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Julie Rovner
KFF Health News

@jrovner

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

The Republican National Convention highlighted a number of policy issues this week, but health care was not among them. That was not much of a surprise, as it is not a top priority for former President Donald Trump or most GOP voters. The nomination of Sen. J.D. Vance of Ohio adds an outspoken abortion opponent to the Republican ticket, though he brings no particular background or expertise in health care.

Meanwhile, abortion opponents are busy trying to block state ballot questions from reaching voters in November. Legal battles over potential proposals continue in several states, including Florida, Arkansas, and Arizona.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.

Panelists

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Among the takeaways from this week’s episode:

• Sen. J.D. Vance of Ohio has cast few votes on health policy since joining Congress last year. He has taken a doctrinaire approach to abortion restrictions, though, including expressing support for prohibiting abortion-related interstate travel and invoking the Comstock Act to block use of the mail for abortion medications. He also speaks openly about his mother’s struggles with addiction, framing it as a health rather than criminal issue in a way that resonates with many Americans.
• Although Republicans have largely abandoned calls to repeal and replace the Affordable Care Act, it would be easy for former President Donald Trump to undermine the program in a second term; expanded subsidies for coverage are due to expire next year, and there’s always the option to cut spending on marketing the program, as Trump did during his first term.
• Trump’s recent comments to Robert F. Kennedy Jr. about childhood vaccinations echoed tropes linked to the anti-vaccination movement — particularly the false claim that while one vaccine may be safe, it is perhaps dangerous to receive several at once. The federal vaccination schedule has been rigorously evaluated and found to be safe and effective.
• Covid is surging once again, with President Joe Biden among those testing positive this week. The virus is proving a year-round concern and has peaked regularly in summertime; covid spreads best indoors, and lately millions of Americans have taken refuge inside from extremely high temperatures. Meanwhile, the virology community is concerned that the nation isn’t testing enough animals or humans to understand the risk posed by bird flu.

Also this week, Rovner interviews KFF Health News’ Renuka Rayasam, who wrote the June installment of KFF Health News-NPR’s “Bill of the Month,” about a patient who walked into what he thought was an urgent care center and walked out with an emergency room bill. If you have an exorbitant or baffling medical bill, you can send it to us here.

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

Julie Rovner: Time magazine’s “‘We’re Living in a Nightmare:’ Inside the Health Crisis of a Texas Bitcoin Town,” by Andrew R Chow.

Joanne Kenen: The Washington Post’s “A Mom Struggles To Feed Her Kids After GOP States Reject Federal Funds,” by Annie Gowen.

Alice Miranda Ollstein: ProPublica’s “Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant To Help Needy Families, but No One Knows if It Works,” by Cassandra Jaramillo, Jeremy Kohler, and Sophie Chou, ProPublica, and Jessica Kegu, CBS News.

Sarah Karlin-Smith: The New York Times’ “Promised Cures, Tainted Cells: How Cord Blood Banks Mislead Patients,” by Sarah Kliff and Azeen Ghorayshi.

Also mentioned on this week’s podcast:

The Wall Street Journal’s “Mail-Order Drugs Were Supposed To Keep Costs Down. It’s Doing the Opposite,” by Jared S. Hopkins.

Click to open the transcript

Transcript: At GOP Convention, Health Policy Is Mostly MIA

KFF Health News’ ‘What the Health?’Episode Title: ‘At GOP Convention, Health Policy Is Mostly MIA’Episode Number: 356Published: July 18, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 18, 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: Sarah Karlin-Smith at the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

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

Joanne Kenen: Hi, everybody.

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Renuka Rayasam, about the latest “Bill of the Month.” This month’s patient went to a facility with urgent care in its name but then got charged emergency room prices. But first, this week’s news.

So as of this morning, we are most of the way through the Republican National Convention, which obviously has a somewhat different tone than was expected, following last weekend’s assassination attempt on former President Donald Trump. The big news of the week is Trump’s selection of Ohio Republican Sen. JD Vance as his running mate. Vance has only been in the Senate since 2023, had not served previously in public office, and he doesn’t have much of a record on much of anything in health care. So, what do we know about what he thinks?

Ollstein: Well, I have been most focused on his abortion record, which is somewhat more extensive than his record on other health policy. Obviously, Congress has not done very much on abortion, but he’s been loud and proud about his anti-abortion views, including calling for national restrictions. He calls it a national minimum standard, but the idea is that he does not want people in conservative states where abortion is banned to be able to travel to progressive states where it is allowed. He has given interviews to that effect. He has signed letters to that effect. He has called for enforcement of the Comstock Act, which, as we’ve talked about before, is this long dormant statute that prohibits the mailing of abortion drugs or medical instruments that could be used to terminate a pregnancy. And so this is a very interesting moment to pick Vance.

The Republican Party is attempting to reach out to more moderate voters and convince them that they are hoping to leave this issue to the states. Vance’s record somewhat says otherwise. He also opposed efforts in his own state of Ohio to hold a referendum that ended up striking down that state’s abortion ban. So, definitely a lot for Democrats to go after in his record and they are not wasting any time; they are already doing it.

Rovner: Yeah, I’m kind of surprised because Vance, very much like Trump, has been kind of everywhere, or at least he has said that he’s kind of everywhere on abortion. But as you mentioned, Alice, you don’t have to look very hard to see that he’s pretty doctrinaire on the issue. Do you think people are going to buy this newer, softer Republicanism on abortion?

Ollstein: Well, abortion rights groups that I’ve spoken to are worried that people are buying it. They’re worried as they campaign around the country that the Republican Party’s attempt to walk away from their past calls for national restrictions on abortion are breaking through to people. And so they are trying really hard to counter that message and to stress that Republicans can and would pursue national restrictions, if elected.

I think both Democratic candidates and abortion rights groups are working to say even the leave-it-to-states position is too extreme and is harming people. And so they’re lifting up the stories of people in Texas and other states with bans who have experienced severe medical harm as a result of being denied an abortion. And so they’re lifting up those stories to say, “Hey, even saying let’s leave it to the states, let’s not do a national ban — even that is unacceptable in the eyes of the left.”

Kenen: The other issue obviously with his life story is opioids. His mother was addicted. Originally it began with being prescribed a legal painkiller. It’s a familiar story: became addicted, he was raised by his grandmother. His mother, who he showed on TV last night and she was either in tears or really close to tears, she’s 10 years sober now. He had a tough life and opioids was part of the reason he had a tough life. And whatever you think of his politics, that particular element of his life story resonates with people because it may explain some of his political views. But that experience is not a partisan experience and he was a kid. So I think he clearly does see opioids as a medical problem, not just, oh, let’s throw them in jail. I mean, the country and the Republican Party, that has been a change. It’s not a change that’s completed, but that shift is across party lines as well. That’s part of him that — it’s something you listen to when he tells that story.

I mean also, he told a story about his grandmother late in life, the grandmother who raised him, having, when she died, they found 19 handguns in the house all over the place. And he told sort of a funny story that she was old and frail and she always wanted to have one within reach. And all I could think of is, all these unlocked handguns with kids in the house! I mean, which is not a regulatory issue, but there’s a gun safety issue there. I’m just thinking, oh my God, 19 guns in drawers all over the house. But he’s obviously a very, the Republican Party is … I mean, after the assassination attempt, you have not heard Donald Trump say, “Maybe I need to rethink my position on gun control.” I mean, that’s not part of the dialogue right now.

I think having someone with that experience, talking about it the way he does, is a positive thing, really. Saying, “Here’s what we went through. Here’s why. Here’s how awful it was. Here’s how difficult it was to get out of it. And this is what these families need.” I mean, that is …

Rovner: Although it’s a little bit ironic because he’s very anti-social programs, in general.

Karlin-Smith: And he’s had a bad track record of trying to address the opioid crisis. He had a charity he started that he ended I guess about when he was running for Senate that really was deemed nonsuccessful. It also had questionable ties to Purdue Pharma, that’s sort of responsible for the opioid crisis. And the other thing that you sometimes hear in both him and Trump’s rhetoric is the blaming of immigrants and the drug cartels and all of that stuff for the opioid crisis. So, there’s a little bit of use of the topic, I think, to drop anti-immigrant sentiment and not really think about how to address the actual health struggles.

Kenen: When he talks about his family, he’s not saying China sent my mother fentanyl. I think it is good for people to hear stories from the perspective of a family who had this, as it is a health problem, reminding people that this is not thugs on the street shooting heroin. It’s a substance abuse disorder, it’s a disease. And so I think the country has come a long way, but it isn’t where it needs to be in terms of understanding that it’s a behavioral health problem. So I think in that sense he will probably be a reminder of that. But he doesn’t have a health record. I mean, he wasn’t there during the Obamacare wars. We don’t really know what he thinks about. I’m not aware of anything he’s really said about entitlements and Medicare. He does come from the state … I mean, Trump is saying he won’t touch it. But I mean if he said Medicare stuff, I missed it. I mean, if one of you knows, correct …

Karlin-Smith: Well, he has actually said that he supports Medicare drug price negotiation at times, which is interesting and unique for a Republican. And I mean Trump, as well, has been a bit different from the traditional Republican, I think, when it comes to the pharma industry and stuff, but I think that maybe is even a bridge too far in some ways.

Rovner: Yeah, he’s generally pretty anti-social program, so it’ll be interesting to see how he walks that line.

Well, this is all good segue into my next question, which is, health in general has been mostly MIA during this convention, including any update on Trump’s ear injury from the attempted assassination. Are we finally post-repeal-and-replace in the Republican Party? Or is this just one of those things that they don’t want to talk about but might yet take up if they get into office?

Kenen: We don’t know what the balance of power is in the Senate and the House, right? I mean, that’s probably going to be part of it. I mean, if they have huge … if they capture both chambers with huge majorities, it’s a new ballgame. Whether they actually try to repeal it, versus there’s all sorts of ways they can undermine it. Trump did not succeed in repealing it. Trump and the House Republicans did not, the Republicans in general did not succeed in repealing it, despite a lot of effort. But they did undermine it in all sorts of ways and coverage actually fell during the Trump administration. ACA [Affordable Care Act] coverage did drop; it didn’t vanish completely, but it dropped. And under Biden it continued to grow. Now, the Republicans get their health care through the ACA, so it’s become much more normalized, but we don’t know what they will do. Trump is not a predictable politician, right? I mean, he often made a big deal about trying to lower drug prices early in his term, and then nothing. And then he even released huge, long list of things …

I remember one of our reporters — Sarah and I were both … Sarah, Alice, and I were all at Politico — and I think it was David who counted the number of question marks in that report. And at the end of the day, nothing much happened. I don’t think the ACA is untouchable; it may or may not be unrepealable in its entirety, but it’s certainly not untouchable.

Rovner: Well, he also changes positions on a whim, as we’ve seen. Most politicians you can at least count on to, when they take a position, to keep it at least for a matter of days or weeks, and Trump sometimes in the same interview can sort of contradict himself, as we know. But I mean, obviously a quick way to undermine the ACA, as you say, would just be to let the extended subsidies expire because they would need to be re-upped if that’s going to continue and there are many millions of people that are now …

Kenen: And they expire next year.

Rovner: … Yes, that are …

Kenen: And there are also two other things. You cut the navigating budget. You cut advertising. You don’t try to sell it. I don’t mean literally sell it, but you don’t try to go out and urge … I mean, that was their playbook last time, and that’s why — it’s one reason enrollment dropped. And that was, the subsidies were under Biden, the extended subsidies. So that’s one year away.

Ollstein: But it’s no surprise that this hasn’t been a big topic of discussion at the RNC [Republican National Convention]. I mean, polling shows that voters trust Democrats more on health care; it’s one of their best issues. It’s not a good issue for Republicans. And so it was fully expected that they would stick to things that are more favorable to them: crime, inflation, whatnot. So, I do expect to hear a lot about health care at the DNC [Democratic National Convention] in a few weeks. But beyond that, we do not know what’s going to happen at the DNC.

Rovner: Yeah.

Karlin-Smith: I was going to say, the one health issue we haven’t really touched on, which the Republicans have been hammering on, is transgender health care and pushing limits on it, especially for people transitioning, children, and adolescents. And I think that’s clearly been a strategic move, particularly as they’ve gotten into more political trouble with abortion and women in the party. They clearly seem to think that the transgender issue, in general, appeals more to their base and it’s less risky for them.

Rovner: Their culture warrior base, as you will. Yeah, and we have in fact seen a fair bit of that. Well, before we leave the convention, one more item: It seems that Trump and RFK Jr. [independent presidential candidate Robert F. Kennedy Jr.] had a phone conversation, which of course leaked to the public, during which they talked about vaccine resistance. Now we know that RFK Jr. is a longtime anti-vaxxer. What, if anything, does the recounting of this conversation suggest about former President Trump’s vaccine views? And we’ve talked about this a little bit before, he’s been very antimandate for the covid vaccine, but it’s been a little bit of a blank on basic childhood vaccines.

Karlin-Smith: And I mean, his remarks are, they’re almost a little bit difficult to parse, they don’t quite make sense, but they seem to be essentially repeating anti-vax tropes around, well, maybe one vaccine on their own isn’t dangerous, but we give kids too many vaccines at a time or too close together. And all of that stuff has been debunked over the years as incorrect. The vaccine schedule has been rigorously evaluated for safety and efficacy and so forth.

That said, Trump obviously was in office when we spearheaded the development of covid vaccines, which ended up being wildly successful, and he didn’t really undermine that process, I guess, for the most part when he was in office. So it’s hard to know. Again, there’s a lot of difficulty in predicting what Trump will actually do and it may depend a lot who he surrounds himself with and who he appoints to key positions in his health department and what their views are. Because he seems like he can be easily persuaded and right now he may just be in, again, campaign mode, very much trying to appeal to a certain population. And you could easily see him — because he doesn’t seem to care about switching positions — just pivoting and being slightly less anti-vax. But it’s certainly concerning to people who have been even more about the U.S. anti-vax sentiments since covid and decreases in vaccination rates.

Rovner: It did feel like he was trying to say what he thought RFK Jr. wanted to hear, so as to win his endorsement, which we know that Trump is very good at doing. He channels what he says depending on who he’s talking to, which is what a lot of politicians do. He just tends to do it more obviously than many others.

Kenen: Julie, we heard this at the tail end of the 2016 campaign. He made a few comments, exactly, very, very similar to this, the size of a horse vaccine and you see the changes — there’s too many, too many vaccines, too large doses. We heard this briefly in the late 2016, and we heard it at the very — I no longer remember whether it was during transition in 2016 or whether it was early in 2017 when he was in the White House — but we heard a little bit of this then, too. And he had a meeting with RFK then. And RFK said that Trump was talking about maybe setting up a commission and RFK at one point said that Trump had asked him to head the commission. We don’t think that was necessarily the case.

First of all, there was no commission. The White House never confirmed that they had asked RFK to lead it. Who knows who said what in a closed room, or who heard what or what they wanted to hear; we don’t know. But we heard this whole episode, including Trump and RFK, at approximately the beginning of 2017, and it did go away. Covid didn’t happen right away; covid was later. There was no anti-vax commission. There was no vax commission. There was no change in vaccination policy in those early years prepandemic. And as Sarah just pointed out, Trump was incredibly pro-vaccine during the pandemic. I mean, the Operation Warp Speed was hailed by even people who didn’t like anything else about Trump. When public health liked Operation Warp Speed, he got vaccines into arms fast, faster than many of us thought, right?

The difference — there were anti-vaxxers then; there have been since smallpox — but it is much more politicized and much more prominent, and in some ways it has almost replaced the ACA as your identifying health issue. If you talk to somebody about the ACA, you know what party they are, you even know where within the party they are, what wing. And that’s not 100% true of anti-vaxxers. There are anti-vaxxers on both sides, but the politicization has been on the Republican-medical-libertarian side, that you-can’t-tell-me-what-to-do-it’s-my-body side. It is much more part of his base and a more intense, visible, and vocal part of his base. So, it’s the same comments, or very similar comments, to the same person in a different political context.

Rovner: Well, I think it’s safe to say that abortion does remain the most potent political health issue of the year, and there was lots of state-based abortion election news this week. As we’ve been discussing all year, as many as a dozen states will have abortion questions on the ballot for voters this November, but not without a fight. Florida has just added an addendum to its ballot measures, suggesting that if passed, it could cost the state money. And in Arkansas and Montana, there are now legal fights over which signatures should or shouldn’t be counted in getting some of those questions to the ballot.

Alice, in every state that’s voted on abortion since Dobbs [v. Jackson Women’s Health Organization], the abortion-right side has prevailed. Is the strategy here to try to prevent people from voting in the first place?

Ollstein: Oh, yes. I wrote a story about this in January. It’s been true for a while, and it’s been true in the states that already had their votes, too. There were efforts in Ohio to make a vote harder or to block it entirely. There were efforts in Michigan to do so. And even the same tactics are being repeated. And so the fight over the cost estimate in Florida, which is usually just a very boring, bureaucratic, routine thing, has become this political fight. And that also happened in Missouri. So, we’re seeing these trends and patterns and basically any aspect of this process that can be mobilized to become a fight between conservative state officials and these groups that are attempting to get these measures on the ballot, it has been. And so Arizona is also having a fight over the language that is going to go in the voter guide that goes out to everybody. So there’s a fight going on there that’s going to go to court next week about whether it says fetus or unborn child. So, all of these little aspects of it, there’s going to be more lawsuits over signature, validation, and so it’s going to be a knockdown, drag-out fight to the end.

