Ollstein: No, it’s certainly not. And Tim Scott and Mike Pence were some of anti-abortion groups’ favorite candidates who were saying what they wanted to hear, and both of their campaigns have now ended. And so, meanwhile, you have the people who have been a little more squishy, from anti-abortion advocates’ perspective anyways, like Nikki Haley and [former President Donald] Trump himself, doing the best. DeSantis also sort of middling right now on the downward trajectory, seemingly.
Rovner: DeSantis, who signed a six-week ban in Florida.
Ollstein: Exactly, but was also kind of unclear about what he would do as president, which the anti-abortion groups did not like. It’s interesting, maybe telling, that the people who were sort of the staunchest anti-abortion voices have not seemed to do well in this moment, but let’s be real. Trump is the far-and-away front-runner here. It’s most important to examine Trump. And he’s sort of trying to have it both ways. He’s both touting his anti-abortion bona fides by talking about appointing the justices to the Supreme Court that overturned Roe v. Wade, taking credit for that. And at the same time sort of pushing this line of, “Oh, we’ll strike some sort of compromise.” He really talks up exemptions for rape and incest, which, by the way, a lot of anti-abortion groups don’t want those. And so he’s sort of speaking out of both sides of his mouth, but, at least according to the polls, it seems to be working.
Rovner: Yeah, maybe that’s the answer for Republicans is tell everybody what you think they want them to know. I guess we will see going forward. Well, I want to move on. I’m calling this next segment, “Getting Old Sucks: Ask Me How I Know.” I want to start with a joint project that KFF Health News has out this week with The New York Times called “Dying Broke.” It’s about, and stop me if you’ve heard me say this before, the fact that the U.S. has no policy to help pay for long-term care, save for Medicaid, which only pays if you basically bankrupt yourself and your family.
There is a lot in this series, and I highly recommend it, but one of the things that jumped out to me is that the cost of long-term care has risen so much faster than incomes that even if you started saving for retirement in your 20s — I started saving for retirement in my 20s — you’d still be unlikely to have enough to self-insure for long-term care when you’re 75 or 80. Joanne, you’ve spent as much time as I have, probably more, writing about our lack of a long-term care policy. Anything jump out at you from this project?
Kenen: It was a terrific, terrific story, and it brought to life that even people who are definitely what you would think of as economically comfortable, it’s not enough. It’s just the luck of the draw, right? I mean, if you die fast, you can at least leave money to your kids. If you die slow, you can’t. It was a really good story. But what I always am left with when I read these stories is it doesn’t make a difference. Congress does not want to deal with this. Julie and I actually did a panel for a health group a few weeks ago, and one of the state … someone from California came up to talk about us and asked, “Why doesn’t the United States have a long-term care policy? I’m going to change that.” And we were trying to be polite, but it was like, “OK, good luck with that.” And this is not a partisan issue. Republicans and Democrats both get old and Republicans and Democrats both end up needing long-term care, whether it’s in the nursing home or assistance in your own home. Republicans and Democrats both get Alzheimer’s and other forms of dementia. They both get disabled. And we have a government that just plugs up its ears because it costs so much money and it’s an entitlement and they just don’t even want to deal with it. And generation after generation, it’s a disaster. It’s inhumane.
Rovner: And, of course, there was this brief effort in the Affordable Care Act with the CLASS Act that everybody was very excited …
Kenen: To nibble around the edges of it. The CLASS Act was good, but it wasn’t even solving the problem.
Rovner: And it went away because they discovered that even that was going to be too expensive. It could not be self-sustaining. And that’s been the problem with the private long-term care insurance market too, that you basically can’t get private long-term care insurance anymore because insurers cannot afford to sell it. They lose too much money on it, and therefore it would be too expensive if they actually charged what they needed to to even break even.
Kenen: Right. And there is an idea circulating, but it’s not getting any traction. It’s circulated in the past too, a joint approach, a reinsurance approach, that you’d try to strengthen the private long-term care insurance market, which is very broken. You’d try to fix that, but you wouldn’t expect the private insurance market to do the whole problem, so that there’d be reinsurance from the government. So for people who had maybe, I don’t know exactly how it works, say a year or two of expenses that private insurance would kick in and we would make that market work better and be there when you needed it. But then if you were somebody who had multiple years and you exhausted that benefit, there would be a backup entitlement.
Rovner: But I’ve heard this talked about for at least 10 years, and it’s never gone anywhere.
Kenen: It’s revived and it’s not getting … I don’t think it has a sponsor in this Congress. It did in the last Congress. There’s no discussion. There’s no … a lot of people think that Medicare actually pays for nursing homes, and then that’s a pretty big surprise because it only pays for very limited … it pays, like if you have surgery and you need some rehab at a nursing home for, what is it? Is it 12 weeks? I forget what it is, but it’s short-term. It’s a couple of months. It’s not dementia care. And even the other thing is when you read about the cost of long-term care, that’s just the room and board, that doesn’t include your doctors’ bills, your medication, clothing, personal aide, because people who are complicated and need a lot of care often need a personal aide in addition to the staff. It’s just a phenomenal amount of money. My kids don’t understand when I say we need to save money, they say, “Don’t you have enough?” And no, nobody has enough. Bill Gates has enough.
Rovner: Yeah, Warren Buffett has enough. Well, so, as I mentioned, one of the big problems with long-term care is that there’s essentially no private insurance for it anymore because it’s so expensive and because so many people end up needing it. That’s very different from Medicare Advantage, where insurers are and have been making lots of money providing benefits that would otherwise be paid for by the federal government. But Rachel, some of your colleagues have discovered that, and in at least some cases, those insurers are making all that money because they’re denying care to patients who need it. This is your extra credit this week, but I want you to talk about it now.
Cohrs: I’ll talk about it early. Yes. So my colleagues, Casey Ross and Bob Herman have been digging into the role of algorithms in insurance decisions for the past year. And they just released a new story this week about — with internal documents of a subsidiary called naviHealth of UnitedHealth — showing that the company was instructing managers to keep care timelines for a really expensive rehab that older people, I think, need after having injuries or something like that within 1% of the time that this algorithm was predicting, regardless of what their actual human doctors were saying. And truly, the stories behind these care denials are just really horrifying … of somebody who had a knee surgery and was expected to slide on their butt down the stairs because they weren’t paying for rehab. Families who’ve had to pay tens of thousands of dollars out of their own pocket after this care was denied because they saw that their loved one clearly needed money, and there was a class-action lawsuit filed, then after the story was published, by people who had deceased relatives who had UnitedHealthcare MA plans, and were denied rehab and later died. And so I think it’s just really eye-opening as to the actual instructions by managers inside the company saying that this is your expectation, and if you’re not keeping coverage care rehab timelines within this 1% margin, then you aren’t performing up to our standards.
Rovner: So this is basically AI being used to deny care. We keep talking about AI and health care. This is it, right? This is an algorithm that says, “Person who goes into rehab with these kinds of problems should only need 19 days.” And if you need more than that, tough. That’s essentially what’s going on here, right?
Cohrs: And the lawsuit did highlight as well that when people did appeal, they won most of the time, but most people didn’t appeal, and the company knew that. And so I think that was also part of the lawsuit that came up. It’s hard to prove intent with these things or what is a denial based on an algorithm? But I think this lays out the case in as explicit terms as we’ve ever seen from the internal side.
Rovner: It does. All right, well let us move on from Medicare to Medicaid, the unwinding — involving reviewing everyone on the program to make sure they’re still eligible now that the pandemic emergency has expired — continues with more than 10 million people now having lost their coverage, according to the tracker being updated by my KFF colleagues. And state Medicaid directors are predicting a year-over-year decrease in enrollment of 8.6%, which is pretty dramatically large. We also know that more than 70% of those being disenrolled may in fact still be eligible, but the state was unable to locate them or they didn’t file the right paperwork. Ironically, even with a much smaller caseload, state Medicaid spending is likely to rise because the additional payments that were provided by the federal government also expired at the end of the public health emergency. So states are basically having to pay more per enrollee than they were paying even when they were leaving everybody on the rolls. Advocates have been complaining all year that the Biden administration isn’t doing enough to ensure that states aren’t tossing people off who should still be covered. Has anything changed on that front? I know that the administration is sort of caught between this rock and a hard place. They don’t want to come out guns blazing and have states saying that they’re making this politicized. On the other hand, the numbers are getting pretty big and there’s increasing evidence that a lot of the people who are being relieved of their coverage should still have it.
Ollstein: Including a lot of children who absolutely did not do anything wrong in this situation. And so it kind of reminds me of some stuff during covid, where the Biden administration did not want to get into a public fight with GOP-controlled states and was trying to negotiate behind the scenes to get the policies they wanted to protect people. But at the same time, not wanting that open confrontation means that a lot of this is continuing to go on unchecked. And so the data is coming out showing that a lot of people who are losing coverage are not reenrolling in other coverage. Some are, but a lot are not. And so I think now that we’re getting, going to get into Obamacare open enrollment, I think that’ll be really key to see — can we scoop up a lot of these newly uninsured people?
Rovner: And we did, we saw the administration put out a press release saying that the early part of open enrollment has seemed very large, much larger-than-expected enrollment. And you kind of wonder, I’m kind of wondering, how many of those people were people who got kicked off of Medicaid. And, of course, we know that when people got kicked off of Medicaid, they were supposed to be steered to the Affordable Care Act, for which they would’ve obviously been eligible. But I’m wondering whether some of those people didn’t get steered and now that they’re seeing that enrollment is open, it’s like, “Oh, maybe I can get this.” I have not seen anybody answer that question, but it’s certainly a question in my mind.
Cohrs: Right. And coverage is more affordable as well because subsidies from the covid-era spending bills do extend through 2025. But again, people might see increases in costs once those end, if Congress doesn’t extend them. So even if we do see some people moving from Medicaid to ACA enrollment, then there’s a chance that they could see spikes in a pretty short amount of time.
Rovner: Yeah, I’ll be curious to see as open enrollment continues, whether they can break down where some of those people are coming from. All right, now it is time for “This Week in Health Misinformation.” I have chosen a KFF Health News story, which is also my extra credit this week, from science journalist Amy Maxmen, called “How Lawmakers in Texas and Florida Undermine Covid Vaccination Efforts.” It seems that in Texas health departments and other organizations funded by the states are now prohibited from advertising or recommending covid vaccines or even saying that they are available, unless that’s in conjunction with telling them about other vaccines that are available, too. In Florida, as we have talked about here before, the health department has issued specific guidance recommending against the new covid vaccine for children and teens and now men under the age of 40. Unless you think this hasn’t had any impact before the vaccines were available, Democrats and Republicans were dying of covid in roughly equal proportions in Florida and Ohio, according to a study published earlier this summer in the journal JAMA Internal Medicine.
But by the end of 2021, which was the first full year that covid vaccines were widely available, Republicans had an excess death rate of 43% higher than Democrats. So medical misinformation has consequences. All right, now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Rachel, you’ve done yours already. Alice, why don’t you go next?
Ollstein: Sure. So I have a very depressing one out of The New York Times by Jack Healy and it’s called “They Wanted to Get Sober. They Got a Nightmare Instead.” And it is about these fraudulent, scammy addiction treatment facilities in Arizona, but it notes that they do exist in other states as well, that have been bilking the state Medicaid program for just millions and millions and millions of dollars and providing inadequate or nonexistent treatment to really vulnerable people in need, with very deadly consequences. And the places profiled in this piece really went after Native American folks specifically. So very sad report, but it sounds like more attention on this is leading to the state cracking down on places like this. So, hopefully, we’ll make some progress there.
Rovner: Yeah, quite a story, Joanne.
Kenen: This is a story, part of an ongoing series from Mississippi Today, in conjunction with ProPublica’s local reporting network: “Mississippi Jailed More Than 800 People Awaiting Psychiatric Treatment in a Year. Just One Jail Meets State Standards.” It’s by Isabella Taft. In Mississippi, if you’re unfortunate enough to have such serious mental illness that a court orders you to have treatment and there’s no room in a state hospital, they put you in jail while you wait for a room in state hospitals. And sometimes they’re housed in these facilities or rooms that are meant for people with severe mental illness, but they’re awful. And sometimes they’re just housed with a regular prison population. And the sheriffs say, “Wait a minute, it’s not really our problem to be housing … state hospitals have to fix this.” And they have a point! But in the meantime, that’s who they have. That’s where they end up. They end up in these jails, these local jails, and the sheriffs are responsible. And only one hospital meets the state certification for what these people need.
And some of these stays. They’re not like two days, they can be prolonged. There’ve been a lot of deaths, there’ve been a lot of suicides. It’s a really pretty disturbing situation. It’s sort of the mental health crisis and the mental health provider shortage and countrywide really writ large among some of the most vulnerable people.
Rovner: All right, well, we’ve had four grim extra credits this week, but they’re all good stories. 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 this week to Zach Dyer for filling in as our technical guru while Francis [Ying] takes some much-deserved time off. We’re going to take next week off, too, for the Thanksgiving holiday. As always, you can email us your comments or questions or your suggestions for our medical misinformation segment. We are at whatthehealth@kff.org. Or you can still find me at X, @jrovner, or @julierovner at Bluesky and Threads. Alice?
Ollstein: @AliceOllstein on X, and at AliceMiranda on Bluesky.
Rovner: Rachel.
Cohrs: I’m @rachelcohrs on X and rchohrsreporter on Threads.
Rovner: Joanne.
Kenen: @JoanneKenen on X, and I’m increasingly switched to Threads at @joannekenen1.
Rovner: We will be back in your feed in two weeks. Until then, be healthy.
Credits
Zach Dyer
Audio producer
Stephanie Stapleton
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 5 months ago
Aging, Courts, Medicaid, Medicare, Multimedia, Abortion, KFF Health News' 'What The Health?', Misinformation, Podcasts, U.S. Congress, Women's Health
KFF Health News' 'What the Health?': A Very Good Night for Abortion Rights Backers
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Supporters of abortion rights again scored big at the polls in several states’ off-year elections Nov. 7, including in some Republican-dominated states like Ohio and Kentucky. The biggest prize came in Ohio, where voters approved a ballot measure writing the right to an abortion into the state constitution, despite strong opposition from the governor and other top elected state officials.
Meanwhile, the Senate approved the nomination of Monica Bertagnolli to become the new director of the National Institutes of Health by a bipartisan 62-36 vote. Bertagnolli — previously director of the National Cancer Institute, a large NIH component — had seen her nomination held up for weeks by Sen. Bernie Sanders (I-Vt.) over a mostly unrelated fight with the Biden administration about prescription drug prices.
This week’s panelists are Julie Rovner of KFF Health News, Tami Luhby of CNN, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll.
Panelists
Tami Luhby
CNN
Alice Miranda Ollstein
Politico
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- Election night 2023 was a very good night for abortion rights supporters generally and, specifically, in Ohio, Kentucky, Virginia, Pennsylvania, and New Jersey. Republican governors and state leaders invested significant political capital to defeat abortion rights ballot questions and candidates, and lost. Some anti-abortion leaders’ embrace of a 15-week abortion ban as a potential compromise didn’t seem to help their cause.
- Abortion rights supporters’ winning streak raises a broader point about ballot initiatives. State legislatures in some red-leaning states have not only enacted abortion restrictions but also fought off Democratic-backed issues like Medicaid expansion only to have the state’s voters reverse them through ballot questions. As a result, conservative leaders are pushing states to make it harder to get referendums on state ballots.
- On Capitol Hill, lawmakers are once again facing a potential government shutdown Nov. 17, with the expiration of the last “continuing resolution” to keep government spending going. But House Republicans are not making much progress on passing individual spending bills, as several measures have been pulled from the House floor because they lacked the votes to pass.
- The Federal Trade Commission this week announced it is challenging more than 100 patents on brand-name medicines. Although mind-numbingly complex, the action, which could open the door to more generic options for some commonly used medicines such as asthma inhalers, could lead to lowering drug costs.
- “This Week in Medical Misinformation” highlights a study from the Ohio State University that found much of the information available to gynecologic cancer patients on TikTok is inaccurate or of little value.
Also this week, Rovner interviews KFF Health News’s Julie Appleby, who reported and wrote the latest “Bill of the Month” feature, about a woman who got billed for what should have been a no-cost physical exam. If you have an outrageous or baffling medical bill you’d like to share with us, you can do that here.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: ProPublica’s “Find Out Why Your Health Insurer Denied Your Claim.”
Alice Miranda Ollstein: Politico’s “Congenital Syphilis Jumped Tenfold Over the Last Decade,” by Alice Miranda Ollstein.
Sandhya Raman: The Texas Tribune’s “Sex Trafficking, Drugs and Assault: Texas Foster Kids and Caseworkers Face Chaos in Rental Houses and Hotels,” by Karen Brooks Harper.
Tami Luhby: ProPublica’s “Big Insurance Met Its Match When It Turned Down a Top Trial Lawyer’s Request for Cancer Treatment,” by T. Christian Miller.
Also mentioned in this week’s episode:
The Journal of Gynecologic Oncology’s “‘More Than a Song and Dance’: Exploration of Patient Perspectives and Educational Quality of Gynecologic Cancer Content on TikTok,” by Molly Morton et al.
Click to open the transcript
Transcript: A Very Good Night for Abortion Rights Backers
[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, Nov. 9, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: Tami Luhby of CNN.
Tami Luhby: Hello.
Rovner: And Sandhya Raman of CQ Roll Call.
Sandhya Raman: Hello, everyone.
Rovner: Later in this episode, we’ll have my interview with my colleague Julie Appleby, who wrote the latest KFF Health News-NPR “Bill of the Month.” This month’s patient had a very small bill, but it violated an important principle. But first, this week’s news, and there is more than enough.
Election night 2023 has come and gone, and it was a very good night for abortion rights supporters in Ohio, Kentucky, Virginia, Pennsylvania, and New Jersey. Alice, catch us up here.
Ollstein: Yeah, so this was a really striking example that I think undermined some of the talking points from the anti-abortion side after the 2022 midterms, where they also did worse than they expected. The narrative after that was that they lose when Republican candidates shy away from the abortion issue and don’t forcefully campaign on it. And the results this week sort of undermined that because, in Ohio, the Republican state officials went all in. I was at rallies where they were speaking, they cut ads saying, “Vote no on this abortion rights amendment.” They really put political capital into it.
An even stronger example is in Virginia, where Gov. Glenn Youngkin went all in on promoting his 15-week ban, wanting to flip the state legislature in order to advance that. He put a lot of his own money into this, et cetera. And it just …
Rovner: And the state legislature did flip, just not his way.
Ollstein: Exactly. It flipped the other way. So it really flopped in both places. And so now you have another round of finger-pointing on the right and disagreements over why they lost and what they need to do better. And so you have some people staying on that same narrative from last year saying, “Oh, they need to campaign even harder on restricting abortion.” And then you have other people saying, “Look, this is clearly a loser for us. We need to talk about other topics.”
But what was really striking, you mentioned New Jersey, and that’s sort of a counter-example because there, the Republican candidates tried to sidestep the abortion issue and say, “Look, this is settled. Abortion is legal in our state. This is not something we’re going to touch.” And they still lost. So it’s like, they lose on abortion when they campaign hard on it, they lose on abortion when they don’t campaign hard on it. And you have people arguing over what sort of magic words to use to connect with voters, but it really seems that it’s not really about the words; it’s about the policy itself.
Rovner: I want to dig a little harder into the whole 15-week-ban thing, and in Ohio it was just a straight up or down, are we going to enshrine abortion rights in the state constitution? And voters said yes, which did surprise a lot of people in a red state, although it’s, what, the fifth red state to do this?
But in Virginia, it was a little more subtle. The governor was trying to push a 15-week and they were calling it a limit, not a ban. And that’s apparently been the talking point for national Republicans, too, on federal, that this could be a compromise to have only a 15-week limit. Not working so well, right?
Ollstein: That’s right. I mean, that goes to what I was saying about you can sort of rebrand all you want. There’s been talk about rebranding “ban” to “limit.” There’s been talking about rebranding the term “pro-life,” but, ultimately, because of the events of the last several years, people associate Republicans with wanting to ban abortion. And that’s true whether it’s a total ban or a 15-week ban. It’s true whether you call it a ban or a limit or a restriction or whatever. And, like I said, it’s true when Republicans talk about it and when they don’t talk about it.
Most people, the country is still quite divided on this, but most people, a majority, enough to sway these elections, are saying that they would rather not have these kinds of imposed restrictions. And that’s really been galvanized by the overturning of Roe [v. Wade]. A lot of people were bringing up what Justice [Samuel] Alito wrote in his opinion overturning Roe saying, “Women are not without political power.” And people are saying, “Hey, look, that’s quite true. Thank you, Justice Alito.”
Rovner: So the other big political event obviously this week was the third Republican presidential candidate debate, this time with only five candidates on the stage, none of them named Trump.
As popular as abortion is turning out to be as a voting issue, President [Joe] Biden is not popular. In fact, I’ve seen many, many of these charts that showed that support for abortion rights is running 10 or 15 points better than President Biden. So these Republicans, who are hoping that something happens to Donald Trump, did finally talk about abortion, and most of them still seem to be in the “I’m proudly pro-life” stage. I mean, is there any way to walk this tightrope for them?
Ollstein: I think what was fascinating about the debate was you’re not really seeing a shift in reaction to this electoral shellacking that they got. The candidates who were for national bans and restrictions are still for national bans and restrictions. The candidates who want the states to decide say, “I want the states to decide.”
And it’s interesting that Nikki Haley is getting a lot of praise for her position, which she came out and said, “Yes, I’ll sign whatever Congress is able to pass that restricts abortion, but we should be upfront with voters and say that it is highly unlikely that anything will be able to pass the Senate.” It’s interesting that that seems to be appealing to people because …
Rovner: It’s true.
Ollstein: It is true, but it pisses off multiple groups. Democrats are zeroing in and hammering her on saying, “I will sign whatever ban Congress is able to pass” as evidence that she is still a threat to abortion access. Meanwhile, folks on the right, conservatives, anti-abortion people, they want her to champion a ban. They don’t want her to sort of downplay its likelihood. They want her to say, “Look, this might be very hard to get done, but I will be your champion for it.” And so she’s sort of not appealing to the left or the right with that stance, but it seems like there are some she is appealing to.
Rovner: Yeah. If anybody has ever succeeded in straddling the middle, she’s certainly making the effort.
I want to go back to the states for a minute. I think it was in your story that I read that one of the anti-abortion groups was talking about “the tyranny of the majority,” which took me a minute to think about, trying to get some of these states that could still put abortion constitutional amendments on their ballots, trying to get that stopped. Is that basically the next battleground we’re going to see?
Ollstein: Oh, yes. And it’s already started, but what really struck me is how open they’re being about it. So over the past year, a lot of states have quietly moved with legislation and through other means to try to make it harder or impossible to put an up-or-down question about abortion before voters, raising the threshold, raising the signature limit, mandating that people get signatures from this many counties and this and that and the other thing, making it more difficult. Mississippi is trying to make a carve-out so you can do a ballot measure on anything but abortion. We’ll see where that goes.
And so this has been going on, but the statements after Tuesday’s election from anti-abortion groups openly saying, “This is the tyranny of the majority and the human rights of babies should not be subject to a popular vote,” just completely going down this anti-Democratic road and being explicit about it. So I think it’s definitely something to keep an eye on.
Luhby: And this started with expanding Medicaid also because there’ve been multiple states now that have expanded Medicaid through ballot measures, multiple red states, and several states, including states that eventually passed that, have been trying to limit the ability of voters to pass it.
Rovner: Yes, we’ve got all these sort of Republican-dominated legislatures, but when the voters actually go to these single topics, they don’t necessarily agree with the legislators that they have elected.
Raman: Last year, one of the ones that abortion rights supporters had really championed was Michigan as the first citizen-led constitutional amendment to codify abortion rights. And then this week, we had a lawsuit brought against to invalidate that passing last year, and it’s unclear how that’ll go and play out in the courts, but it really seems like they’ve been slowly ramping up the strategies to see what sticks to be able to claw back some of this stuff.
Rovner: They, the anti-abortion force.
Raman: Yes, yes. And I was also going to say that when we’re talking about Mississippi, that is probably one of the one places where I think abortion opponents really had their win in that we had Lynn Fitch, their attorney general, who was the one that litigated the Dobbs decision that is making this such a big topic now, who pretty handily won reelection. And her opponent was pretty vocally an abortion rights supporter, Greta Kemp Martin. So that is one …
Rovner: The Republican governor also won in Mississippi.
Raman: Yes, yeah.
Rovner: It kind of prevented it from being a clean sweep for Democrats.
All right, well, I want to go back to the debate for a minute because they also talked mostly about foreign policy, but they did talk about entitlement reform, which had not come up, I don’t think, before. Talk about trying to straddle the middle. Here, Donald Trump has come out and vowed not to cut Social Security and Medicare, and yet we know that both programs need to have some kind of change or else they’re going to run out of money.
So how are these candidates trying to separate themselves on this thorny problem, Tami? They all seemed to say as much as they could without really saying anything.
Luhby: Exactly. I’m not sure there’s a lot of separation there, other than just saying, “We’ll look at it and we’ll see it.” But I mean, to some extent they’re right. The moderators were really trying to press them on what’s the age? What are you going to raise the age to? It’s now, the full retirement age is being ramped up to 67. The early retirement age has stayed at 62, and the moderators were like … they wanted a number.
And the candidates were sort of right in saying that they can’t just give a number because there are multiple things that can be done. I mean, a little bit more than I think what Nikki Haley said, or one of them had said it was three things that can be done. There’s more levers than that, but the age will ultimately depend on what they do with the formula, what they do with COLA, what they do with taxes. So there’s multiple things that can be done.
But what is definitely true is you can’t say that discussions are off the table because, according to the latest Trustees Report, Social Security will not be able to pay full benefits after 2034. At that time, it’ll only be able to pay about 80%. Medicare Part A can only pay full-schedule benefits till 2031. After that, it’ll only be able to cover 89%. And the new [House] speaker, Mike Johnson, has called for a debt commission and he says he wants to address Medicare and Social Security’s insolvency as part of the debt commission, which has really scared a lot of Social Security and Medicare advocates because of his Republican Study Committee background.
Rovner: Of actually wanting to cut Social Security and Medicare.
Luhby: Right. And do a lot of the things, although not raise taxes, but do a lot of things that the advocates don’t like. But yeah, there wasn’t really a lot to take away from the debate on Social Security and Medicare, other than them saying they wanted to do something, which they need to do.
Rovner: I was amused, though, that Nikki Haley said she wanted to expand Medicare Advantage without pointing out that Medicare … as if that was a way to save money because, as we’ve talked about many, many, many times, Medicare Advantage actually costs more than traditional Medicare at the moment. That’s one of the things that’s hastening the demise of Medicare’s trust fund in other places.
While we are on the subject of Washington and spending, we have yet another funding deadline coming up, this one Nov. 17, which is a week from Friday. We’ll obviously talk more about this next week, but Sandhya, how is it looking to keep the lights on?
Raman: I think we could just put a big question mark and that would be evergreen, but we’re still not close to a consensus, either short-term or long-term. So ideally, in the next several days, we’re going to get some sort of short-term selection, solution, and that it would get the votes. And those are big maybes.
Speaker Mike Johnson has said that he would come up with kind of a stopgap plan by the weekend, but this is all allegedly, and if that is something that would also be appeasable to the senators. And so a lot of that is still a question mark, but the House is still going ahead on trying to get HHS funding. So they recently released a revised version of their Labor, HHS, and Education bill. It’s still all the same topline spending, but it has additional …
Rovner: Which is lower than was agreed to. Right?
Raman: Yes, yeah.
Rovner: I mean, this bill’s having trouble … because of the magnitude of the cuts that it would make.
Raman: Yeah. They didn’t do any additional cuts to that, but they did add several more social policy riders. So the revised version would prevent funding from going to a hospital that requires abortion training or funding from athletic programs in schools that allow trans children to participate, which is something the House has passed legislation on earlier this year, calls for barring … calling for a public health emergency related to guns, a lot of just social issues that they’ve been messaging on.
So if this were to pass, this is also going to make it even more difficult to come to an agreement with the Senate. So the next thing to watch is that Monday, the House Rules Committee is going to meet and see the path to get it to the floor. And then even there, if it gets past the Rules Committee, it’s a will-or-will-not pass there. Because if you look at some of the other spending bills that have been going through, a lot of them have been getting pulled or not getting votes or getting pulled and repulled and all sorts of things.
Rovner: Pulled from the House floor?
Raman: Yes.
Rovner: Pulled like … they put them on the House floor and they don’t have the votes and they say, “Oops,” so they pull them back.
Raman: Yeah. So it’s all very tenuous. And I think one other interesting thing is that we didn’t have a full committee markup of this bill, which is something that the House has traditionally done and the Senate has not done in a few years. But the Senate did have their full markup. They did have a bipartisan consensus on it. And so we’ve kind of flipped roles, at least for now, in terms of how the regular order of Congress is going.
Rovner: Yeah, that’s right. Again, because the cuts were so big that the HHS bill couldn’t get through the Appropriations Committee.
Raman: Yeah. A lot of this is to be determined in the next few days.
Rovner: And this whole “laddered CR” that the speaker was talking about that nobody seems to quite understand except it would create different deadlines for different programs, that doesn’t seem to be on the table anymore or is it?
Raman: It also further complicates something that when they all have the same deadline, we’re still already struggling to get that done. So changing the dates is going to make it even more complicated to get to that point, but so much has really been in flux that I don’t think that that’s really on the table right now.
Rovner: Maybe he was hoping that having a partial shutdown would not be as disruptive or look as bad as having a full shutdown. I mean, I kept trying to figure out why he would try to do this because it just seemed, as you say, way more complicated.
Raman: If you look at the letter that he sent to other members of the House before he was elected as speaker, he did have a plan of outlining when he intends to get various bills done. And if you look at Labor, HHS, and Education, that one was one of the later ones kind of pegged to getting a deal for fiscal 2024 in April or so as the deadline, versus we’re still in November and the deadline was technically the end of September. There’s so many loose-hanging threads that hopefully they will come together with some sort of short-term solution over the next few days.
Rovner: They will, obviously, we shall see. Well, the House, as we say, is not getting a lot done, but the Senate is sort of.
The National Institutes of Health has a new director, former Cancer Institute director Monica Bertagnolli, whose nomination was approved on a bipartisan vote of 62 to 36 after being held up for months by Democrats who were upset that she wouldn’t, in the words of Senate Health, Education, Labor, and Pensions Committee Chairman Bernie Sanders, “take on Big Pharma enough.”
So when did controlling drug prices become part of the NIH portfolio? That’s not something that I was aware necessarily went together.
Ollstein: I think it was just that her nomination was the one that was up, so you got to sort of dance with the partner you can find. Obviously, other agencies and other official positions would have made more sense and had more direct power over drug prices. But this was the open seat, and so this was the leverage they thought they could use, and whether what they got out of it made it worth it, that’s up for debate. But yeah, it is very unusual to see somebody going against a president with whom they are largely aligned.
So this was eventually cleared, but Bernie Sanders wasn’t the only one. There were some other Democratic senators who were asking for ethics pledges and other things around this nomination, but it did ultimately go through.
Rovner: Yeah, there was a statement from John Fetterman. He said, “I’m not going to vote for her because she’s not going to be tough enough on the drug industry.” It’s like, I’m pretty sure that’s not her job as the head of NIH.
I mean, before people start to complain, I know that there are some levers that NIH can pull in deciding how to do some of their clinical trials. They can have sort of a secondary effect on drug prices, but it’s certainly not …
Ollstein: Not as direct.
Rovner: … their main role in the federal bureaucracy.
Well, meanwhile, there was some actual real stuff on drug prices this week. The Federal Trade Commission, which the last time I checked was in charge of unfair pricing practices, is officially challenging 100 drug industry patent listings charging that the listings are inaccurate. And because those listings help prevent cheaper generics from entering the market, that’s not fair. This is one of those things that’s kind of mind-numbingly complex, but it can have a real impact, right? If some of these patents get disallowed or delisted, I guess, from the Orange Book, the official listing of patents for drugs?
Luhby: If that happens, it does clear the pathway for us to get generics and cheaper drugs that way. So there definitely is that that could lower the prices of some of these, and some of the ones listed are pretty commonly used things that people use on a regular basis like inhalers, that kind of stuff.
Rovner: So if there was a generic, it could have a big impact because a lot of people would end up using it.
Finally, this week the Biden administration — remember the Biden administration? — issued a rule that would crack down on some marketing tactics by Medicare Advantage plans. Meanwhile, the Senate Finance Committee approved a health “extenders” bill that extends programs that would otherwise expire, and it includes, among lots of Medicare and Medicaid odds and ends, a requirement that Medicare Advantage plans keep a more timely list of the providers that are in and out of network, which I think might be the most frustrating thing about most managed-care plans, not just Medicare Advantage.
Both the administration’s proposed rule and the finance bill are smallish, but they represent stuff that keeps these programs up to date. I mean, Tami, there’s some significant stuff here, isn’t there?
Luhby: Yeah. Medicare Advantage is getting more attention because it’s getting larger. I think this is the first year that it’s crossed the 50% threshold and it’s expected to just continue growing as younger baby boomers coming in who are used to employer health insurance want to keep that. And there are a lot of pros and cons about Medicare Advantage for the consumer, and the administration is making sure … or is trying incrementally to make sure that people understand what they’re getting into.
I’ve seen a couple, now that it’s open enrollment time, I’ve seen a couple of the ads, which interestingly do seem to be targeted towards older women, not necessarily baby boomers coming in, but they’re kind of crazy and they can be very misleading. And the administration, in this latest effort, is trying to limit commissions of brokers because there are additional incentives that companies and insurers can provide to brokers beyond just the fees. So they’re trying to rein that in. Previously, they were working on Medicare Advantage marketing, so there’s a lot that they’re trying to do to just make sure that people are aware of what they can do.
This proposed rule would require that these supplemental benefits, which are one of the attractive features of Medicare Advantage, because Medicare doesn’t cover vision, dental, hearing, et cetera, but the administration wants to make sure that people actually know about these benefits and are using them and it’s not just a sweetener that the insurers are dangling at open enrollment time.
Rovner: To get people to sign up.
Luhby: They’re incremental, but they’re trying to make it a little more transparent.
Rovner: Yeah, I think it’s just important to remember that the incessant marketing, and boy, it is incessant, suggests that these companies are making a lot of money on Medicare Advantage.
Luhby: Oh, yeah.
Rovner: They would not be spending all of this money to advertise if this were not a very profitable line of business for them.
Luhby: And a growing line, of course, because more and more people are going to be eligible.
Rovner: Yeah. So we will watch that space too.
Well, before we get to our “Bill of the Month” interview, it’s time for “This Week in Medical Misinformation.” I chose this week a study from the Ohio State University of health advice related to gynecologic cancers that was most popular on TikTok. The study found at least 73% of content was inaccurate and of poor educational quality and that it furthered already existing racial disparities in cancer care. We will link to the study in the notes, but at least we know that there are people trying to quantify the amount of misinformation that’s out there, if not figure out what to do about it.
OK. That is this week’s news. Now we will play my interview with my colleague Julie Appleby, then we will come back with our extra credits.
I am pleased to welcome back to the podcast my colleague Julie Appleby, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment. Julie, thanks for joining us again.
Julie Appleby: Thanks for having me.
Rovner: So this month’s patient had a very small bill compared to most of them, but likely the kind that affects millions of patients. Tell us who she is and what brought her to our attention.
Appleby: Yes, exactly. Her name is Christine Rogers and she lives in Wake Forest, North Carolina. And like a lot of us, she went in for an exam with her doctor, sort of an annual-type exam. And while she was in the waiting room, they handed her a screening form for depression and for other mental health concerns, and she filled it out, and then went and saw her doctor.
During the discussion with her doctor, her doctor asked her about depression and her general mood, and Rogers had lost her mother that year, and so she told her doctor, “Yeah, it’s been a horrible year. I lost my mom.” So they had some discussion about that, and Rogers estimates it was about a five-minute discussion about depression, and then the visit wrapped up. Her doctor didn’t recommend any treatment or refer her for counseling or anything like that. It was just a discussion.
So Rogers was a little surprised when, later, she got a bill for that visit because, as you’ll remember, under the Affordable Care Act, preventive services, including depression screening, is supposed to be covered without a copay or a deductible. So she was a little surprised, and yeah, it wasn’t much. It was $67. That was her share of the visit. So she was just curious, why is this happening and what’s going on?
Rovner: So she calls the doctor’s office and said, “This is supposed to be free.” And what did they say?
Appleby: Right. She said that, and they explained to her that she had a discussion above and beyond just preventive, and so she was billed for a separate visit, basically, a 20- to 29-minute visit, specifically for the discussion treatment and that’s why she owed the money. So really, it wasn’t part of the wellness exam. It was part of a separate exam even though she was in the same office at the same time.
Rovner: But when I go for an annual physical, they give you a questionnaire. It’s not just about mental health. It’s about a lot of things, and it includes mental health. If you had a discussion about any of them, would that be billed separately? Could it be billed separately?
Appleby: Well, here’s where the nuance kicks in. So, as I said, under the Affordable Care Act, there’s a lot of preventive services that are covered without a copay. Things like certain cancer tests, certain vaccines, and yes, depression screening, but if you bring up something else during your wellness visit, they can indeed bill you for that.
So let’s say, for example, you mentioned to your doctor, “My shoulder’s really been killing me ever since I started playing pickleball,” and so then the doctor did some more exam of your shoulder. That could potentially be billed separately because it’s not part of the wellness visit. And in this case, initially, the doctor’s office coded it as two separate visits because it went above and beyond just a quick discussion of the questionnaire or just filling out the questionnaire.
Rovner: She goes to the doctor, the doctor says, “No, this is correct.” Then what happens?
Appleby: So then after we started calling around, we did talk to the insurer, Cigna, and the doctor’s practice, which is owned by WakeMed Physician Practices. And initially, they said the bill was coded correctly from the doctor’s office because it was a separate discussion. But after Cigna got involved, eventually after we talked to them, Rogers got a new explanation of benefits that zeroed out the visit. And a Cigna spokesperson said that the wellness visit was initially billed incorrectly with these two separate visit codes, basically, and that they had fixed that.
And so Christine Rogers did get her $67 back. But I think this does illustrate the issue of not all preventive services are covered without a copay if it goes beyond what they consider preventive. And that can be challenging. And many people that I spoke with for this article said Rogers did the exact right thing. She talked to her doctor honestly, and everybody emphasized that people should not avoid discussing health concerns with their doctors at a wellness visit for fear of getting a bill because, really, you’re there to get health care.
So what they do suggest is if after one of these wellness visits, if you do get a bill, you should ask about it, ask for an explanation of benefits, ask for an itemized billing statement. And if something seems off, question that. But keep in mind that some things, if they go beyond the preventive care guidelines, that you might get a separate bill even during what you might otherwise think would be a no-cost wellness visit.
Rovner: And if your shoulder’s bothering you after you take up pickleball, you probably should let a doctor look at it.
Appleby: You probably should.
Rovner: And I know that this was a fairly small bill, certainly in the scope of the bills that we usually look at, but this happened a lot with colonoscopies, that people would go in for the preventive colonoscopy that was paid for, but then if they found a polyp and took it off, suddenly they’d be charged for the surgery having the polyp removed. And that’s a lot more than $67.
Appleby: Right. And that has since been fixed. There’s been some clarification issued by CMS and others that that is not supposed to happen. So again, you go in for a screening colonoscopy, and that is supposed to be covered whether they find a polyp or not.
Now, if you go in because you have symptoms and there’s some other kind of problem, that’s where it can get more complicated. And we’ve seen that with other screenings too, such as mammograms. A screening mammogram is covered under the preventive services guidelines, but if you find a lump, there may be some questions to whether it’s gone from a screening mammogram to a diagnostic mammogram, which is covered under different guidelines.