It’s been really interesting to see that conservative efforts to mount these so-called decline-to-sign campaigns, where they go out and try to just convince people not to sign the petition — those have completely failed, even in states that haven’t gotten the kind of national support and funding that Florida and Nevada and some of these states have. Even those places have met their signature goals and so they’re now moving to this next phase of the fight, which is these legal and bureaucratic challenges.

Rovner: This is going to play out, I suspect, right, almost until the last minute, in terms of getting some of these on the ballot.

Meanwhile, here on Capitol Hill, there’s an effort underway by some abortion rights backers to repeal the 1873 Comstock Act, which some anti-abortion activists say could be used to establish a national abortion ban. On the one hand, repealing the law would take away that possibility. On the other hand, suggesting that it needs to be repealed undercuts the Biden administration’s contention that the law is currently unenforceable. This seemed to be a pretty risky proposition for abortion rights forces no matter which way they go, right?

Ollstein: Well, for a while, the theory on the abortion rights side was, oh, we shouldn’t draw attention to Comstock because we don’t want to give the right the idea of using it to make a backdoor abortion ban. But that doesn’t really hold water anymore because they clearly know about it and they clearly have the idea already and are open about their desire to use it in documents like Project 2025, in letters from lawmakers urging enforcement of the Comstock Act. And so the whole …

Rovner: In concurring opinions in Supreme Court cases.

Ollstein: … Exactly, exactly. In legal filings in Supreme Court cases from the plaintiffs. So clearly, the whole “don’t give the right the idea thing” is not really the strategy anymore; the right already has the idea. And so now I think it’s more like you said, about undercutting the legal argument that it is not enforceable anyway. But those who do advocate for its repeal say, “Why wouldn’t we take this tool out of contention?” But this is sort of a philosophical fight because they don’t have the votes to repeal it anyway.

Rovner: Yeah, though I think the idea is if you bring it up you put Republicans on the record, as …

Ollstein: Sure, but they’ve been doing that on so many things. I mean, they’ve been doing that on IVF [in vitro fertilization], they’ve been doing that on contraception, they’ve been doing that on abortion, they’ve been doing it on the right to travel for an abortion. They’ve been doing it over and over and over and I don’t see a lot of evidence that it’s making a big impact in the election. I could be wrong, but I think that’s the current state of things.

Rovner: Yeah, I’m with you on that one.

All right, well, while we are all busy living our lives and talking about politics, covid is making its now annual summer comeback. President Biden is currently quarantining at his beach house in Rehoboth after testing positive. HHS [Department of Health and Human Services] Secretary Xavier Becerra was diagnosed earlier this week. And wastewater testing shows covid levels are “very high” in seven states, including big ones like Florida, Texas, and California. Sarah, do we just not care anymore? Is this just not news?

Karlin-Smith: Probably, it depends on who you ask, right? But I think obviously with Biden getting covid, it’s going to get more attention again. I think that a lot of health officials, including in the Biden administration, spent a lot of time trying to maybe optimistically hope that covid was going to become a seasonal struggle, much like flu, where we really sort of know a more defined risk period in the winter and that helps us manage it a bit. And always sort of seemed a little bit more optimistic than reality. And I think recently I’ve listened to some CDC [Centers for Disease Control and Prevention] meetings and stuff where — it’s not really, it’s a little bit subtle — but I think they’re finally kind of coming around to, oh wait, actually this is something where we probably are going to have these two peaks every year. They’re sort of year-round risk. But there hasn’t been a ton done to actually think through, OK, what does that mean for how we handle it?

In this country, every year they have been approving a second vaccine for the people most at risk, although uptake of that is incredibly low. So it does seem like it’s become a little bit of a neglected public health crisis. And certainly in the news sometimes when something kind of stays at this sort of constant level of problem, but nothing changes, it can sometimes, I think, be harder for news outlets to figure out how to draw attention to it.

Rovner: It does seem like, I mean, most of the prominent people who have been getting it have been getting mild cases. I imagine that that sort of has something to do … We’re not seeing … even Biden, who’s as we all know, 81, is quarantining at his beach house, so.

Karlin-Smith: Right, I mean, if you kind of stay up to date, as the terminology is, on your vaccinations, you don’t have a lot of high-risk conditions, if you are in certain at-risk groups you get Paxlovid. For the most part a lot of people are doing well. But that said, I think, I’m afraid to say the numbers, but if you look up the amount of deaths per week and so forth, it’s still quite high. We’re still losing — again, more people are still dying from covid every year, quite a few more than from the flu. I mean, one thing I think people have also pointed out is when new babies are born, you can’t get vaccinated until you’re 6 months. The under-6-month population has been impacted quite a bit again. So, it is that tension. And we saw it with the flu before covid, which is every year flu is actually a very big issue in the U.S. and the public health world for hospitals and stuff but the U.S. never quite put enough maybe attention or pressure to figure out how to actually change that dynamic and get better flu vaccine uptake and so forth.

Kenen: And the intense heat makes it, I mean — covid is much, much, much, much more transmissible inside than outside. And the intense heat — we’re not sitting around enjoying warm weather, we’re inside hiding from sweltering weather. We’re all in Washington or the Washington area, and it’s been hot with a capital H for weeks here, weeks. So people are inside. They can’t even be outside in the evening, it’s still hot. So we think of winter as being the indoors time in most of the country, and summer sort of the indoors time in only certain states. But right now we are in more transmissible environments for covid and …

Rovner: Meanwhile, while we’re all trying to ignore covid, we have bird flu that seems to be getting more and more serious, although people seem to just not want to think about it. We’re looking at obviously in many states bird flu spreading to dairy cows and therefore spreading to dairy workers. Sarah, we don’t really even know how big this problem is, right? Because we’re not really looking for it?

Karlin-Smith: That seems to be one of the biggest concerns of people in the public health-virology community who are criticizing the current response right now, is just we’re not testing enough, both in terms of animal populations that could be impacted and then the people that work or live closely by these animal populations, to figure out how this virus is spreading, how many people are actually impacted. Is the genetics of the virus changing? And the problem of course then is, if you don’t do this tracking, there’s a sense that we can get ourselves in a situation where it’s too late. By the time we realize something is wrong, it’s going to already be a very dangerous situation.

Rovner: Yeah, I mean, before covid, the big concern about a pandemic was bird flu. And was bird flu jumping from birds to other animals to humans, which is exactly what we’re seeing even though we’re not seeing a ton of it yet.

Kenen: We’re not seeing a ton of it, and in its current form, to the best of our knowledge, it’s not that dangerous. The fear is the more species it’s in and the more people it’s in, the more opportunities it has to become more dangerous. So, just because people have not become seriously ill, which is great, but it doesn’t mean it stays great, we just don’t — Sarah knows more about this than I do, but the flu virus mutates very easily. It combines with other flu viruses. That’s why you hear about Type A and Type B and all that. I mean, it’s not a stable virus and that is not, I’m not sure if stable is the right …

Rovner: It’s why we need a different flu shot every year.

Kenen: Right, and the flu shots we have, bird flu is different.

Rovner: Well, we will continue to watch that.

Kenen: Sarah can correct anything I just got wrong. But I think the gist was right, right?

Rovner: Sarah is nodding.

All right, well finally, one follow up from last week in the wake of the report from the Federal Trade Commission on self-dealing by pharmacy benefits managers: We get a piece from The Wall Street Journal this week [“Mail-Order Drugs Were Supposed To Keep Costs Down. It’s Doing the Opposite.”] documenting how much more mail-order pharmacies, particularly mail-order pharmacies owned by said PBMs [pharmacy benefit managers] are charging. Quoting from the story, “Branded drugs filled by mail were marked up on average three to six times higher than the cost of medicines dispensed by chain and grocery-store pharmacies, and roughly 35 times higher than those filled by independent pharmacies.” That’s according to the study commissioned by the Washington State Pharmacy Association. It’s not been a great month for the PBM industry. Sarah, I’m going to ask you what I asked the panel last week: Is Congress finally ready to do something?

Karlin-Smith: It seemed like Congress has finally been ready to do something for a while. Certainly, both sides have passed legislation and committees and so forth, and it’s been pretty bipartisan. So we’ll see. I think some of it costs — I forget if some of it costs a little money — but some of it does save. And that’s always an issue. And we know that Congress is just not very good at passing stand-alone bills on particular topics, so I think the key times will be to look at when we get to any big end-of-year funding deals and that sort of thing, depending on all the dynamics with the election and the lame duck, but …

Rovner: I mean, this has been so bipartisan. I mean, there’s bipartisan irritation in both houses, in both parties.

Karlin-Smith: Right, and I think the antitrust sort of element of this with PBMs kind of appeals to the Republican side of the aisle quite a bit. And that’s why there’s always been a bit of bipartisan interest. And the question becomes: PBMs sort of fill the role that in other countries government price negotiators fill. And that’s not particularly popular in the U.S., particularly on the Republican side of the aisle. And so most of the legislation that is pending, I think, will maybe hopefully get us to some transparency solutions, tweak some things around the edges, but it’s not really going to solve the crisis. It’s going to be, I mean, a very [Washington,] D.C. health policy move, which is kind of, take some incremental steps that might eventually move us down to later reforms, but it’s going to be slow-moving, whatever happens. So, PBMs are going to be in the spotlight for probably a while longer.

Rovner: Yes, which popular issue moves slower: drug prices or gun control?

All right, well finally this week the health policy community has lost another giant. Gail Wilensky, who ran Medicare and Medicaid under the first President Bush, and the advisory group MedPAC for many years after that, died of cancer last week at age 81. Gail managed to be both polite and outspoken at the same time. A Republican economist who worked with and disagreed with both Democrats and Republicans, and who, I think it’s fair to say, was respected by just about everyone who ever dealt with her. She taught me, and lots of others, a large chunk of what I know about health policy. She will be very much missed. Joanne, I guess you worked with her probably as long as I did.

Kenen: Yeah, I’m the one who told you she had died, right?

Rovner: That’s true.

Kenen: I think that when I heard her speak in a professional setting in the last few years, she talked to her about herself not as a Republican health economist, but as a free market health economist. She was very well respected and very well liked, but she also ended up being a person without a party. But she was a fixture and she was a nice person.

Rovner: And she wasn’t afraid to say when she was the head of MedPAC she made a lot of people angry. She made a lot of Republicans angry in some of those sort of positions that she took. She basically called it as she saw it and let the chips fall.

Kenen: And Julie, she went to Michigan, right?

Rovner: Yes, and she went to Michigan. That’s true. A fellow Michigan Wolverine. All right, well, that is the news for this week. Now we will play my interview with Renuka Rayasam, and then we will come back and do our extra credits.

I am pleased to welcome to the podcast my KFF Health News colleague Renuka Rayasam, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” It’s about what should have been a simple visit to an urgent care center but of course turned out to be anything but. Renu, thanks for joining us.

Renuka Rayasam: Thanks for having me.

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

Rayasam: Sure, let me tell you about the patient in this month’s “Bill of the Month.” His name is Tim Chong. He’s a Dallas man, and last December he felt severe stomach pain and he didn’t know what it was from. And he thought at first maybe he’d had some food poisoning. But the pain didn’t subside and he thought, OK, I don’t want to have to pay an ER bill, so let me go to an urgent care. And he opted to visit Parkland Health’s Urgent Care Emergency Center, where he learned he had a kidney stone and was told to go home and that it would pass on its own.

Rovner: Now, we’re told all the time exactly what he was told, that if we have a health problem that needs immediate attention but probably not a hospital-level emergency, we should go to an urgent care center rather than a hospital emergency room. And most insurers encourage you to do this; they give you a big incentive by charging a far smaller copay for urgent care. So, that’s what he tried to do, right?

Rayasam: That’s what he tried to do, at least that’s what he thought he was doing. Like I said, this is a facility, it’s called Urgent Care Emergency Center. He told me that he walked in, he thought he was at an urgent care, he got checked out, was told it was a kidney stone. He actually went back five days later because his stomach pain worsened and didn’t get better. And it wasn’t until he got the bills the following month that he realized he was actually at an emergency center and not an urgent care center. His bill was $500 for each visit, not $50 for each visit as he had anticipated.

Rovner: And no one told him when he went there?

Rayasam: He said no one told him. And we reached out to Parkland Health and they said, “Well, we have notices all over the place. We label it very clearly: This is an emergency care center, you may be charged emergency care fees,” but they also sent me a picture of some of those notices and those are notices that are buried among a lot of different notices on walls. Plus, this is a person who is suffering from severe stomach pain. He was really not in a position to read those disclosures. He went by what the front desk staff did or didn’t tell him and what the name of the facility was.

Rovner: I was going to say, there was a sign that said “Urgent Care,” right?

Rayasam: Right, absolutely. Urgent Care Emergency Center, right? And so when we reached out to Parkland, they said, “Hey, we are clearly labeled as an emergency center. We’re an extension of the main emergency room.” And that’s the other thing you have to remember about this case, which is that this is the person who knew Parkland’s facility. He knew they had a separate emergency room center and he said, “I didn’t go into that building. I didn’t go into the building that’s labeled emergency room. I run into this building labeled Urgent Care Emergency Center.” Parkland says, hey, this is an extension of their main emergency room. This is where they send lower-level emergency cases, but obviously it’s a really confusing name and a really confusing setup.

Rovner: Yeah, absolutely. So, how did this all turn out? Medically, he was OK eventually, right?

Rayasam: Medically he was OK eventually. Eventually the stone did pass. And it wasn’t until he got these bills that he kind of knew what happened. When he first got the bills, he thought, well, obviously there’s some mistake. He talked to his insurer. His insurer, BlueCross and BlueShield of Texas, told him that Parkland had billed these visits using emergency room codes and he thought, wait a second, why are they using emergency room codes? I didn’t go into the emergency room. And that’s when Parkland told him, “Hey, you actually did go into an emergency room. Sorry for your confusion. You still owe us $1,000 total.” He paid part of the bills. He was trying to challenge the bills and he reached out to us at “Bill of the Month,” but eventually his bill got sent to collection and Parkland’s sort of standing by their decision to charge him $500 for each visit.

Rovner: So he basically still owes $1,000?

Rayasam: Yes, that’s right.

Rovner: So what’s the takeaway here? This feels like the ultimate bait and switch. How do you possibly make sure that a facility that says urgent care on the door isn’t actually a hospital emergency room?

Rayasam: That’s a great question. When it comes to the American medical system, unfortunately patients still have to do a lot of self-triage. One expert I’ve talked to said it’s still up to the patients to walk through the right door. Regulators have done a little bit, in Texas in particular, of making sure these facilities, these freestanding emergency room centers, as they’re called — and this one is hospital-owned, so the name is confusin, but it’s technically a freestanding emergency center, so it did have the name emergency in the name of the facility, and I think that that’s required in Texas — but I’ve talked to others who’ve said, you should ban the term urgent care from a facility that’s not urgent care. Because this is a concept that’s very familiar to most Americans. Urgent care has been around for decades; you have an idea of what an urgent care is.

And when you look at this place on its website, it’s called Urgent Care Emergency Center, it’s sort of advertised as a separate clinic within Parkland structure. It’s closed on nights, it’s closed on Sundays. The list of things they say they treat very much resembles an urgent care. So, this patient’s confusion I think is very, very understandable and he’s certainly not the only one that’s had that confusion at this facility. Regulators could ban the term urgent care for facilities that bill like emergency rooms. But until that happens it’s up to the patients to call, to check, and to ask about billing when they show up, which isn’t always easy to do when you’re suffering from severe stomach pain.

Rovner: Another thing for patients to watch out for.

Rayasam: Yes, absolutely, and worry about.

Rovner: Yes, Renuka Rayasam, thank you so much for joining.

Rayasam: Thank you, Julie.

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

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

Karlin-Smith: Sure, I looked at a New York Times piece called “Promised Cures, Tainted Cells: How Cord Blood Banks Mislead Patients.” And it’s about the often very aggressive sort of tactics of these banks to convince women to save some of the cord blood after they give birth with the promise that it may be able to help treat your child’s illness down the road. And the investigation into this found that there’s a number of problems. One is that, for the most part, the science has progressed in a way that some of what people used to maybe use some of these cells for, they now use adult stem cells. The other is these banks are just not actually storing the products properly and much of it gets contaminated so it couldn’t even be used. Or sometimes you just don’t even collect enough, I guess, of the tissue to even be able to use it.

In one instance, they documented a family that — the bank knew that the cells were contaminated and were still charging them for quite a long time. And the other thing that I actually personally found fascinated by this — because my OB-GYN actually did kind of, I feel like, push one of these companies — was that they can pay the OB-GYNs quite a hefty fee for what seems like a very small amount of work. And it’s not subject to the same sort of kickback type of regulation that there may be for other pharmaceutical/medical device interactions between doctors and parts of the biotech industry. So I found that quite fascinating as well, what the economic incentives are to push this on people.

Rovner: Yeah. One more example of capitalism and health care being uncomfortable bedfellows, Chapter 1 Million. Joanne?

Kenen: There was a fantastic piece in The Washington Post by Annie Gowan: “A Mom Struggles To Feed Her Kids After GOP States Reject Federal Funds,” which was a long headline, but it was also a long story. But it was one of those wonderful narrative stories that really put a human face on a policy decision.