Rovner: Bottom line, you should always look at your bill even if it’s for something small.
Appleby: Yes, that’s always a good rule of thumb. And if you have any questions, certainly contact your physician’s office and start there and ask about that. And you may also want to ask your insurer.
Rovner: Great. Julie Appleby, thanks for joining us.
OK, we’re 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.
Sandhya, why don’t you go first this week?
Raman: So my extra credit is called “Sex Trafficking, Drugs and Assault: Texas Foster Kids and Caseworkers Face Chaos in Rental Houses and Hotels,” and it’s by Karen Brooks Harper at the Texas Tribune.
Her story examines a report that looks at the Texas Department of Family and Protective Services that was done by some court-appointed watchdogs to report about some of the efforts to improve the foster care system. And they found a lot of overworked case workers that didn’t have training and no round-the-clock security. And it’s just a really important story about what’s trying to be done and what needs to be done for caring for some very vulnerable kids. Many of them, as the title suggests, are sex trafficking victims or from psychiatric facilities, and it’s just an unsafe environment for both the workers and the kids. So check that out.
Rovner: Alice?
Ollstein: So I picked a piece I did this week that sort of fell through the cracks in the news, but people should really be paying attention to this. It was a pretty scary report out of the Centers for Disease Control [and Prevention] about congenital syphilis. This is syphilis in pregnant people that is passed to infants in birth. And when not treated, it can be really deadly. It can cause stillbirths, it can cause birth defects, it can cause all kinds of issues, infertility in the parent, et cetera. And this has jumped tenfold over the last decade. It is killing hundreds of infants.
This is really scary. They sound that … so many people are just getting no prenatal care at all. And even when they are, they’re not getting tested for syphilis. And even when they’re getting tested and even when it’s detected, they’re not getting the treatment. And so people are really falling through the cracks. And, hopefully, this gets some more attention on this, but it’s also coming at a time when Congress is debating cutting these kinds of sexual health programs and services even more, not expanding them, which is what the report says is needed.
Rovner: That’s right. These are some of the things that would be cut in the proposed HHS spending bill that’s still kicking around in the House. Tami?
Luhby: So I looked at a ProPublica story. ProPublica has done several excellent deep dives into health insurers’ rejections of policyholders’ claims. These are very hard stories to do. They really are good at pulling back the curtain on these decisions that most people know very little about. So the latest story is by T. Christian Miller. It’s titled, “Big Insurance Met Its Match When It Turned Down a Top Trial Lawyer’s Request for Cancer Treatment.” It’s a long story, but it’s a piece about Robert Salim, I think, a litigator who was diagnosed with stage 4 throat cancer in 2018. His doctor recommended proton therapy, which specifically would minimize the damage to the surrounding tissues. Some of the side effects could be loss of hearing, damage to the sense of taste and smell, brain issues, memory loss. But the insurer, Blue Cross Blue Shield of Louisiana, refused to pay for it, saying it was not medically necessary. So Salim was able to pay the nearly $100,000 cost of treatment because he didn’t want to do these additional therapies first, which could leave him with hearing loss and all these other problems.
Rovner: Yeah, because he’s a rich trial lawyer, so he could afford it.
Luhby: Right, so he could afford it and he didn’t want to waste the time. But he also decided to battle Blue Cross and Blue Shield because, as he put it, he’s paid them $100,000 in premiums for him and for his employees at his law firm. And he’s just like, “Now that I need it, they’re not there.” So the story goes into the lengths that Salim had to go to, including his doctor sending in a 225-page request to Blue Cross to do an independent medical review. But what was interesting was that multiple doctors that were hired by the insurer to battle Salim’s appeal kept referring to guidelines that are created by this company called AIM Specialty Health, which is actually part of Anthem. So Salim, who has now been cancer-free for nearly five years, the appeal didn’t work, so he ended up taking Blue Cross to court and he actually won, but he’s still waiting to get his reimbursement. So read the story. It has a lot of twists and turns and shows that even someone with means and expertise, the battle is still so difficult. How can people who don’t have the resources, both financially and legally to do this … he had to hire a friend of his to take them to court, like a childhood friend or a college friend, because it was such a difficult case to put before the courts. It’s a good story.
Rovner: Yeah, it’s the juicy story of the week.
Luhby: It’s a scary story.
Rovner: Scary and juicy. Well, my story actually builds on Tami’s story. It’s also from ProPublica. It also builds on our “Bill of the Month” project. It is a new tool that can help patients file the paperwork to find out why their insurer denied a claim. As we have pointed out so many times, most people simply don’t bother to argue with their health care providers or insurers because they don’t know how, and it is not easy. They make it difficult on purpose. This tool actually walks you through a key part of the process: how to ask for the information that the insurance company used to deny the claim. It’s super helpful and it’s a good place to go rather than doing the sort of one at a time, “I have this bill, will you look at it, journalist?” Here’s a way where people can at least start to do their own digging. As Tami says, it gets harder, but many people are being denied care that they are, in fact, eligible to. So here’s a way to at least start to try and get that care.
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 tireless engineer, Francis Ying.
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, @jrovner or @julierovner at Bluesky and Threads. Sandhya?
Raman: @SandhyaWrites.
Rovner: Tami?
Luhby: Well, I’m at @Luhby, but it’s not really worth looking at it.
Rovner: Alice?
Ollstein: @AliceOllstein.
Rovner: We will be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Stephanie Stapleton
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 5 months ago
Elections, Multimedia, States, Abortion, KFF Health News' 'What The Health?', NIH, Ohio, Podcasts, U.S. Congress, Women's Health
KFF Health News' 'What the Health?': The New Speaker’s (Limited) Record on Health
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
After nearly a month of bickering, House Republicans finally elected a new speaker: Louisiana Republican Rep. Mike Johnson, a relative unknown to many. And while Johnson has a long history of opposition to abortion and LGBTQ+ rights, his positions on other health issues are still a bit of a question mark.
Meanwhile, a new study found that in the year following the overturn of Roe v. Wade, the number of abortions actually rose, particularly in states adjacent to those that now have bans or severe restrictions.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, and Alice Miranda Ollstein of Politico.
Panelists
Rachel Cohrs
Stat News
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- New House Speaker Mike Johnson (R-La.) doesn’t have much of a legislative record, but in a previous life he worked for the Christian conservative law firm Alliance Defending Freedom. ADF has been on the winning side of several major Supreme Court cases on social issues in the past decade, including the case that overturned Roe v. Wade.
- In Colorado this week, a federal judge ruled that the state cannot enforce a new law banning medication abortion “reversals,” an unproven treatment that most medical associations don’t recognize, because it could violate the religious rights of those who do advocate it.
- A new demonstration Medicaid program in Georgia to require low-income adults who want Medicaid coverage to prove they work a certain number of hours per week is off to a slow start, enrolling in its first three months only about 1,300 of the estimated 100,000 people who could be eligible.
- The National Institutes of Health may soon get a Senate-confirmed director for the first time in more than a year and a half. The Senate Health, Education, Labor and Pensions Committee, after a several-months delay, voted on a bipartisan basis to elevate National Cancer Institute chief Monica Bertagnolli to the top post at NIH. Notably, among the votes against her on the panel came from the committee chair, Sen. Bernie Sanders (I-Vt.), who has been trying to leverage the nomination to win more drug pricing concessions from the Biden administration. Bertagnolli is still expected to win full Senate approval.
- Finally, in the first installment of a new podcast feature, “This Week in Medical Misinformation,” KFF Health News’ Liz Szabo writes about how Suzanne Somers, a popular TV actress from the late 1970s through the 1990s, used her fame to push questionable medical treatments, becoming an “influencer” long before there was such a thing.
Also this week, Rovner interviews Michael Cannon, director of health policy studies for the Cato Institute, a libertarian think tank, about his new book, “Recovery: A Guide to Reforming the U.S. Health Sector.”
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Washington Post’s “The Pandemic Has Faded in This Michigan County. The Mistrust Never Ended,” by Greg Jaffe and Patrick Marley.
Alice Miranda Ollstein: Politico’s “Dozens of States Sue Meta Over Addictive Features Harming Kids,” by Rebecca Kern, Josh Sisco, and Alfred Ng.
Rachel Cohrs: The New York Times’ “Ozempic and Wegovy Don’t Cost What You Think They Do,” by Gina Kolata.
Also mentioned in this week’s episode:
KFF Health News’ “Suzanne Somers’ Legacy Tainted by Celebrity Medical Misinformation,” by Liz Szabo.
click to open the transcript
Transcript: The New Speaker’s (Limited) Record on Health
KFF Health News’ ‘What the Health?’Episode Title: The New Speaker’s (Limited) Record on HealthEpisode Number: 320Published: Oct. 26, 2023
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 26, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this, so here we go.
We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: And Rachel Cohrs of Stat News.
Rachel Cohrs: Hi, everybody.
Rovner: Later in this episode, we’ll have my interview with Michael Cannon, noted libertarian health expert, about his new book called “Recovery: A Guide to Reforming the U.S. Health Sector.” But first, before we get onto this week’s news, a small correction from last week’s podcast. In talking about just how confusing open enrollment for Medicare is, I misstated the open enrollment dates. It runs this year from Oct. 15 to Dec. 7, not to Dec. 15. See, I said it was confusing.
All right, now to the news. Hey, we got a speaker of the House again! Mike Johnson is in his fourth term from the 4th District of Louisiana. He’s not strictly a backbencher; he was in the lower levels of House leadership. But I think it’s fair to say that a lot of people, including me, had no idea who he was until this week, other than that he was involved kind of heavily in trying to overturn the 2020 presidential election. And also, as far as I can tell, he’s not been active in health policy in Congress other than opposing abortion. What have you found out about Mike Johnson? Alice, you wrote about him, right?
Ollstein: Yeah, so I wrote about his anti-abortion record, and that’s just one facet. There has been a lot of good pieces this week on his opposition to gay rights and, on a lot of levels, trans rights, etc. But I focused on his anti-abortion record because that’s my beat. And so, yes, I think it’s worth noting that he used to work for the Alliance Defending Freedom, which is the conservative legal powerhouse that was behind the case that overturned Roe v. Wade, and is now spearheading the case trying to restrict abortion pills nationwide. They’re a part of a lot of other anti-abortion legal battles, as well. And, since coming to Congress, he has co-sponsored a lot of anti-abortion legislation, including bans at 15 weeks and six weeks, and none of those have gone anywhere, but that record has anti-abortion groups stating high hopes for his speakership.
But as we know, with such a narrow majority, House Republicans have been hesitant to really take big votes in anti-abortion space this year. And so, it will be interesting to watch how he navigates that.
Rovner: So, Rachel, we know he’s not on any of the major health committees. Has he done or said anything about any other parts of health care other than his Christian conservative lane?
Cohrs: Well, I think he actually has, and he has a more clear, I think, stance on health care reform more generally than a lot of the other candidates we saw because he did lead the Republican Study Committee. I think his term started in 2019, so he actually did sign on to a health care plan.
Rovner: How rare for a Republican.
Cohrs: Yeah, really. We don’t see many of those that are really spelled out. And there’s a whole white paper, it’s still on the internet, but I think it includes some policies that aren’t terribly surprising. It includes scaling back subsidies for ACA [Affordable Care Act] plans, empowering HSAs [health savings accounts], converting Medicaid funding into block grants for states, and also removing some of the ACA’s preexisting condition protections, and creating high-risk pools in states. So, it is substantive ideas about coverage and costs.
Rovner: It’s also Republican health care orthodoxy that goes back like 25 years, at this point.
Cohrs: Exactly, so nothing crazy, but we do have at least sort of a marker of where he’s at a couple of years ago. But again, I think there’s no reason to believe that he would pursue any of that anytime soon. He has a very full plate with a lot of other things.
Rovner: That’s what I was going to say, which is that Nancy Pelosi came to the speakership as one of the most liberal members of the House. That is certainly not the way she ran the speakership because, basically, her job was to find the votes for things and she had to please both the left wing of her party and the right wing of her party, and that’s hard enough for Democrats. It seems to be even harder these days for Republicans. So, no matter what his personal goals are, I guess we’re about to find out if he can actually bring together this unbelievably fractious Republican caucus.
Ollstein: And I just want to note, too, that it’s not just about the struggle to find the votes, which we saw in the very speakership debacle itself, but also, he has spoken about the need to protect their most vulnerable swing district members who are up for reelection next year. These are Republicans who are elected in districts that voted for Biden. And so those people do not want to vote on red-meat, controversial bills. We’re already hearing some issues coming up in appropriations, which is the first major hurdle he has to confront as speaker to avoid a government shutdown in just a few weeks, potentially.
And so not only is it about just getting enough votes to get bills through, but not putting these people in a position where Democrats will run a bunch of ads saying, oh, so-and-so voted for this anti-abortion thing, to try to knock them out.
Rovner: Well, while we are on the subject of abortion, there’s a lot of news there. I want to start with an update to something we talked about last week: the lawsuit in Colorado challenging the state’s new law banning medication abortion “reversals.” I put reversals in quotes. Over the weekend, a federal district court judge ruled that the law is likely unconstitutional and blocked the state from enforcing it. I imagine this is not the last we will hear about this case, right, Alice?
Ollstein: Oh, certainly. So as we discussed before, this is an issue that’s in multiple courts, potentially designed to create some sort of split that could go up to the Supreme Court and require them to weigh in. But this, in addition to the current case pending before the Supreme Court about abortion pill access, it really presents new territory, in terms of how courts could intervene in the practice of medicine.
Rovner: And as we mentioned in California, we have the opposite case going forward with the state suing a string of crisis pregnancy centers for false advertising for suggesting that they could reverse medication abortions, which, of course, is trying to give large doses of progesterone between the taking of the two medications that create a medication abortion. And it’s turned out to be that there is not a lot of scientific evidence suggesting that this is a thing. And when they tried to do a clinical trial, they had to stop it because women were having serious problems.
We also have an update from Ohio, whose November ballot measure we also talked about, and it’s right around the corner. It seems that the governor, who’s also a former senator, Mike DeWine, is going around saying that the constitutional amendment protecting abortion would allow for “partial birth abortions,” a controversial procedure that Congress actually banned in 2003 and that the Supreme Court upheld in 2007, and it’s a law that DeWine worked on when he was in the Senate. Are these scare tactics? Do we think he really believes that this is what this Ohio ballot measure would do?
Ollstein: This is among the greater arguments that are being made in Ohio around this amendment and saying it’s very similar to the arguments that anti-abortion groups and officials made in all of the states that held their own referendums last year. Basically that, should this pass, it’ll just be a complete abortion-palooza, no regulations, no nothing. And that has not panned out in those other states, and it’s especially unlikely to pan out in Ohio, given the makeup of the state legislature and Republicans controlling the state Supreme Court, all these levers of power, the governorship, etc.
And so this is not Michigan, where Democrats won control of the governorship and the Statehouse and are moving, although it remains to be seen how far they move to unwind some abortion restrictions. But that is not likely to happen in Ohio. I think these groups are parsing language in the amendment, itself, and extrapolating from that and saying, oh, this is a code word for this, and this is a code word for that, but it’s not in the text of the amendment, and because of the balance of powers in the state, it’s not likely to pan out that way,
Rovner: Although they do seem worried. Alice and I, we were both on this call the other night about all of the anti-abortion groups together trying to light a fire under their forces over this Ohio ballot measure, noting, of course, that there have been six votes since Roe was overturned in various states and that they have lost all of them. So Ohio will be a big deal in how this goes into next year.
Ollstein: Yeah, absolutely. It’ll be a big deal for Ohio. Of course, we have a six-week ban in that state that has been on hold. It has been blocked in court, but it very well could be unblocked and put back into effect if this amendment doesn’t pass. That’s the most immediate thing. So it’s a big deal for Ohio, but both sides have also made the case that it’s a big deal beyond Ohio. It really shows what kind of strategies and messaging are effective in these redder-purple states. If we can even call Ohio purple, at this point, it’s quite red.
Rovner: It is very red with one Democratic senator, basically.
Ollstein: Exactly, who is up for reelection next year. So that is going to be interesting, as well. He and other of the remaining endangered Democrats in the state are vocally supporting this, and so that should have an influence, as well, on their races.
Rovner: So we got an interesting study this week that found that abortions have actually increased in the year since Roe was overturned, although, not surprisingly, in the states where abortion was banned, where they dropped dramatically. Do we know, obviously, women are going to other states, but one would not have assumed that it would’ve gone up because we’ve talked about all the places where there were not enough slots, basically, for women wanting to terminate pregnancies and for women who were not able to travel. I was a little bit surprised by this. What did you make of it?
Ollstein: So first I want to give some big caveats. A lot of this data is guesswork. They acknowledge that a lot of the providers they reached out to for data just refused to respond, so they had to model it out based on what they were able to get. Also, this does not count any abortions that are happening outside the formal medical system. So people ordering pills from groups like Aid Access or whatnot, delivered to their home. We know that’s happening. We know that’s a very common thing, and so this doesn’t count any of that. But I think even given all these caveats, there’s some interesting things in there.
I think that what really caught my attention is not just that states like California that really moved to expand access massively, the people taking advantage of that are not just people traveling from red states. It is also reaching people who were in those blue states who struggled to access abortion even in those blue states before. And so they mentioned parts of rural California on the call announcing the data, specifically. So I found that interesting, too.
Rovner: So, well acknowledging, obviously, that more women are traveling to get abortions, abortion opponents are stepping up their efforts to make that illegal, too. This week, Lubbock County in Texas became the fourth Texas county to make it illegal to use its local highways to assist someone in traveling out of state for an abortion. On the one hand, even some anti-abortion lawyers doubt that this is constitutional. But on the other hand, a lot of these laws are more intended to chill behavior than to punish it, right, particularly in Texas?
Ollstein: Yes, like a lot of state laws and now municipal laws that are being passed in the post-Roe era, enforcement and the practicality of enforcement is not, necessarily, something that folks are very focused on because the chilling effect is the main goal. And I think this is true for bans on receiving abortion pills by mail. Unless you’re going through everyone’s mail, you wouldn’t really know. And so these travel bans, travel restrictions, as well, there has been a lot of heated rhetoric about, oh, are they going to set up checkpoints and give pregnancy tests to people? No, they’re not. If they were, please message us and tell us so we can report on it, but we haven’t seen that.
And I think the idea is that people are already scared. People are already confused about what’s legal and what’s not. We know that from polling. And so this just adds to that confusion, and if somebody is already unsure of what they’re allowed to do, this could be a further deterrent from them even pursuing the possibility of an abortion.
Rovner: Well, this will obviously continue. Let’s move on to Medicaid for a minute. Six months into the “unwinding,” an estimated 9 million Medicaid recipients have been removed from the rolls, some of whom are no longer eligible, but most of whom might still qualify, but either fell through the cracks or states were unable to locate them. Meanwhile, a new report from the Robert Wood Johnson Foundation finds that if the 10 states that are still holding out from expanding Medicaid under the Affordable Care Act were to go ahead and expand, nearly 2.5 million more low-income adults would be added to the rolls and the uninsurance rate would drop by 25%.
One of those holdout states, Georgia, is trying to expand using a pilot program with work requirements for those who want to enroll. But so far, three months in, only about 1,300 people have enrolled out of an estimated 100,000 that are potentially eligible. Why is this off to such a slow start?
Cohrs: I think the story that you highlighted from The AP gave some reasons about just the paperwork having to be filed. And honestly, having looked at some safety-net programs, it is a lot to pull together if you’re pulling financial records and all of that. So I think there’s also just the bureaucratic issues that we see with these kinds of programs that are designed to keep people out almost. And I think it’ll be an interesting test case as it continues to move forward, whether uptick increases, whether outreach catches up, and whether nonprofit groups, grassroots organizations in the state can help people navigate the process. But certainly, the paperwork burden isn’t to be underestimated here.
Rovner: Alice, you covered when Arkansas tried to implement this for everybody and it did not go well because even the people who were working, the people who were technically able to fulfill the work requirements, had trouble reporting the fact that they were fulfilling the requirements. Do you think that’s going on at the beginning of the process here, in Georgia, whereas in Arkansas, everybody was suddenly required to do it?
Ollstein: Yeah. I think it’s definitely something to watch because, well, first of all, we know from years of data that the people within Medicaid who can work, are already working. The breakdown of those who are not employed, it’s children, it’s the elderly, it’s people with disabilities, it’s people caring for people with disabilities or an elderly relative, and so this is a massive effort that could, maybe, increase the workforce by a very small number of people. And so some of this is ideological about these kinds of benefits and who is deserving and undeserving and different opinions about that. But in terms of economics and cost-saving, we do not expect this to have a big benefit. And so it’s definitely worth watching if people are falling through the cracks, because in Arkansas people didn’t even know about the requirement or they didn’t have the internet access to be able to report their hours. Lots of different ways.
Rovner: And, of course, in Arkansas, people lost their coverage. Here in Georgia, it’s a matter of people not getting the coverage who are potentially eligible. So yeah, I think we will watch to see how this goes.
Well, back here in Washington, the National Institutes of Health appears on the road to having a Senate-confirmed director for the first time in a year and a half, as the Senate Health, Education, Labor and Pensions Committee voted 15 to 6 on Wednesday to elevate National Cancer Institute chief Monica Bertagnolli to the top spot. Interestingly, one of those no votes came from committee chairman Bernie Sanders, which is pretty much unheard of for a committee chair of the same party as the nominating president. Rachel, what is he trying to prove here, and might it threaten her nomination on the Senate floor, or do we think this is a relatively done deal?
Cohrs: With your first question, I think he, for months, delayed even having this hearing, having this confirmation vote because he wanted to use the only lever he has, which is holding up nominations to pressure the Biden administration to take a more hard-line stance at the NIH and include language in contracts with drugmakers to require some sort of fair pricing or ensuring the U.S. gets the best price when the NIH is investing money in various stages of drug development. So I think that has been his goal. And I think the Biden administration, specifically HHS [Department of Health and Human Services], threw him a bone with a covid therapeutic that’s in the works from Regeneron, but it’s not what he was hoping for. And I think he put out a letter criticizing the NIH granting an exclusive license to a company where a former employee of the NIH works who worked on the medication.
And so I think he is just trying to continue to use what leverage he has, but I think the vote — that this week was a very good vote for her because we saw several Republicans join Democrats in passing her through. Again, nominations only have a 50-vote threshold in the Senate, so they don’t need a whole lot of Republicans, and Sanders, I think, was the only Democrat to oppose her in committee. So it looks like smooth sailing for her whenever they can find floor time for her.
Rovner: Yeah, and I should point out that it is a time-honored tradition in the Senate to hold up a nomination for something that’s unrelated to the person who’s being nominated, for a senator to try and get something out of the administration. What’s odd is when it’s a senator of the same party. Usually it’s somebody from the opposite party of the president trying to stall a nomination in order to get something else that they want. So this was very unusual, I must say.
Cohrs: It was, and I will say, too, that given how politicized the NIH has become with unifunction[al] research or there’s a million things that Republicans could have chosen to take an ideological stance on. We saw this with FDA Commissioner Robert Califf’s confirmation, with CMS chief Chiquita Brooks-LaSure; John Cornyn came out of nowhere and was trying to make demands of her. So we just haven’t seen the full extent that we could have seen from the GOP and trying to hold up her nomination or extract something from the Biden administration.
Rovner: Well, it does still have to get through the floor, so there is time, yet, although I agree with you, it doesn’t look like it’s going to be a huge problem.
Well, finally, this week we are launching a new segment that I’m calling “This Week in Health Misinformation.” Our first featured story is from my KFF Health news colleague Liz Szabo, and it’s called “Suzanne Somers’ Legacy Tainted by Celebrity Medical Misinformation.” It turns out that Somers, who died earlier this month, spun her sitcom fame into an entire career pushing questionable medical treatments and forgoing chemotherapy when she was diagnosed with breast cancer. Basically, in the words of one doctor quoted in this story, “She became an influencer on menopause before being an influencer was even a thing.” And lots of people who believed her were probably worse off because of it.
This is obviously something that continues to this day. We see lots of celebrities pushing dubious things. It used to just be those who were rich enough or who worked for a company that was wealthy enough to advertise on TV, even if it was in the middle of the night, but now we have social media, and this kind of misinformation is pretty rampant, right?
Cohrs: It is. I thought Axios actually had an interesting piece this week, as well, about anecdotal reports of doctors where patients are interested in getting off of birth control pills, even with everything that we’re seeing with the overturning of Roe v. Wade. And I think, again, that story you mentioned, the influencer space where people are trying to sell apps, trying to sell alternatives, spreading information about how it affects your hormone levels. And I think patients don’t have a primary care doctor where they can ask some of these questions in an evidence-based place. I think, certainly, people of all ages are getting information from these influencers on social media, and I think that it is a very interesting trend to see how that’s going to play out from doctors’ side.
Like you said, we’ve seen drug companies advertise on TV for a long time trying to influence the care that patients are getting in the office. But I think we’re seeing these other sources start to influence the choices that patients are making. It’s a really interesting trend.
Ollstein: And I think these influencers and purveyors of misinformation, they’re really taking advantage of real frustrations with the formal medical system and how it has cared for women and our needs over time and ignored people’s complaints and dismissed them, and the fact that technology has not advanced on a lot of these fronts for a long time. So I think that leaves an opening for folks to come in and take advantage of that frustration and confusion and offer a solution that may possibly be even worse.
Rovner: All right, well that is this week’s news. Now we will play my interview with my favorite libertarian health policy expert, Michael Cannon, and then we will come back with our extra credits.
I am thrilled to welcome to the podcast Michael Cannon, who’s director of health policy studies at the Cato Institute, the libertarian think tank here, in Washington. He’s the author of a new book about how to fix our broken health care system and one of my favorite people to argue with about health policy. Michael, welcome to “What the Health?’” It’s great to have you here.
Michael Cannon: Great to be here.
Rovner: So we’ll get to the book in a minute, but first, tell us the difference between the libertarian view of health care and the traditional Democratic or Republican view. I think a lot of people don’t understand that.
Cannon: Well, that actually is a good intro to the book, because the book provides a broad overview of health care, but it starts from the very simple principle that you have rights when it comes to your health care, and the most important right you have is the right to make your own health decisions. That’s where libertarians start, and that means that libertarians end up agreeing with Republicans on some things, and Democrats on other things, because neither party really takes that principle and carries it throughout all aspects of the health care debate. So we might end up agreeing with Republicans that states should not expand the Medicaid program, but we end up agreeing with Democrats.
I would say that people end up agreeing with us that women should get to make their own decisions when it comes to contraceptives, and the government should not be requiring women — if you’ve got a willing seller of oral contraceptives and a willing buyer, the government has no business stepping in between them and requiring women to get a permission slip from a government-appointed gatekeeper, what we call a prescription from a doctor, in order to buy oral contraceptives. In 100 other countries around the world, women can purchase oral contraceptives without a permission slip from a government-appointed gatekeeper without a prescription. But in the United States, the government takes away women’s right to do that. And so Democrats uphold that principle that people should give to make their own health decisions in that realm, but not in others.
Rovner: And should there be an FDA? Should there be a government referee to decide what’s safe?
Cannon: So there should be referees and there should be better referees than the one we have, and that’s actually something that I cover in the book. When you give the government the power to decide whether drugs can come onto the market or not and use the criteria of whether they are safe and effective before they can come onto the market, what ends up happening is the government imposes its values on people, its values about what is safe enough and what is effective enough. And while it does keep some unsafe drugs off the market, and that’s good, it saves lives that way. It also keeps a lot of safe and beneficial drugs off of the market in ways that harm people.
Another example of this is, again, contraceptives. Not just how the government is requiring women to get a prescription in order to buy oral contraceptives, but for a long time, the government was prohibiting emergency contraception, then prohibiting it without a prescription, and then prohibiting it unless you were of a certain age, and there was this huge fight. You covered this story.
Rovner: For many years.
Cannon: To get the government out of the way here, but it’s even worse than that. If you look at the original introduction of the oral contraceptive pill in 1960, there were other countries that had approved the pill earlier. And so when the FDA delayed the introduction of that product onto the market, that had a huge impact. Not only did it violate people’s rights, which is really important — it violates the principle of equality when the government does that — but keeping that beneficial product off the market had tremendous costs. The most recent winner of the Nobel Prize in economics, Claudia Goldin, did a lot of research showing that when the pill finally came onto the market, women were able to delay marriage. They were able to delay conception and marriage and invest in education, and we saw huge gains in women’s equality as a result of that. But when the FDA kept that drug off the market, it delayed the cause of women’s equality.
So do we want someone to provide safety and efficacy assurance? Absolutely. And if we left this to people outside of the government, not only would that system be consistent with your right to make your own health decisions, but we would get better safety and efficacy certification. And I talk about one of the ways that would happen in the book using the example of Vioxx. This is a non-steroidal anti-inflammatory drug that the FDA pulled off the market years ago. Most people, when I ask this question, don’t know the answer, but I bet you do, Julie. Do you remember where they got the evidence showing that Vioxx led to adverse cardiac events, that it was killing people?
Rovner: I do not remember.
Cannon: It was Kaiser Permanente. Kaiser Permanente, which has been investing in electronic health records since the 1960s. Once there were questions about whether Vioxx was causing heart attacks, they said, “Well, you know what? We’ve got all these records. We’ve got lots of people who’ve been taking Vioxx. Let’s do a retrospective observational study, trying to control for everything that we can, and we’ll see if there’s an impact.” And they found there was one, and that convinced the FDA that this drug that the FDA had led on the market, was, in fact, killing people. And so here you have a market-generated way of testing drugs and certifying safety and efficacy that beat the FDA, that did a better job than the FDA did at keeping unsafe drugs off of the market.
Rovner: The FDA will argue that the whole point of the way they approve drugs is that you’re supposed to test them after they get on the market, when they’re in a bigger population, in case there were things that were not seen in the original studies.
Cannon: But there’s definitely a flaw in the FDA’s model is they do randomized controlled trials, or they require randomized controlled trials, that have a few thousand patients in them that will not, cannot detect effects like those of Vioxx because the effects are so small and you will not be able to detect it until hundreds of thousands or millions of people are taking that drug. And so that is a flaw in the FDA’s model.
It’s a flaw in the whole idea of giving government the power to make these decisions and relying on government for safety and efficacy certification because if the government had never gotten involved, if we had left this completely to market forces, then I argue in the book that institutions like Kaiser Permanente, that have the motive and the means and the opportunity to test drugs … all along the way, they would not stop, like the FDA does, at testing it a few thousand people, they would keep monitoring drugs throughout, as the population taking those drugs increases, and they would catch the harmful side effects of drugs a lot faster than the FDA did. But we only have one Kaiser Permanente right now. And the reason we do is because a raft of things that the government has done to violate people’s rights to choose that sort of health plan.
Rovner: And also, we have a vast market in electronic medical records. They were all supposed to be able to talk to each other and they can’t, but let’s not go there. I don’t want to get too far off track.
Cannon: But the electronic records we have right now are there because government spent so many years suppressing them, by suppressing plans like Kaiser, that naturally invested in them, and then woke up one morning and said, well, gosh, we spent decades suppressing electronic health records, and I do talk about this in the book. Why don’t we subsidize them, now? And so now Medicare is subsidizing meaningful use of electronic medical records and they’re still not doing what the Kaiser records do because they’re not interoperable and they don’t focus on a defined patient population so that you can monitor them over time and detect these sorts of effects. That’s another wonderful illustration, electronic health records are, of the things that go wrong when you let government make these decisions for people.
Rovner: So, and I think you’ve already gotten to this. One of the biggest complaints about our health care system now is how ridiculously complicated it is for the average patient to navigate. How would what you’re supporting make that easier?
Cannon: So every economic system, whether we’re talking about socialism and communism on one of the end, and totally free markets on the other end, and things like mixed welfare states or crony capital, it doesn’t matter what economic system you’re talking about, it’s going to serve whoever controls the money. And so if you want a system that is simpler for consumers to understand, then you have to set up a system where nobody gets any money unless consumers understand, unless they’re providing consumers what the consumer wants.
The U.S. health sector consumes about $4.6 trillion, at this point. It’s about one-sixth of GDP on its way to six-sixths of GDP. And most of that money, the consumers don’t control it. One of the things that I write about in the book is I include some OECD [Organization for Economic Cooperation and Development] data that shows that in the United States, government controls, directly or indirectly, about 85% of health spending. That’s the eighth-highest of all OECD countries. Is just two or three percentage points behind the No. 1 country, which I think is Norway or Germany. It keeps changing from year to year. But that’s a larger share that, in countries like the U.K. and Canada that have explicitly socialized systems. So here we have the government compelling people to spend 85% of what we spend on health care the way the government wants, or the way that employers want, and that the industry ends up capturing those decisions about how people have to spend those resources, and we wonder why the system isn’t serving consumers very well.
So what I propose in the book is a number of things, a number of changes that would return that $4.6 trillion that we spend every year on health care to the consumers so that the system would serve them. You have to change the tax code to do that, you have to change the Medicare program and other things to do that, but I think that’s the only way to make things simpler for consumers. And there’s evidence in the book that when consumers are in control of the money, the system does become simpler for them. It provides them the price information they want and becomes easier for them to navigate.
Rovner: So transparency, which I know is a linchpin to a lot of this, and that you’ve been talking about for many more years than, I think, before it even got trendy. It’s one of the few things that Republicans and Democrats have agreed on for years, but it’s been much harder to make happen than I think anybody expected. Even with the power of government, we’re seeing, for example, hospitals pretty flagrantly ignoring the rule that they’re supposed to post prices in a consumer-accessible way. If the government can’t make it happen, how can consumers make it happen?
Cannon: I’m so glad you asked, Julie, because there’s evidence in the book on that. There’s this, what I call the most important chart you’ve never seen in health policy. It collects the results from a series of studies that employers like Safeway and the CalPERS system, for health benefits for California state employees, they did a series of experiments that put the patient in control of the money that they were going to be spending on — things like lab tests and colonoscopies, a knee and shoulder or arthroscopy, MRIs, CT scans, hip and knee replacements.
Rovner: Shoppable services, right?
Cannon: Yeah, what we call shoppable …
Rovner: They’re not emergencies, right?
Cannon: What we call shoppable services. Because the insurance companies and these employers could not get the prices down for these services, try as they might. They had hospitals charging them $60,000 for a hip and knee replacement when others were charging 12, and there was no difference in quality. The hospitals were just exploiting their market, or monopoly, power.
So what CalPERS did in the case of hip and knee replacements was they said, “Look, the hip and knee replacement candidates can go to any hospital they want, but we’re going to pay $30,000 no matter where they go. And if they go to a hospital that charges more than that, then they have to pay the balance.” As soon as the consumer had an incentive to care about price, an amazing thing happened. Not just with hip and knee replacements, but with everything else. They started demanding price information from hospitals. The hospitals began giving them the price information, making prices transparent, and then the consumer started changing their behavior by switching from the high-priced hospitals to the low-priced hospitals. And then the most amazing and glorious thing, and it’s why this is, that chart is the most important chart in health care, hospitals began dropping their prices.
The high-priced hospitals dropped the price for hip and knee replacements by $16,000 per procedure. On average, that was a 37% reduction in just two years. When do you ever see prices falling like that in health care? And if you care about universal health care, then that chart is the most important chart you have ever seen because if you care about your universal health care, nothing is more important than falling prices. But that series of experiments also illustrates that if you care about price transparency, then you want to change who controls the money so that it’s the consumer, so that health care providers have to provide transparent prices and other information that consumers want, or else they’re not going to make any money.
Rovner: So, we’ve both been around Washington for a very long time, and we know that, with very few exceptions, things only happen extremely incrementally. That’s the only way anything gets through either the Congress or the administration or, God forbid, both. So what would be one thing that you think we could do to put the system on a path to where you think it would work better?
Cannon: So in the book, you will not find Michael’s perfectly ideal conception of what a health care sector would look like. I do try to — and I should mention, the book takes that principle that you should be able to make your health decisions, and it applies them throughout the health sector. It looks at clinician licensing at the state level, state health insurance, licensing and regulation laws, health facilities regulation, medical malpractice, the tax code, Medicare, Medicaid, veterans’ benefits. And I would love to have a conversation about that sometime because that’s particularly topical, nowadays. But in each case, I don’t try to present what is the perfect libertarian idea. I try to put out there what I think is the biggest step that people would be willing to talk about, and then some incremental steps that we could take along the way. And in some cases, those incremental steps are actually pretty small, but in other cases, the incremental steps are a little bigger because it wouldn’t make sense to make them any smaller.
And well, let me give you an example. The tax code imposes a payroll tax and an income tax on every dollar of cash that you earn from your employer, up to a point, to be technically accurate, Social Security tax ends at a point. But it does not tax that dollar if your employer provides it to you in the form of health insurance. And what this arguably does is it creates what is, functionally, a mandate. Either you take some portion of your money of your compensation as health insurance, or if you want to take that money as cash and buy your own health insurance, you have to pay higher taxes, and that’s effectively a penalty if you don’t enroll in the kind of health plan the government wants you to enroll in. And I call this the original sin of U.S. health policy because that one mistake, which is an accident that Congress and the Treasury Department stumbled into, has caused just about every form of dysfunction that you will find in the U.S. health sector, and what it doesn’t cause, it made worse. And so the worst part might be that it separates workers from a trillion dollars of their earnings and lets employers control that trillion dollars year after year.
So what I propose is to change the tax code in a way that lets workers control that trillion dollars, lets them choose their health plan, and that levels the playing field between employer-sponsored insurance and other forms of insurance so they’re able to purchase health insurance that doesn’t disappear when their job does. And that might sound like a pretty big step, and I think that, kind of, it is, but it’s not as big as most people would think, I imagine, because the way I propose doing this would, I think, cap the exclusion for the first time, which is something that appeals to Democrats. They tried to do that in the Affordable Care Act. It didn’t work because it was just pure austerity, if all you do is tax health benefits. But what this proposal would do is return that trillion dollars to workers, which is, in effect, a tax cut and a progressive tax cut because it would mean more to low-income workers than high-income workers.
The average amount that employers spend on family coverage for their workers is $17,000 per year. The most recent [KFF] report just came out said, now, up to $17,000 per year, and that’s $17,000 of the worker’s earnings. So returning that money to the worker so they can control it, that’ll mean a lot to someone making six figures, but it’s going to mean a hell of a lot more to someone making $50,000 a year. They get to control a much larger share of their income. So it’s a progressive tax, but it also benefits people with expensive medical conditions more because they would get a bigger cash out than the average. Women, people with obesity, and so forth, that the economic research shows us they are actually losing control over a larger share of their earnings.
So the approach that I propose to reform the tax code might seem like a big step. I don’t think it’s going to happen in this Congress, but I think once people get their heads around how it actually serves both Democratic priorities and Republican priorities that may not only happen, but happen on a bipartisan basis.
Rovner: I can’t resist asking this question because economists love the idea of doing something about the employer tax exclusion for — I think it’s the largest single tax expenditure in the federal budget. But in the past, they’d always said, but what will consumers do if you give them back this money? There’s no market for them. Well, thanks to the Affordable Care Act, now there is a market for them, but you hated the Affordable Care Act. Would you not acknowledge, at some point, that now at least it’s more doable because if you give them back that money, there’s someplace for them to go and spend it on?
Cannon: So if people know me for anything, the role I played in trying to roll back or eliminate the Affordable Care Act. And so if folks who love Obamacare want some reason to dismiss what I have to say, there’s that. That’s there. I still think there’s a lot in the book for fans of Obamacare, but I gladly concede your point, Julie. One of the hardest parts about reforming the tax exclusion for employer-sponsored insurance is that if you do that, if you level the playing field between the employer market and the individual market for health insurance, there is a risk that some employers might drop their health plans and leave people with expensive medical conditions high and dry. That was the fear that Barack Obama exploited to great effect against John McCain in the 2008 presidential campaign, when John McCain proposed a universal tax credit. I think that was a bad proposal, and I’m not sorry that it failed, but listeners who don’t recall should look up “Barack Obama yarn commercial” and they’ll be able to see that 30-second television spot.
But as much as I do not like the Affordable Care Act, or Obamacare, as much as I think it has increased the cost and reduced the quality of health insurance, for everybody, I must concede that, now that it exists, it makes reforming the tax exclusion for employer-sponsored health insurance a lot easier. Because if someone says to me, Cannon, why should we go along with this plan of yours? What if employers drop coverage? I would say, well, first of all, employers are not likely to drop coverage. The Affordable Care Act has taught us that. Everyone thought that after Obamacare passed, employers would drop coverage. They really haven’t in the numbers we expected. But even if they do, there is that heavily regulated, heavily subsidized market that we call the exchanges that will be there for people whose employers do drop their coverage. So that becomes one less reason not to reform the tax exclusion.
Rovner: Such a good example of how it’s going to take everybody’s ideas to actually make all of this work. Michael Cannon, thank you so much. This has been fun. I could go on, I know you could go on, but we should stop now. We’ll have you back soon.
Cannon: That’d be great. Thank you so much, Julie.
Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org, and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?
Ollstein: Sure. So I chose a piece by my colleagues on our technology team about a massive set of lawsuits filed against Meta, which owns Facebook and Instagram. So this is challenging them for lying about their practices regarding children on their platforms, and not doing enough to prevent mental health problems for those children. And the massive array of lawsuits here, from state attorneys general, is being compared to the tobacco lawsuits that resulted in massive settlements and policy changes. And so it remains to be seen if this will result in the same, but I think there’s just been a lot of focus, especially recently, on how these platforms are designed to be addictive, are designed to push content that is outrageous, upsetting, etc., just to keep people scrolling and scrolling and scrolling, and especially how that’s impacting children. We’ve had a lot of concerns about mental health during the pandemic where kids were out of school, and thus, getting sucked into these sort of apps even more. So definitely something to follow.
Rovner: It is. Rachel.
Cohrs: So my story this week, the headline is “Ozempic and Wegovy Don’t Cost What You Think They Do,” from The New York Times and Gina Kolata. I thought this story was interesting. It essentially is a writeup of a study by the American Enterprise Institute just pointing out that net prices for these popular weight loss drugs are lower than their list prices, which may be true. And I think that she points out this interesting historical precedent with hepatitis C medications where they were really transformative, and initially …
Rovner: And crazy expensive.
Cohrs: Yes, very expensive. Also curative, which these drugs are not. But once more competition came on the market, prices did eventually go down, was the example of competition working, how, in theory, it should in this space. And certainly, we could see a similar dynamic play out with these medications. But one thing I think that just personally frustrates me as a reporter is the pharmaceutical industry likes to talk about how net prices are so much lower than list prices, and they’re so frustrated with the focus on list prices, but they never want to tell us what the net prices are. And I think that just puts reporters in a really difficult position where we don’t really know what truth is. And obviously, insurance companies are trying to spin things their own way, and pharma companies are trying to spin stuff their own way and nobody wants to show us the numbers. So I think that puts us in a difficult position.
Also, just would like to point out that a lot of employers’ insurance plans don’t necessarily cover these medications. It has been an uphill battle. Certainly there’s been progress, some state benefits plans, but there are cost concerns with these medications and I think there’s just some counter-programming here, with a new argument about the cost effectiveness long term. I thought it was an interesting point, not one that necessarily is new. And if insurance companies are covering these drugs, then patients are still stuck paying the out-of-pocket price. So interesting thought and would be good to include in cost-benefit analyses going forward. But again, if insurance companies, if pharmaceutical companies aren’t going to give us the numbers, then it just makes it really difficult to crunch those.
Rovner: I was actually interested in this story because one of the big things that I feel like people keep missing with these drugs is that they’re making these long-term assumptions that these drugs are always going to cost what they cost now. And there’s no — which is a lot of money, and would be prohibitively expensive if everybody who’s eligible for them were to take them. Obviously, we can’t afford that, but at some point, there is some competition and if they keep developing drugs, the cost will come down, and then it will be a whole lot easier for people to afford things. And then the cost-benefit analysis changes. So …
Ollstein: It might.
Rovner: Yeah.
Ollstein: We don’t really know.
Rovner: I get frustrated at people who assume that the price is what it is and that’s what it’s going to be going forward, because I suspect that is not the case. But I think you’re right. It will be high as long as they can keep it a secret.
All right, my extra-credit story is from The Washington Post this week by Greg Jaffe and Patrick Marley, and it’s called “The Pandemic Has Faded in This Michigan County. The Mistrust Never Ended.” It’s a long and beautifully written chronicle of just how enough people in Ottawa County in Michigan were convinced that public health is the enemy to result in, basically, a taking apart of the county’s health department. It is well worth reading the whole thing. It’s really heartbreaking.
All right, before we go this week, I have a sneak peek at some of the finalists for our KFF Health News Halloween Haiku Contest. The winners will be unveiled on Halloween, Oct. 31, but here’s one finalist from Michael Lisowski:
A trick or treatment,prior authorization,a fright to patients.
And here’s another, from Meg Murray:
Open enrollment,watch out for ghosts, goblins, andjunk insurance … [boo!]
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 tireless engineer, Francis Ying. 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, @jrovner or @julierovner at Bluesky and Threads. Alice, where are you these days?
Ollstein: I am @AliceOllstein on X and @alicemiranda on Bluesky.
Rovner: Rachel?
Cohrs: I’m @rachelcohrs on X.
Rovner: We will be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Stephanie Stapleton
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 5 months ago
Health Industry, Medicaid, Multimedia, Pharmaceuticals, Abortion, KFF Health News' 'What The Health?', NIH, Opioids, Podcasts, U.S. Congress
KFF Health News' 'What the Health?': The Open Enrollment Mixing Bowl
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Autumn is for pumpkins and raking leaves — and open enrollment for health plans. Medicare’s annual open enrollment began Oct. 1 and runs through Dec. 7. It will be followed shortly by the Affordable Care Act’s annual open enrollment, which starts Nov. 1 and runs until Jan. 15 in most states. But what used to be a fairly simple annual task — renewing an existing health plan or choosing a new one — has become a confusing, time-consuming mess for many, due to our convoluted health care system.
Meanwhile, Ohio will be the next state where voters will decide whether to protect abortion rights. Those on both sides of the debate are gearing up for the November vote, with anti-abortion forces hoping to break a losing streak of state ballot measures related to abortion since the 2022 overturn of Roe v. Wade.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.
Panelists
Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
Alice Miranda Ollstein
Politico
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- The U.S. House of Representatives has been without an elected speaker since Oct. 4. That means lawmakers cannot conduct any legislative business, with several important health bills pending — including renewal of the popular international HIV/AIDS program, PEPFAR.
- Open enrollment is not just for people looking to change health insurance plans. Plans themselves change, and those who do nothing risk continuing in a plan that no longer meets their needs.
- A new round of lawsuits has sprung up related to “abortion reversals,” a controversial practice in which a patient, having taken the first dose of a two-dose abortion medication regimen, takes a high dose of the hormone progesterone rather than the second medication that completes the abortion. In Colorado, a Catholic-affiliated health clinic says a state law banning the practice violates its religious rights, while in California, the state attorney general is suing two faith-based chains that operate pregnancy “crisis centers,” alleging that by advertising the procedure they are making “fraudulent and misleading” claims.
- The latest survey of employer health insurance by KFF shows annual family premiums are again escalating rapidly — up an average of 7% from 2022 to 2023, with even larger increases expected for 2024. It’s not clear whether the already high cost of providing insurance to workers — an annual family policy now averages just under $24,000 — will dampen companies’ enthusiasm for providing the benefit.
Also this week, Rovner interviews KFF Health News’ Arielle Zionts, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” feature about the wide cost variation of chemotherapy from state to state. If you have an outrageous or inscrutable medical you’d like to send us, you can do that here.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: NPR’s “How Gas Utilities Used Tobacco Tactics to Avoid Gas Stove Regulations,” by Jeff Brady.
Lauren Weber: KFF Health News’ “Doctors Abandon a Diagnosis Used to Justify Police Custody Deaths. It Might Live On, Anyway,” by Markian Hawryluk and Renuka Rayasam.
Joanne Kenen: The Washington Post’s “How Lunchables Ended Up on School Lunch Trays,” by Lenny Bernstein, Lauren Weber, and Dan Keating.
Alice Miranda Ollstein: KFF Health News’ “Pregnant and Addicted: Homeless Women See Hope in Street Medicine,” by Angela Hart.
Also mentioned in this week’s episode:
- The Washington Post’s “The Post Spent the Past Year Examining U.S. Life Expectancy. Here’s What We Found,” by The Washington Post staff.
- The Washington Post’s “Primary Care Saves Lives. Here’s Why It’s Failing Americans,” by Frances Stead Sellers.
- Vox’s “Vox Launches New Guide to Open Enrollment,” by Vox Communications.
- Politico Magazine’s “How Dobbs Triggered a ‘Vasectomy Revolution,’” by Jesús A. Rodríguez.
Click to open the transcript
Transcript: The Open Enrollment Mixing Bowl
KFF Health News’ ‘What the Health?’Episode Title: The Open Enrollment Mixing BowlEpisode Number: 319Published: Oct. 19, 2023
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 19, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Ollstein of Politico.
Alice Miranda Ollstein: Good morning,
Rovner: Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.
Joanne Kenen: Hi, everybody.
Rovner: Later in this episode, we’ll have my interview with Arielle Zionts, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” about how chemotherapy can cost five times more in one state than in another. But first this week’s news. So, it’s Oct. 19, the House of Representatives is still without a speaker. That’s 2½ weeks now. That means legislation can’t move. Are there health care items that are starting to stack up? And what would it mean if the House ends up with an anti-federal government conservative like Rep. Jim Jordan, who, at least as of this moment, is not yet the speaker and does not yet look like he has the votes?
Ollstein: So in terms of unfinished health care business, the three big things we are tracking are things that actually lapsed at the end of September. Congress did manage to keep the government open, but they allowed three big health care things to fall by the wayside, and those are PEPFAR, the global HIV/AIDS program, the SUPPORT Act, the programs for opioids and addiction, and PAHPA, the public health, pandemics, biohazards big bill. And so those …
Rovner: I think one of those P’s stands for “preparedness,” right?
Ollstein: Exactly, yes. But it’s related to pandemics, and you would think after all we just went through that that would be more of a priority, but here we are. The reauthorization of all three of those is just dangling out there and it’s unclear if and when Congress can act on them. There is some level of bipartisan support for all of them, but that is what is stacking up, and nothing is really happening on those fronts, according to my conversations with sources on the Hill because everything has just ground to a halt because of the speaker mess.
Rovner: And, of course, we’re less than a month away from the current continuing resolution running out again, and we may go through — who knows? They may get a new speaker and then he may lose his job or her job once they try to keep the government open in November. It’s a mess. I’ve never seen anything like this …
Kenen: Also, in addition to those three very political … even public health and pandemics are now politics … that Alice correctly pointed out, these three huge ideological, how are we going to get them reauthorized in the next 30 days? But there’s also more routine things that are not controversial but are caught up in this such as community health center funding, which has bipartisan support, but they need their apropos and all that stuff. So in addition to these sort of red-blue fights, there’s just, how do we keep the doors open for people who need access to health care? That’s not the only program. There are many day-to-day programs that like everything else in the government are up in the air.
Rovner: I mean, we should point out this is unprecedented. The only other time the House has been without a speaker this long was one year when they didn’t come in at the beginning of the Congress until later in January. It’s literally the only time. There’s never been a mid-session speakerless House. So everything that happens from here is unprecedented. Well, meanwhile, if you have turned on a TV in the past week, you already know this, but Medicare open enrollment began last Sunday, Oct. 15. To be clear, when you first become eligible for Medicare, you can sign up anytime in the three months before or after your birthday. But if you enroll in a private Medicare Advantage plan or a private prescription drug plan, and most people are in one or the other or both, open enrollment is when you can add or change coverage. This used to be pretty straightforward, but it’s only gotten more confusing as private plans have proliferated. This year the Biden administration is trying to fight back against some of the misleading marketing efforts. Politico reports that the government has rejected some 300 different ads. Is that enough to quell the confusion? I’m already seeing ads and kind of look at it, like, “I don’t think that says what it means to say.”
Weber: Yeah, we see this every year. It’s a ton of ads. It’s a barrage of ads that all say, “Hey, this plan is going to get you X, Y, Z, and that’s better than traditional Medicare.” But you got to read the fine print, and I think that is the big thing for all the folks that are looking at this every time. Open enrollment is very confusing, and a lot of times people are trying to sell you things that are not what they appear. So it does appear that there has been more movement to crack down on those ads. But look, the family members I talked to are still confused, so I don’t know how much that’s proliferating down quite yet.
Kenen: And even if the ads were honest, our health system is so confusing. Even if you’re at an employer health system. All of us are employed, all of us get insurance at work, and none of us really know we have made the best choice. I mean, you need a crystal ball to know what illness you and your relatives are going to get that year, and what the copays and deductibles for that specific condition. I’ve never been sure. I have three choices. They’re all decent, whether it’s the best for me and my family, with all that I know about health care, I still don’t know I made the best choice ’cause I don’t have a crystal ball or not one that works.
Rovner: Right. I also have choices, and I did my mom’s Medicare for years, as Joanne remembers …
Kenen: You did a great piece on that one.
Rovner: … this is the way I remember it. I did do a piece on that. Long time ago, when they were first starting the prescription drug benefit and you had to sort of sign up via a computer, and in 2006, not that many seniors knew how to use computers. At least we’re sort of over that, but there’s still complaints about the official website Medicare.gov, which does a pretty good job. It’s just got an awful lot of steps. It’s one of those things, it’s like, “OK, set aside two hours,” and that’s if you know what you’re doing to do this. So meanwhile, if this isn’t all confusing enough, open enrollment for the Affordable Care Act opens in two weeks, and while Medicare open enrollment ends Dec. 7, ACA enrollment goes through Jan. 15 in most, but not every, state. In both cases, if you get your insurance through Medicare or through the ACA, you should look to see what changes your plan might be making. I should say also, if it’s open enrollment for your employer insurance, plans make changes pretty much every year. So you may end up, even if you’re in the same plan, with a plan that you don’t like or a plan that you don’t like as much as you like it now. This is insanely complicated, as you point out, for everybody with insurance. Is there any way to make it easier?
Kenen: There’s no politically palatable way to make it easier. And then things they’ve done to try to make it easier, like consistent claims forms, which most of us don’t have to fill out anymore. Most of that’s done online, but they’re not using consistent claim forms and there’s nothing simple and there’s nothing that’s getting simpler. And we’re all savvy …
Rovner: It’s what keeps our “Bill of the Month” project in business.
Kenen: Right. We’re all pretty savvy and none of us are smart enough to solve every health care problem of us and our family.
Rovner: It’s one of those things where compromise actually makes for complexity. When policymakers can’t do something they really want to do, they do something smaller and more incremental. And so what you end up with is this built on, in every which way, kind of health care system that nobody knows how it works.
Kenen: Like the year I hurt both a finger and a toe. And I had a deductible for the finger, but not for the toe. Explain that!
Rovner: I assume it was in and out of network or not even.
Kenen: No. They were both in network. All of my digits are in network.
Weber: I just got a covid test bill from 2020 that I had previously knocked down by calling, but they rebilled me again. And because I am a savvy health care reporter, I was like, “I’m not paying this. I know that I don’t have to pay this.” But it took probably 10 hours to resolve, I mean, and that’s not even picking insurance. So I’m just saying it’s an incredibly complex marketplace. Shout-out to Vox who had a really nice series that tried to make it easier for people to understand the differences between Medicare and Medicare Advantage, open enrollment, what that all means. If you haven’t seen that and you’re confused about your insurance options, I would highly recommend it.
Rovner: And I will link to the Vox series, which is really good, but it was kind of looking at it. I mean, they had to write six different stories. It’s like that’s how confusing things are, which is really kind of sad here, but we will move on because we’re not going to solve this one today. So speaking of things that are complicated and getting more so, let’s turn to reproductive health. Alice, the big event that people on both sides are waiting for — one of those events, at least — is a ballot measure in Ohio that would establish a state constitutional right to abortion. So far, every state ballot measure we’ve seen has gone in favor of the abortions rights side. How are abortion opponents trying to flip the script here?
Ollstein: So I was in Ohio a couple of weeks ago and was really focused on that very question, just what are they doing differently? How are they learning lessons from all of the losses last year? And why do they think Ohio will be any different? I will say, since my piece came out, there was the first poll I’ve seen of how people are approaching the November referendum, and it showed overwhelming support for the abortion rights side, just like in every other state. So have that color, what I’m about to say next, which is that the anti-abortion side thinks they can win because they have a lot of structural factors working in their favor. They have the governor of Ohio really actively campaigning against the amendment. So that’s in contrast to [Gov. Gretchen] Whitmer in Michigan last year, campaigning actively for it. When you have a fairly popular governor, that does have an impact, they’re a known trusted voice to many. Also …
Rovner: And the governor of Ohio is also a former senator and I mean a really well-known guy.
Ollstein: Yeah. Yeah, exactly. You just have the entire state structure working to defeat this amendment. They tried in a special election in August to change the rules. That didn’t work. Now, you just have all of these top officials using their bully pulpit and their platforms to try to steer the vote in the anti-abortion direction. Also, the actual campaign itself is trying to learn lessons from last year and doing a few things differently. They’re going really aggressively after the African American vote, particularly through Black churches. And so that’s not something I saw in the states I reported on last year, and they’re really aggressively going after the student vote. And I went to a student campus event at Ohio State that the anti-abortion side was holding, and it seemed pretty effective. There was a ton of confusion among the students. A lot of the students are like, “Wait, didn’t we just vote on this?” referring to the August special. They said, “Wait a minute, which side means yes, and which side means no?” There was just rampant confusion, and it wasn’t helped … I observed the anti-abortion side, telling people some misleading things about what the amendment would and wouldn’t do. And so all of that could definitely have an impact. But like I said, since my story came out, a poll came out showing really strong support for the abortion rights amendment, which would block the state’s six-week ban, which is now held up in court, but the court leans pretty far to the right. This would block that from going back into effect potentially.
Rovner: Ohio, the ultimate swing state, probably the reddest swing state in the country. But Ohio is not the only state having an off-year election next month. Virginia doesn’t have an abortion measure on the ballot, but its entire state House and Senate are up for reelection. And from almost every ad I’ve seen from Democrats, it mentions abortion, and there’s a lot of ads here in the Washington, D.C., area for some of the Virginia elections. Republican Gov. Glenn Youngkin, who’s not on the ballot this year, thinks he has a way of talking about abortion that might give his side the edge. What are we going to be able to tell from the ultimate makeup of the very narrowly divided Virginia Legislature when this is all said and done?
Kenen: It won’t be veto-proof. Unlike North Carolina now, even if it’s the Democrats hold the one chamber they have or win both of them, and it’s really close. These are very closely divided, so we really don’t know how it’s going to turn out. But I mean he …
Rovner: One year it was so close that they literally had to draw rocks out of a bowl.
Kenen: Yeah, right. There’s highly unlikely that there will be a scenario where there’s a really strongly Democratic legislature with a Republican governor. That’s not likely. What’s likely is a very narrowly divided, and we don’t know who has the edge in which chamber. So the governor can’t just do things unilaterally, but how it plays out. And Youngkin’s backing a 15-week ban with some exceptions after that for life and health. A year ago, that would’ve seemed like an extreme measure. And now it seems moderate, I mean compared to zero weeks and no exceptions. So Virginia’s a red state, it’s swung blue. It’s now reddish again, I mean, it’s not a swing state so much in presidential, but on the ground, it’s a swing state. And …
Rovner: But I guess that’s what I was getting at was Youngkin’s trying to sort of paint his support as something moderate …
Kenen: That’s how he’s been trying to thread this needle ’cause he comes across as moderate and then he comes across as more conservative. And on abortion, what’s moderate now? I mean, in the current landscape among Republican governors, you could say his is moderate, but Alice follows the politics more closely, but half the country doesn’t think that’s moderate.
Rovner: If the Democrats retain or win both houses of the legislature, I mean, will that send us a message about abortion or is that just going to send us a message about Virginia being a very narrowly divided state?
Ollstein: I think both. I think Joanne is right in that the polling and the voting record over the last year reflect that a lot of people are not buying the idea that 15 weeks is moderate. And a lot of polls show that when presented the choice between a total ban and total protections, even people who are uncomfortable with the idea of abortions later in pregnancy opt for total protections. And so you’ve seen that play out. At the same time, there’s a lot of people on the right who correctly argue that the vast majority of abortions happen before 15 weeks, and so 15 weeks is not going far enough. And they’re not in favor of that as so-called compromise or moderate policy. And so …
Rovner: There are no compromises in abortion.
Ollstein: Truly, truly.
Rovner: If we’ve learned anything, we’ve learned that.
Ollstein: And when you try to please everyone, sometimes you please no one, as we’ve seen with both candidates and policies that try to thread this needle. And so I think it will be a really interesting test because yes, right now the legislature is sort of the firewall between what the governor wants to do on abortion, and whether that will continue to be true is a really interesting question.
Rovner: Meanwhile, we have dueling abortion reversal lawsuits going on in both Colorado and California. Abortion reversal, for those who don’t follow all the jargon, is the concept of interrupting the two-medication regime for abortion by pill. And instead of taking the second medication, the pregnant person takes large doses of the hormone progesterone. The American College of Obstetricians and Gynecologists says there is no evidence that this works to reverse a medication abortion and that it’s unethical for doctors to prescribe it. But in Colorado, a Christian health clinic is charging that a state law that bans the practice offering abortion reversal violates their freedom of religion. In California, it’s actually the opposite. The state attorney general is suing a pregnancy crisis center for false advertising, promoting the practice. Alice, how big a deal could this fight over abortion reversal become? And that’s assuming that the pill remains widely available, which is going to be decided by yet another lawsuit.
Ollstein: Yeah, absolutely. Although it’ll be a long time before we know whether mifepristone is legally available on a federal basis. But I’ve been watching this bubble up for years, but it’s up till now been more of a rhetorical fight in terms of: “Abortion reversal is a thing.” “No, it’s not.” “Yes, it is.” “No, it’s not.” “Here’s my expert saying it is.” “Here’s my expert saying it’s not.” But this is really moving it into a more sort of concrete, legal realm, and not just rhetoric. And so it is an escalation, and it will be interesting to see. Mainstream health care organizations do not support this practice. There was a clinical trial of it going on that was actually called off because of the potential dangers involved and risks to participants …
Rovner: Of doing the abortion reversal method …
Ollstein: Exactly. Yes.
Rovner: … of trying to interrupt a medication abortion.
Ollstein: Yes. This is really on the cutting edge of where medicine and politics are clashing right now.
Rovner: Yeah, we’ll see how it, and, of course, if they end up in different places, this could be something else that ends up in front of the Supreme Court. And this is, I think, less of an argument about religious freedom than an argument about the ability of medical organizations to determine what is or isn’t standard of practice based on evidence. I mean, I guess in some ways it becomes the same thing as the broader mifepristone case, where it’s like, do you trust the FDA to determine what’s safe? And now, it’s like, do you trust ACOG and the AMA [American Medical Association] and other organizations of doctors to decide what should be allowed?
Kenen: I mean, progesterone has medical purposes, it’s used to prevent miscarriages, but it’s off-label. It goes into these other questions, which all of us have written about — ivermectin, and who gets legal substances, and how do you use them properly, and what’s the danger? And there’s a bunch of them.
Weber: I think the fight over standard of care has really become the next frontier in medical lawsuits. I mean, we’ve all written about this, but ivermectin, obviously, misinformation, prescribing hydroxychloroquine, all of these things are now getting into the legal field. Is that the standard of care? What is the standard of care and how does that play out? So I agree with you. I think this is going to end up by the Supreme Court and I think it has much broader implications than just for mifepristone and abortion drugs too.
Rovner: Yeah, I do too. Well, finally, in an update I did not have on my post-Roe Bingo card, it appears that vasectomies are up in some states, including Oregon, where abortion is still legal, and Oklahoma, where it’s not very widely available. Are men finally taking more responsibility for not getting the women they have sex with pregnant? That would be a big sea change.
Ollstein: Yeah, we’ve been hearing anecdotally that this has been the case definitely since Dobbs and even before that as abortion restrictions were mounting. Politico Magazine did a nice piece on this last year profiling vasectomy [in] a mobile van. And it’s also just fascinating and a lot of people have been highlighting just how few restrictions on vasectomies there are compared to more permanent sterilization for women: no waiting periods, no fighting about it. And so it does provide an interesting contrast there.
Rovner: I know there have been stories over the years about how the demand for vasectomies goes up right before the NCAA tournament in March and April because men figure that they can just recuperate while watching basketball.
Ollstein: I thought that was a myth then I looked it up and it’s absolutely true.
Rovner: It is absolutely true.
Kenen: I mean, it also seems to be more common among older men who’ve had a family and because it’s permanent, I mean usually permanent. It’s usually permanent and right, it’s one thing to decide after a certain point in your life when you’ve already had your kids. I mean, it’s not going to be an option for younger men who haven’t had children.
Rovner: It’s also reliable, it is one of those things that you don’t have to worry about.
Kenen: Even though I looked up the figures once, it’s a very, very low failure rate, but it’s not zero.
Rovner: True. We are moving on to what I call this week in declining life expectancy. I’m glad that Lauren is back with us because The Washington Post has published the next pieces of its deep dive into the U.S. population’s declining life expectancy. And we’re going to start with a story that was co-written by Lauren, but that is Joanne’s extra credit this week. So Joanne, you start, and then Lauren, you can chime in.
Kenen: OK. It’s “How Lunchables Ended Up on School Lunch Trays.” For those of you who have never been in a supermarket or who have closed your eyes in certain aisles, Lunchables are heavily processed, encased in plastic, small lunchboxes of a — it’s not even much of a meal or small — which you can buy in the supermarket. And now two of them have been modified so that they’re allowed in schools as healthy enough …
Rovner: They’re quote, unquote, “balanced” because it’s a little piece of meat and a little piece of cheese.
Kenen: They have so far just a turkey cheese option that qualifies for schools and a pizza that qualifies for schools. Not a whole pizza, a little … but the kid in the story, the second grader in the story, didn’t even know it was turkey. It has 14 ingredients. He thought it was ham. So I mean, that just sort of says it, but it’s beyond the lack of nutrition, it started out sort of like what is this child putting in his mouth and why is it called school lunch? But the story was deeper because it was a very long investigation by Lauren and Dan Keating on the relationship between the food industry, the trade group, and the government regulation. And just say, it leaves a lot to be desired. And you should all read the story only because you can click on the story of the oversized Cheez-It.
I mean, it’s a fake one, but the replica of this as big as the planet Mars. I mean, it’s just this huge Cheez-It. And it’s a really good story because it’s overprocessed food is really bad for us. And I mean, scientists have matched the rise of this overprocessed stuff that began as food and the rise of obesity in America. And it’s not just taking the salt out of it, which they’re doing, the sodium out of or adding a little calcium or something to these processed foods. They’re ultra-processed foods, and that’s not what our body needs.
Rovner: So, Lauren, I mean, how does this relate to the rest of this declining life expectancy project and what else is there to come?
Weber: This is our big tranche of stories. I mean, we should have some follows, but that’s it. And well, Joanne, thank you for the kind words on it. We really appreciate that. But I mean, I think the point that she made that I want to highlight for this in general is what was wild in investigating this story is pizza sauce is a vegetable in the U.S. when it comes to school lunch and french fries are also a vegetable. And that’s really all you need to sum up how the industry influence in Congress has resulted in what kids are having for their school lunch today. One of the things we got to do for the story is go to the national School Nutrition Association conference, which is where we saw the giant Cheez-It. And it’s this massive trade fair of all these companies where they throw parties for the school nutrition personnel to try all the different food. And it’s wild to see in real life. And what Joanne made a good point of about ultra-processed food and what the rules do right now is they don’t consider the integrity of the food. They set limits on calories and sodium, but they don’t consider what kids are actually eating. And so you end up with these ultra-processed foods that growing body of research suggests really have some negative health consequences for you. And so, as Joanne talked about, and as our series gets into, obesity is a real problem in this country, and obesity has huge, long-lasting, life-shortening impacts. One of the folks we talked to for the piece, Michael Moss, said, he worries that processed food is the new tobacco because he feels like smoking’s going down, but obesity’s going up. And something he said to me that didn’t make the piece, but I thought was really interesting is that at some point he thinks there’ll be some sort of class-action lawsuit against ultra-processed food, much like a cigarette lawsuit-
Rovner: Like with tobacco.
Weber: Like a tobacco lawsuit, like an opioid lawsuit. I think that’s kind of interesting to think about, but this was just one of the many life expectancy stories. I want to shout out my colleague Frances Stead Sellers’ story, which talked about how it compared is brilliant. It compared two sisters with rheumatoid arthritis, one who lives in the U.S. and one who lives in Portugal. They’re both from Portugal. The one in Portugal has all this fabulous primary health care. The doctors even call her on Christmas and they’re like, “We’re worried you’re going to have chocolate cherries with brandy that would interact with your medicine.” Whereas the one in the U.S. has to go to the ER all the time because she doesn’t have steady health care and she can’t seem to make it work, ends meet. She doesn’t have a primary health care system. She’s a disjointed doctor system. And the end of the story is the sister in the U.S. who has this severe health problem is moving to Portugal because it’s just so much better there for primary care. And I think that gets at a lot of what our stories on life expectancy have talked about, which is that primary care, preventative care in the U.S. is not a priority and it results in a lot of downstream consequences that are shortening America’s life expectancy.
Rovner: Well, I hope when this project is all published that you put all the stories together and send them to every school of public health in the United States. That would be fairly useful. I bet public health professors would appreciate it.
Weber: Thank you.
Rovner: So it is mid-October, that means it is time for the annual KFF survey of employer health insurance. And for the first time since the pandemic, most premiums are up markedly, an average of 7% from 2022 to 2023 with indications of even larger increases coming for 2024. Now, to people like me and Joanne, who’ve been doing this for a long time, lived through years of double-digit increases in the early 2000s, 7% doesn’t seem that big, but today, the average family health insurance premium is about the same as the cost of a small car. So is there a breaking point for the employer health system? I mean, one of the things — to go back to what we were talking about at the beginning — one of the compromised ways we’ve kept the system functional is by allowing these pieces to remain in pieces. Employers have wanted to offer health insurance. It’s an important fringe benefit to help attract workers. But you’re paying $25,000 a year for a family plan, unless you’re a really big company. And even if you are a really big company, that’s an awful lot of money.
Kenen: One of the things that struck me is, we’re at a point when we’ve had a lot of strikes and reactivated labor movement, but 20 years ago, the fights were about the cost of health care. The famous Verizon strike. They were big strikes that were about health care, the cost. And right now, I’m not really hearing that too much. I’m sure it’s part of the conversation, but it’s not the top. It’s not the headline of what these strikes are about. They’re about salaries mostly and working conditions with nurses and ratios and things like that. I’m not hearing health care costs, but I sort of think we will because, yes, we are being subsidized by our employers, most of us. But you said, “What’s the breaking point?” Well, apparently there isn’t one. We’ve asked ourselves that every single year. And when do we stop doing it? No one has a good answer for that. And related is to what Lauren was just talking about, life expectancy. The lack of primary care in this country, in addition to improving our health, it would probably bring down cost. We used to spend 6 cents on the dollar on primary care, 6 cents. Other countries spend a lot more. Now, we’re down to 4.5 cents. So the stuff that keeps you well and spots problems and has somebody who recognizes when something’s going wrong in you because you’re their patient as opposed to … there’s nothing. I don’t mean that urgent care doesn’t have a place. It does, but it’s not the same thing as somebody who gives you continuity of care. So these are all related. I’ll stop. It’s a mess. Someone else can say it’s a mess now.
Rovner: It’s definitely a mess and we are not going to fix it today, but we’ll keep trying.
Kenen: Maybe next week.
Rovner: All right. Yeah, maybe next week. That is this week’s news. Now, we will play my “Bill of the Month” interview with Arielle Zionts. And then we will come back and do our extra credits.
I am pleased to welcome to the podcast my KFF Health News colleague Arielle Zionts who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment. Arielle, welcome to the podcast.
Arielle Zionts: Thanks for having me.
Rovner: So this month’s patient is grappling with a grave cancer diagnosis, a toddler, and some inexplicable bills from hospitals in two different states. Tell us a little bit about her.
Zionts: Sure. So Emily Gebel is from Alaska and has a husband and two young kids. She home-schools them. She really likes the outdoors, reading, foraging, and she was diagnosed with breast cancer. Just something that makes me so sad is she found out when she was basically breastfeeding because she felt a lump. And then when she was diagnosed, her baby was asleep in her arms when she got that call. So it just really shows what it’s like to be a mom and to have cancer. She was living in Juneau at the time. Her friends who’ve had cancer suggested [they] wanted to go to a bigger city. Whether it’s true or not, the idea was, OK, bigger cities are going to have bigger care. Juneau is not a big city, and you cannot drive there. You have to take a ferry or you have to fly in, and this is the capital of Alaska. So that might …
Rovner: Yes, I’ve been there. It’s very picturesque and very small and very hard to get to.
Zionts: Yeah, so that might be surprising for some people. The closest major American city is Seattle. So she went there for her surgery and then she decided to have chemo, and she opted for this special type of chemo that uses lower dose, but more frequent doses. The idea is that it creates less of the side effects, and she went to this standalone clinic in Seattle, flying there every week. It’s not a quick flight. It can take up to two hours and 45 minutes. And that just got really tiring. I mean, physically …
Rovner: And she’s got kids at home.
Zionts: Yes, physically and mentally and just taking up time. So she decided to switch to the local hospital in Juneau. So they had bills from the first clinic in Seattle, and then they got some estimates from the one in Juneau and then finally got a bill from there as well.
Rovner: Yes, as we say, “Then the bill came.” And, boy, there was a big difference between the same chemotherapy in Seattle and in Juneau, Alaska, right?
Zionts: I compared two of Emily’s treatments that used a similar mix of drugs and also had overlapping non-drug charges, such as how much it costs for the first hour of treatment, subsequent hours. And in the Seattle clinic, one round cost about $1,600. And then in Juneau it cost more than $5,000, so more than three times higher. And we were able to look at specific charges. So that first hour of chemo was $1,000 in Juneau, which is more than twice the rate in the Seattle clinic. There was a drug that cost more than three times the price at the clinic. And then even the cheaper charges were more expensive. So the hospital charged $19.15 for Benadryl, which is about 22 times the price at the clinic, which was 87 cents.
Rovner: Now to be clear, the Gebel family seems to have pretty comprehensive insurance. So this case wasn’t as much about their out-of-pocket costs as some of the other Bills of the Month that we’ve covered, but they did want to know why there was such a big difference, and what did they, and we find out?
Zionts: Yeah. So we started the story for NPR, we basically started saying, “Hey, this is a little different than the other ones because the family has met their maximum out-of-pocket.”
Rovner: For the year?
Zionts: Yes. Once you pay a certain amount of money for the year, your insurance will cover everything, and that can be a high number. But if you have cancer, cancer’s expensive, so you will probably hit it at some point. By the time she switched her treatment to Juneau, she had met that, so she wouldn’t actually owe anything.
Rovner: But what did they find out nevertheless, about why it costs that much more in Juneau than it did in Seattle?
Zionts: Yes. So Jered, her husband, he is somewhat of a self-taught medical billing expert. He gained this knowledge by listening to “Bill of the Month” and then reading some books about this. I mean, at first, he thought maybe they would owe money, but then he learned they wouldn’t. But he still didn’t think it was fair. I mean, he didn’t think it was fair for the insurance companies. And he did catch two errors. One of them, an estimate, was wrong. The hospital said, “Oh, it looks like there was a computer error,” and that was lowered. And then when it came for the actual bill, there was a coding error. It made one of the drugs not covered when it should have been. So that would’ve actually left them out-of-pocket costs. So he was able to lower an estimate, lower the bill. But again, even with those changes, it was still so much more expensive. And that’s when I called some experts and someone’s gut reaction or initial hypothesis might be, “Well, of course, it’s more expensive in Alaska. Alaska is small, it’s remote. I mean, it’s just going to cost more to ship things there. You need to pay doctors more to entice them to live there.”
Rovner: And it costs more for doctors to live there anyway, right?
Zionts: Yes.
Rovner: The cost of living is high in Alaska.
Zionts: Yes. The expert I spoke with, an economist who has studied this issue. He said, “Yes, that is part of it.” Like you said, everything is more expensive in Alaska, but even when accounting for that, the prices are even higher. So the growth of cost in the health care sector in Alaska is higher than the growth of overall cost. And he listed some policies or trends that might explain that. There’s one that really stood out, which is something called the “80th percentile rule,” but it was meant to contain cost for when you’re seen by out-of-network providers. And it seems that it may have actually backfired, and the state is considering repealing that. But as Elisabeth Rosenthal, one of our editors at KFF Health News, and she’s written an entire book about this, as she said, “This is how our health system works. There’s no law saying, this is how much you can upcharge for some intrinsic value of a medicine or of a service. So hospitals can do what they want.” So …
Rovner: And we should point out, I mean, this is not a for-profit hospital, right? It’s owned by the city.
Zionts: Yes. This is a nonprofit hospital owned by the city, and they don’t get a ton of money from the city or state, which is interesting though. So they’re really getting their funding from the services they provide. And the hospital said they try to make it fair by comparing it to wholesale costs, what other hospitals in the region are charging. But they also said, “Yes, we do need to account for the higher costs.”
Rovner: So what’s the takeaway here? I mean, basically what it costs is going to depend on where you live?
Zionts: Basically, what we’ve learned from all these Bill of the Months is that it’s going to vary depending on what facility you go to. And that could be within one city, the prices could vary. And then you might see some more variation between states and especially in states where the cost of living is higher or it’s more remote.
Rovner: Of which Alaska is both.
Zionts: Yes. And actually, something to add is that the amount of money that this hospital has to spend to fly in doctors and nurses and also just staff, even nonmedical staff, they spent nearly $11 million last year to transport them and pay them because they don’t have enough local people. And the other takeaway, though, is that yes, this can be explained, but also, it’s unexplainable in the sense that our health care system doesn’t have some magic formula or some hard rules about what is, quote, “fair.”
Rovner: Yes, at least when it comes to Medicare, Congress has been trying to do that for, oh, I don’t know, about 50 years now. Still working on it. Arielle Zionts, thank you very much for joining us.
Zionts: Thank you for having me.
Rovner: OK. We are back, and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Joanne, you’ve already done yours. Alice, why don’t you go next?
Ollstein: I did a piece by my former colleague Angela Hart for KFF Health News, and it’s about street medicine. So teams of doctors working with unhoused people, and this is profiling mainly in Northern California, but it’s sort of discussing this across the country. And in addition to the really very moving personal stories that she found in her reporting, she also talked about some of the structural stuff that is supporting the expansion of this kind of health care. And so California was already putting a lot of money into health care services for the homeless, but in hospitals and in clinics, they were finding that people just aren’t able to come in. Whether it’s because they don’t want to leave all of their earthly possessions unguarded or because they can’t get the transportation or whatever. And so that money’s now being redirected into having the doctors go to them, which seems to be successful in some ways, but the depth of health care problems is just so deep. And …
Rovner: But also, really the importance of primary care.
Ollstein: Absolutely. And so what they’re finding is just a lot of pregnancies and problems with pregnancy in the homeless population. And so they’re doing more services around that and more offering contraception and prenatal care for the people who are already pregnant. It’s very sad, but somewhat hopeful. And the other more structural thing is changing rules so that doctors can get reimbursed at a decent rate for providing street medicine as opposed to in brick-and-mortar facilities.