The federal government has created some extra funds for childhood nutrition, childhood food, and some of the Republican governors, including in this particular family’s case, the Republican Gov. Kevin Stitt in Oklahoma, have turned down these funds. And families … So this is a single, full-time working mom. She is employed. She’s got three teenagers. They’re all athletic and active and hungry and she doesn’t have enough food for them. And particularly in the summer when they don’t get meals in school, the struggle to get enough food, she goes without meals. Her kids — one of the kids actually works in the food pantry where they get their food from. The amount of time and energy this mom spends just making sure her children get fed when there is a source of revenue that her state chose not to us: It’s a really, really good story. It’s long, but I read it all even before Julie sent it to me. I said, “I already read that one.” It’s really very good and it’s very human. And, why?

Rovner: Policy affects real people.

Kenen: This is hungry teenagers.

Rovner: It’s one of things that journalism is for.

Kenen: Right, right, and they’re also not eating real healthy food because they’re not living on grapefruits and vegetables. They’re living on starchy stuff.

Rovner: Alice?

Ollstein: I chose a good piece from ProPublica called “Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant To Help Needy Families, but No One Knows if It Works.” And it is about just how little oversight there is of the budgets of taxpayer dollars that are going to these anti-abortion centers that in many cases use the majority of funding not for providing services. A lot of it goes to overhead. And so there’s a lot of fascinating details in there. These centers can bill the state a lot of money just for handing out pamphlets, for handing out supplies that were donated that they got for free. They get to charge the state for handing those out. And there’s just not a lot of evaluation of, is this serving people? Is this improving health outcomes? And I think it’s a good critical look at this as other states are moving towards adopting similar programs to what’s going on in Texas.

Rovner: Yeah, we’re seeing a lot of states put a lot of money towards some of these centers.

Well, my extra credit this week is from Time magazine. It’s called, “‘We’re Living in a Nightmare:’ Inside the Health Crisis of a Texas Bitcoin Town,” by Andrew Chow. And in case we didn’t already have enough to worry about, it seems that the noise that comes from the giant server farms used to mine bitcoin can cause all manner of health problems for those in the surrounding areasm from headaches to nausea and vomiting to hypertension. At a local meeting, one resident reported that “her 8-year-old daughter was losing her hearing and fluids were leaking from her ears.”

The company that operates the bitcoin plant says it’s in the process of moving to a quieter cooling system. That’s what makes all the noise. But as cryptocurrency mining continues to grow and spread, it’s likely that other communities will be affected in the way the people of Granbury, Texas, have been.

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

Karlin-Smith: I’m mostly on X @SarahKarlin or on some other platforms like Bluesky, at @sarahkarlin-smith.

Rovner: Alice?

Ollstein: I’m on X @AliceOllstein and on Bluesky @alicemiranda.

Rovner: Joanne?

Kenen: A little bit on X @JoanneKenen and a little bit on Threads @joannekenen1.

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

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

Republicans released a draft party platform in advance of the GOP national convention next week, and while it is being described as softening the party’s stance opposing abortion, support from major groups that oppose abortion suggests that claim may be something of a mirage.

Meanwhile, the Federal Trade Commission is taking on the pharmacy benefits management industry as it prepares to file suit charging that the largest PBMs engage in anticompetitive behavior that raises patients’ drug costs.

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

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories.

Shefali Luthra
The 19th

@shefalil

Read Shefali's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• For the first time in decades, the GOP presidential platform will not include a call for a national abortion ban. But Republicans are hardly soft-pedaling the issue: The new platform effectively asserts that abortion violates the 14th Amendment, which guarantees equal protection under the law for all citizens — including, under their reading, human embryos. Under that argument, abortion opponents may already have the constitutional justification they need to defend in court further restrictions on the procedure.
• Lawmakers in Washington are making early progress on government spending bills, including for the Department of Health and Human Services. Some political issues, like access to gender-affirming care for service members and minors, are creating wrinkles. Congress will likely need to pass a stopgap spending measure to avoid a government shutdown this fall.
• And a new report from the Federal Trade Commission illuminates the sweeping control of a handful of pharmacy benefits managers over most of the nation’s prescription drugs. As the government eyes lawsuits against some of the major PBMs alleging anticompetitive behavior, the findings bolster the case that PBMs are inflating drug prices.

Also this week, Rovner interviews Jennifer Klein, director of the White House Gender Policy Council, about the Biden administration’s policies to ensure access to reproductive health care.

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

Julie Rovner: STAT News’ “Troubled For-Profit Chains Are Stealthily Operating Dozens of Psychiatric Hospitals Under Nonprofits’ Names,” by Tara Bannow.

Jessie Hellmann: North Carolina Health News’ “N.C. House Wants to Spend Opioid Money on Multiple Abstinence-Based Recovery Centers, While Experts Stress Access to Medication,” by Grace Vitaglione.

Shefali Luthra: The Washington Post’s “These GOP Women Begged the Party to Abandon Abortion. Then Came Backlash,” by Caroline Kitchener.

Sandhya Raman: Roll Call’s “For at Least One Abortion Clinic, Dobbs Eased Stressors,” by Sandhya Raman.

click to open the transcript

Transcript: GOP Platform Muddies Abortion Waters

KFF Health News’ ‘What the Health?’ Episode Title: ‘GOP Platform Muddies Abortion Waters’Episode Number: 355Published: July 11, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 11, 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 by a video conference by Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: Sandhya Raman of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: And Jessie Hellmann, also of CQ Roll Call.

Jessie Hellmann: Hi there.

Rovner: Later in this episode we’ll have my interview with White House Gender Policy Council Director Jennifer Klein about how the administration is dealing with the recent Supreme Court decisions about abortion access. But first, this week’s news. So, the Republican National Convention is next week. I have no idea how that happened already.

And in preparation, the party’s platform committee, behind closed doors, overwhelmingly approved a document that, depending on who you believe, either weakens the party’s longtime anti-abortion stance or cleverly disguises it. Shefali, what exactly did they do and how is this a change from the last Republican platform, which was actually written in 2016?

Luthra: So this is pretty interesting because there was a lot of attention paid to the fact that this is the first Republican platform in decades to not include a national abortion ban at 20 weeks. And so that got a lot of headlines. People saying, “This is really backpedaling, this is softening the GOP’s abortion stance.” But if you look at the text, that’s not really true. Because while they don’t talk about a national abortion ban, they do cite one of the anti-abortion movement’s favorite legal theories, the 14th Amendment of the Constitution.

And they argue that states when banning abortion can use the 14th Amendment, and they recognize that as protecting essentially the rights of fetuses and embryos. It’s kind of having it both ways because while they argue this is a state decision in the language, they’re using the federal Constitution. And every anti-abortion group that I’ve spoken with sees this as a victory, at least the major ones do. Because if you’re citing the Constitution, you’re opening a door to a national abortion ban through our founding documents.

And that is something that they have been working for for a long time. And so I think it’s really important for us to understand just how drastic in some ways this really is. It is not really soft peddling in terms of what they’re ultimately hoping to achieve.

Rovner: Yeah, I think people have not pointed out that this is the first Republican platform post-Roe v. Wade. So they don’t need to call for federal legislation because they have a court that will basically, as they put in the platform, guarantee what they are asserting, which is that basically the 14th Amendment already effectively bans abortion. So the heck with Congress,

Luthra: And one thing that I do think is worth noting is, in some ways, why, and many have made this point, why would they care about a national 20-week abortion ban? Most abortion opponents don’t see that as a victory because most abortions occur well before that. They would much rather have national restrictions, or at the very least, six or 15.

Rovner: Yeah, and somebody, now I can’t remember who it was, wrote about this. There’s a reference in the platform language to, I think I can’t remember, whether it’s late term or later abortions, but that can be defined many, many, many, many ways, not just… I mean, 20 weeks is, like, that is so three years ago.

Raman: Oh, I was going to say I would agree in part. I do think that, yes, it lets you cater to an array of people, because you can either have someone follow the 14th Amendment language or the only other sentence that anything in this realm says, advocating for prenatal care and access to birth control and IVF. And then with certain forms of birth control, with IVF, we still have some of the same people that are citing personhood concerns as their opposition for that. So it’s playing both ways.

And yes, I would say that most of the anti-abortion groups have been saying that they’re OK with this. But then at the same time, we have someone like former Vice President Mike Pence, who came out pretty strongly against this and is really disappointed, and he’s been a huge player in the anti-abortion advocacy. But I think one thing that was interesting was we focused a lot on just the limit not being in this version.

But the older version also had just more language on preventing fetal tissue research from abortions or federal funding from abortions or sex-specific or disability-specific abortions. It’s just a smaller social issue, I think, in the overall platform, whereas I think they’ve really been playing up some of the other things like gender-affirming care and pushing back against that as you can see throughout ads and stuff.

Rovner: But of course, all of those things are in Project 2025, right?

Raman: Yeah.

Luthra: And part of that also is that this is a fairly short platform as Republican platforms go. It’s clearly written in the Trump voice. Detail is not its desired narrative.

Rovner: It’s not the 900-page Project 2025 …

Luthra: Absolutely not.

Rovner: … that Trump now insists he knows nothing about. Which seems was written, in fact, I think almost exclusively by people who worked for him and who I believe plan to work for him in his second term.

Luthra: And if you see photos from the RNC, it’s very clear that Heritage [Foundation], the organization behind Project 2025, has a strong presence there.

Rovner: Yes, we’ll all be watching the convention carefully next week. I assume that they’re going to do the job that they’ve done so far, which is to keep everybody singing from the same songbook. That’s clearly the goal of every party convention, and so far they seem to have managed to play this both ways enough. As you mentioned, they have the anti-abortion groups on board, but they’ve gotten the mainstream media, if you will, to say, “Oh, look, they’re softening their abortion stance.” We’ll see if that lasts through the week.

So in my conversation with Jen Klein, which we will hear a little bit later, we talked about how the two abortion cases at the Supreme Court this term challenging the abortion pill and the federal emergency abortion requirements under EMTALA [Emergency Medical Treatment and Active Labor Act] are likely to come back at some point since the court didn’t reach the merits of either case.

But those are far from the only cases that could come back to the justices in the next year or so, regardless of who gets elected president. There are also going to be cases about whether women who live in states with abortion bans can travel to other states where abortion is legal. And whether states can really shield doctors who prescribe abortion pills to patients who are residents of states where abortion is banned. The court by itself could effectively ban abortion no matter who’s elected president or controls Congress, right?

Luthra: There’s definitely a lot of unanswered legal questions that we will see coming to the court. The shield law question is one that I think is incredibly interesting with significant tremendous ramifications for how people get abortion. I don’t know that we’ve seen incredible test cases yet that could become the one that the court weighs in on. But it really is only a matter of time until abortion opponents in particular find a way to develop a legal challenge and then advance it.

Rovner: I’m watching the travel cases, because I mean, even [Supreme Court Justice] Brett Kavanaugh wrote in one of these abortion decisions that you cannot ban travel from one state to another. There certainly seem to be ways of trying. I know that there’s been a bill that’s been kicking around in Congress for three decades to make it a crime to take a minor across state lines without the minor’s parents’ permission.

It was based off a case where the guy’s mom took the kid from Pennsylvania to New York. That was the origin of this case in 1997. But certainly that was the first bit of, maybe we should do something about people trying to travel from state to state since we now have cases where abortion is legal in some and not legal in others.

Raman: We’ve definitely seen that historically that certain types of things that if it starts with minors and things like that, that it can grow. I mean, that’s a thing that they’ve been messaging a lot on with the gender-affirming care. If it’s starting with youth, that slowly the age range creeps up. So that even if this is something that starts just in a few states like with what Idaho has been doing with minors, it could change.

Rovner: Well, meanwhile, the number of states with complete bans or major restrictions continues to grow. The Iowa Supreme Court, which ruled as recently as 2018 that abortion was “a fundamental right under the state constitution,” has now reversed itself and has allowed a six-week ban to take effect. Shefali, that’s going to have ramifications way beyond Iowa, right?

Luthra: It always does. We are now up to 14 states with near-total abortion bans and four more with six-week bans. That means Iowa. That is South Carolina. That is Georgia. That is Florida. And what we know is people try and travel from one state to another to access care. And there weren’t a large number of abortions being done in Iowa. I checked the data after this ban took effect, and it’s a small state.

But we’ll see what we always see, which is people trying to travel somewhere else where they can get care, creating longer wait times at clinics that are under-resourced already, overtaxed, making it harder for everyone to access not only abortion, but any other health service they might provide, whether that is STI [sexually transmitted infection] testing, whether that is family planning services, whether that’s cancer screenings.

Rovner: And we’re also seeing doctors leaving some of these states with bans, which means that there’s simply less care available in those states.

Luthra: Absolutely. We’re seeing people have to go from their home states to neighboring states just for basic pregnancy care for when they deliver, because they don’t have maternal fetal medicine specialists. They don’t have OB-GYNs. And eventually they’re going to have fewer family physicians and doctors of all kinds practicing in these states for the reasons, as you’ve reported so often, Julie, that in part they don’t want to practice somewhere where their profession isn’t fully legal. And also they would like full access to health care themselves.

Rovner: Yes, for themselves or their partners. Well, back here in Washington, it’s a million degrees this week and Congress is back, not that those two things are connected, just mentioning. Anyway, unlike last year when the House basically abandoned the appropriations process, culminating in the spending bills for the current fiscal year not being finalized until this past spring, like more than halfway through the year, House Republicans are in fact moving the 12 regular appropriations for next year. Although not in a way that’s likely to become law.

Sandhya, you’re following the gigantic Labor, Health and Human Services, Education spending bill that got marked up in a full committee yesterday. What’s it look like at the moment?

Raman: So yesterday we had our monster markup. Six hours that it took just to get through that bill to approve the Labor-HHS-Education bill. We had 15 different amendments come up, which takes up the bulk of the conversation. What we had approved on a party-line vote was $107 billion in discretionary money for HHS. So if that were to become law, that’s a drop of about $8.5 billion from what we currently have.

And so this is just the first step because the Senate will put out their version in the coming weeks. We can help and they’ll come together on a deal. And even during the markup, it was acknowledged by leadership that this is the first step. This was on party lines. This is not what we’re going to get when we come to law. Democrats had a lot of issues that they voiced throughout the process about the big cuts.

Rovner: Oh, there’s some pretty dramatic cuts in this bill.

Raman: Yeah. The bill, as it stands, would cut a lot of the CDC [Centers for Disease Control and Prevention] prevention programs. It would cut all the funding for Title X family planning funding. It would cut a lot of HIV prevention funding, and has smaller numbers for a variety of programs throughout. And that has just been a nonstarter.

Ranking member [Rep.] Rosa DeLauro has said that she wants at least a 1% increase over what was there last year, and she cited the budget deal that Congress and the White House had agreed to last year, whereas Republicans had said that the numbers in the bill that was approved reflects what they see as following that model. So we’ll see as the Senate moves and then this should eventually get to the House floor if they stick to it.

I mean, last year we had a subcommittee markup and it never went to full committee because of various issues there, but they did take it to the floor. It’s been a different process.

Rovner: It was basically too extreme to pass last year.

Raman: Yeah. Well, last year they also revised it to make it more conservative. And so that also brought up some issues there to get everyone on board. But this is just the first step and we will see what happens in the coming weeks with what the Senate puts out.

Rovner: One of the things that interested me in the bill is that it looks like these are the appropriators. They’re not supposed to be making policy. They’re just supposed to be setting spending, but they seem to want to completely overhaul the National Institutes of Health: cut the number of institutes in half or more; eliminate the Agency for Healthcare Research and Quality. Where did this come from? Does anybody know?

Raman: So this has been like a pet project of [Rep. Robert] Aderholt, the subcommittee chairman of Labor-H, as well as [Rep.] Cathy McMorris Rodgers, the [House] chairwoman of the Energy and Commerce Committee, and they …

Rovner: Which is the authorizing committee.

Raman: … Yeah. So they came together and did an op-ed a little while ago about how this was something that they wanted to do and they’ve put it in this bill. But a thing that has come up at both of the markups on this has been that we have not had hearings on this. This should come up through an authorizing committee, like Energy and Commerce, if you want to make changes.

And I think there are people like Rep. Steny Hoyer who were like, “We’re not against reforming different parts of NIH, but it needs to come through that process rather than this,” especially when this is a partisan bill if we’re going to do something as big as that. Because NIH is one of the biggest agencies in any department. And so changes of that grand of scale need to be done through that process rather than in appropriations.

Rovner: And it has been bipartisanly popular over the years. It was the Republicans who first proposed doubling funding for NIH. So it’s interesting that that popped up. Well, meanwhile, we’ll see how this bill fares when it comes to the House floor and how it changes in the Senate.

Congress is also moving on separate must-pass bills, including the annual defense authorization. There’s a defense appropriation, too, but the authorization is where the policy is supposed to be made, as we just said. And as in years past, the defense authorization is picking up riders that don’t have a lot to do with defense, right?

Raman: Yeah. I think that this is increasingly where we’re seeing some of the varied riders related to gender-affirming care. The Senate and the House’s versions both had provisions related to that. I mean, you could see that, again, as the broad issue for Republicans. Even within the labor age bill, we had different things related to that within the education portion. And so I think that has been the big thing that people are watching there on the health front.

Rovner: And abortion too, right? This continuing concern about allowing service women and dependents to travel for abortion if they’re in states with bans.

Raman: Yeah, and we had that whole issue just last year when we had the Defense nominees held up over a hold from Sen. [Tommy] Tuberville over that policy. So the pushback against those kind of policies in the Defense Department, the VA [Veterans Administration], are not ending here.

Rovner: Yeah.

Luthra: What I find so striking, Julie, if I can add something on, in particular, the exclusion of gender-affirming care, is that trans service members have seen what the laws and their protections are really zigzag back and forth over the past several administrations. And there’s something that I think we haven’t fully grappled with or articulated about the implications for that, right?

Because if you start accessing health care that you want to stay with for the rest of your life, in theory, and you keep seeing your benefits change on and off, that’s not adequate health care, that’s not appropriate. Because your ability to access your medications — for instance, is really subject to the whims of Congress in a way that wouldn’t be the case for other forms of medication — wouldn’t really be tolerated. And I think we haven’t fully understood exactly what this means for service members’ long-term lives and health outcomes.

Rovner: And as we say, and their family members. And when you sign up for the military, I mean, it’s not like you can just get another job with different health benefits. You make a commitment. And you’re right, the commitment that’s made back to you keeps changing. That’s probably not great for military morale.

All right, well, turning to health industry news, the Federal Trade Commission is taking square aim at pharmaceutical benefit managers. On Tuesday, it released the results of a two-year investigation that found the three largest PBMs now control 80% of the nation’s prescriptions while the six largest control 90%. The study also demonstrates what we’ve known for a long time: PBMs tend to steer patients to their own pharmacies even when that tends to cost patients more. And the PBMs pay themselves more than they pay independent pharmacies for the same drugs.

After letting that all settle in for about 24 hours, the agency then leaked the news that it plans to sue those three largest PBMs — the ones owned by UnitedHealthcare, Cigna, and CVS — for a variety of their practices, including steering patients towards more expensive insulin products that the PBMs get larger rebates for. In other words, the patients have to pay more so the PBMs can get more money.

Jessie, PBMs have been targets for several years now. Is this finally something that could take them down a peg? I know Congress has been wringing its hands over this for the last four or five years.

Hellmann: So the announcement hasn’t been officially made, but the FTC has been talking about this for several years. I guess they just wanted to wait until they had this big report out to bolster their case against PBMs. But it seems like this lawsuit specifically might be looking at the rebate situation. According to the report, they just have a lot of concerns about how the rebate structure can favor more expensive drugs, more expensive branded drugs over generics. And they think that that’s anticompetitive.

I know they have said in the past that they think these structures could potentially violate antitrust laws. And so if there is a lawsuit filed targeting these kinds of structures, that could chip out away at a major revenue source for PBMs. The rebates that they get on some of these expensive drugs are really large. In many cases, the patients don’t see those benefits when they’re paying for a drug at the pharmacy counter.

So if you’re a patient and your formulary says, “If you want to access this type of drug, you have to go for this branded amount,” that could increase your out-of-pocket costs. So any kind of lawsuit could take years. But Congress has also been really interested in the rebate issue. There has been many bills that, I think there’s some consensus on that would tie these rebates, basically making them a flat fee versus tying them to the list price. So it’ll be interesting to see where that goes.

There’s been questions about whether that should extend to the private market, and I think that’s what’s been holding up some of the action on this front. But …

Rovner: Rather than just Medicare and Medicaid?

Hellmann: Yeah, exactly. Because Congress prefers to just tweak Medicare and Medicaid and hope that that will change how private insurers behave. But maybe this report, it does have some new details. The FTC was able to access some contracts. It shined more of a light on it. So maybe this report will change that conversation in Congress. We’ll see.

Rovner: I must have gotten a hundred emails from Congress after this report came out and it’s like, yes, you guys have had legislation on this since 2015, and it’s bipartisan. It just never seems to make it over the finish line.

Hellmann: Yeah, it’s going to be interesting to see what happens over the next six months because some of these PBM bills could save money. And Congress wants to pay for a lot of things at the end of the year, like telehealth expansion and things like that. So I think if they can figure it out in the next few months, that could definitely happen this year.

Rovner: What they’re doing on their summer vacation. Also, this week, updating something that we’ve talked about a lot on this podcast; the future of the medical workforce. A billion-dollar gift from Johns Hopkins alum Michael Bloomberg will enable the Johns Hopkins Medical School to go tuition-free for students whose families earn less than $300,000 per year, and will pay tuition and living expenses for those families who earn under $175,000 a year.

Johns Hopkins thus joins NYU, UCLA, and a couple of other medical schools, in helping prevent medical students from graduating with crippling debt that all but forces them into the highest-paying specialties rather than primary care, which is where, of course, they’re most needed. Except that it seems that a lot of these subsidized doctors still aren’t going into primary care. So maybe it’s going to take more than just money to get people to do the hardest job in medicine.

Hellmann: Yeah, I feel like even if someone’s tuition is fully paid for, I don’t know if that’s enough to make them want to go into these lower-paid specialties like primary care. It’s a trend that we’ve seen for a long time that people just want to make more money. And primary care, there’s been a lot of conversation lately about how it’s just the most unappreciated specialty that you can go into. Especially there’s been a lot of frustration around dealing with insurance companies. So I don’t know if this is it.

Rovner: And PBMs.

Luthra: Building on Jessie’s point, we have programs that make it easier to become teachers. That does not mean we have a glut of teachers because of the longer-term underappreciation we have for professions that are quite valuable in our society. And having those benefits early on doesn’t make up for yearslong lower pay and general career frustrations that have only grown in recent decades.

Whether that is because of physician practice consolidation. Whether that is because of electronic health records that doctors find to be so frustrating. Whether that’s just having to navigate patients’ different insurance. And now on top of that, more and more restrictions on health care that you provide. It’s already a really tough industry to go into.

And if you’re going to go into it, there are arguments that you might benefit from a higher-paid specialty and one where you don’t have to navigate as many of these really frustrating challenges that doctors still have to deal with.

Rovner: Yeah, a lot of it is lifestyle. I mean, it’s not just that you get paid less. Even if you got paid more, you’re on call a lot. We’ve seen graduating medical students gravitating towards things like dermatology, and emergency medicine, even, because there’s a shift; you’re either on or you’re off, or you don’t get called in the middle of the night.

Being a primary care doctor is hugely stressful and hugely time-consuming and not the greatest lifestyle. And yes, having $200,000 of debt is a good reason to not go into it. But apparently not having $200,000 of debt is still not enough of a reason not to go into it. Sandhya, you wanted to add something?

Raman: No, I was just going to say that part of this is just that we have to broaden the pipeline in general, and these are careers that take years and years of study and training to get to. So I think a lot of this we’ll have to wait and see that if someone is excited by something like this now, getting up to making this a possibility for them and then going through the training is going to take a while to dig through and see how that data is really affecting people.

Rovner: Yeah, we will. Another space we shall continue to watch. All right, that is this week’s news. Now we will play my interview with the White House’s Jen Klein, and then we will come back with our extra credit.

I am so pleased to welcome to the podcast Jennifer Klein, director of the White House Gender Policy Council. Jen oversees administration policy on a wide range of subjects, domestic and international, affecting women’s health, economic security, and gender-based violence. Jen, welcome to “What The Health?”

Jennifer Klein: Thank you so much for having me.

Rovner: So I want to start with the Supreme Court. In the last few weeks of the term, the court punted on two big abortion cases, one challenging the FDA’s approval of the abortion pill mifepristone, and the other challenging the Biden administration’s interpretation of the Emergency Medical Treatment and Active Labor Act, EMTALA. What’s the status of both of those and has anything changed as a result of these cases?

Klein: Well, as you noted, the Supreme Court didn’t really reach the merits on either of those cases, and in fact, both will be ongoing. And so I won’t get into the back and forth on the litigation, which the Department of Justice is tracking that closely. But I will say, first of all, on the first case, the case about access to mifepristone, we are going to continue to fight to make mifepristone medication abortion available. As you know, this is a drug that has proven to be safe and effective.

Twenty years ago, the FDA approved it. And in 2023, the FDA took independent evidence-based action to give women more options about how and where to pick up their prescription for medication abortion, just as they would for any other medication, including through telehealth and through a retail pharmacy. And earlier this year, two major retail pharmacy chains became newly certified to dispense medication abortion under a new pathway created by the FDA in 2023.

And so we’re continuing to encourage all pharmacies that want to pursue this option to seek certification so that this medication can be widely available. Because back to point one about the Supreme Court, it still is. While they didn’t reach the merits of the case and they sent the case back on standing grounds, they didn’t actually resolve the underlying legal issues.

So we will continue to defend our legal point of view and also make sure that people, first of all, know that this drug should remain available and people should be able to access it, and then do everything we can to make sure that that is easy for people who actually need access to the medication.

Rovner: And then on EMTALA?

Klein: On EMTALA, same issue. As you noted, the Supreme Court didn’t actually reach the merits of the case. So it’s first very important to point out that currently in Idaho, which was the state where the Department of Justice brought this suit to ensure that women in Idaho could have access to emergency medical services when they’re in the middle of an obstetrical emergency. And so they are in Idaho still able to access care.

And we are going to continue to make clear both our legal point of view, but also our policy point of view, that all patients, including women experiencing pregnancy loss and other pregnancy complications in the middle of an emergency, should be legally able to access emergency care under federal law. The federal law is called the Emergency Medical Treatment and Labor Act.

And what that says is that if somebody is in the middle of a medical emergency and they need care and that care includes abortion, that care is legally available to them. And so what we’ve done, and we are going to continue to do, is make sure that patients know what their rights are and that, importantly, that providers know what their responsibilities are under EMTALA.

So HHS, the Department of Health and Human Services, has issued a number of comprehensive plans to make sure that people know their rights and responsibilities. They have created new patient-facing resources, offer training to doctors and health care providers. They actually created a dedicated team of experts at HHS to educate patients and hospitals about their rights and obligations under EMTALA.

And most recently, CMS [Centers for Medicare & Medicaid Services] launched a new option on CMS.gov, which is the ability in both, by the way, English and Spanish, to allow individuals to more easily file a complaint themselves if they have been denied emergency care. The reason that’s important is because previously that had to be done through a state agency, which in some states you might imagine is less possible, less easy to do, than in others.

Rovner: So obviously, as we mentioned, both of these cases are likely to come back to the Supreme Court in the next couple of years. Is there anything that you can do to shore up either of these policies to try to legally brace against what’s likely to be another assault? And we already know, I guess in both cases, the next assault is already ongoing.

Klein: Yeah. I mean, as I said, the Department of Justice is going to be defending our legal point of view, and I can’t really get into that. But what I can say is that we strongly believe that both the medication abortion should be legally available, and is now legally available, and emergency medical services should be legally available, and are legally available under EMTALA. And we are going to continue to do whatever we can through executive action.

This was the subject of … Actually the president has issued three executive orders and a presidential memorandum. The presidential memorandum was focused specifically on medication abortion. The other three were broader, covered all sorts of reproductive health services, including contraception, as well as abortion. And we’re continuing to implement those, every day.

And I will add that today, actually, there’s a new regulation, a notice of proposed rulemaking, I shouldn’t say a regulation, that has come out today from the Department of Health and Human Services, which builds on work we’ve done to improve maternal health and reduce maternal mortality. And what that does is proposes the first-ever baseline health and safety requirements for obstetric services in hospitals.

So separate and apart from EMTALA, which speaks more generally to the services that you get when you walk into an emergency room, what this proposed rule would do is make sure that there are protocols and standards in place for obstetrical emergencies, and also procedures for transfers when somebody is in the middle of an obstetrical emergency or pregnancy complication and that hospital where they are can’t provide the care that they need.

Rovner: So we’ll see how that one goes. After last month’s debate, a lot of abortion rights supporters were dismayed that President Biden didn’t very effectively defend abortion access and didn’t really rebut falsehoods repeated by former President Trump. We know that reproductive health isn’t the issue that the president feels most comfortable talking about anyway. What do you say to those who are worried that the president won’t go far enough or isn’t the right messenger for this extremely critical moment?

Klein: I would say a couple of things: I would say look at what this administration has done under his leadership. I was with him in the Oval Office the day the Dobbs [v. Jackson Women’s Health Organization] decision came down and he was angry. And why was he angry? The same reason we were all angry, because never before had the Supreme Court taken away a fundamental constitutional right. And he has been fighting and asked me to help lead the fight for the last two-plus years to do whatever we can.

And he also was quite clear on that day that the only way to replace a constitutional right that was lost is to restore the protections that existed under Roe v. Wade for nearly 50 years. And that’s what we intend to do, what he intends to do. And he has said many, many times, while the other side would actually ban abortion nationwide, what he is attempting to do and what he will sign the minute a bill reaches his desk is to restore the protections of Roe in federal law so that every woman in every state has the right to access abortion care and other reproductive health services.

By the way, as you well know, many other reproductive health services like contraception, like in vitro fertilization, and other fertility services, are on the chopping block as well. And Republican elected officials, whether that’s in Congress or in states, have been not only unwilling but dramatically invested in reducing access to care and restricting access to care. And so what this president is doing is fighting to make sure that people do have access to abortion and the full range of reproductive health services.

And I think the second point I would make is the contrast could not be clearer. And so as people think about who is protecting their rights and their access to health care, I think that the choice is obvious. And then the third thing I would say is we also have a vice president who has really led and traveled, I think, to 20 states around the country, met with 250 state legislators, state attorneys general, presidents, met with governors. We are here to support the states, which are really the front lines. And she has really led the charge for reproductive freedom.

Rovner: And obviously it is an issue that she does feel comfortable talking about, and does a lot. Speaking of restoring Roe v. Wade, there are a lot of people in the abortion rights community who say that that’s actually not far enough. That even under Roe, there were many, many restrictions on abortion that were still allowed, most notably, the Hyde Amendment that bans virtually all federal funding of abortion. Would the administration support efforts to expand abortion rights beyond Roe?

Klein: Well, the president has been on record, obviously also the vice president, against the Hyde Amendment, would remove the Hyde Amendment to address exactly the issue that you just raised. And yes, what we want to do is ensure that people have access to health care. In the moment we are in, we are fighting that in states across the country, and also want to have a national law that protects access to abortion and all of the other reproductive health services that were lost.

Rovner: So we’ve seen a lot of predictable outcomes of abortion bans around the country, but also some that were more maybe unexpected, including a spike in infant mortality in Texas and graduating medical students avoiding doing their residencies in states with abortion bans. Are you working on policies to address those issues? I guess you mentioned infant mortality already.

Klein: Yes. We’re very focused, as we have been, by the way, the administration released a maternal health blueprint two years ago, actually before the Dobbs decision came down. And we are continuing to work on that. So in addition to what I mentioned earlier, another great example of the work we’ve done is to extend Medicaid postpartum coverage from two to 12 months. That now exists in 46 states, plus the District of Columbia.

The other thing I would say is you raised a very important point, which is, first of all, clinics are closing because of extreme abortion bans across the country. Secondly, training. People are not able to get the training to provide the services that their patients will need in many states. And so we are very focused on addressing issues of training, issues of access to clinics, and other reproductive health services across the country. That’s why we’ve increased Title X funding for family planning clinics.

So the short answer is, yes, we have a very broad agenda. And by the way, this week in Congress there have been several bills introduced on issues like training, to ensure that people have access to care. So the three that were introduced were, first, the freedom to travel for health care, which is obviously another very important issue. Which, by the way, there are states and state attorneys general who are attempting to block people from traveling to seek legal reproductive health care in other states.

There’s another unanimous consent resolution this week to protect health care providers from being held liable for providing services to patients from other states. And third, a unanimous consent resolution to protect reproductive health care training. So those are what our colleagues on the Hill are working on and we firmly support efforts to do that.

Rovner: And obviously two of them got tried yesterday and blocked. And so we know that Congress has stuck on this issue. Even if President Biden is reelected and Democrats keep the Senate and take the majority in the House, it’s unlikely that Congress will be able to pass broad legislation to protect abortion rights.

There has actually never been a pro-choice majority in Congress while a Democrat was in the White House. So how will the administration be able to advance reproductive rights, particularly in light of the Supreme Court’s decision striking down the Chevron doctrine that’s going to make it easier for outsiders to challenge administration actions in court?

Klein: Yeah, this is not easy. We have seen a very concerted effort on the other side. First of all, to pass extreme abortion bans at the state level. We now have 20-plus states with extreme abortion bans in place. One in three women of reproductive age live in a state with an abortion ban right now. And yes, we see that the courts are also challenging. On the other hand, you raised the question earlier about being frustrated with only restoring Roe.

I think our view, my view, is that we need to start somewhere. And while, yes, it has been very difficult at the national level to pass any legislation to support reproductive freedom, I remain optimistic. The president, as we all know, is an eternal optimist. I remain optimistic that we can do that and that we can get bipartisan support.

Because what you’ve seen across the country in states that might not have been obvious, but when people have had the opportunity to speak out about this, state ballot initiatives, we’ve had states like Kansas and Montana. And most recently there’s a few states that have just put abortion ballot initiatives on the ballot for November, like Florida, like Colorado, like Nevada.

There is a broad range of states where when people are given the opportunity to speak to these issues, they speak really loudly and clearly for reproductive freedom. So that’s why I actually remain very optimistic, despite the odds that you rightfully point out, that actually Congress could pass federal legislation which the president would sign.

Rovner: Last question, there’s been a lot of talk about the Comstock Act, it’s 1873 anti-vice law, and whether a future Republican administration could use it to basically ban abortion nationwide. Congress, as I mentioned, seems unlikely to have the votes to repeal it. Is there anything the administration can do to try and forestall that for a future administration?