Rovner: Thanks. Lauren?
Weber: So I also have a KFF special from my former colleagues, Markian [Hawryluk] and Renu [Rayasam]. It’s just a great piece. It’s called “Doctors Abandon a Diagnosis Used to Justify Police Custody Deaths. It Might Live On, Anyway.” So what the piece does is it interviews the doctor who helped debunk what excited delirium is for his medical organization, but it reveals that that may not help in terms of court cases that have already been decided and in terms of science in general. And I think it’s so fascinating because what this piece does is it gets at what happens when flawed science then is used for lawsuits and consequential things for many, many years to come. I think we’ve seen a lot of stories this year about flawed science and what the actual ramifications are after, and this is clearly horrible ramifications here. And it’s just kind of a fascinating question of how does that ever get made right and how do things slowly or ever go back to what they should be after flawed science is revealed? So really, really great work from the team.
Rovner: Yeah, it’s really good piece. Well, keeping with the theme of choosing stories by our former colleagues. Mine is from a former colleague at NPR, Jeff Brady, and it’s “How Gas Utilities Used Tobacco Tactics to Avoid Gas Stove Regulations.” And if you don’t know what that refers to, I have a book or several for you about the huge sums of money that the tobacco industry paid over many decades to have captive, scientific, quote-unquote, “experts” counterclaims that smoking is bad for your health. It turns out that the gas stove industry likewise knew that gas stoves were worse for your health than electric ones, and that those vent hoods don’t really take care of all the problems of the things that gas stoves emit. And that it also paid for studies intended to muddy the waters and confuse both customers and regulators. It’s a pretty damning story, and I say that as someone who is very much attached to my gas stove but am now having second thoughts.
OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks as always to our amazing and patient engineer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me holding down the fort at X, I’m @jrovner or @julierovner at Bluesky and Threads. Joanne, where are you these days?
Kenen: I’m more on Threads, @joannekenen1. I still have a Twitter account, @JoanneKenen, where I’m not very active.
Rovner: Alice?
Ollstein: I am @AliceOllstein on X and @alicemiranda on Bluesky.
Rovner: Lauren?
Weber: I’m @LaurenWeberHP on X, the HP stands for health policy, as I like to tell people.
Rovner: We will be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Stephanie Stapleton
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 6 months ago
Aging, Courts, Elections, Health Care Costs, Insurance, Medicaid, Medicare, Multimedia, Pharmaceuticals, States, Abortion, Children's Health, KFF Health News' 'What The Health?', Podcasts, U.S. Congress, Women's Health
KFF Health News' 'What the Health?': Health Funding in Question in a Speaker-Less Congress
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
As House Republicans struggle — again — to decide who will lead them, the clock is ticking on a short-term spending bill that keeps the federal government running only until mid-November. The turn of the fiscal year has also left key health programs in limbo, including the one that provides international aid to combat HIV and AIDS.
Meanwhile, a major investigation by The Washington Post into why U.S. life expectancy is declining found that the reasons, while many and varied, tend to point to a lesser emphasis on public health here than in many peer nations.
This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Victoria Knight of Axios, and Lauren Weber of The Washington Post.
Panelists
Sarah Karlin-Smith
Pink Sheet
Victoria Knight
Axios
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- House Republicans are choosing a new speaker with government funding still uncertain beyond Nov. 17. But some programs are already experiencing a lapse in their congressional authorizations, notably the global HIV/AIDS program known as PEPFAR — and the problems in renewing it are sending a troubling signal to the world about the United States’ commitment to a program credited with saving millions of lives.
- Drug companies have entered into agreements with federal health officials for new Medicare price negotiations even as many of them challenge the process in court. Early signals from one conservative federal judge indicate the courts may not be sympathetic to the notion that drug companies are being compelled to participate in the negotiations.
- Kaiser Permanente health system employees and pharmacists with major chains are among the American health care workers on strike. What do the labor strikes have in common? The outcry from workers over how staffing shortages are endangering patients, leaving overwhelmed medical personnel to manage seemingly impossible workloads.
- Elsewhere in the nation, new covid-19 vaccines are proving difficult to come by, particularly for young kids. Officials point to this being the first time the vaccines are being distributed and paid for by the private sector, rather than the federal government.
- Reporting shows those getting kicked off Medicaid are struggling to transition to coverage through the Affordable Care Act exchanges, even though many are eligible.
Also this week, Rovner interviews physician-author-novelist Samuel Shem, whose landmark satirical novel, “The House of God,” shook up medical training in the late 1970s. Shem’s new book, “Our Hospital,” paints a grim picture of the state of the American health care workforce in the age of covid.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Atlantic’s “Virginia Could Decide the Future of the GOP’s Abortion Policy,” by Ronald Brownstein.
Sarah Karlin-Smith: The Wall Street Journal’s “Children Are Dying in Ill-Prepared Emergency Rooms Across America,” by Liz Essley Whyte and Melanie Evans.
Lauren Weber: ProPublica’s “Philips Kept Complaints About Dangerous Breathing Machines Secret While Company Profits Soared,” by Debbie Cenziper, ProPublica; Michael D. Sallah, Michael Korsh, and Evan Robinson-Johnson, Pittsburgh Post-Gazette; and Monica Sager, Northwestern University.
Victoria Knight: KFF Health News’ “Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients,” by Susan Jaffe.
Also mentioned in this week’s episode:
- The Washington Post’s “Medicaid Rolls Are Being Cut. Few Are Finding Refuge in ACA Plans,” by Amy Goldstein.
- The Washington Post’s “An Epidemic of Chronic Illness Is Killing Us Too Soon,” by Joel Achenbach, Dan Keating, Laurie McGinley, Akilah Johnson, and Jahi Chikwendiu.
- The Washington Post’s “How Red-State Politics Are Shaving Years Off American Lives,” by Lauren Weber, Dan Diamond, and Dan Keating.
- The Washington Post’s “England Considers Raising Smoking Age Until Cigarettes Are Banned Entirely,” by Andrew Jeong.
click to open the transcript
Transcript: Health Funding in Question in a Speaker-Less Congress
KFF Health News’ ‘What the Health?’Episode Title: Health Funding in Question in a Speaker-Less CongressEpisode Number: 318Published: Oct. 12, 2023
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 12, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this, so here we go.
We are joined today via video conference by Victoria Knight of Axios.
Victoria Knight: Good morning.
Rovner: Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: And Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: Later in this episode, we’ll have my interview with doctor-author Samuel Shem, who wrote “House of God,” the seminal novel about medical training, back in the 1970s, and who has a new take on what ails our health care system. But first, the news. So, we’ve been off for a week so KFF could have an all-staff retreat in California, which was lovely, by the way. And against all odds, it’s Oct. 12 and the federal government is not shut down, although the continuing resolution that squeaked through Congress at the very last minute on Sept. 30 expires Nov. 17, so we could be going through all of this again next month.
Meanwhile, conservative Republicans, who were angry that House Speaker Kevin McCarthy agreed to keep the government open, ousted him from his job, the first time ever a speaker has been kicked out mid-Congress, and things are, to put it mildly, in disarray. But I want to go back to that six-week continuing resolution. It does just continue appropriations, but it also had some important, if temporary, authorizing provisions, like for community health centers, right, Victoria?
Knight: Yeah, that’s right. There were a few provisions that just kind of kept it going as it was, funded at the same level. That was community health centers, and there were a few for the Pandemic and All-Hazards Preparedness Act. Then there were also some things that were not renewed in PAHPA, and then also the PEPFAR program [the U.S. President’s Emergency Plan for AIDS Relief], which I figured we might talk about a little bit, which is the program that funds programs in other countries to help with HIV/AIDS treatment and research, and it’s been a long-standing bipartisan program, and it has come up against some obstacles this Congress.
Rovner: Just to remind people who don’t follow this as closely as we do, the appropriations are what actually keep the lights on. Those are the spending bills that Congress has to pass, either in permanent or temporary fashion, at the beginning of the fiscal year, Oct. 1, or things shut down. Things like PEPFAR and community health centers continue to get funded, but their official authorizations expired at the end of the fiscal year. While the community health centers were kept going, PEPFAR has not. Of course, the House, which is, as we speak, still leaderless, can’t really do anything. Are there, at least, negotiations going on? I know PEPFAR really is a bipartisan program, as you say, and there is some effort to keep it going, because some people frankly say it’s embarrassing for the United States to look like it is reneging on this, even though it’s technically not.
Knight: Well, I know it was originally started under a Republican president, George W. Bush, and has always been reauthorized for five-year intervals. That’s never not happened. I’ve talked to members of Congress about this. In the House, they only want to reauthorize it for one year, and they’ve been very open about that’s because they want a new Republican president to come in and further restrict where funding is going, to really, in their mind, ensure it’s not going to abortion funding, even though there’s really no evidence that funding from PEPFAR goes to NGOs [nongovernmental organizations] that fund abortions or anything like that.
Then, in the Senate, it’s a different story. Another little factor is that Sen. Bob Menendez was the lead on this, and then he had to step —
Rovner: Oops.
Knight: He had to step down from his chair of the Senate Foreign Relations Committee, and that’s just a matter of Senate rules, since he’s under indictment.
Rovner: Again.
Knight: Again, yes, and so Sen. Ben Cardin just took that chairmanship. I’m not sure how much PEPFAR is on his radar. I tried to ask him about it recently, and he was like, “I’ve got to go to a meeting.” I know for Menendez, it was a really big thing that he cared about and was like, “I want to reauthorize it for five years.” So, as far as I can tell, it’s kind of a standstill between the House and the Senate and, to be determined, but maybe at the end of the year, if we get a big bill, something will be put in there. Maybe they’ll negotiate it to three years. I’ve heard something about that, but again, this will be the first time it hasn’t been reauthorized for five years, and that would send a signal to other countries that maybe the U.S. is not as devoted to treating HIV/AIDS and helping programs in other countries.
Rovner: Yeah, obviously, with everything else going on in the world, it’s not the biggest deal, but there are still a lot of people who are very concerned about it. The other at least somewhat surprising thing that happened on Oct. 1, the beginning of the fiscal year, is that all of the drugmakers responsible for the 10 drugs that Medicare has selected for the first round of price negotiation have agreed to negotiate, at least for now. That’s likely because the first round of the first of several lawsuits in federal court seeking to block the program found in favor of the government. In other words, the program did not get blocked by the courts. But Sarah, this fight is a long way from over, right?
Karlin-Smith: Yeah, there’s a number of lawsuits. I think we might be up to eight now, but don’t hold me to that exact figure.
Rovner: Excel spreadsheets.
Karlin-Smith: Yeah. Even this lawsuit, the initial blow I think was pretty big for the drug industry here, because we have a Trump-appointed judge who made a pretty clear preliminary decision that he doesn’t think the drug industry can make its constitutionality challenges that this law is not constitutional, which I think is a pretty big deal, because most of the initial lawsuits revolved around constitutional challenges. Then, there are other issues, in the first particular case, around whether even the people who are suing have standing or it’s ripe for a lawsuit now, whether because anybody’s actually been harmed at this point. Yet, everybody, all the companies, have entered into agreements with Medicare to negotiate now. A lot of them have said, “Well, we’re doing this, but basically because we have no other choice. We have to. We’re doing it in protest. We’re still continuing our lawsuits.”
So, you can expect two parallel tracks to be going on right now, mostly behind the scenes. This is pretty much going to take a whole year for Medicare and the companies to get to the place where we’ll then see a public negotiated price next fall, next September. And these lawsuits to proceed, again, just I think the constitutionality issue got a really big blow. There are some other lawsuits that I think could be more interesting that are arguing more about decisions Medicare made, so more about APA, Procedures Act, cases, which are a little bit different and I think might have a little bit more chance of getting the drug industry some wins.
Rovner: The APA is the Administrative Procedures Act —
Karlin-Smith: Procedures Act, thank you.
Rovner: — and basically saying that Medicare didn’t follow all of the appropriate rules in how it devised and rolled out the program.
Karlin-Smith: Right, and I think —
Rovner: As opposed to the big lawsuits that said, “You can’t force us to do this,” which, not a lawyer, but every other health provider goes under the if you want to play in Medicare, you have to take our price, so it’s hard to see where the drug companies are going to have something completely different, but that’s just me. You never know.
Karlin-Smith: Right, and this Trump-appointed judge — I keep emphasizing that because they picked the 5th Circuit, they looked for a friendly judge, and they couldn’t get the win there. He said, “Medicare is a voluntary program. The government has stopped forcing you to participate in Medicare. If you don’t like this, you can leave.” I think this is a pretty symbolic loss for the industry and some of these arguments they’re going to make.
That said, these APA cases, you can maybe see them getting more tweaks around the edges to shift the program in ways that favor it, but we know the way litigation works in this country; it’s going to be this long slog to figure out how that shakes out as the program is potentially, again, on the other side, getting worked out and maybe implemented.
Rovner: We will see. All right. Well, elsewhere in disarray, if this was the summer of strikes in Hollywood, it’s shaping up as the autumn of strikes by health workers. Last week, 75,000 workers at Kaiser Permanente — no relation, just for my listeners — in several states walked out for three days. Workers at several other hospitals in and around Los Angeles walked out, and we’re seeing pharmacists taking work actions at both of the big chains, CVS and Walgreens. All of these walkouts have basically the same thing in common. Striking workers say that the shortage of personnel is endangering patients, as those who are left at work face impossible workloads.
These employers are not in a great situation to fix this. Covid accelerated the departure of a lot of healthcare workers, and there simply aren’t the bodies to fill all of these vacant positions. Is there any settlement in sight? Any way to fix any of this that anybody’s proposed?
Weber: I think if any of us sitting at this table have family, friends that work as nurses or pharmacists, they’ve been hearing about these problems for years. I mean, all it takes is talking to somebody that works in this industry to realize that they have been short-staffed and underfunded for a very long time. A lot of them really worry about the actual errors that can result from that. I mean, I think what’s really important to consider is to get to a strike, you have to have a lot of bad things going on. I mean, I think some of the reports say that some of these hospitals have filed countless complaints with the local county health in California that had not gotten listened to about their staffing shortages.
When you have short staffing for nurses, that means that you feel like patients are not getting seen. Something could be happening. They feel like they’re putting these people in jeopardy. I don’t really think there’s going to be a lot of end to this in sight. I think, once you kick off these strikes like this, it’s a bit of a chain effect. I mean, we saw CVS pharmacy employees had a strike, and then Walgreens employees have started doing that.
Frankly, the CVS one was pretty successful. The CVS CEO went out there and said, “Look, we hear your conditions. We’ll work on cutting down hours, and we’ll try and accommodate you.” I think we’re going to be in for a lot more of these in the months to come.
Rovner: Yeah, I mean, it’s one thing if workers — there aren’t enough checkers at the grocery store and you have to stand in line for longer, but it’s quite another thing when you have a nurse in an intensive care unit trying to keep track of six patients instead of three or a pharmacist trying to keep track of basically everything that’s going on with no help. That’s what we’re seeing around the country with these shortages of trained health care workers.
In California, there’s another complication, because they actually have laws about patient-nurse ratios in hospitals, and some of them are not being actually obeyed, so I imagine that this is going to go on. We hear a lot about health care worker shortages. I think this is the worst one that I’ve seen in my career, where there just really aren’t the bodies to meet the demand here.
Well, speaking of things that also aren’t going swimmingly — that seems to be our theme this week — there’s a lot of early demand for the new covid vaccine that was approved in September, and apparently not a lot of supply. Also, as we just discussed, a lot of the responsibility for the vaccine is being pushed to pharmacies, whose already overstretched staff simply don’t have the bandwidth to deliver vaccines in addition to all the drugs that they’re asked to be counting out and prescribing. Sarah, shouldn’t the system have been more ready for this? It’s not like we didn’t know pretty much exactly when this vaccine was going to become available. They’ve been saying mid-September for the last five months.
Karlin-Smith: Right, yeah. I mean, there’s definitely been a lot of criticism, particularly on the health insurance side with the codes and things not being set up to put it in. It’s less clear exactly what has gone wrong in the supply chain issue, where there are reports of wholesalers not being able to get supply to the pharmacies. Do you even have enough shots? Lots of people are reporting they have appointments. They get there. They show up. The pharmacist is out.
One thing I’ve been wondering is just there’s been low uptake of boosters in the U.S., and so if it’s been harder for them to predict how much supply they want to have, it’s a bit different when the government is no longer funding those shots. Pharmacies, doctor’s offices have been concerned. What if they buy more than they end up using? Are they out money? I know, in some cases, some of the companies have made some concessions and said, “We will take back unused product,” and so forth, because there’s just different financial considerations that I think are impacting how much supply is on hand at different times right now.
Rovner: And, of course, it’s even worse for kids, right? Because kids can’t go, generally, to the pharmacies to get their vaccines.
Karlin-Smith: Right. Most of the country, to get a vaccine by a pharmacist, you have to be at least 3. It varies a little bit by state and so forth. A lot of pediatricians’ offices don’t have these shots. One of the reasons it seems to be is that, again, these wholesalers who ship the supply around the country have prioritized adult vaccinations. I know, personally, my pediatrician’s office still does not have a shot, as well.
Rovner: And you have two little ones, right?
Karlin-Smith: Right. Again, I have one under 3, and I looked into vaccines.gov the other day to see what would they tell me if I put in for an under-3-year-old. There was one pharmacy in all of D.C. that claimed they would vaccinate someone under 3 for covid, which, I haven’t done the legwork yet to see if that’s actually correct, but, you know, you’re hearing these reports of people traveling really far to get pediatric shots. Again, just to emphasize that there are babies being born all the time who, when they turn 6 months, they are getting their first covid shot, right? They have not, hopefully they haven’t, had covid. You want them protected before they get exposed, so that’s a really crucial gap in the health system that I think people don’t appreciate, because a lot of people are just thinking now, well, oh everybody’s had covid or had two or three shots, and this is a particularly vulnerable population that’s having trouble finding vaccines right now.
Rovner: Yet, I mean, considering it’s very early in the respiratory disease season, there seems to be a lot of covid going around right now, which I suspect is why there’s such a demand, at least among the people who are most concerned about getting the vaccine, for getting the vaccine. It feels like it did at the beginning, when it’s like suddenly there’s this big rush of people at the beginning who want it. Eventually, there’ll probably be more vaccine than is needed, but for right now, I mean, I’m seeing lots and lots and lots of stories and anecdotes and everything about people, as you say, making appointments, showing up, and having the pharmacy saying, “Oops, we didn’t get our supply.”
Karlin-Smith: I mean, there’s been this sort of hope and narrative that covid, is it going to become seasonal in the way we think of flu, where there’s generally a more clear, defined season? You can kind of make a good guess that the best time to get your flu shot is in October and know you’ll be protected all flu season. As much as we hope that’s the case with covid and eventually becomes the case, that’s really not true now. We’ve still had — again, they’re relative maybe compared to some other surges, but we’ve had surges pretty much every summer, so it’s been really difficult. A lot of parents, I think, wanted to get their kids vaccinated before they went back into school and classrooms. If you have little kids, you just know, it becomes a big germ bath, and everybody gets sick.
Rovner: And parents wanted to get themselves vaccinated before their kids went back to school and brought home those germs.
Karlin-Smith: Right, so the timing of it, again, hasn’t been great, for that regard, but I think it is just this difficulty with covid, in that we haven’t had that same predictability of when you might get it during the year, so it is a lot harder to protect yourself.
Rovner: We’ll see how that sorts itself out. Well, keeping with our continuing theme of things that are not going great, let’s talk about the Medicaid unwinding. Our podcast colleague, Amy Goldstein, has a troubling story in The Washington Post about how people whose Medicaid coverage is being canceled but who are eligible for subsidized plans under the Affordable Care Act are in fact having trouble making that transition. Sometimes people are falling through the cracks because states don’t have enough information to know what they’re eligible for or they don’t have the staff to process the transitions.
Sometimes in states like California, people fail to follow up, even when they are given all the information they need. Is this just the inevitable fallout of trying to redetermine the complicated eligibility rules for more than 90 million Americans in a single year, or could something more have been done? I mean, how many times did I hear them say, “It’s OK if you get dropped from Medicaid. We’re going to get you onto your Affordable Care Act plan that’s fully subsidized.” That doesn’t seem to be happening in every state.
Karlin-Smith: I mean, it seemed like, from Amy’s reporting, that there are some states that have connected their Medicaid systems and their exchange sign-ups really closely, and those are going better, but —
Rovner: California, yeah.
Karlin-Smith: Right. Yeah, she mentioned the Medi-Cal system, but then even these states that she calls out as the success stories still have fairly low transition rates. It’s just one of the many examples of our country of having such separate systems and very different bureaucratic processes for sign-up that really hurt people. As we’ve seen with this Medicaid process, a lot of it is just about these paperwork, if you will, call them burdens, that really get people to lose their health insurance and not be covered, so that’s really —
Rovner: I taped a podcast earlier this week aimed at young adults, teaching them how to quote-unquote “adult,” talking about health insurance and open enrollment and how to get signed up. After the Affordable Care Act, there are so many more protections than there were before, and yet it is still unbelievably complicated to try to explain to somebody who’s facing this for the first time. There are just so many possibilities and so many ways. There’s lots of ways to get health insurance, and there’s even more ways to fall through the cracks and not get health insurance. It seems that the more we try to put band-aids on the system, the more confusing it gets to everybody. Maybe I’ve been doing this for too long.
All right, well, finally this week, also in not great news, The Washington Post has published a giant project on declining life expectancy in the United States. It turns out the problem is a lot more complicated than just covid and drug overdoses. Those are the things we’ve been hearing about for a while, although those are indeed a piece of it. Lauren, you were part of the team that put this project together. Tell us the real reasons why Americans aren’t living as long as they used to and aren’t living as long as people in other countries.
Weber: Our team found that income had a big, big part to do with that. The poorest counties in the U.S., compared to the richest counties of the U.S., are doing 6 times worse than they were 40-some years ago, when it comes to life expectancy. The income gap has increased, obviously, but not nearly as much as the life expectancy gap has increased. I think that says something about the U.S.
In general, I mean, as you mentioned, a lot of people consider opioids, deaths of despair, to be what’s killing Americans across the country, but they’re really overlooking chronic illness. Our reporting, my reporting with Dan Diamond and Dan Keating and I, we looked at how the politics also play into life expectancy. What we found is that public health initiatives and public health laws, like tobacco laws for tobacco taxes, seat belt laws, and investing in public health, does have a direct correlation to longevity of life.
State politics and state policies and lawmaker decisions can shave years off of Americans’ lives. What we found in our reporting and in our analysis is that that was happening in red states, particularly those in the South and the Midwest. What we did is we compared three counties that ring Lake Erie: Ashtabula, Ohio; Erie County, Pennsylvania; and Chautauqua, New York. These three counties, they’re all pretty down on their luck. Industrially, the jobs have gone. None of these counties is a success story in health, but they’re all across state lines. It’s just very vivid to see how the different tobacco taxes, seat belt laws have resulted in totally different outcomes when it comes to life expectancy. And you could see, even reflected in these counties, the covid death rates tracked the state investments in public health and the state infrastructure in public health.
So, you know, something that our series looks to do is explain why a state like Ohio has the same life expectancy as Slovakia. One in 5 Ohioans won’t make it to 65. That’s a pretty wild stat. I think a lot of people in this country don’t realize that life expectancy, some of these preventable diseases are preventable.
Rovner: Yeah, I mean, I was really taken by the comparison of tobacco taxes. Where the tobacco taxes were the lowest, which I guess was Ohio, the rate of smoking and, surprise, smoking-related diseases was much higher, and therefore life expectancy was much lower. I noticed The Washington Post had yet another story this week, not quite the same, but how Great Britain and some other countries in Europe are trying to effectively ban smoking, not by banning it outright, which will just make it a black market, but by doing it year by year so that the current cohort of people who smoke will be able to continue but as younger people get older, it will become illegal, until eventually, when everybody dies off, smoking will be basically banned in Great Britain. Somehow, I can’t see that ever happening here, but it’s certainly a public health initiative that’s pretty bold.
Weber: It’s pretty bold. It would not happen here. I mean, look, one of the legislators that we talked to in Ohio, who had stopped a lot of the tobacco taxes — Bill Seitz, House floor majority leader for Ohio — he smoked for 50 years before he quit this summer, actually, because he got kidney cancer and lost a kidney, so he stopped smoking. But what he said to us, when we asked him how he felt about having blocked all these tobacco taxes and if he planned to keep doing that, he said, “Well, just because I quit smoking doesn’t mean I’m going to become a smoke Nazi now. People have the liberty and the right to smoke.”
I mean, a lot of what our reporting came down to is this concept of personal freedom and liberty versus public health, looking at the community as a whole. It was really fascinating to dig into some of the interesting dynamics in Ohio, especially because Gov. DeWine, who is a Republican, has been more bold on public health and has tried to push the legislature to consider more of these initiatives, in part because he has a personal story. His daughter died over 30 years ago in a car accident, and so he’s been very aggressive in especially car safety, but really in a lot of public health initiatives because, as he told us, that kind of death clarifies things for you when it comes to tipping the scales for people’s loved ones. We’ll see that dynamic play out across the U.S., but it is fascinating to examine how tobacco is very much with us. I mean, 20% of Ohioans smoke. I mean, this is not — I think a lot of people consider opioids and these things to still be the new thing to focus on, but tobacco cessation is still very much a fight happening across the country.
Rovner: It’s interesting to me that it’s not just — I mean, the shorthand is red versus blue, but it’s not really just red versus blue because, as you point out, Gov. DeWine’s a Republican, fairly conservative Republican. Before him, Gov. Kasich, also fairly conservative, or used to be considered a fairly conservative Republican. I mean, it’s really about being pro-public health or anti-public health. It gets us back to PEPFAR, right? Victoria, in the early 2000s, Republicans were very pro-public health. Newt Gingrich led the charge to double the funding at the National Institutes of Health. And these days, what you have are very conservative Republicans who apparently don’t believe in public health or in science.
Knight: I was going to say, I think what this series does so well is it emphasizes that so much of our challenges in the U.S. with health is not about the medical system of health; it is the things that we sometimes don’t even think about as health care, not even just public health, but the economic practices, our labor practices, our housing, our food system, that actually these are some of the main things that end up impacting who is living longer and healthier, and so forth. I actually did an interview with an outgoing pharma lobbyist this week, and she was saying — she mentioned chronic diseases, which was a big part of Lauren’s story, and saying, “We actually have more problems with chronic disease now than we did when I started, even though now we have all these cheap, generic medicines for, you know, we have statins and blood thinners and a lot of diabetes medicines that are generic and all these things.” Yes, we have problems with people accessing this medical system and affording it in the U.S., and that’s a big thing, but a lot of this is starting way before you get to the hospital and the doctor’s office, and the U.S. has all these amazing technologies, but we’re failing on these much more basic solutions to keeping people healthy and alive.
Rovner: It’s also not just physical access to health care. I mean, Ohio’s the home of the Cleveland Clinic, for heaven’s sakes, one of the major health care providers in the country. Many parts of Ohio are pretty rural, but it’s not like people have to drive hundreds of miles to get health care. I mean, this whole public health issue is not simply a matter of people can’t get to the doctor, the way we have concerns about that in places like Texas and the Far West. I mean, it really is just these everyday things, whether you wear your seat belt, whether you start smoking. I think it kind of shined a light on actual public health and the importance of public health to life expectancy.
Knight: I think, also, just going back to the politics of it for one second, I mean, I think the result of some of this is just the increased polarization between the two parties, and Republicans also, I think, were really mad about some decisions made during covid, and so we’re also seeing that where they’re, at the state and local level, wanting to strip money from public health departments, as Lauren has reported on at KFF Health News and the Post, and then that’s also, you’re seeing that in Congress as well, now, where they’re not wanting — they’re angry at some of these decisions made, and they want to strip funding from the CDC. They want to strip it from the NIH. We don’t know how the appropriations bills are going to end up, but it’s definitely something that they’re talking about in the House, at least, which is in Republican control.
Karlin-Smith: Everybody I talk to about anti-vaccine sentiment, they say once these sort of sentiments become aligned with your political identity, it makes it so much harder to shift course, so again, this idea that there’s political alignment around how we think about public health is just seen as so problematic because of how people see their identities. It becomes much harder to change people’s opinions when it’s tied into your politics like that.
Weber: Yeah, and I just wanted to highlight, so one of the folks I met in Ashtabula, Ohio, was Mike Czup, who was a funeral home owner, who was 52 years old. What he told me is that a quarter of the people he buries are younger than him. I mean, that’s just a wild statistic; a quarter of the people he buries are younger than him. Honestly, he wasn’t even surprised. I mean, that was just the norm. That was the way of life. I think that’s what this series shines a light on is that people across the U.S. just assume that lung cancer, heart attack, stroke — that’s just what happens. But that’s not the case across the world. It doesn’t have to be the case, and in certain states it’s not the case. California has much better life expectancy than Ohio does, despite them both being on a very similar trajectory in the ’90s. It’s pretty stark findings.
Rovner: Yeah, it’s a really, really, really good series. We will link to it on the podcast page. All right, well, that is this week’s news. Now we will play my interview with Sam Shem, physician, author, and playwright, and then we will come back and do our extra credits for this week.
I am honored to welcome to the podcast Samuel Shem — not his real name, by the way. Dr. Shem shook up the world of medical training back in 1978, when he wrote a groundbreaking novel about his first year as a medical resident, called “House of God.” It was funny and sad and painted an altogether not very pretty picture of medical training in Boston at some of the nation’s most esteemed hospitals and medical schools.
He has spent most of the past five decades crusading, if I can use that verb, to “put the human back in health care.” Fun fact: My mom interviewed him for The Washington Post in 1985. Now Shem has a new novel called “Our Hospital.” It paints a funny and sad picture of the state of medical practice and the state of the American patient in the era of covid. It’s actually the fourth and final volume of his irreverent evaluation of the U.S. health care system. I spoke to Dr. Shem from his home office in upstate New York and started by asking him why he wanted to write a novel about covid.
Samuel Shem: I don’t know how much longer I’m going to be able to write. Nobody does, really. What I did is I said, “Someone has to write about what’s going on in a hospital, and we have to now talk about nurses.” I haven’t put them at the forefront until now, because they have done so incredibly much. I’m taking all the other books, the “House of God” books and others, and I’m bringing them all together like a family. I don’t have a big family, so I’m absolutely doing this with care and vehemence and also a lot of skill in shifting gears, so go read it.
Rovner: I sort of approached this with trepidation, because who wants to read a novel about covid? But, in the end, it’s a pretty optimistic book about what the future of medicine can be, which, forgive me, feels odd for a novel about covid and the possible end of democracy. Are you really that optimistic about America’s ability to cure what ails our health care system, or did you just get tired of writing depressing literature about the health care system?
Shem: Well, I am a crazy optimist, because I grew up in a time, like your mother, when things changed. They changed because we got out there and we were in the streets, and it changed. I was partly in the USA and partly on a Rhodes in Oxford. I think we just have to get together and try to stay together. What this book does: The doctors and the nurses come together, and that is an immense force. We can do this. That’s what I think. The best person in the book, that I have ever written, in some ways, were the women nurses.
Rovner: The heroes of this book are all women, doctors and nurses. You’ve obviously been roundly criticized for your portrayal of women in the original “House of God.” Is it just that you wanted to make it up, or do you really think that women are the future of fixing health care?
Shem: The future of anything. My wife, Janet Surrey, and I, we worked a lot a long time ago on male-female relationships. Women are a beacon of what men could do in medicine. You’ve got to have some kind of group that can get what we need.
Rovner: You’ve watched the evolution of medical practice in America for half a century now, the amazing advances and depressing depersonalization and corporatization. Which one is winning, at this point?
Shem: Well, both. The money — it’s hard to take money from people with so much money. It’s crazy. It’s insane. There are other models, in Australia and all that stuff. What’s happening, unfortunately, is that doctors are running. They’re saying, “I don’t want to do this anymore.” Sooner or later, with some giant people talking about it — doctors and nurses — it can’t go on. It really can’t go on.
Some of the things that I’m hearing: Doctors, they’re saying, “Well, in two years, I’m gone. I can’t do this anymore.” But we can’t do it alone. I can’t say it so more and more. I mean, I know a lot about this in various different jobs I’ve had. It’s got to be with doctors and nurses.
Rovner: What ties a lot of your writing together is the notion of burnout for medical professionals, which may be, as you mentioned, one of the biggest problems right now in U.S. health care. If you could wave a magic wand, what’s one thing that you could do that could help medical professionals, both doctors and nurses and everybody else who works in medicine, love their work again?
Shem: It’s terrible. Young doctors, they don’t know what to do, you know?
Rovner: I mean, do you worry that people won’t want to go into medicine because it’s now viewed as doctors particularly don’t have the community esteem that they used to? Health workers are in danger sometimes in their own workplaces. It’s not a great situation.
Shem: Yes, I think we became horrified when we went on our first medical school times that we were in the hospital. Right when the kids go into the hospital, it’s obvious. It’s really obvious. They’re seeing the house staff spending 80% in front of a computer to bill, so they can’t help but do it.
The problem is you’ve spent so much money and so much time. What the hell should I do? But there are people who are really paying attention to this. I don’t really do it in person too much, but in everything I say these kinds of things, so I think it might help.
Rovner: You’ve now influenced several generations of medical practitioners. Is there a single lesson that you hope you have imparted on all of them?
Shem: Yes. This is what I start my addresses with. I call it staying human in medicine, the danger of isolation and the healing power of good connection. It’s not I-you; it’s the connection that goes after each of them. What’s good connection? Mutual connection. If it’s not mutual, it’s not that good. If you let me, maybe I could read the very end. Is that all right?
Rovner: Yes, please.
Shem: “I’m with you totally. Almost everyone in medicine is hurting, doctors, nurses, and all the others, working in the money-driven hell realms of American care. We’re all suffering terribly. Covid has lit it all up for all to see. The resists to our bodies, minds, and spirits are profound, killing ourselves, acting normal, the poor and people of color dying in droves.”
He paused, scanning the trees for the fat man. Nothing. He went on, “We do miracles every day, we doctors, but we haven’t been able to get a place to work in body and spirit. One in 5 health care workers have quit. Many of us died. At the start of covid, we did the most important thing for us and our patients. We stuck together.” We did. It’s a model, right? But not lasting into the daytime. Hatred and money killed it. I have confidence. We’re no dopes, we docs.
I just think people like you, and people who pay attention, it’s inevitable. I do think it’s inevitable that we’re going to get better stuff. It really will.
Rovner: And get some of the greed out of medicine?
Shem: Yes, because it’s going to crash. You can’t go on like this. Nobody can go on like this. I think so. I really do. You know what? It doesn’t take much. How did we get rid of the presidents in the ’60s? Basically, people who are into power are scared about losing the power, you know, all of the people who protect them and all that stuff.
Rovner: Well, thank you very much, Dr. Samuel Shem. Thank you for joining us.
Shem: OK.
Rovner: We are back, and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?
Knight: Sure thing. My extra credit is from KFF Health News, and it is called “Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients,” by Susan Jaffe. This basically was looking at how Medicare Advantage plans, which are plans that private health insurers run for people that are of Medicare age — they’re basically running their health insurance programs — it’s talking about how these MA plans are using predictive software systems to make coverage decisions for patients, and so they’re looking at other patients that may have similar illnesses and what their treatments were and how long it took to treat them and then, based on that, deciding when they should cut off coverage for patients.
Rovner: That doesn’t always work very well, does it?
Knight: No, it does not. This story chronicles how this has happened to several patients, who were not ready to finish having whatever their treatment, illness — the person profiled in the story still couldn’t walk well. She had a colostomy bag, and they were going to cut off her coverage, and so she had to keep paying for it, almost $10,000, just because this software said, “Oh, you should be done by now, based on other people’s cases.”
But there is some good news, in that there is a Biden administration regulation that will be put into effect in January, and that’s going to do a better job of making sure these plans take the individual patient’s circumstances into account when making these coverage decisions, but we’ll see how that actually plays out. It takes effect in January.
Rovner: Really good story.
Knight: Yes, it’s a very good story, yes.
Rovner: Sarah.
Karlin-Smith: I looked at a Wall Street Journal story, “Children Are Dying in Ill-Prepared Emergency Rooms Across America,” by Liz Essley Whyte and Melanie Evans. It’s a piece that talks about how so many hospitals are not properly equipped to treat pediatric patients when they go to the ER. It’s a failure of regulations, standards, and so forth. They really document how this has been a long-known problem, going back 20-plus years, and things have not changed. This may mean that you might not — even if you have a hospital near you — you might not have a hospital that really can successfully save your child’s life. That is because children are not little adults. There’s different — you really have to be trained to know how to deal with them in emergencies and also even just have the equipment, the specialized sized equipment and so forth, to deal with them in emergencies.
It’s a really sad story. It gets into some of the economic reasons why these hospitals are not prepared. But again, it gives you a sense of a connection to Lauren’s piece, and the Post’s big piece, which is that we have a lot of tools and technology we’ve developed in this country, but if it’s not available to the people when and where they need it, lives don’t get saved.
Rovner: This piece really shook me, because I assume that — I mean, kids are the ones who seem to end up in the emergency room most often. They’re the ones who have accidents and fall off their bikes and get sick in the middle of the night and all those other things, and yet so many emergency rooms are not prepared for them. Anyway, Lauren.
Weber: I picked a piece that is particularly alarming if you know anyone that has a CPAP [continuous positive airway pressure] machine, but it’s titled “Philips Kept Complaints About Dangerous Breathing Machines Secret While Company Profits Soared.” It’s a collaboration between ProPublica, the Pittsburgh Post-Gazette, and Northwestern, and I believe a Netherlands paper, as well. It’s a very disturbing investigation about how Philips knew, had been getting a ton of complaints, that when they rejiggered some of their breathing machines, the foam was disintegrating and chunks of the black material was then getting into people who were using the breathing machine’s lungs and, from the court cases, it appears, causing them potential cancers and adverse health effects.
The FDA, I guess, from reading the piece, requires that companies report complaints, but according to this, Philips did not tell the FDA about all these complaints. It’s a really alarming story, because you’re like, how many other companies are not telling anyone about the complaints they’re receiving? Just really well-done investigation. It appears to be based on court documents, so hats off to them, but very disturbing, again, if you have anyone that has a CPAP or breathing machine they need to sleep, which is vital for everyone. If you have an understanding about how those work, you are hooked up to it, so you are forced to breathe through it, so it really disturbed me that that could be causing you adverse health effects down the road.
Rovner: Yeah, I mean, this is obviously not the first story we’ve seen on this, but it’s certainly one of the most detailed stories that we have seen about this. Well, my story this week is from The Atlantic, by Ron Brownstein. It’s called “Virginia Could Determine the Future of the GOP’s Abortion Policy.” I think he’s right. Virginia votes in odd-numbered years, remember. While Republican Gov. Glenn Youngkin isn’t on the ballot next month, the entire state legislature, which has teetered between Republican and Democratic control over the past several elections, is facing the voters.
Democrats in Virginia, as elsewhere, are charging that if Republicans take back the majority in the State House and Senate, they will restrict abortion, which is likely true, but Republicans say they won’t, quote, “ban abortion,” per se, but would rather set a limit of 15 weeks, with exceptions for rape, incest, and the life of the pregnant person. If voters in a purple state like Virginia see that as a compromise position, rather than a ban, it could set the stage for Republicans elsewhere to fight the current Democratic advantage on the abortion issue. We will see, in about a month, how that all shakes out.
OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. 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 @jrovner or @julierovner at Bluesky and Threads. Sarah?
Karlin-Smith: I’m @SarahKarlin or @sarahkarlin-smith.
Rovner: Lauren.
Weber: I’m @LaurenWeberHP, for health policy.
Rovner: Victoria.
Knight: I’m @victoriaregisk [on X and Threads].