Klein: Not for a future administration, which is why our interpretation of what the Comstock Act does and doesn’t do is really important. So this Department of Justice under the Biden-Harris administration has made it clear that the Comstock Act does not apply to lawful abortion. And by the way, four appellate courts, Congress for more than 50 years, agreed with that interpretation.

So we stick by our interpretation, which means that there’s no restriction on the transport, shipping of medication abortion or, by the way, any other supply that’s used in abortion for lawful purposes. And there is a lawful purpose, by the way, in every state for medication abortion because it is also used for miscarriage management, for example. And there are states which have exceptions for rape or incest, where obviously medication abortion could be used in those cases.

So our interpretation I think is not only legally viable, but just makes a lot of sense. And I do think that people should really understand that a future administration could come in with a very different view, and actually have completely signaled that they would do that. If you look at some of the policy papers and documents, it makes really clear that the other side doesn’t think they need to pass a national abortion ban. They think they have one on the books, and they think that’s the Comstock Act.

Rovner: Jen Klein, thank you so much for joining us. I hope we can do this again.

Klein: Thank you so much. It was great to be with you.

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

Luthra: I’m very excited about this story. It’s by Caroline Kitchener at The Washington Post, who everyone should be reading all the time. The headline: “These GOP Women Begged the Party to Abandon Abortion. Then Came Backlash.” And the story fits into a pattern of reporting that we’ve started to see about what it means to be a Republican woman in state politics at a time when the party’s views on abortion are out of step with the national norm.

We saw these effects happen in South Carolina where the Republican women who opposed their state’s abortion ban have all lost their seats. And Caroline’s story does a really good job of getting into the tensions that have come up at the state GOP convention and how these women have said, “Hey, maybe abortion is not a winning issue. We already have an abortion ban. Maybe we shouldn’t make this the thing that is our No. 1 concern. Maybe we should focus on other things.”

And at the same time, you have very influential anti-abortion organizations in the state that are not satisfied with the status quo and want a place like Texas to go much further, and to find ways to ban medication abortion from being mailed into states or find ways to restrict travel. And what happened to these women in Caroline’s story is they fought at the convention to have abortion not be an issue, and then afterward they were ostracized.

And that I think is going to be very indicative of what we will see in the Republican Party moving forward. And it’s something that has come up over and over again; is that lawmakers on a state level are really nervous about the politics of pursuing further abortion restrictions. But also there is a very influential group of people who do not want them to stop. And this is only going to be a tension that keeps coming to a head and very often on lines of gender.

Rovner: I’m old enough to remember when abortion was not a completely partisan issue, when there were lots and lots and lots of Republicans who supported abortion rights and lots and lots and lots of Democrats who didn’t. I think in both cases they’re being… Each is being shoved into the other party. Sandhya, why don’t you go next?

Raman: So I picked “For at Least One Abortion Clinic, Dobbs Eased Stressors,” and that’s by me this week on Roll Call. So following the Dobbs decision, North Dakota’s only abortion clinic of the past 20 years moved to Minnesota. And so I spent a week there in June in Moorhead, Minnesota, where they moved, which is on the border with Fargo, North Dakota, and just looked at the mental well-being of people associated with the clinic and the community and was surprised by what I found.

Rovner: Well, I’m looking forward to reading it because I haven’t actually read it yet. Jessie?

Hellmann: My story is from North Carolina Health News [“N.C. House Wants to Spend Opioid Money on Multiple Abstinence-Based Recovery Centers, While Experts Stress Access to Medication,”] and it’s looking at this debate I think a lot of states are going to be facing pretty soon, about how to spend the massive amount of money that’s coming in from these opioid settlements. And in North Carolina specifically, there is a little bit of a push to award funds to clinics that may not be using evidence-based approaches to the opioid epidemic. Some of these centers, they don’t offer medication at all, which is the gold standard for treating opioid use disorder.

Some of these centers go even further and say, “If you are on these medications, you cannot stay in our facilities,” which is very antithetical to how you should treat someone with opioid use disorder. And then some of these centers are not licensed. So I think this is definitely something that we’re going to be seeing coming up in the next few years about who is qualified to treat people for opioid use disorder and how are they doing it.

Rovner: Yeah, lots of important stories for local reporters to pursue. Well, my extra credit this week is an investigation from Stat News by Tara Bannow called “Troubled For-Profit Chains Are Stealthily Operating Dozens of Psychiatric Hospitals Under Nonprofits’ Names.” And it’s about how nonprofit hospital systems, who are in many cases desperate for places to put psychiatric patients who are crowding their emergency departments, are creating these joint ventures with the two major national for-profit psychiatric hospital chains, UHS and Acadia, both of which have been cited repeatedly by state and local regulators for lack of staffing, lack of training, and lack of security that’s resulted in patient injuries and deaths.

Under these deals, the psychiatric hospitals operate under the banner of the nonprofits, which are usually well-known in their communities, and then the revenues get split. But some of the stories here are pretty hair-raising, and you really should read the whole story because it is quite an investigation.

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

Raman: @SandhyaWrites on X.

Rovner: Shefali?

Luthra: I’m @shefalil on the same platform.

Rovner: Jessie?

Hellmann: @jessiehellmann on X.

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

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

In what will certainly be remembered as a landmark decision, the Supreme Court’s conservative majority this week overruled a 40-year-old legal precedent that required judges in most cases to yield to the expertise of federal agencies. It is unclear how the elimination of what’s known as the “Chevron deference” will affect the day-to-day business of the federal government, but the decision is already sending shockwaves through the policymaking community. Administrative experts say it will dramatically change the way key health agencies, such as the FDA and the Centers for Medicare & Medicaid Services, do business.

The Supreme Court also this week decided not to decide a case out of Idaho that centered on whether a federal health law that requires hospitals to provide emergency care overrides the state’s near-total ban on abortion.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine, Victoria Knight of Axios, and Alice Miranda Ollstein of Politico.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• In 1984, the Supreme Court ruled broadly that courts should defer to the decision-making of federal agencies when an ambiguous law is challenged. On Friday, the Supreme Court ruled that the courts, not federal agencies, should have the final say. The ruling will make it more difficult to implement federal laws — and draws attention to the fact that Congress, frequently and pointedly, leaves federal agencies much of the job of turning written laws into reality.
• That was hardly the only Supreme Court decision with major health implications this week: On Thursday, the court temporarily restored access to emergency abortions in Idaho. But as with its abortion-pill decision, it ruled on a technicality, with other, similar cases in the wings — like one challenging Texas’ abortion ban.
• In separate rulings, the court struck down a major opioid settlement agreement, and it effectively allowed the federal government to petition social media companies to remove falsehoods. Plus, the court agreed to hear a case next term on transgender health care for minors.
• The first general-election debate of the 2024 presidential cycle left abortion activists frustrated with their standard-bearers — on both sides of the aisle. Opponents didn’t like that former President Donald Trump doubled down on his stance that abortion should be left to the states. And abortion rights supporters felt President Joe Biden failed to forcefully rebut Trump’s outlandish falsehoods about abortion — and also failed to take a strong enough position on abortion rights himself.

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 “Masks Are Going From Mandated to Criminalized in Some States,” by Fenit Nirappil.  

Victoria Knight: The New York Times’ “The Opaque Industry Secretly Inflating Prices for Prescription Drugs,” by Rebecca Robbins and Reed Abelson. 

Joanne Kenen: The Washington Post’s “Social Security To Drop Obsolete Jobs Used To Deny Disability Benefits,” by Lisa Rein.  

Alice Miranda Ollstein: Politico’s “Opioid Deaths Rose 50 Percent During the Pandemic. in These Places, They Fell,” by Ruth Reader.  

Also mentioned in this week’s podcast:

• Politico’s “Inside the $100 Million Plan To Restore Abortion Rights in America,” by Alice Miranda Ollstein.
• JAMA Network Open’s “Use of Oral and Emergency Contraceptives After the US Supreme Court’s Dobbs Decision,” by Dima M. Qato, Rebecca Myerson, Andrew Shooshtari, et al.
• JAMA Health Forum’s “Changes in Permanent Contraception Procedures Among Young Adults Following the Dobbs Decision,” by Jacqueline E. Ellison, Brittany L. Brown-Podgorski, and Jake R. Morgan.
• JAMA Pediatrics’ “Infant Deaths After Texas’ 2021 Ban on Abortion in Early Pregnancy,” by Alison Gemmill, Claire E. Margerison, Elizabeth A. Stuart, et al.

click to open the transcript

SCOTUS Ruling Strips Power From Federal Health Agencies

KFF Health News’ ‘What the Health?’Episode Title: ‘SCOTUS Ruling Strips Power From Federal Health Agencies’Episode Number: 353Published: June 28, 2024

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

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, June 28, at 10:30 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: Victoria Knight of Axios News.

Victoria Knight: Hello, everyone.

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

Joanne Kenen: Hi, everybody.

Rovner: I hope you enjoyed last week’s episode from Aspen Ideas: Health. This week we’re back in Washington with tons of breaking news, so let’s get right to it. We’re going to start at the Supreme Court, which is nearing, but not actually at, the end of its term, which we now know will stretch into next week. We have breaking news, literally breaking as in just the last few minutes: The court has indeed overruled the Chevron Doctrine. That’s a 1984 ruling that basically allowed experts at federal agencies to, you know, expert. Now it says that the court will get to decide what Congress meant when it wrote a law. We’re obviously going to hear a lot more about this ruling in the hours and days to come, but does somebody have a really quick impression of what this could mean?

Ollstein: So this could prevent or make it harder for health agencies, and all the federal agencies that touch on health care, to both create new policies based on laws that Congress pass and update old ones. Things need to be updated; new drugs are invented. There’s been all these updates to what Obamacare does and doesn’t have to cover. That could be a lot harder going forward based on this decision. It really takes away a lot of the leeway federal agencies had to interpret the laws that Congress passed and implement them.

I think kicking things back to courts and Congress could really slow things down a lot, and a lot of conservatives see that as a good thing. They think that federal agencies have been too untouchable and not have the same accountability mechanisms because they’re career civil servants who are not elected. But this has health policy experts … Honestly, we interviewed members of previous Republican administrations and Democratic administrations and they’re both worried about this.

Rovner: Yeah, going forward, if Donald Trump gets back into the presidency, this could also hinder the ability of his Department of Health and Human Services to make changes administratively.

Knight: These agencies are stacked with experts. This is what they work on. This is what they really are primed to do. And Congress does not have that same type of staffing. Congress is very different. It’s very young. There’s a lot of turnover. There are experienced staffers, but usually when they’re writing these laws, they leave so much up to interpretation of the agency because they are experts.

So I think pushing things back on Congress would really have to change how Congress works right now. When I talked to experts, we would need staffers who are way more experienced. We would need them to write laws that are way more specific. And Congress is already so slow doing anything. This would slow things down even more. So that’s a really important congressional aspect I think to note.

Rovner: I think when we look back at this term, this is probably going to be the biggest decision. Joanne, you want to add something before we move on?

Kenen: We’re recording. We don’t know if immunity just dropped, which is all still going to be, not a health care decision but an important decision of the country. I’ve got SCOTUSblog on my other screen. Here’s a quote from [Justice Elena] Kagan’s dissent. She says, because it’s very unfocused for what we do on this podcast, “Chevron has become part of the warp and woof of modern government, supporting regulatory efforts of all kinds, to name a few, keeping air and water clean, food and drugs safe and financial markets honest.” So two of the three of us. Financial markets affect the health industry as well.

Rovner: Oh, yeah.

Kenen: But I think that what the public doesn’t always understand is how much regulatory stuff there is in Washington. Congress can write a 1,000-page law like the ACA [Affordable Care Act]. I’ve never counted how many pages of regulation because I don’t think I can count that high. It’s probably tens of thousands.

Rovner: At least hundreds of thousands.

Kenen: Right. And that every one of those, there’s a lobbying fight and often a legal fight. It’s like the coloring book when we were kids. Congress drew the outline and then we all tried to scribble within the lines. And when you go out of the lines, you have a legal case. So the amount of stuff, regulatory activity is something that the public doesn’t really see. None of us have read every reg pertaining to health care. You can’t possibly do it in a lifetime. Methuselah couldn’t have done it. And Congress cannot hire all the expert staff and all the federal agencies and put them in; they won’t fit in the Capitol. That’s not going to happen. So how do they come to grips with how specific are they going to have to be? What kind of legal language can they delegate some of this to agency experts. We’re in really uncharted territory.

Rovner: I think you can tell from the tones of all of our voices that this is a very big deal, with a whole lot of blanks to be filled in. But for the moment …

Kenen: Maybe they’ll just let AI do it.

Rovner: Yeah, for the moment, let’s move on because, until just now, the biggest story of the week for us was on Thursday. We finally got a decision in that case about whether Idaho’s near-total ban on abortion can override a federal law called EMTALA, the Emergency Medical Treatment and Active Labor Act, which requires doctors in emergency rooms to protect a pregnant woman’s health, not just her life. And much like the decision earlier this month to send the abortion pill case back to the lower courts because the plaintiffs lacked legal standing, the court once again didn’t reach the merits here. So Alice, what did they do?

Ollstein: So like you said, both on abortion pills and on EMTALA, the court punted on procedural issues. So it was standing on the one and it was ripeness on the other one. This one was a lot more surprising. I think based on the oral arguments in the mifepristone case, we could see the standing-based decision coming. That was a big focus of the arguments. This was more of a surprise. This was a majority of justices saying, “Whoops, we shouldn’t have taken this case in the first place. We shouldn’t have swooped in before the 9th Circuit even had a chance to hear it. And not only take the case, but allow Idaho to fully enforce its law even in ways that people feel violate EMTALA in the meantime.” And so what this does temporarily is restore emergency abortion access in Idaho. It restores a lower-court order that made that the case, but it’s not over.

Rovner: Right. It had stayed Idaho’s ban to the extent that it conflicted with EMTALA.

Ollstein: So this goes back to lower courts and it’s almost certain to come back to the Supreme Court as early as next year, if not at another time. Because this isn’t even the only major federal EMTALA case that’s in the works right now. There’s also a case on Texas’ abortion ban and its enforcement in emergency situations like this. And so I think the main reaction from the abortion rights movement was temporary relief, but a lot of fear for the future.

Rovner: And I saw a lot of people reminding everybody that this Texas ruling in Idaho, now the federal law is taking precedence, but there’s a stay of the federal law in the 5th Circuit. So in Texas, the Texas ban does overrule the federal law that requires abortions in emergency circumstances to protect a woman’s health. That’s what the dispute is basically about. And of course, you see a lot of legal experts saying, “This is a constitutional law 101 case that federal law overrides state law,” and yet we could tell by some of the add-on discussion in this case, as they’re sending it back to the lower court, that some of the conservatives are ready to say, “We don’t think so. Maybe the federal law will have to yield to some of these state bans.” So you can kind of see the writing on the wall here?

Ollstein: It’s really hard to say. I think that you have some justices who are clearly ready to say that states can fully enforce their abortion bans regardless of what the federal government’s federal protections are for patients. I think they put that out there. I think the case is almost certain to come back to them, and there was clearly not a majority ready to fully side with the Biden administration on this one.

Rovner: And clearly not a majority ready to fully side with Idaho on this one. I think everything that I saw suggested that they were split 3-3-3. And with no majority, the path of least resistance was to say, “Our bad. You take this back lower court. We’ll see when it comes back.”

Ollstein: It was a very unusual move, but some of the justification made sense to me in that they cited that Idaho state officials’ position on what their abortion ban did and didn’t do has wavered over time and changed. And what they initially said when they petitioned to the court is not necessarily exactly what they said in oral arguments, and it’s not exactly what they have said since. And so at the heart here is you have some people saying there’s a clear conflict between the patient protections under EMTALA — which says you have to stabilize anyone that comes to you at a hospital that takes Medicare — and these abortion bans, which only allow an abortion when there’s imminent life-threatening situation. And so you have people, including the attorney general of Idaho, saying, “There is no conflict. Our law does allow these emergency abortions and the doctors are just wrong and it’s just propaganda trying to smear us. And they just want to turn hospitals into free-for-all abortion facilities.” This is what they’re arguing. And then you have people say …

Rovner: [inaudible 00:11:12] … in the meanwhile, we know that women are being airlifted out of Idaho when they need emergency abortions because doctors are worried about actually performing abortions …

Ollstein: Correct.

Rovner: And possibly being charged with criminal charges for violating Idaho’s abortion ban.

Ollstein: Sure, but I’m saying even amongst conservatives, there are those who are saying, “There’s no conflict between these two policies. The doctors are just wrong either intentionally or unintentionally.” And then there’s those who say there is a conflict between EMTALA and state bans, and it should be fine for the state to violate EMTALA.

Rovner: No. Obviously this one will continue as the abortion pill case is likely to continue. Well, also in this end-of-term Supreme Court decision dump, an oddly split court with liberals and conservatives on both sides, struck down the bankruptcy deal reached with Purdue Pharma that would’ve paid states and families of opioid overdose victims around $6 billion, but would also have shielded the company’s owners, the Sackler family, from further legal liability. What are we to make of this? This was clearly a difficult issue. There were a lot of people even who were involved in this settlement who said the idea of letting the Sackler family, which has hidden billions of dollars from the bankruptcy settlement anyway, and clearly acted very badly, basically giving them immunity in exchange for actually getting money. This could not have been an easy… obviously was not an easy decision even for the Supreme Court.

Kenen: No, it wasn’t theoretical. The ones who opposed blowing up the agreement were very much, “This is going to add delay any kind of justice for the families and the plaintiffs.” It was not at all abstract. It was like there are a lot of people who aren’t going to get help. At least the help will be delayed if this money doesn’t start flowing. So I was struck by how practical, relating to the families who have lost people because of the actions of Purdue. But the other side was, also that was much more a clear-cut legal issue, that people didn’t give up their right to sue. It was cutting off the right to sue was imposed on potential plaintiffs by the settlement. So that was a much more legalistic argument versus, it was a little bit more real world, but they need the help now. And including some of the conservatives. This is an interesting thing to read. This was painstaking. This is a huge settlement. It took so long. It had many, many moving parts. And I don’t know how you go back and put it together again.

Rovner: But that’s where we are.

Kenen: Yes.

Rovner: They have to basically start from scratch?

Kenen: I don’t know if they have to start entirely from scratch. You’d have to be nuts to get the Sacklers to say, “OK, we’ll be sued,” which they’re obviously you’re not going to. Is somebody going to come up with a “Split the difference, let’s get this moving and we won’t sue anymore?” I don’t know. But I don’t know that you have to start 100% from scratch, but you’re surely not anywhere near a finish line anymore.

Rovner: That’s big Supreme Court case No. 3 for this week. Now let’s get to big Supreme Court case No. 4. Earlier this week, the court turned back a challenge that the government had wrongly interfered with free speech by urging social media organizations to take down covid misinformation. But again, as with the abortion pill case, the court did not get to the merits. But instead, they ruled that the states and individuals who sued did not have standing. So we still don’t know what the court thinks of the role of government in trying to ensure that health information is correct. Right?

Knight: Right. And I thought it was interesting. Basically the White House was like, “Well, we talked to the tech companies, but it was their decision to do this. So we weren’t really mandating them do this.” I think they’re just being like, “OK, we’ve left it up to the tech companies. We haven’t really interfered. We’re just trying to say these things are harmful.” So I guess we’ll have to see. Like you said, they didn’t take it up on standing, but overall, conservatives that were saying, “This was infringing on free speech.” It was particularly some scientists, I think, that promoted the herd immunity theory, things like that.

So I think they’re obviously going to be upset in some way because their posts were depromoted on social media. But I think it just leaves things the way they are, the same way. But it would be interesting, I guess, if Trump does go to the White House, how that might play out differently?

Rovner: This court has been a lot of the court deciding not to decide cases, or not to decide issues. Sorry, Alice, go ahead.

Ollstein: Yeah, so I think it is pretty similar to the abortion pill case in one key way, which is that it’s the court saying, “Look, the connection between the harm you think you suffered and the entity you are accusing of causing that suffering, that connection is way too tenuous. You can’t prove that the Biden administration voicing concerns to these social media companies directly led to you getting shadow-banned or actual banned,” or whatever it is. And the same in the abortion pill case, the connection between the FDA [Food and Drug Administration] approving the drug and regulating the drug and these individual doctors’ experiences is way too tenuous. And so that’s something to keep in mind for future cases that, we’re seeing a pattern here.

Rovner: Yes, and I’m not suggesting that the court is directly trying to duck these issues. These are legitimate standing cases and important legal precedents for who can sue in what circumstance. That is the requirement of constitutional review that first you have to make sure that there’s both standing in a live controversy and there’s all kinds of things that the court has to go through before they get to the merits. So more often than not, they don’t get there.

Well, meanwhile, we have our first hot-button, Supreme Court case slotted in for next term. On Monday, the court granted “certiorari” [writ by which a higher court reviews a decision of a lower court] to a case out of Tennessee where the Biden administration is challenging the state’s ban on transgender care for minors. It was inevitable that one of these cases was going to get to the high court sooner or later, right?

Kenen: Yeah, I think it’s not a surprise, the politics of it and the techniques or tools used by the forces that are against the treatment for minors. It’s very similar to the politics and patterns of the abortion case, of turning something into an argument that it’s to protect somebody. A lot of the abortion requirements and fights were about to protect the woman. Ostensibly, that was the political argument. And now we’re seeing we have to protect the children so that it’s the courts, as opposed to families and doctors, who are, “protecting the children.”

There’s a lot of misunderstanding about what these treatments do and who gets them and at what age;  that they’re often described as mutilation and irreversible. For the younger kids, for preteen, middle school age-ish, early teens, nothing is irreversible. It’s drugs that if you stop them, the impact goes away. But it has become this enormous lightning rod for the intersection of health and politics. And I think we all have a pretty good guess as to where the Supreme Court’s going to end up on this. But you’re sometimes surprised. And also, there could be some …

Rovner: Maybe they don’t have standing.

Kenen: There could be some kind of moderation, too. It could be a certain … they don’t have to say all … it depends on how clinical they want to get. Maybe they’ll rule on certain treatments that are more less-reversible than a puberty blocker, which is very reversible, and some kind of safeguards. We don’t know the details. We’re not surprised that it ended up … and we know going in, you could have a gut feeling of where it’s likely to turn out without knowing the full parameters and caveats and details. They haven’t even argued it yet.

Rovner: This is a decision that we’ll be waiting for next June.

Kenen: Right. Well, could not. Maybe it’s so clear-cut, it’ll be May. Who knows, right?

Rovner: Yeah, exactly. All right, well, moving on. There was a presidential debate last night. I think it was fair to say that it didn’t go very well for either candidate, nor for anybody interested in what President Biden or former President Trump thinks about health issues. What did we learn, if anything?

Ollstein: Well, I was mainly listening for a discussion of abortion and, boy was it all over the place. What I thought was interesting was that both candidates pissed off their activist supporters with what they said. I was texting with a lot of folks on both sides and conservatives were upset that Trump doubled down on his position that this should be entirely left to states, and they disagree. They want him to push for federal restrictions if elected.

And on the left, there was a lot of consternation about Biden’s weird, meandering answer about Roe v. Wade. He was asked about abortions later in pregnancy. One, neither he nor the moderators pushed back on what Trump’s very inflammatory claims about babies being murdered and stuff. There was no fact-checking of that whatsoever. But then Biden gave a confusing answer, basically saying he supports going to the Roe standard but not further, which is what I took out of it. And that upset a lot of progressives who say Roe was never good enough. For a lot of people, when Roe v. Wade was still in place, abortion was a right in name only. It was not actually accessible. States could impose lots of restrictions that kept it out of reach for a lot of people. And in this moment, why should we go back to a standard that was never good enough? We should go further. So just a lot of anxiety on both sides of this.

Rovner: Yeah. Meanwhile, Trump seemed to say that he would leave the abortion pill alone, which jumped out at me.

Kenen: But that was a completely … CNN made a decision not to push back. They were going to have online fact-checking. Everybody else had online fact. … And they didn’t challenge. And I guess they assumed that the candidates would challenge each other, and Biden had a different kind of challenging night. Trump actually said that the previous Supreme Court had upheld the use of the abortion drug and that it’s over, it’s done. That was not a true statement. The Supreme Court rejected that case, as Alice just explained, on standing. It’s going to be back. It may be back in multiple forms, multiple times. It is not decided. It is not over, which is what Trump said, “Oh, don’t worry about the abortion drug. The Supreme Court OK’d it.” That’s not what the Supreme Court did, and Biden didn’t counter that in any way.

And then Biden, in addition to the political aspect that Alice just talked about, he also didn’t describe Roe, the framework of Roe, particularly accurately. And, as Alice just pointed out, the things that Trump said were over-the-top even for Trump, and that they went unchallenged by either the moderators or President Biden.

Rovner: I was a little bit surprised that there wasn’t anything else on health care or there wasn’t much else.

Knight: Biden tried to hit his health care talking points and did a very terrible job. Alice had a really good tweet getting the right. … He initially said wrong numbers for the insulin cap, for the cap on out-of-pocket for Medicare beneficiaries, how much they can spend on prescription drugs. He got both of those wrong. I think he got insulin right later in the night. And then the very notably, “We will beat Medicare.” That was just unclear what he even meant by that. Maybe it was about drug price negotiations, I’m sure. So he was trying, but just could not get the facts right and I don’t think it came across effective in any way. And health care does do really well for Democrats. Abortion does really well for Democrats. So he was not effective in putting those messages.

I also noticed the moderators asked a question about opioids, addressing the opioid epidemic. Trump did not answer at all, pivoted to I think border or something like that. I don’t think Biden really answered either, honestly. So that was an opportunity for them to also talk about addressing that, which I think is something they could both probably talk about in a winning way for both. But I thought it was mentioned more than I expected a little bit. I thought they may want to talk about it at all. So it was still not much substantive policy discussion on health care.

Kenen: Biden tried to get across some of the Democratic policies on drug prices and polls have shown that the public doesn’t really understand that is actually the law in going forward. So if any attempt to message that in front of a very large audience was completely muddled. Nobody listening to that debate would’ve come out — unless they knew going in — they would’ve not have come out knowing what was in the law about Medicare price negotiations. They would’ve gotten four different answers of what happened with insulin, although they probably figured something good, helpful happened. And a big opportunity to push a Democratic achievement that has some bipartisan popularity was completely evaporated.

Rovner: I think Biden did the classic over-prepare and stuff too many talking points into his head and then couldn’t sort them all out in the moment. That seemed pretty clear. He was trying to retrieve the talking point and they got a little bit jumbled in his attempt to bring them out. Well, back to abortion: Alice, you got a cool scoop this week about abortion rights groups banding together with a $100 million campaign to overturn the overturn of Roe. Tell us about that?

Ollstein: Yeah, so it’s notable because there’s been so much focus on the state level battles and fighting this out state by state, and the ballot initiatives that have passed at the state level and restored or protected access have been this glimmer of hope for the abortion rights movement. But I think there was a real crystallization of the understanding that that strategy alone would leave tens of millions of people out in the cold because a lot of states don’t have the ability to do a ballot initiative. And also, if there were to be some sort of federal restrictions imposed under a Trump presidency or whatever, those state level protections wouldn’t necessarily hold. So I think this effort of groups coming together to really spend big and say that they want to restore federal protections is really notable.

I also think it’s notable that they are not committing to a specific bill or plan or law they want to see. They are keeping on the, “This is our vision, this is our broad goal.” But they’re not saying, “We want to restore Roe specifically, we want to go further,” et cetera. And that’s creating some consternation within the movement. I’ve also, since publishing the story, heard a lot of anxiety about the level of spending going to this when people feel that that should be going to direct support for people who are suffering on the ground and struggling to access abortion. Right now you have abortion funds screaming that they’re being stretched to the breaking point and cannot help everyone who needs to travel out of state right now. So, of course, infighting on the left is a perennial, but I think it’s particularly interesting in this case.

Rovner: Well, meanwhile, we have a trio this week of examples of what I think it’s safe to call unintended consequences of the Supreme Court’s overturn of Roe. First, a study in the medical journal JAMA Pediatrics this week, found that in the first year abortion was dramatically restricted in Texas — remember, that was before the overturn of Roe — infant deaths rose fairly dramatically. In particular, deaths from congenital problems rose, suggesting that women carrying doomed fetuses gave birth instead of having abortions. What’s the takeaway from seeing this big spike in infant mortality?

Ollstein: So I’ve seen a lot of anti-abortion groups trying to spin this and push back really hard on it. Specifically picking up on what you just said, which is that a lot of these are fatal fetal anomalies. And so they were saying, “Were abortion still legal, those pregnancies could have been terminated before birth.” And so they’re saying, “There’s no difference really, because we consider that an infant death already. So now it’s an infant death after birth. Nothing to see here.”

Rovner: When everybody has suffered more, basically.

Ollstein: Yeah, that is the response I’m seeing on the right. On the left, I am seeing arguments that anyone who labels themselves pro-life should think twice about the impact of these policies that are playing out. And like you said, we’re only just beginning to get glimmers of this data. In part because Texas was out in front of everybody else, and so I think there’s a lot more to come.

The other pushback I’ve seen from anti-abortion groups is that infant mortality also rose in states where abortion remains legal. So I think that’s worth exploring, too. Obviously, correlation is not always causation, but I think it’s hard when you’re getting the data in little dribs and drabs instead of a full complete picture that we can really analyze.

Rovner: Well, in another JAMA study, this one in JAMA Network Open, they found that the use of Plan B, the morning-after birth control pill, fell by 60% in states that implemented abortion bans after the Dobbs [v. Jackson Women’s Health Organization] decision. Now, for the millionth time, Plan B is not the same as the abortion pill. It’s a high-dose contraceptive. But apparently, a combination of the closure of family planning clinics in states that impose bans, which are an important source of pills for people with low incomes who can’t afford over-the-counter versions, and misinformation about the continuing legality of the morning-after pill, which continues to be legal, contributed to the decline. At least that’s what the authors theorize. This is one of many ironies in the wake of Dobbs; that states with abortion bans may well be ending up with more unintended pregnancies rather than fewer.

Ollstein: Well, one trends that could be feeding this is that some of the clinics where people used to go to to access contraception, also provided abortion and have not been able to keep their doors open in a post-Roe environment. We’ve seen clinics shutting down across the South. I went to Alabama last year to cover this, and there are clinics there that used to get most of their revenue from abortion, and they’re trying to hang on and provide nonabortion gynecological services, including contraception, and the math just ain’t mathing, and they’re really struggling to survive.

And so this goes back to the finger-pointing within the movement about where money should be going right now. And I know that red state clinics that are trying to survive feel very left behind and feel that this erosion of access is a result of that.

Kenen: Julie, and also to put in, even before Dobbs, it was not easy in many parts of the country for low-income women to get free contraception. There are states in which clinics were few and far between. Federal spending on Title X has not risen in many years.

Rovner: Title X is a federal [indecipherable].

Kenen: Right. Alice knows this, and maybe I’ve said on the podcast, I once just pretty randomly with me and my cursor plunked my cursor down on a map of Texas and said, “OK, if I live here, how far is the nearest clinic?” And I looked at the map of the clinics and it was far, it was something like 95 miles, the nearest one. So we had abortion deserts. We’ve also had family planning deserts, and that has only gotten worse, but it wasn’t good in the first place.

Rovner: Well, finally, and for those who really want to make sure they don’t have unintended pregnancies, according to a study in a third AMA journal, JAMA Health Forum, the number of young women aged 18 to 30 who were getting sterilized doubled in the 15 months after Roe was overturned. Men are part of this trend, too. Vasectomies tripled over that same period. Are we looking at a generation that’s so scared, they’re going to end up just not having kids at all?

Kenen: Well, there are a lot of kids in this generation who are saying they don’t want to have kids for a variety of reasons: economic, climate, all sorts of things. I think that I was a little surprised to see that study because there are safe long-acting contraceptives. You can get an IUD that lasts seven to nine years, I think it is. I was a little surprised that people were choosing something irreversible because.. I do know young people who… You’re young, you go through lots of changes in life, and there is an alternative that’s multiyear. So I was a little surprised by that. But that’s apparently what’s happening. And it’s for… This generation is not as… What are they, Gen[eration] Z? They’re not as baby-oriented as their older brothers and sisters even.

Knight: Well, that age range is millennial and Gen Z. But I don’t know. I’m a millennial. I think a lot of my friends were not baby-oriented. So I think that’s probably a fair statement to say. But it is interesting that they wouldn’t choose an IUD or something like that instead. But I do think people are scared. We’ve seen the stories of people moving out of states that have really strict abortion bans because they are so concerned on what kind of medical care they could have, even if they think they want to get pregnant. And sometimes you don’t have a healthy pregnancy and then need to get an abortion. So I’m sure it has something to do with that but…

Rovner: Yeah, it’s one of those trends to keep an eye out for. Well, moving on, U.S. Surgeon General Vivek Murthy has been busy these past couple of weeks. First, he published an op-ed in The New York Times calling for a warning label for social media that’s similar to the one that’s already on tobacco products, warning that social media has not been proven safe for children and teenagers. Of course, he doesn’t have his own authority to do that. Congress would have to pass a law. Any chance of that? I know Congress is definitely into the “What are we going to do about social media” realm.

Kenen: But talking about it and doing something or thinking, it’s a long way. Is this as, compared to his other topic of the week, which was gun safety? He’s got a lot more bipartisan …

Rovner: We’re getting to that.

Kenen: … He’s got a lot more bipartisan support for the concern about health of young people and what social media is. What is social media? Social media is mixed. There are good things and bad things, and what is that balance? There is a bipartisan concern. I don’t know that that means you get to the labeling point. But the labeling point is one thing. That the larger concept of concern about it, and recognition about it, and what do we do about it, is bipartisan up to a point. How do you even label? What do you label? Your phone? Your computer? I’m not sure where the label goes. Your eyelids? [inaudible 00:33:07]

Knight: Right. Well, tech bills in Congress in general are like… Even though TikTok was surprisingly able to get done in the House. But TikTok lobby was big. But there would be a big social media lobby, I’m sure, against that. I guess there is bipartisan support. I don’t know. It’s not something I’ve asked members about, but I think that would be pretty far off from a reality actually happening.

Rovner: Well, also this week, as Joanne mentioned, the surgeon general issued a Surgeon General’s Advisory, declaring gun violence a public health crisis, calling for more research funding on gun injuries and deaths, universal background checks for gun buyers, and bans on assault weapons and high-capacity ammunition magazines. I feel like the NRA [National Rifle Association] has lost some of its legendary clout on Capitol Hill over the past few years, thanks to a series of scandals, but maybe not enough for some of these things. I feel like I’ve heard these suggestions before, like over the last 25 or 30 years.