Rovner: We will be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Emmarie Huetteman
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 6 months ago
COVID-19, Health Industry, Medicaid, Multimedia, Pharmaceuticals, Drug Costs, KFF Health News' 'What The Health?', Podcasts, Prescription Drugs, U.S. Congress, vaccines
KFF Health News' 'What the Health?': Countdown to Shutdown
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Health and other federal programs are at risk of shutting down, at least temporarily, as Congress races toward the Oct. 1 start of the fiscal year without having passed any of its 12 annual appropriations bills. A small band of conservative House Republicans are refusing to approve spending bills unless domestic spending is cut beyond levels agreed to in May.
Meanwhile, former President Donald Trump roils the GOP presidential primary field by vowing to please both sides in the divisive abortion debate.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat News, and Tami Luhby of CNN.
Panelists
Alice Miranda Ollstein
Politico
Rachel Cohrs
Stat News
Tami Luhby
CNN
Among the takeaways from this week’s episode:
- The odds of a government shutdown over spending levels are rising. While entitlement programs like Medicare would be largely spared, past shutdowns have shown that closing the federal government hobbles things Americans rely on, like food safety inspections and air travel.
- In Congress, the discord isn’t limited to spending bills. A House bill to increase price transparency in health care melted down before a vote this week, demonstrating again how hard it is to take on the hospital industry. Legislation on how pharmacy benefit managers operate is also in disarray, though its projected government savings means it could resurface as part of a spending deal before the end of the year.
- On the Senate side, legislation intended to strengthen primary care is teetering under Bernie Sanders’ stewardship — in large part over questions about how to pay for it. Also, this week Democrats broke Alabama Republican Sen. Tommy Tuberville’s abortion-related blockade of military promotions (kind of), going around him procedurally to confirm the new chair of the Joint Chiefs of Staff.
- And some Republicans are breaking with abortion opponents and mobilizing in support of legislation to renew the United States President’s Emergency Plan for AIDS Relief — including the former president who spearheaded the program, George W. Bush. Meanwhile, polling shows President Joe Biden is struggling to claim credit for the new Medicare drug negotiation program.
- And speaking of past presidents, former President Donald Trump gave NBC an interview over the weekend in which he offered a muddled stance on abortion. Vowing to settle the long, inflamed debate over the procedure — among other things — Trump’s comments were strikingly general election-focused for someone who has yet to win his party’s nomination.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Washington Post’s “Inside the Gold Rush to Sell Cheaper Imitations of Ozempic,” by Daniel Gilbert.
Alice Miranda Ollstein: Politico’s “The Anti-Vaccine Movement Is on the Rise. The White House Is at a Loss Over What to Do About It,” by Adam Cancryn.
Rachel Cohrs: KFF Health News’ “Save Billions or Stick With Humira? Drug Brokers Steer Americans to the Costly Choice,” by Arthur Allen.
Tami Luhby: CNN’s “Supply and Insurance Issues Snarl Fall Covid-19 Vaccine Campaign for Some,” by Brenda Goodman.
Also mentioned in this week’s episode:
- The AP’s “Biden’s Medicare Price Negotiation Is Broadly Popular. But He’s Not Getting Much Credit,” by Seung Min Kim and Linley Sanders.
- Roll Call’s “Sanders, Marshall Reach Deal on Health Programs, but Challenges Remain,” by Jessie Hellmann and Lauren Clason.
CLICK TO EXPAND THE TRANSCRIPT
Transcript: Countdown to Shutdown
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Sept. 21, at 9 a.m. because, well, lots of news this week. And as always, news happens fast, and things might well have changed by the time you hear this. So here we go. We are joined today via video conference by Tami Luhby of CNN.
Tami Luhby: Good morning.
Rovner: Rachel Cohrs of Stat News.
Rachel Cohrs: Hi, everybody.
Rovner: And Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Let’s get to some of that news. We will begin on Capitol Hill, where I might make a T-shirt from this tweet from Wednesday from longtime congressional reporter Jake Sherman: “I feel like this is not the orderly appropriations process that was promised after the debt ceiling deal passed.” For those of you who might’ve forgotten, many moons ago, actually it was May, Congress managed to avoid defaulting on the national debt, and as part of that debt ceiling deal agreed to a small reduction in annual domestic spending for the fiscal year that starts Oct. 1 (as in nine days from now). But some of the more conservative Republicans in the House want those cuts to go deeper, much deeper, in fact. And now they’re refusing to either vote for spending bills approved by the Republican-led appropriations committee or even for a short-term spending bill that would keep the government open after this year’s funding runs out. So how likely is a shutdown at this point? I would hazard a guess to say pretty likely. And anybody disagree with that?
Ollstein: It’s more likely than it was a week or two ago, for sure. The fact that we’re at the point where the House passing something that they know is dead on arrival in the Senate would be considered a victory for them. And so, if that’s the case, you really have to wonder what the end game is.
Rovner: Yeah, I mean it was notable, I think, that the House couldn’t even pass the rule for the Defense Appropriations Bill, which is the most Republican-backed spending bill, and the House couldn’t get that done. So I mean it does not bode well for the fate of some of these domestic programs that Republicans would, as I say, like to cut a lot deeper. Right?
Cohrs: Democrats are happy, I think, to watch Republicans flail for a while. I think we saw this during the speaker votes. Obviously, a CR [continuing resolution] could pass with wide bipartisan support, but I think there’s a political interest for Democrats going into an election year next year to lean into the idea of the House Republican chaos and blaming them for a shutdown. So I wouldn’t be too optimistic about Democrats billing them out anytime soon.
Rovner: But, bottom line, of course, is that a shutdown is not great for Democrats who support things that the government does. I mean, Tami, you’re watching, what does happen if there’s a shutdown? Not everything shuts down and not all the money stops flowing.
Luhby: No, and the important thing, unlike in the debt ceiling, potentially, was that Social Security will continue, Medicare will continue, but it’ll be very bothersome to a lot of people. There’ll be important things that … potentially chaos at airlines and food safety inspectors. I mean some of them are sometimes considered essential workers, but there’s still issues there. So people will be mad because they can’t go to their national parks potentially. I mean it’s different every time, so it’s a little hard to say exactly what the effects will be and we’ll see also whether this will be a full government shutdown, which will be much more serious than a partial government shutdown, although at this point it doesn’t look like they’re going to get any of the appropriation bills through.
Rovner: I was going to say, yeah, sometimes when they get some of the spending bills done, there’s a partial shutdown because they’ve gotten some of the spending bills done, but I’m pretty sure they’ve gotten zero done now. I think there’s one that managed to pass both the House and the Senate, but basically this would be a full shutdown of everything that’s funded through the appropriations process. Which as Tami points out, the big things are the Smithsonian and the National Zoo close, and national parks close, but also you can’t get an awful lot of government services. Meanwhile, the ill will among House Republicans is apparently rubbing off on other legislation. The House earlier this week was supposed to vote on a relatively noncontroversial package of bills aimed at making hospital insurance and drug prices more transparent, among other things. But even that couldn’t get through. Rachel, what happened to the transparency bill that everybody thought was going to be a slam-dunk?
Cohrs: Well, I don’t think everybody thought it was going to be a slam-dunk given the chaos that we saw, especially in the Democratic Caucus last week, where one out of three chairmen who work on health care in the House endorsed the package, but the other two would not. And they ran into a situation where, with the special rule that they were using to consider the House transparency package, they needed two-thirds vote to pass and they couldn’t get enough Democrats on board to pass it. And I think there were some process concerns from both sides that there was a compromise that came out right after August recess and it hadn’t been socialized properly and they didn’t have their ducks in a row in the Democratic side. But ultimately, I mean, the big picture for me I think was how hard it really is to take on the hospital industry. Because this was the first real effort I think from the House and it melted down before its first vote. That doesn’t mean it’s dead yet, but it was an embarrassment, I think, to everyone who worked on this that they couldn’t get this pretty noncontroversial package through. And when I tried to talk to people about what they actually oppose, it was these tiny little details about a privacy provision or one transparency provision and not with the big idea. It wasn’t ideological necessarily. So I think it was just a reflection on Congress has taken on pharma, they’re working on PBMs this year, but if they really do want to tackle hospital costs, which are a very big part of Medicare spending, it’s going to be a tough road ahead for them.
Rovner: As we like to point out, every single member of Congress has a hospital in their district, and they are quick to let their members of Congress know what they want and how they want them to vote on things. Before we move on, where are we on the PBM legislation? I know there was a whole raft of hearings this week on doing something about PBMs. And my inbox is full of people from both sides. “The PBMs are making drug prices higher.” “No, the PBMs are helping keep drug prices in check.” Where are we with the congressional effort to try and at least figure out what the PBMs do?
Cohrs: Yeah, I think there is still some disarray at this point. I would watch for action in December or whenever we actually have a conversation about government funding because some of these PBM bills do save money, which is the golden ticket in health care because there are a lot of programs that need to be paid for this year. So Congress will continue to debate those over the next couple of weeks, but I think everyone that I talk to is expecting potential passage in a larger package at the end of the year.
Rovner: So speaking of things that need to be paid for, the saga of Sen. Bernie Sanders and the reauthorization of some key primary care programs, including the popular community health center program, continues. When we left off last July, Sen. Sanders, who chairs the Senate Health, Education, Labor & Pensions Committee [HELP], tried to advance a bill to extend and greatly expand primary care programs without negotiating with his ranking Republican on the committee, Louisiana Sen. Bill Cassidy, who had his own bill to renew the programs. Cassidy protested and blocked the bill’s movement and the whole enterprise came to a screeching halt. Last week, Sanders announced he’d negotiated a bipartisan bill, but not with Cassidy, rather with Kansas Republican Roger Marshall, who chairs the relevant subcommittee. Cassidy, however, is still not pleased. Rachel, you’re following this. Sanders has scheduled a markup of the bill for later today. Is it really going to happen?
Cohrs: Well, I think things are on track and the thing to remember about a markup is it passes on a majority. So as long as Sen. Sanders can keep his Democratic members in line and gets Sen. Marshall, then it can pass committee. But I think there are some concerns that other Republicans will share with Sen. Cassidy about how the bill is paid for. There are a lot of ambitious programs to expand workforce training, have debt forgiveness, and address the primary care workforce crisis in a more meaningful way. But the list of pay-fors is a little undisciplined from what I’ve seen, I would say.
Rovner: That’s a good word.
Cohrs: Sen. Sanders is pulling some pay-fors from other committees, which he can’t necessarily do by himself, and they don’t actually have estimates from the Congressional Budget Office for some of the pay-fors that they’re planning to use. They’re just using internal committee math, which I don’t think is going to pass muster with Republicans in the full Senate, even if it gets through committee today. So I think we’ll see some of those concerns flare up. It could get ugly today compared with HELP markups of the past of community health center bills. And there are certainly some concerns about the application of the Hyde Amendment too, and how it would apply to some of this funding as it moves through the appropriations process.
Rovner: That’s the amendment that bans direct government funding of abortion, and there’s always a fight about the Hyde Amendment, which are reauthorizing these health programs. But I mean, we should point out, I mean this is one of the most bipartisanly popular programs, both the community health center program and these programs that basically give federal money to train more primary care doctors, which the country desperately needs. I mean, it’s something that pretty much everybody, or most of Congress, supports, but Cassidy has what, 60 amendments to this bill. I guess he’s really not happy. Cassidy who supports this in general just is unhappy with this process, right?
Cohrs: I think his concern is more that the legislation is half-baked, not that he’s against the idea of it. And Sen. Cassidy did sign on to a more limited House proposal as well, just saying, we need to fund the community health centers, we need to do something. This isn’t ready for prime time. We could see further negotiations, but the time is ticking for this funding to expire.
Rovner: Well, another program whose authorization expires at the end of the month is PEPFAR, the international AIDS/HIV program. It’s being blocked by anti-abortion activists among others, even though it doesn’t have anything to do with the abortion. And this is not just a bipartisan program, it’s a Republican-led program. Former President George W. Bush who signed it into law in 2003, had an op-ed this week pushing for the program in The Washington Post. Alice, you’ve been following this one. Is there any progress on PEPFAR?
Ollstein: Yes and no. There’s not a vote scheduled, there’s not a “Kumbaya” moment, but we are seeing some movement. I call it “Establishment Republican Strike Back.” You have some both on- and off-the-Hill Republicans really mobilizing to say, “Look, we need to reauthorize this program. This is ridiculous.” And they’re going against the anti-abortion groups and their allies on Capitol Hill who say, “No, let’s just extend this program just year by year through appropriations, not a reauthorization.” Which they say would rubber-stamp the Biden administration redirecting money towards abortion, which the Biden administration and everybody else denies is happening. And so we confirmed that Chairman Mike McCaul in the House and Lindsey Graham in the Senate are working with Democrats on some sort of reauthorization bill. It might not be the full five years, it might be three years, we don’t really know yet. But they think that at least a multiyear reauthorization will give the program some stability rather than the one-year funding patch that other House Republicans are mulling. So we’re going to see where this goes; obviously, it’s an interesting test for the influence of these anti-abortion groups on Capitol Hill. And my colleague and I also scooped that former President Bush, who oversaw the creation of this program, is quietly lobbying certain members, having meetings, and so we will see what kind of pull he still has in the party.
Rovner: Well, this was one of his signature achievements, literally. So it’s something that I know that … and we should point out, unlike the spending bills, the appropriation bills, if this doesn’t happen by Oct. 1, nothing stops, it’s just it becomes theoretically unauthorized, like many programs are, and it’s considered not a good sign for the program.
Luhby: One thing I also wanted to just bring up quickly, tangentially related to health care, but also showing how bipartisan programs are not getting the support that they did, is the WIC program, which is food assistance for women, infants and children, needs more money. Actually participation is up, but even before that, the House Republicans wanted to cut the funding for it, and that was going to be a big divide between them and the Senate. And now because participation is up, the Biden administration is actually asking for another $1.4 billion for the program. This is a program that, again, has always had support and has been fully funded, not had to turn people away. And now it’s looking that many women and small children may not be able to get the assistance if Congress isn’t able to actually fund the program fully.
Rovner: Yes, they’re definitely tied in knots. Well, Oct. 1 turns out to be a key date for a lot of health care issues. It’s also the day drugmakers are supposed to notify Medicare whether they will participate in negotiations for the 10 high-cost drugs Medicare has chosen for the first phase of the program that Congress approved last year. But that might all get blocked if a federal judge rules in favor of a suit brought by the U.S. Chamber of Commerce, among others. Rachel, there was a hearing on this last week, where does this lawsuit stand and when do we expect to hear something from the judge?
Cohrs: So the judge didn’t ask any questions of the attorneys, so they were essentially presenting arguments that we’ve already seen previewed in some of the briefing materials. We are expecting some action by Oct. 1, which is when the Chamber had requested a ruling on whether there’s going to be a preliminary injunction, just because drugmakers are supposed to sign paperwork and submit data to CMS by that Oct. 1 date. So I think we are just waiting to see what the ruling might be. Some of the key issues or whether the Chamber actually has standing to file this lawsuit, given it’s not an actual drug manufacturer. And there was some quibbling about what members they listed in the lawsuit. And then I think they only addressed the argument that the negotiation program violated drugmakers’ due process rights, which isn’t the full scope of the lawsuit. It’s not an indicator of success really anywhere else, but it is important because it is the very first test. And if a preliminary injunction is issued, then it brings everything to a halt. So I think it would be very impactful for other drugmakers as well.
Rovner: Nobody told me when I became a health reporter that I was going to have to learn every step of the civil judicial process, and yet here we are. Well, while we are still on the subject of drug prices, a new poll from the AP and the NORC finds that while the public, Republicans and Democrats, still strongly support Medicare being able to negotiate the price of prescription drugs, President [Joe] Biden is getting barely any credit for having accomplished something that Democrats have been pushing for for more than 20 years. Most respondents in the survey either don’t think the plan goes far enough, because, as we point out, it’s only the first 10 drugs, or they don’t realize that he’s the one that helped push it over the finish line. This should have been a huge win and it’s turning out to be a nothing. Is that going to change?
Ollstein: It’s kind of a “Groundhog Day” of the Obamacare experience in which they pass this big, huge reform that people had been fighting for so long, but they’re trying to campaign on it when people aren’t really feeling the effects of it yet. And so when people aren’t really feeling the benefit and they’re hearing, “Oh, we’re lowering your drug prices.” But they’re going to the pharmacy and they’re paying the same very high amount, it’s hard to get a political win from that. The long implementation timeline is against them there. So there are some provisions that kick in more quickly, so we’ll have to see if that makes any kind of difference. I think that’s why you hear them talk a lot about the insulin price cap because that is already in effect, but that hits fewer people than the bigger negotiation will theoretically hit eventually. So it’s tough, and I think it leaves a vacuum where the drug industry and conservatives can fearmonger or raise concerns and say, “This will make drugs inaccessible and they won’t submit new cures for approval.” And all this stuff. And because people aren’t feeling the benefits, but they’re hearing those downsides, yeah, that makes the landscape even tougher for Democrats.
Luhby: This is very much the pattern that the Biden administration has had with a lot of its achievements or successes because it’s also not getting any credit for anything in the economy. The job market is relatively strong still, the economy is relatively strong. Yes, we have high inflation and high prices, even though that’s moderated, prices are still high, and that’s what people are seeing. Gas prices are now up again, which is not good for the administration. But they’re touting their Bidenomics, which also includes lowering drug prices. But generally polling shows, including our CNN polling shows, that people do not think the economy is doing well and they’re not giving Biden any credit for anything.
Cohrs: I think part of the problem is that … it’s different from the Affordable Care Act where it was health care, health care, health care for a very long time. This is lumped into a bill called the Inflation Reduction Act. I think it got lumped in with climate, got looped in with tax. And the media, we did our best, but it was hard to explain everything that was in the bill. And Medicare negotiation is complicated, it’s wonky, and I don’t know that people fully understood everything that was in the Inflation Reduction Act when it passed and they capitulated to Sen. [Joe] Manchin for what he wanted to name it. And so I think some of that got muddled when it first passed and they’re kind of trying to do catch-up work to explain, again, like Alice said, something that hasn’t gone into effect, which is a really tough uphill climb.
Rovner: This has been a continuing frustration for Democrats, which is that actually getting legislation done in Washington always involves some kind of compromise, and it’s always going to be incremental. And the public doesn’t really respond to things that are incremental. It’s like, “Why isn’t it bigger? Why didn’t they do what they promised?” And so the Republicans get more credit for stopping things than the Democrats get for actually passing things. Right. Well, let us turn to abortion. The breaking news today is that the Senate is finally acting to bust the blockade Alabama Republican Sen. Tommy Tuberville has had on military promotion since February to protest a Defense Department policy allowing service people leave to travel to other states for abortions. And Tuberville himself is part of this breakage, right, Alice? And it’s not a full breakage.
Ollstein: Right. And there have also been some interesting interviews that maybe raise questions on how much Tuberville understands the mechanics of what he’s doing because he said in an interview, “Oh, well, the people who were in these jobs before, they’ll just stay in it and it’s fine.” And they had to explain, “Well, statutorily, they can’t after a certain date.” And he seemed surprised by that. And now you’re seeing these attempts to go around his own blockade, and Democrats to go around his blockade. In part, for a while, Democrats were really not wanting to do that, schedule these votes, until he fully relented because they thought that would increase the pressure.
Rovner: They didn’t want to do it nomination by nomination for the big-picture ones because they were afraid that would leave behind the smaller ones.
Ollstein: Exactly. But this is dragging on so long that I think you’re seeing some frustration and desire to do something, even if it’s not fully resolving the standoff.
Rovner: And I’m seeing frustration from other Republicans. Again, the idea of a Republican holding up military promotions for six months is something that was not on my Republican Bingo card five years ago or even two years ago. I’m sure he’s not making a lot of his colleagues very happy with this. So on the Republican presidential campaign trail, abortion continues to be a subject all the candidates are struggling with — all of them, it seems, except former President Donald Trump, who said in an interview with NBC on Sunday that he alone can solve this. Francis, you have the tape.
Donald Trump: We are going to agree to a number of weeks or months or however you want to define it, and both sides are going to come together, and both sides, and this is a big statement, both sides will come together and for the first time in 52 years, you’ll have an issue that we can put behind us.
Rovner: OK. Well, Trump — who actually seemed all over the place about where he is on the issue in a fairly bald attempt to both placate anti-abortion hardliners in the party’s base and those who support abortion rights, whose votes he might need if he wants to win another election — criticized his fellow Republicans, who he called, “inarticulate on the subject.” I imagine that’s not going over very well among all of the other Republican candidates, right?
Ollstein: We have a piece up on this this morning. One, Trump is clearly acting like he has already won the primary, so he is trying to speak to a general audience, as you noted, and go after those votes in the middle that he may need and so he’s pitching this compromise. And we have a piece that the anti-abortion groups are furious about this, but they don’t really know what to do about it because he probably is going to be the nominee and they’re probably going to spend tens of millions to help elect him if he is, even though they’re furious with these comments he’s making. And so it’s a really interesting moment for their influence. Of course, Trump is trying to have it both ways, he also is calling himself the most pro-life president of all time. He is continually taking credit for appointing the justices to the Supreme Court who overturned Roe v. Wade.
Rovner: Which he did.
Ollstein: Exactly.
Rovner: Which is true.
Ollstein: Which he definitely did. But he is not toeing the line anymore that these groups want. These groups want him to endorse some sort of federal ban on abortion and they want him to praise states like Florida that have passed even stricter bans. He is not doing that. And so there’s an interesting dynamic there. And now his primary opponents see this as an opening, they’re trailing him in the polls, and so they’re trying to capitalize on this. [Gov. Ron] DeSantis and a bunch of others came out blasting him for these abortion remarks. But again, he’s acting like he’s already won the primary, he’s brushing it off and ignoring them.
Rovner: I love how confident he is though, that there’s a way to settle this — really, that there is a compromise, it’s just nobody’s been smart enough to get to it.
Ollstein: Well, he also, in the same interview, he said he’ll solve the Ukraine-Russia war in a day. So I mean, I think we should consider it in that context. It was interesting when I talked to all these different anti-abortion groups, they all said the idea of cutting some sort of deal is ludicrous. There is no magic deal that everybody would be happy about. If anything …
Rovner: And those on the other side will say the same thing.
Ollstein: Exactly. How could you watch what’s happened over the past year or 30 years and think that’s remotely possible? However, they did acknowledge that him saying that does appeal to a certain kind of voter, who is like, “Yeah, let’s just compromise. Let’s just get past this. I’m sick of all the fighting.” So it’s another interesting tension.
Rovner: Yeah. And I love how Trump always says the quiet part out loud, which is that this is not a great issue for Republicans and they’re not talking about it right. It’s like Republicans know this is a not-great issue for Republicans, but they don’t usually say that in an interview on national television. That is Trump, and this will continue. Well, finally this week I wanted to talk about what I am calling the dark underbelly of the new weight loss drugs. This is my extra credit this week. It’s a Washington Post story by Daniel Gilbert called “Inside the Gold Rush to Sell Cheaper Imitations of Ozempic.” It’s about the huge swell of sometimes not-so-legitimate websites and wellness spas selling unapproved formulations of semaglutide and tirzepatide — better known by their brand names Ozempic, Wegovy, and Mounjaro — to unsuspecting consumers because the demand for these diabetes drugs is so high for people who want to lose weight. The FDA has declared semaglutide at least to be in shortage for the people it was originally approved for, those with Type 2 diabetes. But that designation legally allows compounding pharmacies to manufacture their own versions, at least in some cases, except to quote the piece, “Since then, a parallel marketplace with no modern precedent has sprung up attracting both licensed medical professionals and entrepreneurs with histories ranging from regulatory violations to armed robbery.” Meanwhile, and this is coming from a separate story, both Eli Lilly and Novo Nordisk, the manufacturers of the approved versions of the drugs, are suing companies they say are selling unapproved versions of their drug, including, in some cases, drugs that actually pretend to be the brand name drug that aren’t. This is becoming really a big messy buyer-beware market, right? Rachel, you guys have written about this.
Cohrs: It has. Yeah, my colleagues have done great coverage, including I think the lawsuit by manufacturers of these drugs who are seeing their profits slipping through their fingers as patients are turning to these alternatives that aren’t necessarily approved by the FDA. And I think there are also risks because we have seen some side effects from these medications; they range from some very serious GI symptoms to strange dreams. There’s just a whole lot going on there. And I think it is concerning that some patients are getting ahold of these medications, which are expensive if you’re buying them the traditional way. And again, for weight loss, I think some of these medications are still off-label, they’re not FDA-approved. So if they’re getting these without any supervision from a medical provider or somebody who they can ask when they have questions that come up and are monitoring for some of these other side effects, then I think it is a very dangerous game for these patients. And I think it’s just a symptom of this outpouring of interest and the regulators’, I think, failure to keep up with it. And there’s also some supply concerns. So I think it’s just this perfect storm of desperation from patients and the bureaucracy struggling to keep up.
Rovner: Yeah. One of the reasons I chose the story is I really feel like this is unprecedented. I mean, I suppose it could have been predicted because these drugs do seem to be very good at what they do and they are very expensive and very hard to get, so not such a surprise that not-so-honest people might spring up to try and fill the void. But it’s still a little bit scary to see people selling heaven only knows what to people who are very anxious to take things.
Luhby: And in related news, there are more doctors who are interested in obesity medicine now, so everyone is trying to cash in.
Rovner: Yeah, I mean, eventually I imagine this will sort itself out. It’s just that at the beginning when it’s so popular, although I will still … I keep thinking this, is the solution to really throw this much money at it or to try to figure out how to make these drugs cheaper? If it’s going to be such a societal good, maybe we should do something about the price. Anyway, that is my extra credit in this week’s news. Now we will take a quick break and then we’ll come back with the rest of our extra credits.
Hey, “What the Health?” listeners, you already know that few things in health care are ever simple. So, if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system. Hosted by longtime health care journalist and friend Dan Gorenstein, “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctors’ offices, and even Congress. Subscribe wherever you listen to your podcasts.
OK, we are back and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it; we will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Tami, why don’t you go first this week?
Luhby: Sure. Well, this week I chose a good story by one of my colleagues, Brenda Goodman. It’s titled “Supply and Insurance Issues Snarl Fall Covid-19 Vaccine Campaign for Some.” And we’ve all been hearing this, I heard this from a friend of mine who’s a doctor, we know Cynthia Cox at KFF tweeted about this. And that even though the new vaccines are ready and the Biden administration has been pushing people to go get them, and many people are eager to get them, they’re not so easy to get. Either because drugstores are running out, that’s what happened to my friend. She went in and said there just wasn’t any supply available. Or for some other people, they’re supposed to be free for most Americans, but the insurance companies haven’t caught up with that yet. So they go in and either they’re denied or the pharmacy tells them that they have to pay potentially $200 for the vaccines. So the problem here is that there’s already an issue with getting vaccines and people getting vaccinated in this country and then putting up extra hurdles for them will only cause more problems and cause fewer people to get vaccinated because some people may not come back.
Rovner: Talk about something that should have been predictable. The distributors knew it was going to be available and pretty much when, and the insurance companies knew it was going to be available and pretty much when, and yet somehow they seem to have not gotten their act together when the predictable surge of people wanting to get the vaccine early came about. Alice, you wanted to add something?
Ollstein: Just anecdotally, the supply and the demand are completely out of whack. My partner is back home in Alabama right now and he was at a pharmacy where they were just wandering around asking random people, “Will you take the shot? Will you take the shot?” And a bunch of people were saying, “No.” And meanwhile, here in D.C., myself and everyone I know is just calling around wanting to get it and not able to. And so you think we’d have figured this out better after so many years of this.
Rovner: Well, I have an appointment for tomorrow. We’ll see if it happens. Rachel, why don’t you go next?
Cohrs: Sure. I chose a KFF Health News story by Arthur Allen, and the headline is “Save Billions or Stick With Humira? Drug Brokers Steer Americans to the Costly Choice.” And I just love a story where it’s off the news cycle a little bit and we see this big splashy announcement. And I think Arthur did a great job of following up here and seeing what actually was happening with formulary placement for Humira and the new biosimilars that just came on the market.
Rovner: Yep. Remind us what Humira is?
Cohrs: Oh, yeah. So it’s one of the most profitable drugs ever. The company that makes it, AbbVie, had created this big patent thicket to try to prevent it from competition for a very long time, but this year saw competition that had been on the market in Europe finally come online in the U.S. So again, a big change for AbbVie, for the market. But I think there was concern about whether people would actually switch to these new medications that have lower prices. But again, as it gets caught up and spit out of our drug supply chain, there are a whole lot of incentives that don’t necessarily result in the cheaper medication being prescribed. And Arthur found that Express Scripts and Optum, which are two of the three biggest pharmacy benefit managers, have the biosimilar versions of Humira at the same price as Humira. So that doesn’t really create a lot of incentive for people to switch. So I think it was just great follow-up reporting and we don’t really have a lot of visibility into these formularies sometimes. So I think it was a illuminating piece.
Rovner: Yeah. And the mess that is drug pricing. Alice.
Ollstein: So I also chose a great piece by my colleague Adam Cancryn and it’s called “The Anti-Vaccine Movement Is on the Rise. The White House Is at a Loss Over What to Do About It.” It’s part of a series we’re doing on anti-vax sentiment and its impacts. And this is just going into how the Biden administration really doesn’t have a plan for combating this, even as it’s posing a bigger and bigger public health threat. And some of their attempts to go after misinformation online were stymied in court and they also are struggling with not wanting to elevate it by debunking it — that that age-old tension of, is it better to just ignore it or is it better to combat it directly? A lot of this is also tying into RFK Jr.’s presidential bid and how much to acknowledge that or not. But the impact is that they’re not really taking this on, even as it’s getting worse and worse in the country.
Rovner: And I got a bunch of emails this week about the anti-vax movement spreading to pets — that people are now resisting getting their dogs and cats vaccinated. Seriously. I mean, it is a serious problem. Obviously, if people stop getting rabies vaccines, that could be a big deal. So something else to watch. All right. Well, I already did my extra credit. So that is it for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our indefatigable engineer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me; I’m still @jrovner on X and on Bluesky. Tami?
Luhby: You can tweet me at @Luhby. I sometimes check it still.
Rovner: Rachel.
Cohrs: I’m on X @rachelcohrs.
Rovner: Alice.
Ollstein: I’m @AliceOllstein.
Rovner: We will be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Emmarie Huetteman
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 6 months ago
Elections, Health Care Costs, Health Industry, Medicaid, Medicare, Multimedia, Pharmaceuticals, Public Health, Abortion, Biden Administration, Drug Costs, HIV/AIDS, KFF Health News' 'What The Health?', Podcasts, U.S. Congress, Women's Health
KFF Health News' 'What the Health?': Welcome Back, Congress. Now Get to Work.
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Congress returns from its August recess with a long list of things to do and not a lot of time to do them. The fiscal year ends Sept. 30, and it’s possible that lawmakers will fail to finish work not only on the annual appropriations bills, but also on any short-term spending bill to keep the government open.
Meanwhile, Medicare has announced the first 10 drugs whose prices will be negotiated under the Inflation Reduction Act of 2022. Exactly how the program will work remains a question, however. Even how the process will begin is uncertain, as drugmakers and other groups have filed lawsuits to stop it.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Alice Miranda Ollstein of Politico.
Panelists
Rachel Cohrs
Stat News
Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- Hard-line Republicans are refusing to back even a temporary government spending bill, suggesting a government shutdown looms — with repercussions for health programs. While the Senate and House have come to intra-chamber agreements on subjects like community health center funding or even have passed spending bills, Congress as a whole has been unable to broker an overarching deal.
- A coalition of House Republicans is falsely claiming that global HIV/AIDS funding through PEPFAR promotes abortion and is battling efforts to extend the program’s funding. PEPFAR is a bipartisan effort spearheaded by then-President George W. Bush and credited with saving millions of lives.
- The PEPFAR fight underscores the dysfunction of the current Congress, which is struggling to fund even a highly regarded, lifesaving program. Another example is the months-long blockade of military promotions by a freshman Republican senator, Alabama’s Tommy Tuberville, a member of the Senate Armed Services Committee. His objections over an abortion-related Pentagon policy have placed him at odds with top military leaders, who recently warned that his heavy-handed approach is weakening military readiness.
- The Biden administration recently announced new staffing requirements for nursing homes, as a way to get more nurses into such facilities. But how long will compliance take, considering ongoing nursing shortages? And the drug industry is reacting to the news of which 10 drugs will be up first for Medicare negotiation, with much left to be sorted out.
- In abortion news, a Texas effort to block patients seeking abortions from using the state’s roads is spreading town to town — and, despite being dubiously enforceable, it could still have a chilling effect.
Also this week, Rovner interviews Meena Seshamani, who leads the federal Medicare program, about the plan to start negotiating drug prices.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: JAMA Health Forum’s “Health Systems and Social Services — A Bridge Too Far?” by Sherry Glied and Thomas D’Aunno.
Alice Miranda Ollstein: The Washington Post’s “Heat’s Hidden Risk,” by Shannon Osaka, Erin Patrick O’Connor, and John Muyskens.
Rachel Cohrs: The Wall Street Journal’s “How Novartis’s CEO Learned From His Mistakes and Got Help From an Unlikely Quarter,” by Jared S. Hopkins.
Joanne Kenen: Politico’s “How to Wage War on Conspiracy Theories,” by Joanne Kenen, and “Court Revives Doctors’ Lawsuit Saying FDA Overstepped Its Authority With Anti-Ivermectin Campaign,” by Kevin McGill.
Also mentioned in this week’s episode:
- The Washington Post’s “Highways Are the Next Antiabortion Target. One Texas Town Is Resisting,” by Caroline Kitchener.
- KFF Health News’ “Biden Administration Proposes New Standards to Boost Nursing Home Staffing,” by Jordan Rau.
- Stat’s “The Curious Case of J&J’s Stelara, The Unluckiest Drug on Medicare’s List,” by Rachel Cohrs.
Click to open the transcript
Transcript: Welcome Back, Congress. Now Get to Work.
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Sept. 7, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Rachel Cohrs of Stat News.
Rachel Cohrs: Good morning.
Rovner: Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.
Joanne Kenen: Hi, everybody.
Rovner: And Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Later in this episode, we’ll have an interview with Meena Seshamani, who runs the Medicare program for the federal government, with an update on the Medicare drug negotiation debate as, we’ll discuss, the first 10 drugs that will be subject to negotiation were announced last week. But first, this week’s news. So Labor Day is behind us, and Congress is back — sort of. The Senate is back. The House returns next week. And there are lots of questions to be answered this fall, starting with whether or not Congress can finish the annual spending bills before the start of fiscal 2024 on Oct. 1. Spoiler: They cannot. But there’s also a real question whether Congress can even pass a short-term bill to keep the government running while lawmakers continue to work on the rest of the appropriations. As of now, what do you guys think are the odds that we’re going to end up with some kind of government shutdown at the end of the month?
Ollstein: Well, it’s whether it happens at the end of the month or at the end of the year, really. Folks seem pretty convinced that it will happen at some point. It could be short-lived. But, yeah, like you said, you have some hard-line House Republicans who say they won’t support even a temporary stopgap bill without spending cuts, policy changes, without sort of extracting some of their demands from leadership. And you could work around that in the House by cobbling together a coalition of Republicans and Democrats. But that also puts [House Speaker Kevin] McCarthy’s leadership in jeopardy. And so, we’re having sort of the same dynamic play out that we saw earlier this year, trying to navigate between the hard-line House Republicans and, you know, the more vulnerable swing districts’ members. So it’s … tough.
Rovner: Yeah, it’s the Republicans from districts that [President Joe] Biden won … basically.
Ollstein: Yeah. And so you have this weird game of chicken right now where both the House and Senate are trying to pass whatever they can to give themselves more leverage in the ultimate House-Senate negotiations. They think, OK, if we pass five bills and they only pass one, you know, then we have the upper hand. So we’ll see where that goes.
Rovner: It’s funny, because the Senate has been a well-oiled machine this year on the spending bills, which is unusual. I was about to say I will point out that there are two women: the chairman and ranking member. But that’s actually also true in the House. We do have women running the appropriations process this year. But I was amused that Kevin McCarthy, sometime during August, a couple of weeks ago, said, you know, very confidently, well, we’ll pass a short-term spending bill. You know, we won’t let the government shut down. And by the next day, the hard-line Republicans, the right wing, were saying, yeah, no you won’t. You’re going to have to deal with us first. And, obviously, there’s lots of health stuff that’s going to get caught up in that. The end of the fiscal year also marks the end of funding authority for a number of prominent programs. This is not the same as the appropriations programs whose authorizations lapse can continue, although things can get complicated. PEPFAR, the two-decade-old bipartisan program that provides AIDS and HIV prevention and treatment around the world, is one of those programs that, at least as of now, looks pretty stuck. Alice, is there any movement on this? We’ve talked about it before.
Ollstein: Not yet. So the latest we know, and we got this last night, is that [Foreign Relations Committee] Chairman [Bob] Menendez in the Senate is floating a new compromise. Basically, supporters of PEPFAR have been pushing for the full five-year standard reauthorization. And a coalition of House Republicans who are claiming that PEPFAR money is going to abortion say they want no reauthorization at all. They just want the program to sort of limp along through appropriations. So between five years and zero, Menendez is now suggesting a three-year extension. There is a huge desire not to just have the one-year funding patch because that would kick all of this into the heat of the 2024 season. And if you think the debate is ugly now over abortion and federal spending, just wait until 2024.
Kenen: I mean, this … [unintelligible] money … it’s saved tens of millions of lives — and with bipartisan support in the past.
Rovner: It was a Republican initiative.
Kenen: Right. It was President Bush, George the second.
Rovner: George W. Bush. Yeah.
Kenen: And they’re not saying they’re actually going out and using the AIDS dollars to conduct, to actually do abortions. They’re saying that there’s, you know, they’re in the world of abortion and they’re promoting abortion, etc., etc. So the conversation gets really, really, really, really muddled. Under U.S. law, they cannot use U.S. dollars for abortion under the Hyde Amendment, you know, all sorts of other foreign policy rules. So it’s hard to overstate how important this program has been, particularly in Africa. It has saved millions and millions of lives. And I think Alice might have broken the story originally, but it got caught up in abortion politics, and it caught people by surprise. This is not something … everything in Washington gets caught up in politics, except this! So I think it’s been quite shocking to people. And it’s, I mean — life-and-death sounds like a, you know, it’s a Washington cliché — this is life-and-death.
Ollstein: Yeah, absolutely. And, you know, even though the program won’t shut down if they don’t manage to get a reauthorization through, you know, I talked to people who run PEPFAR services in other countries, and they said that, you know, having this year-to-year funding and instability and uncertainty — you know, they won’t be able to hire, they won’t be able to do long-term planning. They said this will really undermine the goal to eliminate HIV transmission by 2030.
Cohrs: Oh, I actually did just want to jump in about another Sept. 30 deadline, because there was a big development this week. I know we were just talking about long-term planning. There is funding for community health centers that’s expiring at the end of September as well. DSH cuts could go into effect for hospitals. We do this routine every so often, but the House is actually more in step than the Senate on this issue; they released — at least Republicans released — a draft legislation, where all three committees of jurisdiction are in agreement about how to proceed. There are some transparency measures in there.
Rovner: The three committees in the House.
Cohrs: In the House. Yes, yes, we’re talking about the House. Yeah. So, they have reconciled their differences here and are hoping to go to the floor this month. So, I think they are out of the gate first, certainly with some sort of longer-term solution here. Again, could get punted. But I think it is a pretty big development when we’re talking about these extenders that the industry cares about very much.
Kenen: Congress is so polarized that it can’t even do the things that it agrees on. And we have seen this before where CHIP [Children’s Health Insurance Program] got caught up a few years ago. Community health clinics have gotten caught right in that same bill, right? But, you know, we really have this situation where it’s so dysfunctional they can’t even move fully on things that everybody likes. And community health centers date back to the early ’60s. However, they got a really big expansion, again, under second President Bush. And they’re popular, and they serve a need, and everybody likes them.
Rovner: They got a bigger expansion under the Affordable Care Act.
Kenen: Right, but they, you know — but I think that the Bush years was like the biggest in many years. And then they got more. So again, I mean, are they going to shut their doors? No. Is it going to be a mess? It is already a mess. They can’t — they don’t know what’s coming next. That’s no way to run a railroad or a health clinic.
Rovner: All right, well, one more while we’re on the subject of abortion-related delays: Alabama Sen. Tommy Tuberville is still blocking Senate approval of routine military promotions to protest the Biden administration’s policy of allowing funding for servicewomen and military dependents to travel for abortions if they’re posted to states where it’s banned. Now, the secretaries of the Army, Navy, and Air Force are joining together to warn that Tuberville’s hold is threatening military readiness. Tuberville apparently went on Fox News last night and said he’s got more people who are coming to support him. Is there any end to this standoff in sight? I mean, people seem to be getting kind of upset about it. It’s been going on since, what, February?
Ollstein: Yeah, there is not yet an end in sight. So far, all of the attempts to pressure Tuberville to back down have only hardened his resolve, it seems, you know, and he’s gone beyond sort of his original statement of, you know, all of this is just to get rid of this policy that doesn’t pay for abortions; it just allows people to travel out of state if they’re stationed — they don’t get to choose where they’re stationed — if they’re stationed somewhere where abortion is not legal or accessible. And so now he’s making claims about other things in the military he considers too woke. He’s criticized some of these individual nominees themselves that he’s blocking, which was not sort of part of the original stand he took. And so, it’s tough, and there isn’t enough floor time to move all of these and go around him. And so this pressure campaign doesn’t seem to be really making any headway. So I don’t really see how this gets resolved at this point.
Kenen: Except that other Republicans are getting a little bit more public. I mean, they were sort of letting him run out for a while. And there’s more Republicans who are clearly getting enough of this. But I mean, unless McConnell can really get him to move — and we don’t know what’s gone on behind closed doors, but we’re certainly not seeing any sign of movement. In fact, as Alice said, he’s digging in more. I mean, like, Marines and woke are not the two words you usually hear in one sentence, but in his worldview, they are. So, I think it’s unprecedented. I mean, I don’t think anyone’s ever done this. It’s not like one or two people. It’s like the entire U.S. military command can’t move ahead.
Rovner: I’ve been doing this a very long time, and I don’t remember anything quite like this. Well, the one thing that we do expect to happen this fall is legislation on — and Rachel, you were referring to this already — sort of health care price transparency and PBMs, the pharmacy benefit managers. Where are we with that? They were supposed to work on it over the August break. Did they?
Cohrs: They were supposed to work on it. The House was clearly working on it and reconciling some of their differences. They’re planning to introduce legislative text on Friday. So, I think Democrats aren’t on board yet, so things could change from the draft they had been circulating early this week. But again, Republicans don’t really need Democrats to move forward, at least in the House. The Senate has been pretty quiet so far. Not to say that no work has gone on, but they certainly weren’t ready for the rollout in the same way that the House was. You know, I think there are still some big questions about, you know, what they’re planning to accomplish with insulin policy, how they’re planning to fit together this jigsaw puzzle of PBM transparency and reforms that have come out of different committees. And I think it’ll come down to [Senate Majority Leader] Sen. Schumer making some tough choices. And from my understanding, that hasn’t quite happened yet. But if the actual showdown happens November, December, they still have some time.
Rovner: Yeah. Now they’re not going out early. They’re clearly going to be fighting over the appropriation. So, the legislative committees have plenty of time to work on these other things. All right. Well, let’s turn to Medicaid for a moment. The quote-unquote “unwinding” continues as states move to redetermine who remains eligible for the program and who doesn’t following the pandemic pause. As predicted, it’s been a bit of a bumpy road. And now it seems a bunch of states have been incorrectly dropping children from Medicaid coverage because their parents are no longer eligible. That’s a problem because nationwide, income limits for children’s eligibility is higher than parents’. In some states, it is much higher. I remember after Hurricane Katrina, in Louisiana, parents were only eligible if they earned 15% of poverty. Somebody said 50, and the Medicaid director said, “No, 15, one-five.” Whereas kids are eligible to, I believe it’s 200% of poverty. And I think that’s a national level.
Kenen: Now, in some states it’s higher.
Rovner: Yes. But I say this is happening in a bunch of states because federal government won’t tell us how many or which ones. We do know it’s more than a dozen, but this is the second time the administration has admonished states for wrongly canceling Medicaid coverage. And they wouldn’t say which states were involved at that time either. Is this an effort to keep this as apolitical as possible, given that the states most likely to be doing this are red states who are trying to remove ineligible people from Medicaid as fast as they can, that they’re trying to sort of keep this from becoming a Republican versus Democrat thing.
Ollstein: It seems like, from what we’re hearing, that the administration is really wary of publicly picking a fight with these states. They want the states to work with them. And so, even if the states are going about this in a way they think is totally wrong, they don’t want to just put them publicly on blast, because they think that’ll make them, again, double down and refuse to work with the government at all. And so, they’re trying to maintain some veneer of cooperation. But at the same time, you’re having, you know, millions of people, including children, falling through the cracks. And so, you know, we have sort of this sternly-worded-letter approach and we’ll see if that accomplishes anything, and if not, you know, what measures can be taken. You know, the administration also created a way for states to hit pause on the process and take a little more time and do a little more verification of people’s eligibility. And some — a couple states — have taken advantage of that, and it’s been successful in, you know, having fewer people dropped for paperwork reasons, but it’s not really happening in the states where it sort of most needs to happen, according to experts.
Rovner: The administration has had fingers pointed at it, too, because apparently it approved some of these plans from the states that were going to look at total family income without realizing that, oh, that meant that kids who are still eligible could end up losing coverage because their parents are no longer eligible.
Kenen: Right. And I also read something yesterday that in some cases it’s sort of a technical issue rather than a “how much outreach and what your intentions are,” that it’s a programing issue, which is related to what Julie just said about the plan. So, it’s not that these states set about to drop these kids, and there may be some kind of goodwill to fix it, in which case you don’t want to get in — and I don’t know that it’s 100% red states either. So —
Rovner: No, that’s clear. We assume, because they’re the ones going fastest, but we do not know.
Kenen: Right, so that there seems to be some kind of — the way it was set up, technically, that can be remedied. And if it’s a technical fix as opposed to an ideological fight, you don’t really want to — you want to figure out how to reprogram the computer or whatever it is they have to do and then go back and catch the people that were lost. So, they’ve been pretty low-key about politicizing rewinding in general. But on the kids, I think they’re going to be even more — CHIP passed, another thing with bipartisan support that’s a mess. I mean, it seems to be the theme of the day. But, you know, CHIP was created on a bipartisan basis, and it’s always been sustained on a bipartisan basis. So, I think that the issue, I don’t know how technically easy it is to fix, but there’s a big difference in how the administration goes after someone that’s intentionally doing something versus someone who wrote their computer programmer set something up wrong.
Rovner: Well, we will definitely keep on this one.
Kenen: But it’s a big mess. It’s a lot of kids.
Rovner: It is a big mess. And let’s turn to the thing that is not bipartisan in Congress, and that is —
Kenen: That’ll be a bigger mess.
Rovner: — Medicare drug negotiations. Yes. While we were away, the federal government released its much-anticipated list of the 10 brand-name drugs that will be the first tranche up for potential price negotiation. I say potential, because the companies have the option of negotiating or not — sort of — and because there are now, I think, nine lawsuits challenging the entire program. My interview with Medicare administrator Meena Seshamani will get into the nuts and bolts of how the negotiation program is supposed to work. But Rachel, tell us a little bit about the drugs on the list and how their makers are trying to cancel this entire enterprise before it even begins.
Cohrs: Sure. So, a lot of these drugs that we’re seeing on the list are blood thinners. Some are diabetes medications. There are drugs for heart failure, rheumatoid arthritis, Crohn’s disease, and there’s also a cancer treatment, too. But I think overall, the drugs were chosen because they have high cost to Medicare. And it was —
Rovner: So that either could mean a lot of people use an inexpensive drug —
Cohrs: Yes.
Rovner: — or a few people use a very expensive drug.
Cohrs: Correct. And it was Wall Street’s favorite parlor game to try to guess what drugs were going to be on this list of 10 drugs that are going to be the guinea pigs to go through this program for the very first time. But it was interesting, because there were a few surprises. Medicare officials were using newer data than Wall Street analysts had access to. So, there were a couple drugs, especially further down on the list, that people used more in the period CMS [Centers for Medicare & Medicaid Services] was studying than had been used previously. So, we saw a couple very interesting instances of a drug being chosen for the list, even though it just kind of fell through the cracks. It was J&J’s [Johnson & Johnson’s] Stelara. It’s a Crohn’s disease treatment, and it does have competition coming in the market soon, but just because of a fluke of kind of when it was approved by the FDA, it just missed cutoffs for some of these exemptions and is now subject to some pretty significant discounts through the program.
Rovner: We’ll link to your very sad story about Stelara.
Cohrs: Sad for the company, but not sad for the patients who will hopefully be paying less for this medication. And there’s also the case of Astellas [Pharma Inc.], which makes a prostate cancer drug that’s very expensive. A lot of people expected that to be selected, but actually wasn’t. And Astellas had sued the Biden administration already before the list came out and then had to withdraw their lawsuit yesterday because their argument that they were going to be harmed by this legislation was made much weaker by the fact that they weren’t selected for this first year of the program. So, who knows? They could dust off their arguments a year from now or two years from now. But it was interesting to see kind of some of these surprises on the list. Again, there are still several, like you mentioned, outstanding lawsuits in several different jurisdictions. I think the main one that we’re watching is by the [U.S.] Chamber of Commerce, which requested a preliminary injunction by the end of this month. So, we’ll see if that comes through. But it is a very long road to 2026. There might be a new administration by then. So, I think there are still a lot of questions about whether this reaches the finish line. But I think it’s a very important step for CMS to get this list out there in the world.
Rovner: So, I spent some time digging in my notes from earlier years, and I dug up notes from an interview I did on Aug. 26 with a spokesperson from the drug industry about how the Medicare drug benefit, quote, “impact the ability of companies to research new medicines. And if that happens, the elderly would be the ones hurt the most.” That quote, by the way, was from Aug. 26 of 1987. Some things truly never change. But is this maybe, possibly, the beginning of the end of drugmakers being able to charge whatever they want in the United States? Because it’s the only country where they can.
Cohrs: Oh, they can still charge whatever they want. This law doesn’t change that. It just changes the fact that Medicare won’t be paying whatever drugmakers happen to charge for an unlimited amount of time. Like, they can still charge whatever they want to Medicare for as long as they can get on the market before they’re selected for this negotiation program. But certainly there could be significant cost — significant savings to Medicare, even if those prices are high. And it’s just kind of a measure that forces price reductions, even if the generic or biosimilar market isn’t functioning to lower those prices through competition.
Kenen: Right. And it’s only Medicare. So, people who are not on Medicare — insurance companies also negotiate prices, but they’re not the government. It’s different. But I mean, these drugs are not going to start being, you know, three bucks.
Rovner: But they may stop being 300,000.
Kenen: Well, we don’t know, because there are some people who think that if Medicare is paying less, they’re going to charge everybody else more. We just don’t know. We don’t know what their behavior is going to be. But no, this does not solve the question of affordability of medication in the United States.
Rovner: The drug companies certainly think it’s the camel’s nose under the tent.
Kenen: They have some medicine for camels’ noses that they can charge a lot of money for, I’m sure.
Rovner: I bet they do. While we are on the subject of things that I have covered since the 1980s, last week the Biden administration finally put out its regulation requiring that nursing homes be staffed 24/7/365 by, you know, an actual nurse. One of the first big reconciliation bills I covered was in 1987 — that was a big year for health policy — and it completely overhauled federal regulation of nursing homes, except for mandating staffing standards, because the nursing homes said they couldn’t afford it. Basically, that same fight has been going on ever since. Except now the industry also says there aren’t enough nurses to hire, even if they could afford it. Yet patient advocates say these admittedly low staffing ratios that the Biden administration has put out are still not enough. So, what happens now? Is this going to be like the prescription drug industry, where they’re going to try to sue their way out of it? Or is it going to be more like the hospital transparency, where they’re just not going to do it and say, “Come and get us”?
Kenen: My suspicion is litigation, but it’s too soon to know. I assume that either one of the nursing home chains — because there are some very big corporations that own a lot of nursing homes — there are several nursing home trade industry groups, for-profit, nonprofit. Does one owner — is in an area where there is a workforce shortage, because that does exist. I mean, I’d be surprised if we don’t see some litigation, because when don’t we see that? I mean, it’s rare. That’s the norm in health care, is somebody sues. Some of the workforce issues are real, but also this proposal doesn’t go into effect tomorrow. It’s not like — but I mean, there are issues of the nursing workforce. There are issues about not just the number of nurses, but do we have them in the right places doing the right jobs? It’s not just RNs [registered nurses]; there are also shortages of other direct care workers. I did a story a few months ago on this, and there are actually nursing homes that have closed entire wings because they don’t have enough staff, and those are some of the nonprofits. There are nursing issues.
Rovner: And a lot of nursing home staff got sick at the beginning of the covid pandemic, and many of them died before there were good treatments. I mean, it’s always been a very hard and not very well-paid job to care for people in nursing homes. And then it became a not very pleasant, not very well-paid, and very deadly job. So I don’t think that’s probably helping the recruitment of people to work in nursing.
Kenen: Right, but the issue — I think a lot of people, when you have your first family experience with a nursing home or, you know, or those of us reporters who hadn’t been familiar with them until we went and did some stories on them, I think people are surprised at how little nursing there actually is. It’s nurses’ aides; it’s, you know, what they used to call licensed practical nurses or nursing assistants; and CNAs, certified nursing assistants. They’re various; different states have different names. But these are not four-year RNs. The amount of actual nursing — forget doctors. I mean, there’s just not a lot of RNs in nursing homes. There’s not a lot of doctors who spend time in nursing homes. A lot of the care is done through people with less training. So, this is trying to get more nurses in nursing homes. And there’s been a lot of stories about inadequate care. KFF Health News — I think it was Jordan Rau who did them. There have been some good stories about particularly nights and weekends, just really nobody there. These are fragile people. And they wouldn’t be in a nursing home if they weren’t fragile people. There are a lot of horror stories. At the same time, there are some legitimate — How fast can you do this? And how well can you do it? And can you do it across the country? I mean, it’s going to take some working out, but I don’t think anybody thinks that nursing home care in this country is, you know, a paragon of what we want our elders to experience.
Rovner: And the nursing home industry points out, truthfully, that most nursing home payments now come from Medicaid, because even people who start out being able to afford it themselves often run out of money and then they end up — then they qualify for Medicaid. And Medicaid in many states doesn’t pay very much, doesn’t pay nursing homes very much. So it’s hard for these companies. We’re not even talking about the private equity companies. A lot of nursing homes operate on the financial edge. I mean, there are —our long-term care policy in this country is, you know, just: What happens, happens, and we’ll worry about it later. And this has been going on for 50 years. And now we have baby boomers retiring and getting older and needing nursing home care. And at some point, this is all going to come to a head. All right. Well, let us turn to abortion. This week marks the second anniversary of the Texas abortion ban, the so-called heartbeat bill, that bans most abortion and lets individuals sue other individuals for helping anyone getting an abortion, which the Supreme Court, if you’ll recall, allowed to take effect months before it formally overturned Roe v. Wade. And, I guess not surprisingly, Texas is still in the news about abortion. This time. The same people who brought us Texas SB 8, which is the heartbeat bill, are going town by town and trying to pass ordinances that make it illegal to use roads within that town’s borders to help anyone obtain an abortion. They’re calling it abortion “trafficking.” Now, it’s not only not clear to me whether a local ordinance can even impact a state or an interstate highway, which is what these laws are mostly aimed at; but how on earth would you enforce something like this, even if you want to?
Ollstein: So, my impression is that they do not want to. These are not meant to be practical. They are not meant to be enforced, because how would you do it other than implementing a very totalitarian checkpoint system? This is meant to —
Rovner: Yes, have you been drinking and are you on your way to get an abortion?
Ollstein: Right. Right, right, right. So, it seems like the main purpose is to have a chilling effect, which it very well could have, even if it doesn’t stand up in court. You know, you also have this situation that we’ve had play out in other ways, where people are challenging laws in courts for having a chilling effect, and courts are saying, look, you have to wait till you actually get prosecuted and challenge it, you know, do an as-applied challenge. If you can’t challenge unless there’s a prosecution but there’s no prosecutions, then you sort of just have it hanging over your head like a cloud.
Kenen: Like Alice said, there’s no way you could do this. Like, what do you do, stop every car and give every person a pregnancy test? Are you going to, like, have, you know, ultrasounds on the E-ZPass monitors? Like, you go through it, it checks your uterus. So, I mean, it’s just not — you can’t do this. But I think one of the things that was really interesting in one of the stories I read about it, I think it was in The Washington Post, was that when they interviewed people about it, they thought it was trafficking, like really trafficking, that there were pregnant woman being kidnapped and forced to have an abortion. So even if you’re pro-choice, you might say, “Oh, I’m against abortion trafficking. I mean, I don’t want anyone to be forced to have an abortion.” You know, so, it’s — the wording and the whole design of it is, they know what they’re doing. I mean, they want to create this confusion. They want to create a disincentive. There’s no way — you know, radar guns? I mean, it’s just, there’s no way of doing this. But it is part of the effort to clamp down even further on a state that has already really, really, really clamped down.
Rovner: Although, I mean, if one could sue and if one could then know about something that’s happening and then you could presumably take the person to court and say, I know you were pregnant and now you’re not, and somebody took you in a car to New Mexico or whatever …
Kenen: You can’t even prove — how do you prove that it wasn’t a miscarriage?
Rovner: That’s —
Kenen: Right? I mean …
Rovner: I’m not saying — I’m not talking about the burden of proof. I’m just saying in theory, somebody could try to have a case here. I mean, but we certainly know that Texas has done a very good job creating a chilling effect, because we still have this lawsuit from the women who were not seeking abortions, who had pregnancy complications and were unable to get health-saving and, in some cases, lifesaving care promptly. And that’s still being litigated. But meanwhile, we have, you know, just today a study out from the Guttmacher Institute that showed that despite how well these states that are banning abortion have done in banning abortion, there were presumably more abortions in the first half of 2023 than there were before these bans took effect, because women from ban states were going to states where it is not banned. And there has been, ironically, better access in those states where it is not banned. I can’t imagine that this is going to please the anti-abortion community. One would think it would make them double down, wouldn’t it?
Ollstein: We know that people are leaving their states to obtain an abortion. We also know that that’s not an option for a lot of people, and not just because a lot of people can’t afford it or they can’t take time off work, they can’t get child care — tons of reasons why somebody might not be able to travel out of state. They have a disability, they’re undocumented. We also have — it’s become easier and easier and easier to obtain abortion pills online through, you know, a variety of ways: individual doctors in more progressive states, big online pharmacies are engaged in this, overseas activist groups are engaged in this. And so, you know, that’s also become an option for a lot of people. And anti-abortion groups know that those are the two main methods. People are still continuing to have abortions. And so, they’re continuing to just throw out different ways to try to either, you know, deter people or actually block them from either of those paths.
Rovner: This fight will also continue on. So, that is this week’s news. Now we will play my interview with Meena Seshamani, and then we will come back and do our extra credits.
Hey, “What the Health?” listeners, you already know that few things in health care are ever simple. So, if you like our show, I recommend you also listen to “Tradeoffs,” a podcast that goes even deeper into our costly, complicated, and often counterintuitive health care system. Hosted by longtime health care journalist and friend Dan Gorenstein, “Tradeoffs” digs into the evidence and research data behind health care policies and tells the stories of real people impacted by decisions made in C-suites, doctors’ offices, and even Congress. Subscribe wherever you listen to your podcasts.
I am pleased to welcome back to the podcast Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services. Meena was with us to talk generally about Medicare’s new prescription drug negotiation program earlier this summer. But now that the first 10 drugs subject to negotiation have been announced, we’re pleased to have her back. Welcome.
Meena Seshamani: Thank you for having me.
Rovner: So, remind our listeners, why hasn’t Medicare been able to negotiate drug prices until now — they negotiate prices of everything else — and what changed to make that happen?
Seshamani: That’s right. It was because of the Medicare law that Medicare did not have the ability to negotiate drugs. And thanks to the new drug law, the Inflation Reduction Act, now Medicare has the ability to negotiate the prices of the highest-cost drugs that don’t have competition. And that is part of the announcement that we had on what the first 10 drugs are that have been selected.
Rovner: So, as you say, last week, for the first time and in time for the Sept. 1 deadline, Medicare announced the list of the first 10 drugs that will be part of the first round of price negotiations. Why these 10 specifically? I imagine it’s not a coincidence that the list includes some of the drugs whose ads we see the most often on TV: drugs like Eliquis, Xarelto, and Jardiance, which I of course know how to pronounce because I see the ads all the time.
Seshamani: Well, the process of selection really was laid out in the drug law and also through the guidance that we put out that we had incorporated everybody’s comment for. So, what we did is we started with the, you know, over 7,500 drugs that are covered in the Part D Medicare prescription drug program. From there, we picked those drugs that had been on the market for seven years for a drug product or 11 years for a larger molecule or biologic product that did not have competition. And then from there, there are various exemptions and exclusions that, again, are laid out in the law: for example, drugs that have low Medicare spend, of less than $200 million; drugs that are plasma-derived products; certain orphan drugs. An orphan drug is a drug that is indicated for a rarer disease. So that, again, those specific criteria are laid out in the law and in our guidance. And then there were opportunities for manufacturers to apply, for example, for a small biotech exemption; if their drug was, you know, 80% of their, you know, Medicare Part D revenue, they could say, “Hey, I’m a small biotech.” Again, a lot of these criteria were laid out in the law. Or for a manufacturer of a biosimilar, which is kind of like a generic drug for one of these biologic drugs, they could say, “Hey, we have a biosimilar that’s going to be coming on the market, has a high likelihood of coming on the market, so you should delay negotiating” the brand, if you will, drug. So, again, all of these steps were laid out in the drug law, and those are the steps and criteria that we followed that came to that list of 10 drugs that we published.
Rovner: I did see the makers of one drug — and forgive me, I can’t remember which one it was — saying, “But our drug isn’t that expensive.” On the other hand, their drug is used by a lot of people on Medicare. So, it’s not just the list price of the drug, right? It’s how much it costs Medicare overall.
Seshamani: That’s right. The list is made up of those drugs that have the highest gross total cost to the program — so, price per unit times units of volume that is used.
Rovner: So, how does this negotiation process work? What happens now? Now we have this list of 10 drugs.
Seshamani: Yeah, a lot of this is also laid out in the law, and then we fleshed out further in our guidance. So, from the list of 10 drugs, on Oct. 1, manufacturers now have to decide if they want to participate in the negotiation program. It is a voluntary program. It is our hope that they will come to the table and want to negotiate, because I think we all have shared goals of improving access and affordability and really driving innovation for the cures and therapies that people need. So, Oct. 1, they sign agreements for the negotiation program if they decide to participate. And Oct. 2 is the deadline for gathering data. We put out what’s called an information collection request to say, this is the kind of data we’re thinking about collecting. We got lots of comments and incorporated that. So, that provides the framework for the data that we’re requesting both from the manufacturer of the selected drug, but also, there are aspects open to the public on, you know, how the drug benefits populations, for example. So that’s Oct. 2. Then we’re going to have patient-focused listening sessions, a session for each drug, for patients, their caregivers, you know, other advocates, to be able to share what they see as the benefits of the drugs that are selected. And, we will have meetings with each of the manufacturers. All of that information will come together in an initial offer that CMS will make Feb. 1, 2024, and that is a date that is stipulated in the law. The manufacturer then has about 30 days to evaluate that. If they like that offer, they can agree. If they want, they can make a counteroffer. From that counteroffer, CMS has the ability to agree or to say, “You know, we don’t agree, so let’s now have a series of negotiation meetings.” There can be up to three negotiation meetings that provides that back-and-forth, ultimately leading to an agreed-upon what’s called maximum fair price in the law. And those maximum fair prices are published by Sept. 1, 2024. Again, that Sept. 1 is stipulated in the law. And also as part of this process, CMS will publish a narrative about that negotiation process — you know, the data that was received, you know, the back-and-forth, and also we’ll publish ultimately the maximum fair prices that are agreed to.
Rovner: And does that maximum fair price just apply to Medicare?
Seshamani: The maximum fair price just applies to Medicare. The information will be available. I mean, we don’t have any authority. You know, the commercial sector, they do their own negotiations, and they will continue to do so. But part of this is an opportunity to really further the conversation about how drugs impact the lives of people. We have an opportunity now with some drugs that have been on the market for quite a while, right? Minimum of seven years or 11 years, to see how these drugs work in the real world, in people’s communities, so that we can incorporate that into what it is that we need and want for people to be healthy, to stay out of the hospital, to live meaningful lives. So it’s really an opportunity to further that conversation. And a lot of that data, a lot of those listening sessions, that will all go into our negotiation process and will be part of the narrative that we publish.
Rovner: And what happens if the drug company says either we don’t want to negotiate or we don’t like our final offer? If they say they don’t want to play, what happens?
Seshamani: Julie, I will say again, to start with, we are hopeful that the drug companies will come forward and will want to negotiate because, again, through many conversations that we have had, we do have shared goals of access and affordability and really driving innovation and procures and therapies that people need. And it is a choice for drug companies if they want to participate or not, as stipulated in the law. If a drug company decides not to sign, you know, the negotiation agreement, not to participate in negotiation, then we would refer them to the Department of Treasury for an excise tax. That excise tax is also described in the law. If a drug company has this excise tax applied, they can get out of paying the excise tax. If, No. 1, they decide to come to the table and negotiate, or No. 2, if they exit the Medicare and Medicaid market. So those are kind of their off-ramps, if you will, for that excise tax.
Rovner: So they don’t have to participate in the negotiation, but they also don’t have to participate in Medicare and Medicaid.
Seshamani: Correct.
Rovner: So I saw a lot of complaining last week with the first group of drugs that this is really only going to benefit the people on Medicare who take those drugs. But, in fact, if there really is a lot of money saved, the benefits could go well beyond this, right?
Seshamani: Yeah, I think two points. So, yes, this negotiation is for, you know, some of the highest-cost drugs to the Medicare program that don’t have competition. And the negotiated drug prices apply to the Medicare program. However, as we talked about, this really drives a conversation around drugs and really grounding this negotiation process in the clinical benefit that a drug provides. Considering things like if a drug is easier for someone to take and it’s easier for a caregiver, that can have tangible improvements to the health of the person they’re caring for, right? And I think we have that opportunity to really drive the conversation. And as we know in many aspects of health care, people look to Medicare to see what Medicare is doing. And also, the transparency around providing that narrative of the negotiation, publishing the maximum fair prices that are agreed to. That’s all data that anybody can use as they would like. And I think the second piece that’s important to remember is that negotiation is one very important piece of a very big change to Medicare prescription drug coverage. You know, alongside the $2,000 out-of-pocket tab that’s going to go into effect in 2025, the no-cost vaccines, $35 copay cap for insulin that have already gone into effect. So, really, it is part of a larger sea change in Medicare drug coverage that will help millions of people and their families. You know, I did a roundtable with seniors as we were rolling out the insulin copay cap. And one woman was telling me that she was providing money to her brother every month so that he could pay for his insulin on Medicare. So, really, I mean, this has tremendous impact not just for people on Medicare, but their families, their communities, and really furthers the conversation for the entire system.
Rovner: I was actually thinking of more nitty-gritty money, which is if you save money for Medicare, premiums will be lower for people who are getting drug coverage, and taxpayers will save money, too, right? I mean, this is not just for these people and their families.
Seshamani: Our priority is being able to reach agreement on a fair price for the people who rely on these medications for their lives and the American taxpayer in the Medicare program.
Rovner: I know you can’t comment on lawsuits, and there are many lawsuits already challenging this. But the drug companies, one of their major arguments is that if you limit what they can charge for their drugs, particularly in the United States, the last country where they can charge whatever they want for their drugs, they will not be able to afford to keep the pipeline going to discover more new, important drugs. This is an argument they’ve been making since, I told somebody earlier, since I covered this in the late 1980s. What is your response just to that argument?
Seshamani: Well, I think there were several articles, many articles were written about this on the day that the 10 selected drugs were published. They were published before the stock market opened. And there really was no impact on the stocks of the companies. There were many financial pieces written about this. So I think that is one indication of the fact that the pharmaceutical industry is strong, it is thriving, and it is designed to innovate. And what we’re hoping to do through this negotiation program is really reward the kinds of innovations that we all need, the cures and therapies that people need. Recently, the venture fund that backed Moderna invested in a new startup for small molecules. Bayer has recently invested a billion dollars in the U.S. So you see, the industry very much is thriving. That is what the stock market response also shows. And it’s also the way that we are approaching negotiation to make sure that we’re rewarding the kinds of innovations that people need.
Rovner: Well, Meena Seshamani, thank you so much. I hope we can come back to you as this negotiation process for the first time proceeds.
Seshamani: Absolutely. Thanks again, Julie.
Rovner: OK. We are back, and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?
Ollstein: Yeah, I picked a very sad story from The Washington Post about how people who have schizophrenia are a lot more vulnerable to extreme heat. And it’s rare to find one of these health care stories where you’re just astonished. You know, I had no idea about this. You know, it really walks through not only are people more vulnerable for mental health reasons, you know, it profiles this terrible story of a guy in Phoenix who wandered off into the desert and died because he was experiencing paranoid delusions. But also, just physically, people with schizophrenia have difficulty regulating their body temperature. A lot of medications people take make people more dehydrated, less able to cope. And just an astonishingly high percentage of people hospitalized and killed by extreme heat have these mental illnesses. Of course, they’re also more likely to have housing instability or be out on the street. So just a fascinating piece, and I hope it spurs cities to think of ways to address it. One other small thing I want to compliment is it just, technically, on this article online, they have a little widget where you can convert all of the temperatures cited in the lengthy story from Fahrenheit to Celsius. And I just really appreciated that for allowing, you know, no matter where you live, you sort of get what these high temperatures mean.
Rovner: Yeah, graphics can be really helpful sometimes. Rachel.
Cohrs: Yeah. So I chose a story in The Wall Street Journal and the headline is “How Novartis’s CEO Learned From His Mistakes and Got Help From an Unlikely Quarter,” by Jared S. Hopkins. And I think it was a really interesting and rare look inside one of these pharmaceutical companies. And Novartis hired a Wall Street analyst, Ronny Gal, to help advise them. And I think I had read his analysis before he crossed over to Novartis. So I think it was interesting to just hear how that has integrated into Novartis’ strategy and just how they’re changing their business. But I think as we’re, you know, having these conversations about drug pricing and how strategies are changing due to some of these policies, it is helpful to look at who these executives are listening to and what they’re prioritizing, whose voices in this decision-making process that really has impacts for so many people who are waiting for treatments. And I think there are tough choices that are made all the time. So I just thought it was very illuminating and helpful as we’re talking about how medicines get made in D.C.
Rovner: Yeah, maybe there will be a little more transparency to actually how the drug industry works. We will see. Joanne.
Kenen: With Julie’s permission, I have two that are both short and related. I wrote a piece for Politico Nightly called “How to Wage War on Conspiracy Theories,” and I liked it because it really linked political trends and disinformation and attempts to debunk, with very parallel things going on in the world of health care and efforts to the motivations and efforts to sow trust and what we do and do not know about how to debunk, which we’re not very good at yet. And then the classic example, of course, is the related AP story, which has a very long headline, so bear with me. It’s by Kevin McGill: “Court Revives Doctors’ Lawsuit Saying FDA Overstepped Its Authority With Anti-Ivermectin Campaign.” And, basically, it’s that the 5th Circuit, a conservative court that we’ve talked about before, is saying that the FDA is allowed to inform doctors, but it can’t advise doctors. And I’m not really sure what the difference is there, because if the FDA is informing doctors that ivermectin, we now know, does not work against covid, and it can in fact harm people, there’s ample data, that the FDA is not allowed to tell doctors not to use it. So the ivermectin campaign is a form of disinformation, or misinformation, whatever you want to call it, that at the very beginning, people had, you know, there were some test-tube experiments. We had nothing else. You can sort of see why people wanted … might have wanted to try it. But we have lots and lots and lots of good solid clinical research and human beings and, no, it does not cure covid. It does not improve covid. And it can be damaging. It’s for parasites, not viruses.
Rovner: It can cure worms. Well, I’m going to channel my inner Margot Sanger-Katz this week and choose a story from a medical journal, in this case the Journal of the American Medical Association. Its lead author is Sherry Glied, who’s dean of the NYU Robert F. Wagner Graduate School of Public Service and former assistant HHS [Department of Health and Human Services] secretary for planning and evaluation during the Obama administration — and I daresay one of the most respected health policy analysts anywhere. The piece is called “Health Systems and Social Services — A Bridge Too Far?” And it’s the first article I’ve seen that really does question whether what’s become dogma in health policy over the past decade that — tending to what are called social determinants of health, things like housing, education, and nutrition — can improve health as much as medical care can. Rather, argues Glied, quote, “There are fundamental mismatches between the priorities and capabilities of hospitals and health systems and the task of addressing social determinants of health,” and that, basically, medical providers should leave social services to those who are professional social service providers. That is obviously a gross oversimplification of the argument of the piece, however, but I found it really thought-provoking and really, for the first time, someone saying, maybe we shouldn’t be spending all of this health care money on social determinants of health. Maybe we should let social service money go to the social service determinants of health. Anyway, we will see if this is the start of a trend or just sort of one outlier voice. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our amazing engineer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me, or X me, or whatever. I’m still there @jrovner, also on Bluesky and Threads. Rachel?
Cohrs: I’m @rachelcohrs on X.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: Joanne.
Kenen: @JoanneKenen on Twitter, @joannekenen1 on Threads.
Rovner: We will be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Emmarie Huetteman
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 7 months ago
Aging, Health Industry, Medicaid, Medicare, Multimedia, Pharmaceuticals, Public Health, States, Abortion, Biden Administration, Drug Costs, HIV/AIDS, KFF Health News' 'What The Health?', Long-Term Care, Nursing Homes, Podcasts, U.S. Congress, Women's Health
Trabajadores sufren mientras el Congreso y empresarios debaten la necesidad de normas contra el calor
A veces el calor te hace vomitar, contó Carmen García, trabajadora agrícola en el Valle de San Joaquín, en California. Ella y su marido pasaron el mes de julio en los campos de ajo, arrodillados sobre la tierra ardiente mientras las temperaturas superaban los 105 grados.
El cansancio y las náuseas de su marido fueron tan intensas que no fue a trabajar por tres días. Pero bebió agua con lima en lugar de ir al médico porque no tienen seguro médico. “A mucha gente le pasa esto”, agregó.
No existen normas federales para proteger a los trabajadores como los García cuando los días son excesivamente calurosos. Y sin el apoyo bipartidista del Congreso, incluso con la atención urgente de la administración Biden, es posible que el alivio no llegue en años.
El presidente Joe Biden encargó en 2021 a la Administración de Seguridad y Salud Ocupacional (OSHA) la elaboración de normas para prevenir los accidentes y las enfermedades causados por el calor.
Pero ese proceso de 46 pasos puede llevar más de una década y podría estancarse si un republicano es elegido presidente en 2024, porque el Partido Republicano se ha opuesto generalmente a las regulaciones de salud laboral en los últimos 20 años.
Estas normas podrían obligar a los empleadores a proporcionar abundante agua potable, descansos y un espacio para refrescarse a la sombra o con aire acondicionado cuando las temperaturas superen un determinado umbral.
El 7 de septiembre, OSHA comenzó reuniones con propietarios de pequeñas empresas para discutir sus propuestas, incluidas las medidas que deberían adoptar las empresas cuando las temperaturas llegan a los 90 grados.
Como este verano se han batido récords de calor, la congresista Judy Chu (demócrata de California) y otros miembros del Congreso han impulsado una legislación que aceleraría el proceso de elaboración de normas de OSHA.
El proyecto de ley lleva el nombre de Asunción Valdivia, una trabajadora agrícola que se desmayó mientras recogía uvas en California en un día de 105 grados en 2004. Su hijo la recogió del campo y Valdivia murió de un golpe de calor en el trayecto a su casa.
“Ya sea en una granja, conduciendo un camión o trabajando en un almacén, los trabajadores como Asunción mantienen nuestro país en funcionamiento mientras soportan algunas de las condiciones más difíciles”, dijo Chu en declaraciones en julio en la que instaba al Congreso a aprobar el proyecto de ley.
Las organizaciones profesionales que representan a los empresarios se han opuesto a las normas, calificándolas de “exageradas”. También afirman que faltan datos que justifiquen regulaciones generales, dada la diversidad de trabajadores y lugares de trabajo, desde restaurantes de comida rápida hasta granjas.
La Cámara de Comercio de Estados Unidos, uno de los grupos de presión más poderosos de Washington, argumentó que tales medidas carecen de sentido “porque cada empleado experimenta el calor de forma diferente”. Además, según la Cámara, normas como los ciclos de trabajo-descanso “amenazan con perjudicar directa y sustancialmente… la productividad de los empleados y, por lo tanto, la viabilidad económica de su empleador”.
“Muchos de los problemas relacionados con el calor no son consecuencia del trabajo agrícola ni de la mala gestión del empresario, sino del moderno estilo de vida de los empleados”, escribió el Consejo Nacional del Algodón en su respuesta a la legislación propuesta.
Por ejemplo, el aire acondicionado hace más difícil que las personas se adapten a un ambiente caluroso después de haber estado en una vivienda o un vehículo fríos, y señaló que “los trabajadores más jóvenes, más acostumbrados a un estilo de vida más sedentario, no pueden aguantar un día trabajando al aire libre”.
La Asociación de Recursos Forestales, que representa a los propietarios de terrenos forestales, la industria maderera y los aserraderos, agregó que “las enfermedades y muertes relacionadas con el calor no figuran entre los riesgos laborales más graves a los que se enfrentan los trabajadores”. Citaron cifras de OSHA: la agencia documentó 789 hospitalizaciones y 54 muertes relacionadas con el calor a través de investigaciones e infracciones de 2018 a 2021.
OSHA admite que sus datos son cuestionables. Ha dicho que sus cifras “sobre enfermedades, accidentes y muertes relacionadas con el calor en el trabajo son probablemente grandes subestimaciones”.
Los accidentes y enfermedades no siempre se registran, las muertes provocadas por las altas temperaturas no siempre se atribuyen al calor, y los daños relacionados con el calor pueden ser acumulativos, provocando infartos, insuficiencia renal y otras dolencias después de que la persona haya abandonado su lugar de trabajo.
El efecto de la temperatura
Para establecer normas, OSHA debe conocer los efectos del calor en los que trabajan en interiores y al aire libre. La justificación es una parte necesaria del proceso, porque las normativas aumentarán los costos para los empresarios que necesiten instalar sistemas de aire acondicionado y ventilación en el interior, y para aquellos cuya productividad pueda bajar si se permite a los que trabajan a la intemperie tomar descansos o reducir las jornadas cuando suban las temperaturas.
Lo ideal sería que los empresarios tomaran medidas para proteger a los trabajadores del calor independientemente de las normas, afirmó Georges Benjamin, director ejecutivo de la Asociación Americana de Salud Pública. “Tenemos que hacer un mejor trabajo para convencer a los empresarios de que hay una compensación entre la eficiencia y los trabajadores enfermos”, dijo.