Kenen: I think one of the interesting things about Vivek Murthy is he came to public prominence on gun safety and guns in public health before people were really talking about guns in public health. I forgot what year it was — 2016, 2017, whenever Obama first nominated him. Because remember, this is his second run as surgeon general. It was an issue that he had spoken about and had made a signature issue, and as he became a more public figure before the nomination. And then he went silent on it. He had trouble getting confirmed. He didn’t do anything about it. We never really heard … as far as I can recollect, we never even heard him talk about it once. Maybe there was a phrase or two here or there. He certainly didn’t push it or make it a signature issue.

Right now, he’s at the end of the last year with the Biden administration. Some kind of arc is being completed. He’s a young man, there’ll be other arcs. But this arc is winding down and the president cares about gun violence. Congress actually did, not the full agenda, but they did something on it, which was unusual. And I think that this is his chance to use his bully pulpit while he still has it in this particular perch to remind people that we do have tools. We don’t have all the solutions to gun violence. We do not understand everything about it. We do not understand why some people go and shoot a movie theater or a school or a supermarket or whatever, and there are multiple reasons. There are different kinds of mass killers. But we do know that there are some public health tools that do work. That red flag laws do seem to help. That safe gun storage … There are things that are less controversial than a spectrum of things one can do.

Some of them have broader support, and I think he is using this time — not that he expects any of these things to become law in the final year of the Biden administration — but I think he’s using it. This is bully pulpit. This is saying, “Moving forward, let’s think about what we can come to agreement on and do what we can on certain evidence-based things.” Because there’s been a lot of work in the last decade or so on the public health, not just the criminal… Obviously, it’s a legal and criminal justice issue. It’s also a public health issue, and what are the public health tools? What can we do? How do we treat this as basically an epidemic? And how can we stop it?

Rovner: Finally this week, since we didn’t really do news last week, there have been a couple of notable stories we really ought to mention. One is a court case, Braidwood v. Becerra. This is the case where a group of Christian businesses are claiming that the Affordable Care Act’s preventive services provisions that require them to provide no cost-sharing access to products, including HIV preventive medication, violates their freedom of religion because it makes them complicit in homosexual behavior. Judge Reed O’Connor, district court judge — if that name is familiar, it’s because he’s the Texas judge who tried to strike down the entire ACA back in 2018. Judge O’Connor not only found for the plaintiffs, he tried to slap a nationwide injunction on all of the ACA’s preventive services, which even the very conservative 5th Circuit appeals court struck down. But meanwhile, the appeals court has come up with its ruling. Where does that leave us on the ACA preventive services?

Ollstein: It leaves us right where we were when the 5th Circuit took the case because they said that, “We’re going to allow the lower court ruling to be enforced just for the plaintiffs in the meantime, but we’re not going to allow the entire country’s preventive care coverage to be disrupted while this case moves forward.” And so that basically continues to be the case. Some of the arguments are getting sent back down to the lower court for further consideration. And we still don’t know whether either side will appeal the 5th Circuit’s ruling to the Supreme Court.

Rovner: But notably, the appeals court said that U.S. Preventive Services Task Force, which is appointed by the Department of Health and Human Services, is basically illegally constituted because it should be nominated by the president, approved by the Senate, which it is not. That could in the long run be kind of a big deal. This is a group of experts that supposedly shielded from politics.

Kenen: Yeah, I don’t think this story is over either. It is for now. Right now we’re at the status quo, except for this handful of people who brought recommendations on all sorts of health measures, including vaccination and cancer screenings and everything else. They stand. They’re not being contested at this moment. How that will evolve under the next administration and this court remains to be seen.

Rovner: Finally, finally, finally, to end on a bit of a frustrating note, the National Academies of Sciences, Engineering, and Medicine, has found that two decades after it first called out some of the most egregious inequities in U.S. health care, not that much has changed. Joanne, this has been a very high-profile issue. What went wrong?

Kenen: Well, I think this report got very little attention probably because it’s like, oh, reports aren’t necessarily news stories. And it was like nothing changed, so why do we report it? But I think when I read the report — and I did not get through all 375 pages yet, but I did read a significant amount of it and I listened to a webinar on it — I think what really struck me is how we’re not any better than we really were 20 years ago. And what really was jarring is the report said, “And we actually know how to fix this and we’re not doing it. And we have the scientific and public health and sociological knowledge. We know if we wanted to fix it, we could, and we haven’t. Some of that is needing money and some of it is needing will.” So I thought the bottom line of it was really quite grim. If we didn’t know how bad it was, if the general public didn’t know how bad it was, the pandemic really should have taught them that because of the enormous disparities, and we’re back on this glide path toward nothing.

Rovner: I do think at very least, it is more talked about. It’s a little higher profile than it was, but obviously you’re right.

Kenen: They didn’t say no gains in any… I mean, the ACA helped. There are people who have coverage, including minorities, who didn’t have it before. That was one of the bright spots. But there’s still 10 states where it hasn’t been fully implemented. It was a pretty discouraging report.

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

Knight: Sure. So I was reading a story in The New York Times about PBMs [pharmacy benefit managers]. It was called “The Opaque Industry Secretly Inflating Prices for Prescription Drugs.” It’s by Rebecca Robbins and Reed Abelson. And so it kind of is basically an investigation into PBM practices. It was interesting for me because I cover health care in Congress, and so it’s always the different industries are fighting each other. And right now, one of the biggest fights is about PBMs. And for those that don’t know, PBMs negotiate with drug companies, they’re supposed to pay pharmacies, they help patients get their medications. And so they’re this middleman in between everyone. And so people don’t really know they exist, but they’re a big monopoly. There’s only three of them, really big ones in the U.S. that make up 80% of the market. And so they have a lot of control over things.

Pharma blames them for high drug prices and the PBMs blame pharma. So that’s always a fun thing to watch. There actually is quite a bit of traction in Congress right now for cracking down on PBM practices. Basically, The Times reporters interviewed a bunch of people and they came away with saying that PBMs …

Rovner: They interviewed like 300 people, right?

Knight: Yes, it said 300.

Rovner: A large bunch.

Knight: Yeah, and they came away with a conclusion that PBMs are causing higher drug prices and they’re pushing patients towards higher drugs. They’re charging employers of government more money than they should be. But it was interesting for me to watch this play out on Twitter because the PBM lobby was, of course, very upset by the story. They were slamming it and they put out a whole press release saying that it’s anecdotal and they don’t have actual data. So it was interesting, but I think it’s another piece in the policy puzzle of how do we reduce drug prices? And Congress thinks at least cracking on PBMs is one way to do it, and it has bipartisan support.

Rovner: And apparently this story is the first in a series, so there’s more to come.

Knight: Yes, I saw that. Yeah, more to come, so it’ll be fun. I also just noticed as I was just pulling it up on my phone and they had closed the comment section. It was causing some robust debate.

Rovner: Yes, indeed. Joanne?

Kenen: I should just say that after I read that story in The Times that same day, I think I got a phone call from a relative, a copay that had been something like $60 for 30 days is now $1,000. And this relative walked away without getting the drug because that’s not OK. So anyway, my extra credit [“Social Security To Drop Obsolete Jobs Used To Deny Disability Benefits,”] is from The Washington Post. Lisa Rein posted an investigation a couple of years ago, and this was the coda of the Social Security Administration finally followed through on what that investigation revealed. And Lisa wrote about the move, how it’s being addressed. That to get disability benefits, you have to be unemployable basically. And the Social Security Administration had a list of … it’s called the Dictionary of Occupational Titles. It had not been updated in 47 years. So disabled people were being denied Social Security disability benefits because they were being told, well, they could do jobs like being a nut sorter or a pneumatic tube operator or a microfilm something or other. And these jobs stopped existing decades ago.

So the Social Security Administration got rid of these obsolete jobs. You’re no longer being told, literally, to go store nuts. If you are, in fact, legitimately disabled, you’ll now be able to get the Social Security disability benefits that you are, in fact, qualified for. So thousands of people will be affected.

Rovner: No one can see this, but I’m wearing my America Needs Journalists T-shirt today. Alice?

Ollstein: I chose a piece [“Opioid Deaths Rose 50 Percent During the Pandemic. in These Places, They Fell”] by my colleague Ruth Reader, about a county in Ohio that, with some federal funds, implemented all of these policies to reduce opioid overdoses and deaths, and they had a lot of success. Overdoses went down 20% there, even as they went up by a lot in most of the country. But bureaucracy and expiring funding means that those programs may not continue, even though they’re really successful. The federal funding has run out. It is not getting renewed, and the state may not pick up the slack.

So it’s just a really good example. We see this so often in public health where we invest in something, it works, it makes a difference, it helps people, and then we say, “Well, all right, we did it. We’re done.” And then the problems come roaring back. So hopefully that does not happen here.

Rovner: Alas. Well, my extra credit this week is from The Washington Post. It’s called “Masks Are Going From Mandated to Criminalized in Some States.” It’s by Fenit Nirappil. I hope I’m pronouncing that right. In some ways, it’s a response to criminals who have obviously long used masks, and also to protesters, particularly those protesting the war in Gaza. But it’s also a mark of just how intolerant we’ve become as a society that people who are immunocompromised or just worried about their own health can’t go out masked in public without getting harassed. The irony, of course, is that this is all coming just as covid is having what appears to be now its annual summer surge, and the big fight of the moment is in North Carolina where the Democratic governor has vetoed a mask ban bill, that’s likely to be overridden by the Republican legislature. Even after covid is no longer front and center in our everyday lives, apparently a lot of the nastiness remains.

All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comment or questions. We’re at whatthehealth@kff.org, or you can still find me at Twitter, which the Supreme Court has now decided it’s going to call Twitter. I’m @jrovner. Alice?

Ollstein: I’m @AliceOllstein on X.

Rovner: Victoria?

Knight: I’m @victoriaregisk.

Rovner: Joanne?

Kenen: I’m at Twitter, @JoanneKenen. And I’m on Threads @joannekenen1, and I occasionally decided I just have better things to do.

Rovner: It’s all good. We will be back in your feed next week. Until then, be healthy.

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Before Ohio voters amended their constitution last year to protect abortion rights, the state’s attorney general, an anti-abortion Republican, said that doing so would upend at least 10 state laws limiting abortions.

But those laws remain a hurdle and straightforward access to abortions has yet to resume, said Bethany Lewis, executive director of the Preterm abortion clinic in Cleveland. “Legally, what actually happened in practice was not much,” she said.

Today, most of those laws limiting abortions — including a 24-hour waiting period and a 20-week abortion ban — continue to govern Ohio health providers, despite the constitutional amendment’s passage with nearly 57% of the vote. For abortion rights advocates, it’s going to take time and money to challenge the laws in the courts.

Voters in as many as 13 states could also weigh in this year on abortion ballot initiatives. But the seven states that have voted on abortion-related ballot measures since the Supreme Court overturned federal abortion protections two years ago in Dobbs v. Jackson Women’s Health Organization show that an election can be just the beginning.

The state-by-state patchwork of constitutional amendments, laws, and regulations that determine where and how abortions are available across the country could take years to crystallize as old rules are reconciled with new ones in legislatures and courtrooms. And even though a ballot measure result may seem clear-cut, the residual web of older laws often still needs to be untangled. Left untouched, the statutes could pop up decades later, like an Arizona law from 1864 did this year.

Michigan was one of the first states where voters weighed in on abortion rights following the Dobbs decision in June 2022. In November of that year, Michigan voters approved by 13 percentage points an amendment to add abortion rights to the state constitution. It would be an additional 15 months, however, before the first lawsuit was filed to unwind the state’s existing abortion restrictions, sometimes called “targeted regulation of abortion providers,” or TRAP, laws. Michigan’s include a 24-hour waiting period.

The delay had a purpose, according to Elisabeth Smith, state policy and advocacy director at the Center for Reproductive Rights, which filed the lawsuit: It’s preferable to change laws through the legislature than through litigation because the courts can only strike down a law, not replace one.

“It felt really important to allow the legislative process to go forward, and then to consider litigation if there were still statutes that were on the books the legislature hadn’t repealed,” Smith said.

Michigan’s Democratic-led legislature did pass an abortion rights package last year that was signed into law by the state’s Democratic governor in December. But the package left some regulations intact, including the mandatory waiting period, mandatory counseling, and a ban on abortions by non-doctor clinicians, such as nurse practitioners and midwives.

Smith’s group filed the lawsuit in February on behalf of Northland Family Planning Centers and Medical Students for Choice. Smith said it’s unclear how long the litigation will take, but she hopes for a decision this year.

Abortion opponents such as Katie Daniel, state policy director for Susan B. Anthony Pro-Life America, are critical of the lawsuit and such policy unwinding efforts. She said abortion rights advocates used “deceptive campaigns” that claimed they wanted to restore the status quo in place before the Dobbs decision left abortion regulation up to the states.

“The litigation proves these amendments go farther than they will ever admit in a 30-second commercial,” Daniel said. “Removing the waiting period, counseling, and the requirement that abortions be done by doctors endangers women and limits their ability to know about resources and support available to them.”

A lawsuit to unwind most of the abortion restrictions in Ohio came from Preterm and other abortion providers four months after that state’s ballot measure passed. A legislative fix was unlikely because Republicans control the legislature and governor’s office. Preterm’s Lewis said she anticipated the litigation would take “quite some time.”

Dave Yost, the Ohio attorney general, is one of the defendants named in the suit. In a motion to dismiss the case, Yost argued that the abortion providers — which include several clinics as well as a physician, Catherine Romanos — lacked standing to sue.

He argued that Romanos failed to show she was harmed by the laws, explaining that “under any standard, Dr. Romanos, having always complied with these laws as a licensed physician in Ohio, is not harmed by them.”

Jessie Hill, an attorney representing Romanos and three of the clinics in the case, called the argument “just very wrong.” If Romanos can’t challenge the constitutionality of the old laws because she is complying with them, Hill said, then she would have to violate those laws and risk felonies to honor the new amendment.

“So, then she’s got to go get arrested and show up in court and then defend herself based on this new constitutional amendment?” Hill said. “For obvious reasons, that is not a system that we want to have.”

This year, Missouri is among the states poised to vote on a ballot measure to write protections for abortion into the state constitution. Abortions in Missouri have been banned in nearly every circumstance since 2022, but they were largely halted years earlier by a series of laws seeking to make abortions scarce.

Over the course of more than three decades, Missouri lawmakers instituted a 72-hour waiting period, imposed minimum dimensions for procedure rooms and hallways in abortion clinics, and mandated that abortion providers have admitting privileges at nearby hospitals, among other regulations.

Emily Wales, president and chief executive of Planned Parenthood Great Plains, said trying to comply with those laws visibly changed her organization’s facility in Columbia, Missouri: widened doorways, additional staff lockers, and even the distance between recovery chairs and door frames.

Even so, by 2018 the organization had to halt abortion services at that Columbia location, she said, with recovery chairs left in position for a final inspection that never happened. That left just one abortion clinic operating in the state, a separate Planned Parenthood affiliate in St. Louis. In 2019, that organization opened a large facility about 20 miles away in Illinois, where lawmakers were preserving abortion access rather than restricting it.

By 2021, the last full year before the Dobbs decision opened the door for Missouri’s ban, the number of recorded abortions in the state had dwindled to 150, down from 5,772 in 2011.

“At that point, Missourians were generally better served by leaving the state,” Wales said.

Both of Missouri’s Planned Parenthood affiliates have vowed to restore abortion services in the state as swiftly as possible if voters approve the proposed ballot measure. But the laws that diminished abortion access in the state would still be on the books and likely wouldn’t be overturned legislatively under a Republican-controlled legislature and governor’s office. The laws would surely face challenges in court, yet that could take a while.

“They will be unconstitutional under the language that’s in the amendment,” Wales said. “But it’s a process.”

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

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

June means it’s time for the Supreme Court to render rulings on the biggest and most controversial cases of the term. This year, the court has two significant abortion-related cases: one involving the abortion pill mifepristone and the other regarding the conflict between a federal emergency care law and Idaho’s near-total abortion ban.

Also awaiting resolution is a case that could dramatically change how the federal government makes health care (and all other types of) policies by potentially limiting agencies’ authority in interpreting the details of laws through regulations. Rules stemming from the Affordable Care Act and other legislation could be affected.

In this special episode of “What the Health?”, Laurie Sobel, an associate director for women’s health policy at KFF, joins host Julie Rovner for a refresher on the cases, and a preview of how the justices might rule on them. 

The cases highlighted in this episode:

• Loper Bright Enterprises v. Raimondo and Relentless Inc. v. Department of Commerce, about how much discretion federal agencies should have in interpreting laws passed by Congress.
• U.S. Food and Drug Administration v. Alliance for Hippocratic Medicine, about whether the FDA exceeded its authority in relaxing restrictions on the abortion pill mifepristone.
• Moyle v. United States and Idaho v. United States, about whether the federal Emergency Medical Treatment and Labor Act requirement for hospitals participating in Medicare to provide needed medical care overrides Idaho’s near-total abortion ban in emergency cases.