García y su marido sufrieron los síntomas del golpe de calor: vómitos, náuseas y fatiga. Pero sus casos forman parte de los miles que no se contabilizan cuando la gente no va al hospital ni presenta denuncias por miedo a perder su empleo o estatus migratorio.
Los trabajadores agrícolas están notoriamente subrepresentados en las estadísticas oficiales sobre accidentes y enfermedades laborales, según David Michaels, epidemiólogo de la Universidad George Washington y ex administrador de OSHA.
Investigadores que encuestaron a trabajadores agrícolas de Carolina del Norte y Georgia encontraron que más de un tercio presentaba síntomas de enfermedad por calor durante los veranos analizados, una cifra muy superior a la registrada por OSHA. En particular, el estudio de Georgia reveló que el 34% de los trabajadores agrícolas no tenía descansos regulares, y una cuarta parte no tenía acceso a espacios con sombra.
Incluso los casos en los que los trabajadores son hospitalizados pueden no atribuirse al calor si los médicos no documentan la conexión. Muchos estudios relacionan los accidentes laborales con el estrés térmico, que puede causar fatiga, deshidratación y vértigo.
En un estudio realizado en el estado de Washington, se observó que los trabajadores agrícolas se caían de las escaleras con más frecuencia en junio y julio, unos de los meses más calurosos y húmedos. Y en un informe de 2021, investigadores calcularon que las temperaturas más cálidas causaron aproximadamente 20,000 accidentes laborales al año en California entre 2001 y 2018, según los reclamos de compensación de los trabajadores.
Las lesiones renales por calor también aparecen en la base de datos de OSHA de trabajadores lesionados gravemente en el trabajo, como el caso de un empleado de una planta de procesamiento de carne hospitalizado por deshidratación y lesión renal aguda en un caluroso día de junio en Arkansas.
Sin embargo, la investigación revela que el daño renal provocado por el calor también puede ser gradual. Un estudio de trabajadores de la construcción que estuvieron durante un verano en Arabia Saudita reveló que el 18% presentaba signos de lesión renal, lo que los ponía en riesgo de insuficiencia renal futura.
Además de cuantificar las lesiones y muertes causadas por el calor, OSHA trata de atribuirles un costo para poder calcular el ahorro potencial derivado de la prevención. “Hay que medir las cosas, como ¿cuánto vale una vida?”, afirmó Michaels.
Para los trabajadores y sus familias, el sufrimiento tiene consecuencias de largo alcance que son difíciles de enumerar. Los gastos médicos son más obvios. Por ejemplo, OSHA calcula que el costo directo de la postración por calor (sobrecalentamiento debido a insolación o hipertermia), es de casi $80,000 en costos directos e indirectos por caso.
Si esto parece elevado, hay que pensar en un trabajador de la construcción de Nueva York que perdió el conocimiento en un día caluroso y se cayó de una plataforma, y sufrió una laceración renal, fracturas faciales y varias costillas rotas.
El precio de los golpes de calor
Investigadores también han intentado determinar el costo que supone para los empresarios la pérdida de productividad. El trabajo es menos eficiente cuando suben las temperaturas, y si los trabajadores se ausentan por enfermedad y tienen que ser reemplazados, la producción disminuye mientras se entrena a nuevos trabajadores.
Cullen Page, cocinero de Austin, Texas, y miembro del sindicato Restaurant Workers United, trabaja durante horas frente a un horno de pizza, donde, según dijo, las temperaturas oscilaron entre los 90 y los 100 grados cuando las olas de calor golpeaban la ciudad en agosto.
“Es brutal. Afecta tu forma de pensar. Estás confundido”, dijo. “Me dio un sarpullido por calor que no se me quitaba”. Como hace tanto calor, agregó, el restaurante tiene un alto índice de rotación de empleados. Una campana extractora adecuada sobre los hornos y un mejor aire acondicionado ayudarían, pero los propietarios aún no han hecho las mejoras, dijo.
Via 313, la cadena de pizzerías en la que trabaja Page, no respondió al pedido de comentario.
Page no es el único. Una organización que representa a los empleados de restaurantes, Restaurant Opportunities Centers United, encuestó a miles de trabajadores, muchos de los cuales informaron de condiciones inseguras por el calor: el 24% de los trabajadores de Houston, por ejemplo, y el 37% de los de Philadelphia.
“Los trabajadores estuvieron expuestos a temperaturas de hasta 100 grados después de que se rompieron los aparatos de aire acondicionado y los ventiladores de las cocinas, lo que les dificultaba respirar”, escribió el Sindicato Internacional de Empleados de Servicios, que incluye a trabajadores del sector de comida rápida, en una nota a OSHA. “No hay razón para retrasar más la creación de una norma cuando conocemos la magnitud del problema y sabemos cómo proteger a los trabajadores”, dijeron.
Investigadores del Atlantic Council calculan que Estados Unidos perderá una media de $100,000 millones anuales por la baja de la productividad laboral inducida por el calor a medida que el clima se vuelve más cálido. “A los empresarios les cuesta mucho dinero no proteger a sus trabajadores”, afirmó Juley Fulcher, defensora de salud y seguridad de los trabajadores de Public Citizen, organización de Washington D.C. que aboga por que el proyecto de ley Asunción Valdivia permita a OSHA promulgar normas el año que viene.
Como modelo, Fulcher sugirió fijarse en California, Maryland, Nevada, Oregon y Washington, los únicos estados con normas que obligan a que todos los trabajadores al aire libre tengan acceso a agua, descanso y sombra.
Aunque las normas no siempre se hacen cumplir, parece que surten efecto. Después de que California instaurara la suya en 2005, se registraron menos accidentes en los reclamos de indemnización de los trabajadores cuando las temperaturas superaban los 85 grados.
Michaels afirmó que OSHA ha demostrado que puede actuar con más rapidez de lo habitual cuando el Congreso se lo permite.
En los primeros días de la epidemia de VIH/SIDA, la agencia aprobó rápidamente normas para evitar que médicos, enfermeras y dentistas se infectaran accidentalmente con agujas. Ahora existe una urgencia similar, dijo. “Dada la crisis climática y la prolongación de los períodos de calor extremo”, señaló, “es imperativo que el Congreso apruebe una legislación que permita a OSHA promulgar rápidamente una norma que salve vidas”.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 7 months ago
Noticias En Español, Public Health, Rural Health, Arkansas, Biden Administration, california, Environmental Health, Georgia, Legislation, Maryland, Nevada, North Carolina, Oregon, texas, U.S. Congress, Washington
KFF Health News' 'What the Health?': Congress Is Out. The Presidential Campaign Is In.
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Congress has left for its annual August recess, but lawmakers have a long to-do list waiting when they return — and only a handful of legislative days to fund the government before the Oct. 1 start of the new fiscal year.
Meanwhile, Republican presidential candidates who are not named Donald J. Trump are preparing for their first televised debate and making interesting promises about health care.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.
Panelists
Alice Miranda Ollstein
Politico
Sandhya Raman
CQ Roll Call
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- Work has paused on Capitol Hill. Among other items of unfinished business, lawmakers returning next month will have to pass at least a short-term spending bill — or soon face a government shutdown with implications for health programs and much, much more. Authorizations are also on the agenda, with programs like community health centers on the line. But the path to passage winds through a social issues minefield, owing to conservative House Republicans who have inserted measures targeting abortion access and gender-affirming care for transgender people.
- Access to women’s health care in the United States is worsening, with maternal health deserts popping up around the nation even in the years before the overturn of Roe v. Wade. Some states in particular have seen a huge decline in the number of maternal health providers, including the closures of obstetric wards. The fact that more people are living in counties with no maternal health providers is troubling news for a nation experiencing a maternal mortality crisis.
- State medical boards across the country have disciplined fewer than two dozen providers reported for spreading covid-19 misinformation, according to a new investigation by The Washington Post. The paucity of punishments demonstrates how ill-equipped such boards are to address the serious problem of health misinformation.
- On the 2024 presidential campaign trail, Republican candidates like Gov. Ron DeSantis of Florida are signaling that re-litigating the covid pandemic is part of their playbook — but do voters still care that strongly about vaccine mandates and business shutdowns?
- And the National Institutes of Health has moved to officially study long covid, a little-understood condition that impacts the lives of many Americans.
Also this week, Rovner interviews KFF Health News senior correspondent Phil Galewitz, who reported the latest KFF Health News-NPR “Bill of the Month” installment, about how a bill that should never have been sent created headaches for one patient. If you have an outrageous medical bill you’d like to share with us, you can do that here.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Stat’s “Henrietta Lacks Settlement Hailed by Experts as Step Toward Correcting Medicine’s Racist History,” by Annalisa Merelli.
Alice Miranda Ollstein: The Tampa Bay Times’ “Florida Veered From Norms to Strip Transgender Care From Medicaid, Records Show,” by Emily L. Mahoney and Romy Ellenbogen.
Sandhya Raman: KFF Health News’ “Black Women Weigh Emerging Risks of ‘Creamy Crack’ Hair Straighteners,” by Ronnie Cohen.
Lauren Weber: Politico’s “CDC Investigators Find More TB Infections Linked to Bone Graft Materials,” by Alice Miranda Ollstein and Lauren Gardner.
Also mentioned in this week’s episode:
- The Washington Post’s “Doctors Who Put Lives at Risk With Covid Misinformation Rarely Punished,” by Lena H. Sun, Lauren Weber, and Hayden Godfrey.
- Roll Call’s “Health Deadlines Pile Up as Congress Adjourns for August,” by Lauren Clason, Ariel Cohen, Jessie Hellmann, and Sandhya Raman.
- Slate’s “How Meta Created a Wild West for Abortion Misinformation,” by Jennifer Neda John.
- Politico’s “‘It’s a Crisis’: Maternal Health Care Disappears for Millions,” by Alice Miranda Ollstein and Megan Messerly.
click to open the transcript
Transcript: Congress Is Out. The Presidential Campaign Is In.
KFF Health News’ ‘What the Health?’Episode Title: Congress Is Out. The Presidential Campaign Is In.Episode Number: 308Published: Aug. 3, 2023
[Editor’s note: This transcript, generated using transcription software, 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. 3, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Ollstein, of Politico.
Ollstein: Good morning.
Rovner: Lauren Weber, The Washington Post.
Lauren Weber: Hello, hello.
Rovner: And Sandhya Raman, of CQ Roll Call.
Sandhya Raman: Good morning.
Rovner: Later in this episode we’ll have my interview with my KFF Health News colleague Phil Galewitz, who wrote the latest “Bill of the Month” for KFF Health News and NPR. This month’s patient never should have gotten a bill for his care, but he and his family ended up with a giant mess nonetheless. But first, this week’s news. It is officially August. Congress is gone until September, which makes it a good time to take stock of what has and hasn’t been accomplished on the health agenda and what might feasibly get done this fall, which is always shorter than you think. The biggest outstanding issue, literally and figuratively, is the spending bill for the Department of Health and Human Services. When Congress comes back, members theoretically only have 11 legislative days before Oct. 1, when the new fiscal year begins. And if Congress doesn’t complete work on the spending bill, which has yet to come to the House or Senate floor or even get out of the House Appropriations Committee, a lot of Health and Human Services programs could shut down unless Congress passes a temporary bill to keep them open. Sandhya, right now everything kind of points to an Oct. 1 shutdown, or am I missing something?
Raman: Yeah, I think at this point we’re looking at either a shutdown or just, like, a continuing resolution, just kicking the can a little bit down the road and giving them some more time. So right before Congress left, the Senate did advance, in the Appropriations Committee, their spending bill for [the departments of] Labor, HHS, and Education. And that means that all 12 of theirs have gotten at least that far, through the Senate Appropriations Committee, but they would still need to come to the floor, and it doesn’t mean that the House is going to agree to any of that. And the House is a lot further behind in that the only markup they’ve had on the HHS bill is on the subcommittee level. It’s not even at the House Appropriations level. And you can kind of see the tea leaves in that they were trying to get the agriculture bill done before they left, which has all the FDA money in it, and they didn’t end up bringing it to the floor because they didn’t think they would have the votes to pass it. So I think that we’re going to need some time, given that I don’t think that, even though the Senate bills have been bipartisan so far, that they’re going to be eager to jump on those.
Rovner: Every year when there’s a change in leadership in either the House or the Senate, they vow, “This is the year we’re not going to do a big omnibus spending bill. We’re going to do all 12 appropriations separately, and we’re going to run them through the House and the Senate floors, and we’re going to have a conference.” And it hasn’t happened in more than 20 years now. And there’s clearly no reason to think it’s going to happen this year, right?
Ollstein: And one of the biggest sticking points: There are the fights that happen every single year over things like the Hyde Amendment, which prevents federal spending on abortion, but that has spread to almost every single appropriations bill. There are anti-abortion budget riders. There are anti-trans health care budget riders. There are all kinds of things tucked in there that Democrats say they will oppose and that the Senate bills don’t have. But, you know, you have this disconnect where there are plenty of House members who would be completely fine with a shutdown; they’ve said publicly that they think that would not be so bad.
Rovner: You have to say it wouldn’t be as bad as letting the debt ceiling get breached.
Ollstein: Right, right, right, right. Whereas Democrats are very much saying it would be horrible to have a shutdown. And so I was talking to some Democratic House members who say that people are really torn between the pressure to make a deal to keep the government open and the pressure to oppose all of these conservative budget riders. And that tension is going to really come into play in the fall.
Rovner: Yeah. Alice, you wrote a wonderful story on all the abortion fights in all these different bills, and I just had sort of deja vu to the ’90s. If you were following abortion, you had to keep track of obviously the ag bill with FDA in it, HHS bill, and the Department of Justice bill because of abortion in prisons, and the defense bill because of, you know, abortions for servicewomen. I mean, we basically had some kind of abortion fight in more than half of the appropriations bills. So we’re coming back to that right now. Well, there are also lots of programs whose authorizations expire Oct. 1. That’s not the same as the appropriations bills that we’ve just been talking about. Without appropriations, programs have to shut down, at least temporarily. Authorizations, though, can lapse as long as the programs are funded through the appropriations. But it’s still nice to, you know, get your work done on time. Some of the big programs Congress is working on include renewing authority for community health centers, for pandemic preparedness programs, for a big group of graduate medical education programs. What’s the fall outlook for those authorizations?
Raman: So I think part of it is tied into what we see with appropriations, because a lot of these programs — even if they come to an agreement, it’s likely to ride on whatever big spending bill we have next, whether that’s a continuing resolution, whether that’s an omnibus or anything like that. So if we end up seeing some sort of continuing resolution, which is looking likely, a lot of these are going to be short-term, maybe extended if they have an agreement there, which is what they traditionally do, and then something longer — the next vehicle that pops up, the next one, or sometimes they even get a one-year, even if there is agreement, just because this is what Congress does. So some of them, I think, are looking more promising than others. We’ve seen things kind of happen with some of the graduate medical education, the [National] Health Service Corps, like those have kind of come to some sort of agreement, but —
Rovner: And those are typically bipartisan programs.
Raman: Yeah, but then others are not as far along and will take time. I mean, the process to even do like the SUPPORT [for Patients and Communities] Act, which was a 2018 law that had a bunch of different opioid provisions in it, that was bipartisan, got through: I mean, we’ve been marked up in [the] Energy and Commerce [Committee] in the House, and the Senate has not done a markup; they just have a bill that has come out so far. And so getting that done before the Sept. 30 deadline is tricky. There are some that are a little bit more partisan that I think would be more difficult to get done. I mean, the Children’s Hospitals Graduate Medical Education has been a little bit derailed over, like, political back-and-forth over policies for transgender children. And so I think even some things that have been more easy to get across the finish line in the past are having factors that are weighing them down. So a lot of these are a question mark. Yeah.
Rovner: So that was originally a Republican program. I remember when it was created because Medicare funds most of the graduate medical education, but obviously there’s not a lot of Medicare beneficiaries who are children, so they had been left out and this is their own program. But I always get at this point to share my favorite piece of trivia about authorizations versus appropriations, which is that the federal family planning program, Title X [“ten”], has not been reauthorized since 1984. Congress has tried any number of times and has failed. It continues to get funded, but it has literally been operating without authorization for all of those years. Well, one more important authorization that’s not part of the Department of Health and Human Services but is part of health care is PEPFAR [the United States President’s Emergency Plan for AIDS Relief], the very successful international AIDS and HIV program begun under President George W. Bush 20 years ago this year. But this time around, the bipartisanly popular program is hung up over — what else? — abortion. Alice, you wrote about this. I mean, PEPFAR, this is really a Republican-backed program.
Ollstein: Yes. It was created by George W. Bush and has had bipartisan support for most of its life. It’s credited with saving the lives of tens of millions of people. Few programs can say that, of any kind. And millions of people are depending on it right now for access to medications around the world. So Republicans are saying that they won’t support reauthorizing it but they will keep it funded through appropriations, just like you were talking about, keep it sort of limping along on a one-year budget, with language restoring the Trump-era restrictions on the program. So, of course, for the entirety of the program, money has not gone to providing abortions, but this expands that and says money can’t go to any organization that, you know, uses other money to provide abortions or even an organization that gives money to another organization and that subsequent organization does abortions. And so this really has been tough for the program in the last few years. And independent experts are telling me that not reauthorizing it, yes, it wouldn’t shut down the program, but they worry it would send a signal to other countries that this is not something the U.S. is really invested in going forward and it would lead other people to cutting their contributions.
Rovner: Yeah, I mean, in addition to saving millions of lives or tens of millions of lives, this has been an important piece of international diplomacy, particularly in Africa, right?
Ollstein: Right. And that was the point Sen. [Bob] Menendez [(D-N.J.)], who had wanted a full five-year reauthorization attached to the NDAA [National Defense Authorization Act], which he said his Republican colleagues killed — he made that exact point.
Rovner: The defense authorization bill.
Ollstein: Exactly, yes. They were trying that as a workaround to get it reauthorized. And it didn’t work because of GOP opposition. But Menendez was saying, you know, this will only empower countries like China that have been trying to make inroads in Africa with philanthropic work and reduce the influence of the U.S. The geopolitics are definitely on people’s mind as well as the basic humanitarian value.
Rovner: So it’s going to be a busy fall. Well, while we are on the subject of reproductive health, the problem of getting maternal health care here in the U.S. is growing, according to a new study from the March of Dimes. We are the country that already has the worst record for maternal mortality in the developed world. Yay, us. How much worse has it gotten?
Ollstein: It’s gotten a lot worse. So in just one year, between 2019 and 2020, there was a 4% decline in the number of hospitals that have birthing services, OB [obstetrics] wards. And 4% may not sound like a lot, but it’s not evenly distributed; that’s just the national average. Some states had a nearly 25% decline. And like you said, you know, we’re already doing so much worse than other countries with maternal mortality. And this just means millions of more people than before are living in a county that has zero hospitals, zero OB-GYNs, zero maternal health care providers — and then a lot of those same places, these same states and counties, also have really high rates of chronic health conditions that are contributors to maternal mortality. And so all of this is coming as births are expected to go up because of abortion bans. This data was from before Dobbs [v. Jackson Women’s Health Organization, the 2022 Supreme Court ruling overturning the nationwide right to abortion], so we don’t know yet what’s going to happen, but the expectation is that births will go up. And at the same time, there’s just fewer care providers to meet that need.
Rovner: And we also know that in the states with bans, we’re starting to see providers either leave or not go there to train in the first place, which is just going to make the whole thing worse. This week the action is going on in a couple of Midwestern states, Indiana and Ohio, I guess both of which have bans, and one of which is in force and one of which isn’t. Where are we with Indiana and Ohio? I know it changes from hour to hour.
Ollstein: So Ohio’s ban is still enjoined, so that means abortion is still legal in Ohio. The development was about this upcoming vote, and there are two upcoming votes. This is kind of wonky, but the upcoming vote that’s happening in less than a week is whether to make ballot initiatives in general harder to pass, to raise the threshold from 50 to 60%. And that’s explicitly intended to thwart the fall vote on legalizing abortion in the state and putting something in the state constitution that supports it.
Rovner: Which, coincidentally, polls show has about like 56, 57% support, right? So 60% would make it more likely to fail.
Ollstein: Right. Right. That’s coming up. But for now, because of a court injunction, abortion remains legal and the ban is not enforced.
Rovner: And Indiana, which had a very stringent ban that was about to go into effect?
Ollstein: Sandhya, do you want to?
Raman: Oh, yeah. I was just going to add to Ohio first that, as of this morning, the voter turnout for the Ohio election next week is super high. It was, like, over 380,000 people have already cast their ballot, and that was higher than, I guess, you know, when they had, like, [a] competitive Senate primary before. And so it will definitely be something to watch. I mean, we don’t know if the voter turnout is high one way or the other, but I just thought that was really interesting. But with Indiana, their abortion ban was supposed to take effect on Tuesday and then it was halted by another lawsuit, and they were the state that was the first one to pass a post-Dobbs, new abortion ban last year. So it’s, like, another sticking point in that a lot of the bans that have gone into effect are older laws or things that have been unblocked in court.
Rovner: So, yes, it really does depend on the day. I guess I read that a bunch of clinics that had been providing abortion have stopped, even though the ban is, at least for the moment, on hold. So rather typically around the country, you literally have to go day by day to figure out what is allowed and what is not. All right. Well, let us turn now to a segment I’m calling “Myths and Disinformation” this week. Lauren, I was so glad you could join us this week because you and a couple of your colleagues at the Post have a new investigation into how doctors who were peddling bad and often dangerous information during the pandemic were called to account. Spoiler: Not a lot of them were, right?
Weber: Yeah, I was going to say spoiler alert that not a lot of them were called to account. So essentially my colleagues Lena Sun, Hayden Godfrey, and I reviewed the records from all 50 states’ various medical boards, both MD boards and osteopathic boards, to see who actually had been punished for spreading covid misinformation or for practicing in a way that is misinformation-related. And despite discovering from our various records requests over hundreds of complaints for doctors that asked patients to remove masks or told them the vaccines were full of metal or told them not to get a vaccine or a various number of the —or prescribed ivermectin or hydroxychloroquine — only 20 doctors have been disciplined, and we are three and a half years into covid. And you know, what our investigation found is something that everyone on this panel has known for quite some time. But state medical boards are historically weak, underfunded, and are very ill-equipped in the social media age, where misinformation is a deluge, to really step into that breach. And what our investigation essentially found is that they’ve really failed to stop doctors that are spreading misinformation or, you know, prescribing drugs that are not deemed the consensus around the standard of care.
Rovner: So everybody says, oh, well, this is up to medical boards in every state, and they keep doctors honest and keep them on the straight and narrow and sanction them when they do wrong things. That’s not been true for a long time. And I guess now it’s still not true, right?
Weber: Yeah, exactly. And it’s really interesting. And this came up, too, in the case in Idaho for abortion, you see a lot of misinformation folks cite free speech in their ability to practice medicine. It’s actually — you know, it makes it difficult to discipline people because it is being able to prescribe things off-label, or your medical judgment is not something people — medical boards are loath to discipline over, and for good reason. You understand why that may be, but in the case of covid, where this has continued and, you know, treatments like hydroxychloroquine or ivermectin have been deemed outside of the standard of care, it is very surprising that we’ve seen such a low number of disciplinary actions taken. It really goes to show that the boards are not equipped to kind of step into this breach as misinformation has flooded the zone.
Rovner: Well, meanwhile, abortion rights groups are getting frustrated with Meta, Facebook’s parent company, over its inconsistent moderation of information about abortion and reproductive health. It reminds me of some years ago when public libraries would try to limit internet search terms to keep people away from online porn but ended up barring people from searching about breast cancer because it had the word “breast” in it. So this isn’t something that’s new. In fact, going back decades, anti-abortion groups used to advertise their crisis pregnancy centers, which don’t offer abortion but sound like they do, in the yellow pages of the phone book. And kids, ask your parents what a Yellow Pages was. But social media algorithms have the ability to determine what information a lot more people see or don’t see. This one looks pretty hard to resolve. I know that, unlike Twitter, Facebook is trying here, but this is going to be difficult, yes?
Weber: Yeah, I would say it’s a really hard — you know, it’s interesting that the article in particular that you’re talking about, there were two different camps opposed that were saying abortion is killing the unborn child versus you’re killing people if they have an abortion. And both of those got sanctioned by Facebook because it had the word kill in it. And so what we’re going to see is how they come down on this information. But in a world where you see misinformation — in [Judge Matthew] Kacsmaryk’s circuit [district] court ruling, you know, it’s kind of hard to see how this is going to be resolved by Facebook. I do not envy them in this task. I don’t really know how you would come down on this and how you would comprehensively evaluate all of these posts in a fair manner that is respective of free speech. And like you said, Julie, you know, a lot of times it leads to unintended consequences when you try and restrict posts like this on all sides. And there are some smart people that are trying to advise in the correct way, but we’ll see what happens.
Rovner: Yeah, it is not easy. Speaking of mis- and disinformation and real information, we’re going to move to the campaign trail, because it’s only August of an odd-numbered year but the 2024 presidential campaign is in full swing, with the first Republican candidate debate later this month. And while health care, specifically the desire to repeal the Affordable Care Act, is far from the rallying cry for Republicans that it has been in the last couple of presidential campaigns, we are seeing some interesting stances and comments from candidates who are not named Donald Trump. We will start with the candidate who’s running second in the Republican primary polls. That would be Florida Gov. Ron DeSantis, whose campaign launch has been anything but smooth. DeSantis, perhaps looking for some publicity, raised some eyebrows last week when he suggested on a conservative podcast that, if elected, he might install Democratic presidential candidate and known anti-vaxxer Robert F. Kennedy Jr. at the CDC [Centers for Disease Control and Prevention] or the FDA. DeSantis has been trying to stake out kind of a middle ground on his vaccine position. He’s not outright anti-vax, but he doesn’t support mandates and he’s kind of hot and cold on supporting vaccines in general. I don’t see how this would actually win him love on either side. I mean, he actually said that they would sic RFK Jr. on the CDC or the FDA.
Weber: I got to say, I find it fascinating. I mean, look, RFK Jr. has a cult following. And I think if anything, it speaks to the fact that Republicans are very much anti-vaccine mandate, anti-government shutdown, all things that RFK says all the time. And DeSantis did walk it back and said he would put him on a committee because, you know, we wouldn’t want a Democrat actually running these things. But I think really what this episode shows is the salience that words like the CDC, and we’ll talk later about the FDA — you know, the American voting public cares about these things now. They know what these agencies are, and they have strong feelings. They blame them for pandemic policies. And I think it just goes to show that relitigating the pandemic and different people’s versions of how they believe the pandemic went is really going to be a constant in this political run-up to 2024.
Ollstein: While I agree with that, I also think it is maybe not as salient as DeSantis was hoping it would be. I mean, he really has formed his candidacy on his governorship during the pandemic, and it doesn’t seem to be breaking through. He’s still just miles and miles and miles behind Trump. And depending on the polls, some of these people with way less of a platform than the governor of Florida are doing quite well. And so I think that people do have strong feelings about vaccine mandates and mask mandates and school closures and all of that, but not nearly as strong as a year ago. So I think that he maybe isn’t getting the juice from saying a lot of these things that he was hoping he would.
Rovner: Well, speaking of candidates who have less of a platform and yet seem to be making inroads — long shot but picking-up-momentum candidate Vivek Ramaswamy, who actually does know something about health policy, as the founder of a biotech firm, has vowed to, quote, “expose and [to] ultimately gut” the FDA. Now, he is a former libertarian rapper, so it is not a shock that he opposes most federal regulatory entities. But I wonder how even Republican voters would feel about actually gutting the FDA. It’s one thing — Alice, you were talking about feelings about the pandemic, but the FDA obviously does a lot more things than just deal with masks and covid vaccines. I mean, is there really a Republican constituency for wiping out the federal regulatory mechanism?
Ollstein: I mean, there at least seems to be at the state level in some states. We’ve talked so much about how GOP lawmakers have voted to roll back public health powers in a bunch of states because of covid. But it’s set to have implications way beyond covid and limit public health workers’ ability to respond to foodborne outbreaks and other things — things in the water, things in the air. So you could see that skepticism and desire to strip the government of its public health powers at the federal level as well.
Rovner: And, Lauren, you’ve been looking at this at the state level, too, right, sort of the slow decline of trust in public health, or maybe not-so-slow decline of trust in public health.
Weber: Yeah. I mean, you know, I found this February, 30 states have passed laws that have rolled back public health powers. There’s litigation at the federal level that has really stripped a lot of executive power for the public health system. As we know, public health leaders on the ground have resigned, quit, or been fired in droves due to political pushback. There’s a lot of concern among the public health community and the folks that I talk to constantly that we have seen just a massive hollowing-out of the workforce that will be impossible to replace. And so I think you’re seeing, you know, kind of as we’ve talked about, how I think this is a talking point among Republican candidates, to kind of bash these government agencies because it’s something that is appealing to people that are irritated over these deals.
Raman: Like, if you look at his comments about this, does this really hold up to the scrutiny? I mean, FDA is not the one that would mandate vaccines, mandate mask-wearing. They don’t set prices. None of that is under their jurisdiction. And, you know, you can assume that he knows this given his background, but I think it just kind of goes with some of his other comments about, you know, defunding a lot of the other agencies that he’s made. So I think some of this also just banks on people maybe not knowing, you know, what falls under what bucket. And it just might be an easy punching bag to lump it in together if the people aren’t aware of what falls under CDC versus FDA or any other agency or state-level.
Rovner: And he’s one of those people that just seems very sure of himself, even when what he’s saying isn’t necessarily true. And the very-sure-of-himself part seems to appeal to voters. But I want to go back to DeSantis just one more time. But before we’re done, speaking of trying to have it both ways, DeSantis stepped into a bees’ nest on abortion, of all things. This is the governor who signed a six-week abortion ban bill in Florida, but he kind of hemmed and hawed about saying whether he would support a national abortion ban. So that won him a firm rebuke from the Susan B Anthony List, which is a pretty powerful political arm of conservative Republicans. Does DeSantis really think he can sustain a position like this, where you can really say, “We only want states to deal with this and we don’t really want it to be at the federal government”? I mean, that was sort of the Supreme Court’s argument. But I think that there’s a lot of grassroots Republicans who would like to not have to fight this state by state and would like to see a national ban.
Ollstein: Yes, the major anti-abortion groups have said that that, you know, “leave it to the states” is not an answer they will accept and they will continue to put the pressure on candidates. Their argument is that, you know, because of things like the appropriations process and because of things like access via Medicaid — [that] is a fight and access in prisons is a fight and access for — you know, their argument is the federal government is already involved in abortion, so you should support the federal government getting involved in banning abortion.
Rovner: Which is kind of true. I mean, the part about the federal government already being heavily involved in abortion.
Ollstein: Sure. Do with that what you will. But candidates keep falling into this same trap. I mean, you had Nikki Haley, who is not polling very well at the moment — she held a whole event with Susan B. Anthony List that they hyped, and she said she would lay out her plan for abortion and there were, like, no specifics whatsoever. And then the group said, “Oh, she assured us she supports a national ban,” but then she said she didn’t. And this is going to continue to be a fight. I think really Mike Pence is the one who is most firm in saying, “Yeah, I support a national ban.”
Rovner: Yeah, and he’s been consistent his entire career, when he was in the House and when he was governor.
Ollstein: He is also not polling very well, I will note.
Rovner: Yes, that’s true. Fair point. We will obviously continue to talk about things on the campaign trail as we move along the campaign trail. Well, finally this week, I want to talk about covid, which we haven’t done for a while. It is still around, and cases, while still low, are on the upswing at the moment. But the news this week is that after almost three years, the National Institutes of Health is finally acting on directions from Congress to get moving on efforts to study and treat so-called long covid, which as many as 10% of patients end up with after having the virus. The long covid community, which could be several million people, have been agitating for scientists to take their symptoms more seriously and do more work in the research realm. Now, NIH has finally created an Office of Long COVID [Research and Practice], albeit with only two full-time staffers to start with. It’s also started enrolling an estimated 24,000 people in several clinical trials to test things like a longer course of the drug Paxlovid. But patient groups say it’s still way too little for what’s a serious and growing more widespread ailment. Why is this all taking so long? I mean, we have a Democratic administration. One would think that they would be anxious to do this.
Weber: I mean, I think if you look at it, there was over a billion dollars allocated to this. I mean, I don’t know why it’s taking so long, Julie. I think a lot of advocates are asking the same question and really beating the drum around that — and especially if you look at things that are named Operation Warp Speed or, you know, other covid treatments, vaccine, other things that were able to move at a much quicker pace and get done in a much quicker time frame — I think there’s a lot of agitation among what could be a very large group of people that their concerns and quality of life and some of these horrible symptoms are not being addressed. And as you noted, I think it’s very fascinating there are only two full-time staffers. I’ll be curious to see if this continues to change, but historically, it hasn’t been very promising.
Rovner: This is not new that Congress will direct, particularly the NIH, to study something that NIH just doesn’t seem prepared to study. Of course, as we know, there’s no NIH director at the moment. We’ve talked about the fact that nominee is being blocked by Democrat Bernie Sanders. But still, I mean, this is something — and I think Congress wants NIH to do because so many of their constituents are coming to them and saying, “We have this problem; please go out and study it.” And yet the federal scientists don’t seem to know really what to do.
Weber: Well, and there was a congressman, I don’t remember his name, but someone on this panel probably does, who said he was retiring because he has long covid, and I think he has colleagues that also have long covid. So, I mean, I think that probably helped get them a fair amount of cash. But as you said, the delivery mechanism on getting clinical trials rolling has really not been there.
Rovner: Well, we will keep an eye on this, too. That is this week’s news. Now we will play my interview with KFF Health News’ Phil Galewitz, and then we will come back with our extra credits. We are pleased to welcome back to the podcast my colleague Phil Galewitz, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” story. Phil, thanks for being here.
Phil Galewitz: Nice to be back.
Rovner: So, this month’s patient was well covered by insurance and, to cut to the chase, shouldn’t have paid anything for a surgery he had in 2021. Tell us who he is and what kind of care he got.
Galewitz: Thomas Greene had complications from diabetes, and he had to get some clogged arteries cleared out in his leg to treat something called peripheral artery disease. So he went to the hospital in 2021 for the procedure. He recovered pretty well. He had some other health issues, but he recovered fine from the procedure. The issue then came when the bills started coming in.
Rovner: And Mr. Greene has both Medicare and a supplemental Medigap policy, which should have brought his out-of-pocket cost to zero. But that’s not what happened. What did happen?
Galewitz: Yes, the Greenes, because of their good insurance, were used to whenever they got health care, that they did not have any out-of-pocket expenses. But this time, about a year later, or over a year, after the procedure, they suddenly started getting some letters from collection agencies who were looking to collect bills for about $3,000 for anesthesia.
Rovner: So, just the anesthesia part.
Galewitz: It was just the anesthesia. The hospital was fine. The surgeon who did the procedure was fine, but the anesthesiologist, who they were not even familiar with, started sending them bills through a collection agency, and they were perplexed about what was going on. And they tried to reach out and call and find out what was happening, why they were getting bills. And they said they were getting a runaround and couldn’t really get a clear answer.
Rovner: They went for help, too, and the people who were helping them had trouble getting answers.
Galewitz: Yes. They went to some organizations within Pennsylvania that specialize in helping seniors with their medical bills, and even them couldn’t get any clear answers. And then thankfully, they kept pushing and kept pushing, and they were able to get another advocacy group to work on their behalf, who talked to this organization called the North American Partners in Anesthesia, which is a large anesthesia group, to stop sending them bills, and thankfully, the bills have stopped coming. They did not pay anything, but they were worried about that this was going to affect your credit.
Rovner: So what did happen? How did they end up with these bills that they shouldn’t have had?
Galewitz: It’s still a mystery. North American would not talk to us, KFF Health News, to give us answers, and they don’t really have a clear answer. By law, providers are supposed to bill Medicare within one year to have their claims paid. In this case, the records that the Greenes have show that the bills to the claims to Medicare were sent in after a year, and that because of that, Medicare clearly marked down and said these bills are after a year, we’re not paying anything, and the patient owes zero. And when a patient gets a notice from Medicare saying, “You owe zero,” that’s supposed to be it. You don’t owe anything. No matter what letters you get from the provider, you’re not supposed to pay anything. But in this case the provider continued to bill and continued to send collection agencies after the patient. And they were perplexed.
Rovner: And just to be clear, when they billed this supplemental policy, the supplemental policy has to deny it if Medicare denied it, right?
Galewitz: Right. Humana was their supplemental provider, and that was actually the answer from Humana. If Medicare is not covering it, then we’re not going to cover it.
Rovner: So, in the meantime, even if you get one of these bills and you know that you don’t owe anything but there are collection letters coming, you do need to do something, right?
Galewitz: Yes. You should open your mail. The Greenes did say at one point they think they may have gotten some letters earlier from the anesthesia group and they may not have opened them. Because they didn’t expect any bills, they didn’t open them. The lesson is open your mail. Even if you think you shouldn’t get any bill, you should at least know ahead of time that you may be able to stave off problems down the road. So always open your mail, and then you may be able to handle the problem earlier on. So they may have stopped some of the collections. But again, they were covered. They reached out. They tried to do everything that they can within their realm, and they struggled. They’re feeling OK now. They never got a letter from North American saying, “Hey, we apologize,” or, “You’re in the clear.” They’ve just stopped getting bills. And it’s been since last year that they’ve gotten a bill, so they feel like they should be OK.
Rovner: And just the one little quirk also of this story is that it looked like the anesthesia group overbilled, right?
Galewitz: There was a question on the bills, on the claims, that it appeared that an anesthesiologist and a nurse anesthetist both billed Medicare for the exact same time, though it could be that maybe there was both, that one assisted the other. This was not a complex procedure. So there were questions about that. But it would be unusual that they would both bill for the exact same time period. And so there’s a question if they were double billing; it could not have been. North American would not answer our question.
Rovner: Well, so we have discovered another thing that, even if you don’t necessarily get answers, it appears that they got their problem solved, right?
Galewitz: Yes.
Rovner: OK. Phil, Galewitz, thank you very much.
Galewitz: Thank you.
Rovner: OK. We are back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We’ll post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Alice, why don’t you go first this week?
Ollstein: Sure. Staying on the DeSantis train, I have a piece from the Tampa Bay Times called “Florida Veered From Norms to Strip Transgender Care From Medicaid, Records Show.” And this came out of a lawsuit that was challenging the state’s decision to strip Medicaid coverage of gender-affirming care, not just for children, but for adults as well. So what came out in discovery in the lawsuit was that the state did just all of these really unusual things. And the judge thought it showed a political motivation rather than, you know, a serious health care motivation for doing this. They paid all of these outside contractors with dubious backgrounds to be part of this effort. They came up with a slogan for the report, which is completely unusual. And the reporters found that staffers who supported defunding gender-affirming care got huge raises, and people who were not supportive of it did not. So, really good accountability reporting, and it seems to have played out in court as well.
Rovner: Yeah, quite a story. Sandhya.
Raman: My extra credit this week is called “Black Women Weigh Emerging Risks of ‘Creamy Crack’ Hair Straighteners.” And it’s from Ronnie Cohen for KFF Health News and on BET. The story takes a look at the messaging and awareness related to increasing health risks that people are worried about related to relaxers or, you know, chemically straightened hair. And it’s something that is especially popular among Black women. I think it was really interesting that only about half of states have anti-hair-discrimination laws, and so a lot of women might be more eager to get their hair chemically straightened for various reasons, workplace or things like that. And there’s not a ton of research.
Rovner: Right. It’s not just that they think it looks better.
Raman: No, no. And there’s not a ton of research on the cancer risk, but personal care products like hair relaxers don’t have the same kind of approval process through the FDA as food and drugs. So, it just takes a look at some of the different things there and what different providers are kind of considering and watching out for.
Rovner: Yeah, it’s really kind of scary. Lauren.
Weber: I actually flagged one of Alice’s stories, which is, “CDC Investigators Find More TB Infections Linked to Bone Graft Materials,” and it details how a bunch of patients have tested positive for tuberculosis after receiving bone grafts. And one of them has died. And there’s 36 more that are being treated for tuberculosis. And I find this fascinating because I find the coverage of tuberculosis in this country totally not where it should be. I mean, TB is — there are a lot of cases in the U.S. It’s a highly infectious — I mean, not a lot; there’s like 10,000 — but there’s a lot more than people realize. And it can be latent and lie in wait and, you know, to have some sort of medical procedure and then find out that whatever was implanted in you has given you a very dangerous, highly infectious disease that could result in you having to quarantine for months, depending on what it is, is really alarming. And there’s a lot of accountability follow-up questions on this for the FDA, these bone graft companies. And it gets at, do we want to gut the FDA, that is hopefully trying to stop things like this, even if it’s not preventing it here? It just leads to a lot of accountability questions that I think are quite fascinating.
Rovner: Yeah, a lot a lot of things that people have not thought about. Well, my story this week is from Stat, but it’s not so much a story as it is an event. Aug. 1 would have been the 103rd birthday of Henrietta Lacks, who longtime listeners to the podcast will remember we talked about a few years back when the book about her life, “The Immortal Life of Henrietta Lacks,” was made into a movie. For those of you without such long memories, Henrietta Lacks was an African American woman from Baltimore who was admitted to Johns Hopkins Hospital for cervical cancer in 1951. She died later that year at age 31. But the doctors who treated her also harvested cells without her knowledge or permission that turned out to be the first-ever self-perpetuating cell line. So HeLa cells, as they are called, for Henrietta Lacks, have been used in more than 75,000 different studies since then and have led to the development of such breakthroughs as the polio vaccine, treatments for cancer, and even the mapping of the human genome. While Hopkins has given the cells away for free to researchers, many of the companies that have used them have developed products that have made them, the companies, very rich. But until this week, no one in Henrietta Lacks’ family ever profited from the enormous contribution that she made to medical science. This week, the family’s lawyers reached a confidential but presumably significant settlement with one of those companies, Thermo Fisher, which makes a wide range of scientific supplies. But this is not just about justice for the family of Henrietta Lacks; it’s about starting to recognize and atone for unethical medical research over many, many years, particularly on African Americans. A good birthday present indeed. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still tweet me. I’m @jrovner. Sandhya.
Raman: I’m @SandhyaWrites.
Rovner: Lauren.
Weber: @LaurenWeberHP.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: We will be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Emmarie Huetteman
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ ‘What the Health?’ on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 8 months ago
Elections, Multimedia, Abortion, KFF Health News' 'What The Health?', Long Covid, Misinformation, NIH, Podcasts, Pregnancy, U.S. Congress, Women's Health
KFF Health News' 'What the Health?': Let’s Talk About the Weather
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
2023 will likely be remembered as the summer Arizona sizzled, Vermont got swamped, and nearly the entire Eastern Seaboard, along with huge swaths of the Midwest, choked on wildfire smoke from Canada. Still, none of that has been enough to prompt policymakers in Washington to act on climate issues.
Meanwhile, at a public court hearing, a group of women in Texas took the stand to share wrenching stories about their inability to get care for pregnancy complications, even though they should have been exempt from restrictions under the state’s strict abortion ban.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.
Panelists
Rachel Cohrs
Stat News
Shefali Luthra
The 19th
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- Tensions over abortion access between the medical and legal communities are coming to the fore in the courts, as doctors beg for clarification about bans on the procedure — and conservative state officials argue that the law is clear enough. The risk of being hauled into court and forced to defend even medically justified care could be enough to discourage a doctor from providing abortion care.
- Conservative states are targeting a Biden administration effort to update federal privacy protections, which would make it more difficult for law enforcement to obtain information about individuals who travel outside a state where abortion is restricted for the procedure. Patient privacy is also under scrutiny in Nebraska, where a case involving a terminated pregnancy is further illuminating how willing tech companies like Meta are to share user data with authorities.
- And religious freedom laws are being cited in arguments challenging abortion bans, with plaintiffs alleging the restrictions infringe on their religious rights. The argument appears to have legs, as early challenges are being permitted to move forward in the courts.
- On Capitol Hill, key Senate Democrats are holding up the confirmation process of President Joe Biden’s nominee as director of the National Institutes of Health to press for stronger drug pricing reforms and an end to the revolving-door practice of government officials going to work for private industry.
- And shortages of key cancer drugs are intensifying concerns about drug supplies and drawing attention in Congress. But Republicans are skeptical about increasing the FDA’s authority — and supply-chain issues just aren’t that politically compelling.
Also this week, Rovner interviews Meena Seshamani, director of the Center for Medicare at the Centers for Medicare & Medicaid Services at the Department of Health and Human Services.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Los Angeles Times’ “Opinion: Crushing Medical Debt Is Turning Americans Against Their Doctors,” by KFF Health News’ Noam N. Levey.
Rachel Cohrs: The New York Times’ “They Lost Their Legs. Doctors and Health Care Giants Profited,” by Katie Thomas, Jessica Silver-Greenberg, and Robert Gebeloff.
Alice Miranda Ollstein: The Atlantic’s “What Happened When Oregon Decriminalized Hard Drugs,” by Jim Hinch.
Shefali Luthra: KFF Health News’ “Medical Exiles: Families Flee States Amid Crackdown on Transgender Care,” by Bram Sable-Smith, Daniel Chang, Jazmin Orozco Rodriguez, and Sandy West.
Also mentioned in this week’s episode:
- Stat’s “From Rapid Cooling Body Bags to ‘Prescriptions’ for AC, Doctors Prepare for a Future of Extreme Heat,” by Karen Pennar.
- Politico’s “The Sleeper Legal Strategy That Could Topple Abortion Bans,” by Alice Miranda Ollstein.
click to open the transcript
Transcript: Let’s Talk About the Weather
KFF Health News’ ‘What the Health?’Episode Title: Let’s Talk About the WeatherEpisode Number: 306Published: July 20, 2023
[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]
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 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein, of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Rachel Cohrs, of Stat News.
Rachel Cohrs: Hi, everybody.
Rovner: And Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: Later in this episode we’ll have my interview with Meena Seshamani, director of the Center for Medicare at the Center for Medicare & Medicaid Services at the Department of Health and Human Services. She has an update on drug price negotiations, Medicare Advantage payments, and more. But first, this week’s news. So let’s talk about the weather. Seriously, this summer of intense heat domes in the South and Southwest, flash floods in the East, and toxic air from Canadian wildfires almost everywhere below the border has advertised the dangers of climate change in a way scientists and journalists and policymakers could only dream about. The big question, though, is whether it will make any difference to the people who can actually do something about it. I hasten to point out here that in D.C., it’s normal — hot and humid for July, but nothing particularly out of the ordinary, especially compared to a lot of the rest of the country. Is anybody seeing anybody on the Hill who seems at the least alarmed by what’s going on?
Ollstein: Not other than those who normally speak out about these issues. You’re not seeing minds changed by this, even as the reports coming out, especially of the Southwest, are just devastating — I mean, especially for unhoused people, just dying. I was really interested in the story from Stat about doctors moving to start prescribing things to combat heat, like prescribing air conditioners, prescribing cooling packs and other things, really looking at heat as a medical issue and not just a feature of our lives that we have to deal with.
Rovner: Well, emergency rooms are full of patients. You can now burn yourself walking on the sidewalk in Arizona. You know, last summer was not a great summer for a lot of people, particularly in California and in western Canada. But this year, it’s like everywhere across the country, everybody’s having something that’s sort of, oh, a hundred-year something or a thousand-year something. And yet we just sort of continue on blithely.
Ollstein: And just quickly, what really hits me is how much of a vicious cycle it can create, because the more people use air conditioners, those give off heat and make the bigger situation worse. So making it better for yourself makes it worse for others. Same with driving. You know, the worse the weather is, the more people have to drive rather than bike or walk or take public transit. And so it gets into this vicious cycle that can make it worse for everyone and create these so-called heat islands in these cities.
Rovner: All right. Well, let us move on to a more familiar topic: abortion and reproductive health. In case you’re wondering why it’s hard to keep track of where abortion is legal, where it’s banned, and where it’s restricted, let’s talk about Iowa. When we last checked in, last week, state lawmakers had just passed a near-total ban after the state Supreme Court deadlocked over a previous ban and the Republican governor, Kim Reynolds, was poised to sign it. Then what happened?
Luthra: The governor signed the ban right as the hearing for the ban concluded in which Planned Parenthood and another abortion clinic in the state sued, arguing, right, that this is the exact same as the law that was just struck down and therefore should be struck down again. And this judge said that he wouldn’t rush to his ruling. He wanted to, you know, give it the time that it deserved so he wouldn’t be saying anything on Friday, which meant as soon as the law was signed, it took effect. It was in effect for maybe a little over 72 hours, essentially through the weekend. And then on Monday, the judge came and issued a ruling blocking the law. And even that is temporary, right? It only lasts as long as this case is proceeding. And one of the reasons Republicans came back and passed this ban is they are hopeful that something has changed and that this time around the state Supreme Court will let the six-week ban in Iowa stand, which really just would have quite significant implications for the Midwest, where it’s been kind of slower to restrict abortion than the South has been because of the role the courts have played in Ohio, in Iowa, blocking abortion bans, and we could very soon see restrictions in Iowa, in Indiana, potentially in Ohio, depending on how the election later this year goes. And it will look like a very different picture than it did even six months ago.
Rovner: And for the moment, abortion is legal in Iowa, right?
Luthra: Correct.
Rovner: Up to 20 weeks?
Luthra: Up to 20, 22, depending on how you count.
Rovner: But as you say, that could change any day. And it has changed from day to day as we’ve gone on. Well, if that’s not confusing enough, there are a couple of lawsuits that went to court in Texas and Missouri, and neither of them is actually challenging an abortion ban. In Texas, women who were pregnant and unable to get timely care for complications are suing to clarify the state’s abortion ban so patients don’t have to literally wait until they are dying to be treated. And in Missouri, there’s a fight between two state officials over how to describe what a proposed state ballot measure would do, honestly. So what’s the status of those two suits? Let’s start with Texas. That was quite a hearing yesterday.
Luthra: It is really devastating to watch. And the hearing continues today, Thursday. And we are hearing from these women who wanted to have their pregnancies, developed complications where they knew that the fetus would not be viable, could not get care in the state. One of them who came to the State of the Union earlier this year, she had to wait until she was septic before she could get care. Another woman traveled out of state. Another one had to give birth to a baby that died four hours after being born, and she knew that this baby wouldn’t live. And it’s really striking to watch just how obviously difficult it is for these women to relive this thing that happened to them, clearly one of the worst things in their lives, maybe the worst thing. And the state’s arguments are very interesting, too, because they appear to be trying to suggest that it is actually not that the law is unclear, but that doctors are just not doing their jobs and they should do, you know, the hard work of medicine by understanding what exceptions mean and interpreting laws that are always supposed to be a little ambiguous.
Ollstein: So when states were debating abortion bans and really Republicans were tying themselves in knots over this question of exemptions — How should the exemptions be worded? Should there be any exemptions at all? Who should they apply to? — a lot of folks on the left were yelling at the time that that’s the wrong conversation, that exemptions are unworkable; even if you say on paper that people can get an abortion in a medical emergency, it won’t work in practice. And this is really fodder for that argument. This is that argument playing out in real life, where there is a medical exemption on the books, and yet all of these women were not able to get the care they needed, and some have suffered permanent or somewhat permanent repercussions to their health and fertility going forward. As more states debate their own laws, and some states with bans have even tried to go back and clarify the exemptions and change them, I wonder how much this will impact those debates.
Rovner: Yeah, I mean, if you just say that doctors are being, you know, cowards basically by not providing this care, think of it from the doctor’s point of view, and now we see why hospital lawyers are getting involved. Even if there’s a legitimate medical reason, they could get dragged into court and have to pay tens or hundreds of thousands of dollars in legal fees just to prove that their medical judgment was correct. You can kind of see why doctors are a little bit reluctant to do that.
Ollstein: And just to stress, these laws were not written by doctors. These laws were written by politicians, and they include language that medical groups have pointed out doesn’t translate to the actual practice of medicine. Some of these bans’ exceptions’ language use terms like irreversible, and they’re like, “That’s not something we say in medicine. That doesn’t fit with our training. We don’t think in terms of that.” Also, terms like life-threatening: It’s like, OK, well, is it imminently life-threatening? And even then, what does that mean? How close does someone need to be to losing their life in order to act?
Rovner: And pregnancy itself is life-threatening.
Ollstein: Right. Or something could be life-threatening in a longer-term way, you know, down the road. Other conditions like diabetes or cancer could be life-threatening even if it won’t kill you today or tomorrow. So this is a real battle where medicine meets law.
Rovner: Well, in Missouri, it’s obviously not nearly as dramatic, but it’s also — you can see how this is playing out in a lot of these states. This is basically a fight between the state attorney general and the state auditor over how much an abortion ban might end up costing the state. They’re really sort of fighting this as hard as they can. It’s basically to make it either more or less attractive to voters, right?
Ollstein: It’s similar to some of the gambits we saw in Michigan to keep the measure off the ballot or put it on the ballot in a way that some would say would be misleading to voters. So I think you’re seeing this more and more in these states after so many states, including pretty conservative states, voted in favor of abortion rights last year. You know, the right is afraid of that continuing to happen, and so they’re looking at all of these technical ways — through the courts, through the legislatures, whatever means they can — to influence the process. And Democrats cry that this is antidemocratic, not giving people a say. Republicans claim that they’re preventing big-money outside groups from influencing the process. And I think this is going to be a huge battle. Missouri and Ohio are up next in terms of voting. And after that, you have Florida and Nevada and a bunch of other states in the queue. And so this is going to continue to be something we’re discussing for a while.
Luthra: And to flag the case in Ohio, what’s happening there, right, is the state is having voters vote onto whether to make it harder to pass constitutional amendments. There’s an election in August that would raise the threshold to two-thirds. And what we know from all of the evidence why they don’t typically have August referenda in Ohio is because the turnout is very, very low, and they are expecting that to be very low. And they’ve made it explicit that the reason they want to make it harder to pass constitutional amendments is, in fact, the concern around Ohio’s proposed abortion protection.
Rovner: Of course, that’s what they said about Kansas last year, that people wouldn’t vote because it was in the summer, so — but this is a little bit more obtuse. This is whether or not you’re going to change the standard for passing constitutional change that would enshrine abortion. So, yeah, clearly —
Luthra: It’s hard to get people excited about votes on voting.
Rovner: Yeah, exactly. An underlying theme for most of this year has been efforts by states that restrict or ban abortion to try to prevent or at least keep tabs on patients who leave the state to obtain a procedure where it is legal. Attorneys general in a dozen and a half states are now protesting a Biden administration effort to protect such information under HIPAA, the medical records privacy provisions of the Health Insurance Portability and Accountability Act. Alice, you’ve written about this. What would the HIPAA update do, and why do the red states oppose it?
Ollstein: The HIPAA update, which was proposed in April, and comment closed in June, and so we’re basically waiting for a final rule — at some point, you know, it can take a while — but it would make it harder for either law enforcement or state officials to obtain medical information about someone seeking an abortion, either out of state or in state under one of these exemptions. This would sort of beef up those protections and require a subpoena or some form of court order in order to get that data. And you have sort of an interesting pattern playing out, which you’ve seen just throughout the Biden administration, where the Biden administration hems and haws and takes an action related to abortion rights and the left says it’s not good enough and the right says it’s wild overreach and unconstitutional and they’re going to sue. And so that’s what I was documenting in my story.
Rovner: Is it 18 red states saying —
Ollstein: Nineteen, yes, yeah.
Rovner: Nineteen red states saying that this is going too far.
Ollstein: They say they want to be able to obtain that data to see if people are breaking the law.
Rovner: Well, Shefali, you wrote this week about sort of a related topic, whether states can use text or social media messages as evidence of criminal activity. That sounds kind of chilling.
Luthra: Yeah, and this is, I think, a really interesting question. We saw it in this case in Nebraska, where a sentencing for one of the defendants is happening today in fact. And I want to be careful in how I talk about this because it concerns a pregnancy that was terminated in April of 2022, before Roe was even overturned. But it sort of offered this test case, this preview for: If you do have law enforcement going after people who have broken a state’s abortion laws, how might they go about doing that? What statutes do they use to prosecute? And what information do they have access to? And the answer is potentially quite a lot. Organizations like Meta and Google are quite cooperative when it comes to government requests for user data. They are quite willing to give over history of message exchanges, history of your searches, or of, you know, where you were tracked on Google Maps. And the bigger question there is how likely are we to see individual prosecutors, individual states, going after patients and their families, their friends for breaking abortion laws? Right now, there’s been some hesitation to do that because the politics are so terrible. But if they do go in that direction, people’s internet user data is, in most states, unprotected. There is no federal law protecting, you know, your Facebook messages. And it could be quite a useful piece of information for people trying to build a case, which should raise concern for anyone trying to access care.
Rovner: Yeah, this is exactly why women were taking their period-tracking apps off of their phones, to worry about the protection of quite personal information. Well, finally this week on the abortion front, we have talked so, so much about how conservative Christians complain that various abortion and even birth control laws violate their religious beliefs. Well, now representatives of several other religions, including Judaism and even some of the more liberal branches of Christianity, say that abortion bans violate their right to practice their religion. This is going on in a bunch of different states. I think the first one we talked about was Florida, I think a year ago. Are any of these lawsuits going anywhere? Do we expect this to end up before the Supreme Court at some point?
Ollstein: So most of them are in state court, not federal. I mean, it’s always possible it could go to the Supreme Court. A couple of them are in federal court and a couple of them have already reached the appeals court level. But the experts I talked to for my story on this said this is mainly going to have an impact in state courts and how they interpret state constitutions. A lot of states have stronger language around religious protections than the federal Constitution, including some laws that pretty conservative state leaders passed in the last few years, and I doubt they expected that same language would be cited to defend abortion rights. But here we are. And yeah, a Missouri court recently ruled that the lawsuit can go forward, the religious challenge to the state’s abortion ban. It’s a coalition of a bunch of different faith leaders bringing that challenge. And in Indiana, they won a preliminary ruling on that case. And there are others pending in Kentucky, Florida, a bunch of other states. And so, yeah, I think this definitely has legs.
Rovner: Yeah, we’re all learning an awful lot about court procedure in lots of different states. Let us move to Capitol Hill, where Congress is in its annual July race to the August recess. Seriously, this is actually a month in which Congress typically does get a lot done. Maybe not so much this year. One perhaps unexpected holdup in the U.S. Senate is where the confirmation of Monica Bertagnolli, President Biden’s nominee to head the National Institutes of Health, is being held up not by a Republican but by two Democrats: health committee chair Bernie Sanders, another member of the committee, Elizabeth Warren. Rachel, what is going on with this?
Cohrs: Sen. Bernie Sanders has long wanted the Biden administration to be more aggressive on drug pricing. And there is one issue in particular that Sen. Sanders has wanted the NIH specifically to use to challenge drug companies’ patents or at least put some pricing protections in there for drugs that are developed using publicly funded research. And the laws that the NIH potentially could use to challenge these companies for high-priced medications have never been used in this way. And Sen. Sanders is using his bully pulpit and the main leverage he has, which is over nominations, to get the White House’s attention. And I think the White House’s position here is that they have done more than any administration in the past 20 years to lower drug prices.
Rovner: Which is true.
Cohrs: It is true. And — but Sen. Sanders still is not satisfied with that and wants to see commitments from the White House and from NIH to do more.
Rovner: And Sen. Elizabeth Warren.
Cohrs: Sen. Elizabeth Warren, yes, who my colleague Sarah Owermohle first reported had some concerns over the revolving door at NIH and wanted a commitment that the nominee wouldn’t go to lobby or work for a large pharmaceutical company for four years after leaving the position, and I don’t know that she’s agreed to that yet. So I don’t see where this resolves. It’s tough, because we’re looking so close to an election, and I think there are big questions about what breaks this logjam. But it certainly has slowed down what looked like a very smooth and noncontroversial nomination process.
Rovner: Yeah, I mean, obviously, you know, we’ve seen many, many times over the years nominations held up for other reasons — I mean, basically using them as leverage to get some policy aim. It’s more rare that you see it on the president’s own party but obviously, you know, not completely unprecedented. Certainly in this case we have a lot of things to be worked out there. Well, Sen. Sanders also seems to be threatening the reauthorization of one of his very pet programs, the bipartisanly popular community health centers. His staff this week put out a draft bill and announced a markup before sharing it with Republicans on the committee. Now Ranking Member Bill Cassidy, who also supports the community health centers program — almost everybody in Congress supports the community health centers program — Cassidy complains there’s no budget score, that the bill includes programs from outside the committee’s jurisdiction, and other details that can be very important. Is Sanders trying to make things partisan on purpose, or is this just sloppy staff work?
Cohrs: Honestly, I can’t answer that question for you, but I don’t think that it’s going to result in a productive outcome for the community health centers. And I think we have in recent years seen significant cooperation between the chair and ranking member, but with Lamar Alexander, with Richard Burr, with Patty Murray, you know, we have seen a lot civility on this committee in the recent past, and that appears to have ended. And I think Sen. Cassidy’s response that he hadn’t seen the legislation publicly was, I think, telling. We don’t usually see that kind of public fighting from a committee chair.
Rovner: He put out a press release.
Cohrs: Right, put out a press release. Yeah. This is not what we usually see in these committees. And it is true that Sen. Sanders’ bill is so much more money than I think is usually given to community health centers in this reauthorization process. I think it’s true that the bill that he dropped touches issues that would anger almost every other stakeholder in the health care system. And I don’t think Sen. Cassidy quite envisioned that. And he introduced his own bill that would have introduced —
Rovner: Cassidy introduced his own bill.
Cohrs: Yes, Sen. Cassidy introduced his own bill last week that would have continued on with what the House Energy and Commerce Committee had passed unanimously earlier this summer to give community health centers a more modest boost in funding for two years.
Rovner: And obviously, there’s some urgency to this because the authorization runs out at the end of September and now we’re in July and they’re going to go away for August. So this is obviously something else that we’re going to need to keep a fairly close eye on. Well, meanwhile, elsewhere, as in at the Senate Finance Committee, which oversees Medicare and Medicaid, we’re starting to see legislation to regulate PBMs — pharmacy benefit managers — or are we? Rachel, we’ve come at this several times this year. How close are we getting?
Cohrs: We’re getting closer. And I think that two key committees are really feeling the heat to get their proposals out there before the end of the year. The first, like you mentioned, was the Senate Finance Committee, which is planning a markup next week, right before senators leave for August recess. They’ve asked for feedback from CBO [the Congressional Budget Office] around the end of August recess so that they’ll be ready to go. But I think it’s no secret that their delay in marking anything up or introducing anything has slowed down this process. And in the House, I know the Ways and Means Committee is trying to put together their own proposal and find time for a markup, whereas the House Energy and Commerce Committee, which also has jurisdiction over many of these issues, is frustrated, because they got their bill introduced, they had all the full regular order of subcommittee and then full committee hearings and then markups, got this bill unanimously out of their committee, and now everyone’s kind of waiting around on these two committees with jurisdiction over the Medicare program to see what they’re going to put together before any larger package can be compiled.
Rovner: Well, you know things are heating up when you start seeing PBM ads all over cable news. So even if you don’t understand what the issue is, you know that it’s definitely in play on Capitol Hill. Well, while we’re on the subject of drug prices, we have another lawsuit trying to block Medicare’s drug price negotiation, this one filed by Johnson & Johnson. Why so many? Wouldn’t these drug companies have more clout if they got together on one big suit, or is there some strategy here to spread it out and hope somebody finds a sympathetic judge?
Ollstein: Yes, I think the latter is exactly what they’re doing, because if they were to all kind of band together, then it would be putting all their eggs in one basket. And this way we see most of the companies have filed in different jurisdictions. I think Johnson & Johnson did file in the same court as Bristol Myers Squibb did, so I think it’s not a perfect trend. But generally what we are seeing is that the trade groups like the [U.S.] Chamber of Commerce and PhRMA [the Pharmaceutical Research and Manufacturers of America] kind of have their own arguments that they’re making in different venues. The drug manufacturers themselves have their own arguments that they’re making in their own venues, and they’re spreading out across the country in some typically more liberal courts and circuits and some more conservative. But I think that it’s important to note that the Chamber of Commerce so far is the only one that’s asked for a preliminary injunction, in Ohio. That is kind of the motion that, if it’s approved, could potentially put a stop to this program even beginning to go into effect. So they’ve asked for that by Oct. 1.
Rovner: And remember, I guess we’re supposed to see the first 10 drugs from negotiation in September, right?
Cohrs: By Sept. 1, yes.
Rovner: By Sept. 1.
Cohrs: Pretty imminently here.
Rovner: Also happening soon. Well, before we stop with the news this week, I do want to talk briefly about drug shortages. This has come up from time to time, both before and during the pandemic, obviously, when we had supply chain issues. But it seems like something new is happening. Some of these shortages seem to be coming because generic makers of some drugs just don’t find them lucrative enough to continue to make them. Now we’re looking at some major shortages of key cancer drugs, literally causing doctors to have to choose who lives and who dies. Are there any proposals on Capitol Hill for addressing this? It’s kind of flying below the radar, but it’s a pretty big deal.
Cohrs: I think we’ve seen Congressman Frank Pallone make this his pet issue in the reauthorization of PAHPA [Pandemic and All-Hazards Preparedness Act], which is the pandemic preparedness bill, which also expires on Sept. 30. So, you know, they have a full plate.
Rovner: Which we will talk about next week because they’re marking it up today.
Cohrs: Exactly. Yes. So but what we have seen is that Democrats in the House Energy and Commerce Committee have made this a top priority to at least have something on drug shortages in PAHPA. And I think my colleague John Wilkerson watched a hearing this week and noted that the chair of the committee, Cathy McMorris Rodgers, seemed more open to adding something than she had been in the past. But again, I think it’s kind of uncertain what we’ll see. And Sen. Bernie Sanders did add a couple of drug shortage policies to his version of PAHPA in the HELP Committee [Senate Committee on Health, Education, Labor and Pensions]. So I think we are seeing some movement on at least some policies to address it. But the problem is that the supply chain is not sexy and Republicans are not crazy about the idea of giving the FDA more authority. I think there is just so much skepticism of these public health agencies. It’s a hard systemic issue to crack. So I think we may see something, but it’s unclear whether any of this would provide any immediate relief.
Rovner: Everybody agrees that there’s a problem and nobody agrees on how to solve it. Welcome to Capitol Hill. OK, that is this week’s news. Now we will play my interview with Medicare chief Meena Seshamani, and then we’ll come back and do our extra credit. I am pleased to welcome to the podcast Meena Seshamani, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services at the Department of Health and Human Services. That must be a very long business card.
Meena Seshamani: [laughs]
Rovner: Translated, that means she’s basically in charge of the Medicare program for the federal government. She comes to this job with more than the requisite experience. She is a physician, a head and neck surgeon in fact, a PhD health economist, a former hospital executive, and a former top administrator there at HHS. Meena, welcome to “What the Health?” We are so happy to have you.
Seshamani: Thank you so much for having me, Julie.
Rovner: So, our podcast listeners will know, because we talk about it so much, that the biggest Medicare story of 2023 is the launch of a program to negotiate prescription drug prices and hopefully bring down the price of some of those drugs. Can you give us a quick update on how that’s going and when patients can expect to start to see results?
Seshamani: Absolutely. The new prescription drug law, the Inflation Reduction Act, really has made historic changes to the Medicare program. And to your point, people are seeing those results right now. There is now a $35 cap on what someone will pay out-of-pocket for a month’s supply of covered insulin at the pharmacy, which is huge. I’ve met with people all over the country. Sometimes people are spending up to $400 for a month’s supply of this lifesaving medication. Also, vaccines at no cost out-of-pocket. And a lot of this leads to what you’re mentioning with the drug negotiation program, a historic opportunity for Medicare to negotiate drugs. In January, we put out a timeline of the various pieces that we’re putting in place to stand up this negotiation program. Along that timeline, we have released guidance that describes the process that we will undergo to negotiate, what we’ll think about as we’re engaging in negotiation. And the first 10 drugs for negotiation that are selected will be announced on Sept. 1. And that will then lead into the negotiation process.
Rovner: And as we’ve mentioned — I think it was on last week’s podcast — there’s a lot of lawsuits that are trying to stop this. Are you confident that you’re going to be able to overcome this and keep this train on the tracks?
Seshamani: Well, we don’t generally comment on the lawsuits. I will say that we are implementing this law in the most thoughtful manner possible. From the day that the law was enacted, we have been meeting with drug manufacturers, health plans, patient groups, health care providers, you know, experts in the field, to really understand the complexity of the drug space and what we can do with this opportunity to really improve things, improve access and affordability to have innovative therapies for the cures that people need.
Rovner: Well, while we are on that subject, we — not just Medicare, but society at large — is facing down a gigantic conundrum. The good news is that we’re finally starting to see drugs that can treat or possibly cure such devastating ailments as Alzheimer’s disease and obesity. But those drugs are currently so expensive, and the population that could benefit from them is so large, they could basically bankrupt the entire health care system. How is Medicare approaching that? Obviously, in the Alzheimer’s space, that could be a very big deal.
Seshamani: Well, Julie, we are committed to helping ensure that people have timely access to innovative treatments that can lead to improved care and better outcomes. And in doing this, we take into account what the Medicare law enables coverage for and what the evidence shows. So with Alzheimer’s, CMS underwent a national coverage determination. And consistent with that, Medicare is covering the drug when a physician and clinical team participates in the collection of evidence about how these drugs work in the real world, also known as a registry. And this is very important because it will enable us to gather more information on patient outcomes as we continue to see innovations in this space. And you mentioned obesity. In the Medicare law, there is a carve-out for drugs for weight loss.
Rovner: A carve-out meaning you can’t cover them.
Seshamani: Correct. It says that the Medicare Part D prescription drug program will not cover drugs for weight loss. So we are looking at the increasing evidence. And for example, where there is a drug that is used for diabetes, for example, you know, then it can certainly be covered. And this is an area that we are continuing to partner with our colleagues in the FDA on and that we’d like to partner with the broader community to continue to build the evidence base around benefits for the Medicare population as we continue to evaluate where we want to make sure that people have access.
Rovner: But are you thinking sort of generally about what to do about these drugs that cost sometimes tens of thousands of dollars a year, hundreds of thousands of dollars a year, that half the population could benefit from? I mean, that cannot happen, right, financially?
Seshamani: Well, Julie, this is where the new provisions in the new drug law really come into play. Thinking from access for people for the high-cost drugs, I think we all know what a financial strain the high cost of drugs have created for our nation’s seniors, where now, in 2025, there will be a $2,000 out-of-pocket cap, that people will not have to pay out-of-pocket more than $2,000, which enables them to access drugs. And on the other side, as we talked about with drug negotiation, where for drugs that have been in the market for seven years or 11 years, if they are high-cost drugs, they could potentially be selected for negotiation where we can then, you know, as we laid out in the guidance that we put out, look at what is the benefit that this drug provides to a population? What are the therapeutic alternatives? And then also consider things like what’s the cost of producing that drug and distributing it? How much federal support was given for the research and development of that drug? And how much is the total R & D costs? So I think that there are several tools that we’ve been given in the Inflation Reduction Act that demonstrate how we are continuing to think about how we can ensure that Medicare is delivering for people now and in the future.
Rovner: Well, speaking of things that are popular but also expensive, let’s talk briefly about Medicare Advantage. More and more beneficiaries are opting for private plans over traditional, fee-for-service Medicare. But the health plans have figured out lots of ways to game the system to make large profits basically at taxpayers’ expense. Is there a long-term plan for Medicare Advantage or are we just going to continue to play whack-a-mole, trying to plug the loopholes that the plans keep finding?
Seshamani: You know, as now we have 50% of the population in Medicare Advantage, Medicare Advantage plays a critical role in advancing our vision for the Medicare program around advancing health equity, expanding access to care, driving innovation, and enabling us to be good stewards of the Medicare dollar. And that vision that we have is reflected in all of the policies that we have put forward to date. And I might add that those policies really have been informed by engagement with everyone who’s interested in Medicare Advantage. We did a request for comment and got more than 4,000 suggestions from people. This has now come out in recent policies like cracking down on misleading marketing practices so that people can get the plan that best suits their needs; ensuring clear rules of the road for prior authorization and utilization management so we can make sure that people are accessing the medically necessary care that they need; things like improving network adequacy, particularly in behavioral health, so people can access the health care providers in the networks of the plans; and then the work that we’re doing around payment, to make sure that we’re paying accurately, updating the years that we use for data, looking at the coding patterns of Medicare Advantage. And again, this is all work that is important to make sure that the program is really serving the people in the Medicare program.
Rovner: So, as you know, we’ve done big investigative projects here at KFF Health News about both medical debt and nonprofit hospitals not living up to their responsibilities to the community. As the largest single payer of hospitals, what is Medicare doing to try and address requirements for charity care, for example?
Seshamani: Well, the. IRS oversees the requirements for community benefit, which is how hospitals maintain or get a nonprofit status. We have certainly worked with the Consumer Financial Protection Bureau and the Department of Treasury on, for example, issuing a request for information, seeking public comment on, you know, medical credit cards. But even beyond that, I think this is an example of where we need to bring more payment accuracy and transparency in the health care system. So, for example, we have recently just proposed strengthening hospital price transparency so that people can know what is the cost of services, standard charges that hospitals provide. We also are adding quality measures to hospitals, particularly around issues around health equity, making sure that hospitals are screening patients for social needs. And we’re also tying increasingly our payment programs to making sure that those underserved populations are receiving excellent care, so again, really trying to drive transparency, quality, and access through all of the work that we’re doing with hospitals.
Rovner: But can you leverage Medicare’s power? Obviously, you know, that was what created EMTALA [the Emergency Medical Treatment and Labor Act], was leveraging Medicare’s power. Can you leverage it here to try and push some of these hospitals to do things they seem reluctant to do?
Seshamani: Where we have our levers in the Medicare program, we absolutely are working with hospitals around issues of equity, so as I mentioned, you know, really embedding equity not only in our quality requirements but also in hospital operations — for example, that as part of their operations they need to be looking at health equity. You know, where we are looking at how they are providing care and addressing issues of patient safety. So, we continue to look into all of these angles, and where we can support good practices. For example, we just proposed in our inpatient prospective payment system rule that when hospitals are taking care of homeless patients, that can be considered in their payment, because we have found through our analyses that additional resources are being used to make sure that those patients are supported for all of their needs, and we’re encouraging hospitals to code for these social needs so that we can continue to assess with them where resources and supports are needed to provide the kind of care that we all want for our populations.
Rovner: Last question, and I know that this is big, so it’s almost unfair. One of the reasons we know that it’s getting so expensive to manage medical costs is the increasing involvement of private equity in health care. What’s the Biden administration doing to address this growing profit motive?
Seshamani: Yeah, Julie, I’ll come back to, you know, what I alluded to before around transparency. We are really committed to transparency in health care, and we are continuing to focus on gathering data that sheds light on what is happening in the health care market so that we can be good stewards of the taxpayer dollar. So I mentioned our work in hospital price transparency, where we have streamlined the enforcement process; we have proposed to require standard ways that hospitals are reporting their charges and standard locations where they have to put a footer on the hospital’s homepage so that people can find that data easily. In Medicare Advantage, we are requiring more reporting for the medical loss ratio for plans to report spending on supplemental benefits like dental, vision, etc. And we really want to hone in on where else we can gather more data to be able to enable all of us to see what is happening in this dynamic health care market; what’s working? What isn’t? And so we’re very interested in getting ideas.from everyone of where more data can be helpful to enable us to then enact policies that can make sure that the health care industries and the market are really serving people in the most effective way possible.
Rovner: Well, you’ve got a very big job, so I will let you get back to it. Thank you so much, Meena Seshamani.
Seshamani: Thank you for having me.
Rovner: OK, we’re back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week?
Luthra: Sure. So mine is from KFF Health News by a dream team, Bram Sable-Smith, Daniel Chang, Jazmin Orozco Rodriguez, and Sandy West. The headline is “Medical Exiles: Families Flee States Amid Crackdown on Transgender Care.” And I mean, it’s exactly what it sounds like. It’s this really person-grounded, quite deeply reported story about how restrictions on gender-affirming health care, especially for young people, are forcing families to leave their homes. And this is a really tough thing for people to do, you know, leave somewhere where you’ve lived for 10 years or longer and go somewhere where you don’t have ties. Moving is quite expensive. And I think this is a really important look at something that we anecdotally know is happening, haven’t seen enough really great deep dives on, and is something that potentially will happen more and more as people are forced to leave their homes if they can afford to do so because they don’t feel safe there anymore.
Rovner: Yeah, and this is the issue of doing these social issues state by state by state, just what’s happening now. Alice.
Ollstein: So I chose a piece from The Atlantic called “What Happened When Oregon Decriminalized Hard Drugs,” by Jim Hinch. It was really fascinating. On the one side, they say this is evidence that the policy has failed, that decriminalizing possession of small amounts of cocaine, heroin, all hard drugs, has been a failure because overdoses have actually gone up since then. But other experts quoted in this article say that, look, we tried the punitive war on drugs model for decades and decades and decades before declaring it a failure; how can we evaluate this after just a few years? It just takes more time to make this transition and takes more time to, you know, ramp up treatment and services for people, and because this happened three years ago, it was disrupted by the pandemic and, you know, services were not able to reach people, etc. So a really fascinating look.
Rovner: Yes, it’s quite the social experiment that’s going on in Oregon. Rachel.
Cohrs: So mine is from The New York Times, a group of reporters and a new series called “Operating Profits.” And the headline is “They Lost Their Legs. Doctors and Health Care Giants Profited.” And I think I’m just really excited to see more about this line of reporting about overutilization in health care and how certain payment incentives — I mean, they made a story about payment incentives in hospital outpatient departments and how pay rates change really personal and interesting, and it’s important. So, I mean, all these really dense rules that we’re seeing drop this summer do really have implications for patients. And there are bad actors out there who are kind of capitalizing on that. So I felt it was like really responsible reporting, mostly focused on one physician who, you know, was doing procedures that he shouldn’t have and other doctors ultimately were left to clean up the damage for these patients. And they had amputations that they maybe shouldn’t have had, which is such a serious and devastating consequence. I thought that was very important reporting, and I’m excited to see what’s next.
Rovner: Yeah, I’m looking forward to seeing the rest of the series. Well, my story this week is in the Los Angeles Times from my KFF Health News colleague Noam Levey, who’s been working on a giant project on medical debt. It’s called “Crushing Medical Debt Is Turning Americans Against Their Doctors.” And it points out something I hadn’t really thought about before, that outrageous and unexpected bills are undermining public confidence in medical providers and the medical system writ large. And so far, nobody’s doing very much about it. To quote from Noam’s piece, “Hospitals and doctors blame the government for underpaying them and blame insurers for selling plans with unaffordable deductibles. Insurers blame providers for obscene prices. Everyone blames drug companies.” Well, it’s going to take a lot of time to dig out of this hole, but probably it would help if everybody stopped digging. OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m still @jrovner, and I’m on Threads @julie.rovner. Shefali.
Luthra: I’m @shefalil.
Rovner: Alice.
Ollstein: @AliceOllstein.
Rovner: Rachel.
Cohrs: I’m @rachelcohrs.
Rovner: We will be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Emmarie Huetteman
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ ‘What the Health?’ on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.
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.
USE OUR CONTENT
This story can be republished for free (details).
1 year 9 months ago
Courts, Multimedia, Pharmaceuticals, Public Health, States, Abortion, CMS, Environmental Health, HHS, KFF Health News' 'What The Health?', NIH, Podcasts, Pregnancy, texas, U.S. Congress, Women's Health