Previous “What the Health?” coverage of these cases:

• KFF Health News' 'What the Health?': Abortion — Again — At the Supreme Court

  Apr 24, 2024

• KFF Health News' 'What the Health?': The Supreme Court and the Abortion Pill

  Mar 28, 2024

• KFF Health News' 'What the Health?': Health Enters the Presidential Race

  Jan 25, 2024

• KFF Health News' 'What the Health?': The Supreme Court vs. the Bureaucracy

  Jan 18, 2024

Where to find Supreme Court opinions as they are announced:

• The Supreme Court’s official website
•  The SCOTUSblog (not an official government website but run by lawyers and journalists)

Click to open the Transcript

Transcript: Waiting for SCOTUS

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

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. We’re taping this week on Wednesday, May 29, at 1 p.m. As always, news happens fast and things might’ve changed by the time you hear this. So here we go.

Because it’s a holiday week and health news is a little bit slow, we’re going to do something a little different. It’s about to be June, and that means the Supreme Court is going to issue opinions in some of the biggest cases argued this past term, including two abortion-related cases and one that could literally disrupt the way the entire federal government operates. I’m not sure I remember all the details of these cases, even though we have talked about them all on the podcast. So I’ve asked someone here to remind us what they’re about and give us a preview of how the court might rule in some of them. Laurie Sobel is associate director for women’s health policy here at KFF, and one of our top in-house legal experts. Laurie, welcome to “What the Health?” Thanks for joining us.

Laurie Sobel: Hi, Julie. It’s great to be here.

Rovner: So I thought we’d take the cases in the order they were argued before the court, although I know that’s not necessarily the order that we will see the opinions issued in. First up: In January, the justices heard arguments in two cases about, of all things, herring fishing. Loper Bright Enterprises v. Raimondo and Relentless Inc. v. Department of Commerce. But these cases are about a lot more than herring and could affect a lot more than the Department of Commerce, right?

Sobel: Absolutely. These cases are about what’s called the Chevron doctrine [deference], which requires courts to defer to an agency’s interpretation of a law when the law is silent or ambiguous and the agency’s interpretation is reasonable.

Rovner: And what would an example of that be?

Sobel: Oh, there’s many, many examples. Essentially, Congress doesn’t fill in the details of many laws, and they rely on agencies to fill in those details, assuming that the agency has the expertise to figure out what those details might be. And also, many times the details change as new scientific evidence becomes available or there’s changed circumstances, or there’s a pandemic or something in which the agency needs to respond to.

Rovner: This is basically the entire federal regulatory process we’re talking about here, right?

Sobel: That’s correct.

Rovner: And in health care, there’s a lot of places that regulation affects.

Sobel: Absolutely. So Congress relies on the agencies to implement laws, the ACA [Affordable Care Act], Medicare, Medicaid, CHIP [Children’s Health Insurance Program]. So there’s a lot in health care. In addition, Title X is regulated by the Office of Population Affairs, and those also have regulations. So overturning Chevron would make it very difficult for Congress to continue to rely on agencies to fill in these gaps and to react to real-time situations.

Rovner: And there’s private entities that get regulated, are freaked out by the possibility that they won’t be able to rely on the agencies either.

Sobel: Absolutely. So everything from payment rates to providers and hospitals to negotiating prescription drug prices for the Medicare program. The ACA, I think, has probably more regulations than most laws. And relationship — we’ll talk about the FDA [Food and Drug Administration] in the next case, but the FDA also sets out regulations as does CDC [Centers for Disease Control and Prevention], and we really rely on those agencies to have the scientific expertise to react to the situation. So if Congress has to either fill in all the gaps, which is by most people’s assessment impossible, it might really stall how things get implemented and/or create a whole lot of new litigation.

Rovner: And I would say it would give courts a whole lot more authority than they have now, right?

Sobel: Certainly. So right now, the rule is that the agency’s interpretation stands as long as the law is ambiguous or silent and the agency’s interpretation is reasonable. This would give that power back to the courts to then guess what Congress meant or to interpret what Congress meant.

Rovner: Somebody I was talking to about this case suggested that, I hadn’t really thought about before, that if Chevron were to get struck down, that those who had sued over regulations and lost might be able to go back and reopen those cases. I mean, it could just be a flood of litigation.

Sobel: Absolutely. And that came up during oral argument about what would that mean for all the settled cases. And both sides offered different interpretations with the solicitor general arguing that it would really open up this can of worms to tons of litigation, and the plaintiffs essentially saying, “No, no, no, we could let those all stand and just going forward, the Chevron deference would be undone.” And there were some hints that maybe some compromises like that between the justices as they were talking.

Rovner: Exactly. You’re anticipating my next question, which is did we get any hints from the oral arguments about where they might be going with this case? It’s hard to imagine them just completely overturning Chevron.

Sobel: It is hard to imagine, but there are some justices that have been known to wanting to overturn Chevron for quite some time. So in that category I would put Justices [Clarence] Thomas and [Samuel] Alito, as well as [Neil] Gorsuch, as justices that have really been critical of the Chevron deference. Justice [Brett] Kavanaugh highlighted that the rules change when administrations change, and so he tried to counter the argument that there’s a reliance on Chevron for stability. He said, “Wait, wait, wait a minute. Every time there’s a new president, the rules change. So what kind of stability is that?”

Chief Justice [John] Roberts and [Justice Amy Coney] Barrett were really harder to read, and that might be where the decision relies on, where they come out and whether or not they’re able to forge a compromise with the three liberal justices who indicated support for keeping Chevron; both because of precedent, as well as they pointed out examples where they said, “We’re not subject matter experts here. We don’t want to be making these decisions.” Justice [Elena] Kagan was talking about AI and how that would change, and “we really don’t want to be in the position of Justice Kagan figuring out how that should be regulated.”

Rovner: Well, that seems to be an excellent segue to the next case, which is an abortion case concerning the availability of the abortion pill mifepristone. The case, which was argued in March, is called Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration. Let’s start, because it’s about to become important, with what is the Alliance for Hippocratic Medicine? And what did their members have against the abortion pill?

Sobel: Well, the Alliance for Hippocratic Medicine is a newly formed anti-abortion advocacy coalition. It was formed specifically for this litigation. And they contend that they have members, which are doctors and organizations and associations, in Texas and around the country, who have treated and will continue to treat people who have experienced a complication from medication abortion. So to be clear, none of their members prescribe mifepristone. They don’t believe in abortion. They don’t want to have anything to do with abortion. But their contention is that they are injured based upon having to divert their time and resources away from their regular patients when they have to treat somebody who has had a side effect from mifepristone. Similarly, the association and organizations contend that they’ve had to divert their time to educate people about the dangers of medication abortion.

Rovner: So those are the plaintiffs. And, as you mentioned, some of them are in Texas and they sued in Texas very specifically to get a certain judge, right?

Sobel: Yes, to get Judge [Matthew] Kacsmaryk, who is known for being friendly to these types of cases.

Rovner: So Judge Kacsmaryk, who as you say, is known to be friendly to these types of cases, originally ruled that mifepristone’s entire approval should be rescinded. It was approved in the year 2000, so it’s been on the market for quite a long time. But that’s actually not what’s on the table at the moment before the justices. Explain how we got there.

Sobel: So that decision was then appealed to the 5th Circuit, and the 5th Circuit said, “We’re not going to roll back the original approval of mifepristone to the year 2000, but instead we’ll roll back the requirements to 2011 and say that those are the rules that should be enforced, and that the FDA exceeded their authority in changing the rules since 2011.”

Rovner: And some of those changed rules basically made it easier to get, and you could use it a little bit later into pregnancy because it was found to be safe, right?

Sobel: Exactly. So what those new rules have done is said that you can use it up to 10 weeks instead of seven weeks, that you don’t have to be in person to receive it. So the newest rules have opened up the possibility of using it for telehealth abortion, and also for pharmacists prescribing it. And so if the Supreme Court were to affirm the 5th Circuit’s decision, that would eliminate these new protocols the FDA has established in removing the in-person dispensing requirement, permitting telehealth abortions, and establishing the process for pharmacies to become certified to dispense mifepristone. In addition, it would roll back the gestational ages you just said, from 10 weeks to seven weeks, which is significant because, according to the CDC data, more than 4 in 10 medication abortions occur at seven weeks or later.

Rovner: I was going to say, and yeah, this could be super disruptive. I mean medication abortion is now more than half of all abortions in this country.

Sobel: Oh, it’s two-thirds.

Rovner: So without banning it, making it harder to get could have a big impact.

Sobel: Oh, absolutely. Medication abortion now accounts for nearly two-thirds of all abortions, and telehealth abortions have become very common, from the latest data that we have from WeCount, 1 in 5 abortions was provided via telehealth in December of 2023. So that’s one in all abortions, not one in medication abortions. So that’s quite a big number.

Rovner: Now, this case, even though it could be very disruptive to abortion, is about a whole lot more than abortion. Drugmakers in general seem pretty concerned by the idea of judges making scientific decisions that overrule the FDA. This hearkens back to the last case we talked about, right?

Sobel: Oh, absolutely. So this is the first case to ask the Supreme Court to overrule an FDA decision that a drug is safe and effective. So the outcome of this case could really have very far-reaching implications for the FDA’s authority to continue to regulate not only mifepristone, but a wide range of other drugs. And most likely the other drugs that are perceived to be controversial — gender-affirming care or PrEP — those are the drugs that are most likely to be litigated if this door is opened.

Rovner: And I know that there’s nothing that makes drugmakers … I mean, patent issues and drugmakers and court issues are hard enough, the idea that they could be granted approval by the FDA and then somebody could just come in and sue and make that go away.

Sobel: Oh, absolutely. This got the attention of the entire industry. There were many, many amicus briefs that were filed.

Rovner: So normally you can’t really tell from the oral arguments, as we said, how the justices are leaning. But in this case, the justices seemed fairly transparent about where we think they’re going to go. What are we expecting here?

Sobel: Yes. I mean, as I said before, it’s always dangerous to read the tea leaves too much, but this did seem more transparent than most, and that most justices seemed not convinced that the plaintiffs in this case have legal standing, which requires that you have an injury and that injury can be addressed by what the court decides. So even assuming that the plaintiffs have an injury, the question is what would happen if we roll back the rules that the FDA has back to 2011? Does that make it more or less likely that these plaintiffs would see people with side effects of mifepristone? It’s not really clear. In addition, many of the justices, including Justice Barrett, really pushed back on the lawyer representing the Alliance for where in the doctors’ affidavits it said they were actually participating in something they objected to. Notably, not really about necessarily this case, but about what might come up in the future, both Justice Thomas and Alito did bring up the Comstock Act and signaled that they would uphold the enforcement of the Comstock Act, pretty much inviting a future case or a future administration to enforce the Comstock Act.

Rovner: As much as we’ve talked about it, remind us again what the Comstock Act is.

Sobel: Sure. So it’s a law from 1873, which was an anti-obscenity law, and as part of it, it banned the mailing of any drug or device or instrument that could be used for abortion.

Rovner: Well, I guess during the entirety of Roe [v. Wade], it was irrelevant, right? Because abortion was legal,

Sobel: Right. And it’s been dormant. I mean, we can’t find any enforcement in any modern era.

Rovner: Yes, so it goes back a long ways, but it’s top of mind for a lot of people.

All right, moving on to our last case. On April 24, the court heard Idaho v. United States and Moyle v. United States, both of which challenged the federal government’s interpretation of the Emergency Medical Treatment and Active Labor Act, EMTALA, to override Idaho’s near-complete abortion ban, at least in medical emergencies. Let’s start by explaining what EMTALA is and how it relates to abortion?

Sobel: Sure. So EMTALA requires hospitals that participate in Medicare, which is pretty much every acute hospital, to provide stabilizing treatment within the hospital’s capability when there’s an emergency medical condition, which includes when the absence of immediate medical attention could reasonably be expected to place the health of the individual in serious jeopardy or serious impairments of bodily functions. So it was really intended as an anti-dumping law initially so that people who were uninsured weren’t just transferred or sent away to another hospital because they didn’t have the capacity to pay.

Idaho’s abortion ban only has an exception for life. It doesn’t have an exception to preserve the health of the pregnant person. And so the Biden administration sued Idaho and said this law then, essentially, puts these hospitals that have this requirement, because they accept Medicare payments, to stabilize patients. And when that care includes abortion care, they’re required to provide that under federal law. So the question is, does the EMTALA preempt the Idaho abortion ban?

It’s clear from the oral argument that Idaho’s position is that there is no conflict because they read into the EMTALA law that “within the hospital’s capability” includes the laws of Idaho and that Idaho gets to set the standard of care, and that that’s up to states, not up to the federal government. Whereas the federal government, the Biden administration’s position, is that, no, EMTALA specifically was an antidumping law, and that includes stabilizing all patients regardless of the care. And we don’t have to say including abortion in order for it to include abortion, it includes all care that’s required to stabilize patients.

Rovner: Of course, a lot of anti-abortion activists will say that the only time abortion is medically necessary is when it threatens life and that would be covered. But we’re seeing that that’s not necessarily the case, right? I mean, we’re seeing individual instances of this these days.

Sobel: Yeah. I mean, we know from Idaho that many patients have been helicoptered out of the state into nearby states that also have some abortion restrictions but just aren’t as restrictive as Idaho is, because they’re going to become septic or they’re going to lose kidney function, or they’re going to lose their reproductive organs. So they’re not in danger of losing their life immediately, but they’re in danger of losing serious bodily functions.

The other question that came up during oral argument was about just how imminent the life needs to be. And this comes down to how this is putting doctors in a pretty uncomfortable place. So yes, the doctors are permitted to provide abortion care in Idaho when they can certify in good faith that without the abortion care, the person’s life is endangered. But they’re concerned that, after the fact, attorneys for the state could come back and say, “Oh, wait a minute, that wasn’t your really good-faith decision and we’re going to prosecute you and we’re going to bring in our own expert.” And the question is really, how much should doctors have on the line? It’s a criminal statute, so there’s jail time involved. Of course, there’s a loss of license. And so how far out should doctors be required to go? And this is, again, it’s making people really uncomfortable, and there are anecdotes of people leaving the state because of this and not feeling comfortable practicing there.

Rovner: More than anecdotes of people leaving the state, there are people who come forward and said they’re leaving the state. And as a result, some hospitals are having to shut down their OB services. I mean, because when the doctors, OB-GYNs who are leaving, so in the ironic position of people who are having babies not being able to find someone who can deliver their baby at the same time.

Sobel: Right, right.

Rovner: That’s obviously one ramification within Idaho, but there could be ramifications outside just on the idea: Isn’t federal law supposed to trump state law? Isn’t that sort of a basic foundation of how we work?

Sobel: Yes. The supremacy clause is pretty basic when you go to law school. So yes. And I think how they word this decision will be very interesting to see because it’s a question of, is there a conflict or is there not? And the attorneys for Idaho were basically suggesting that there’s no conflict. So you don’t even need to say that there’s a preemption. You just have to find that there’s no conflict between Idaho law and EMTALA.

However they rule, if they rule for Idaho and say that you’re allowed to continue having this abortion ban that only has a life exception with no health exception, immediately, there’s four additional states with abortion bans that do not make exceptions for health as well. And those states are Arkansas, Mississippi, Oklahoma, and South Dakota. So in those states, like Idaho, a hospital cannot legally provide an abortion as stabilizing treatment when a person presents with a health endangerment and not a life endangerment. And so again, those risks can include sepsis, kidney failure, loss of fertility, they’re serious risks, even though they may not be life-threatening at the moment.

And even in the states that do have exceptions for health, we have seen that those exceptions are often very narrow and vague and hard to be implemented in real time. So pregnant people can still be denied emergency abortion care that’s needed to preserve their health, even in states that have a health exception. And if EMTALA doesn’t act as a backstop to say, “But wait, hospital, you’re violating this federal law,” then people are stuck with the state law that is narrow and vague.

Rovner: So I mean, overturning Roe, the justices says, “Oh, great, we won’t have to deal with abortion anymore. It’s all about the states.” But as we can see, it’s not all about the states. The Supreme Court is going to have to continue to deal with this issue.

Sobel: Right. Definitely.

Rovner: All right, well, finally, just a couple of housekeeping issues. We don’t actually know when these decisions will come, right? People who don’t follow the court on a regular basis often think that opinions are scheduled the same way oral arguments are, but it’s always a surprise.

Sobel: Unfortunately, they are not. Right now, the court lists their decision days on their website, which is on their calendar. Right now Thursdays seem to be the popular day, they have Thursdays through June listed. They most likely will add more decision days. On decision days, they start posting decisions at 10 a.m. Eastern Time, and you can follow along either on the Supreme Court’s website or many people go to SCOTUSblog, which also has a live blog that interprets some of what’s happening for people who are new to the court.

Rovner: And I will put both of those links in the show notes. Laurie Sobel, this has been so helpful. Thank you so much for joining us.

Sobel: Thank you for having me, Julie.

Rovner: OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Rebecca Adams. 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. We will be back in your feed next week with the news. Until then, be healthy.

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

With abortion shaping up as a key issue for the November elections, the movement that united to overturn Roe v. Wade is divided over going further, faster — including by punishing those who have abortions and banning contraception or IVF. Politicians who oppose abortion are already experiencing backlash in some states.

Meanwhile, bad actors are bilking the health system in various new ways, from switching people’s insurance plans without their consent to pocket additional commissions, to hacking the records of major health systems and demanding millions of dollars in ransom.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Rachel Roubein of The Washington Post, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.

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Alice Miranda Ollstein
Politico

@AliceOllstein

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Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories.

Among the takeaways from this week’s episode:

• It appears that abortion opponents are learning it’s a lot easier to agree on what you’re against than for. Now that the constitutional right to an abortion has been overturned, political leaders are contending with vocal groups that want to push further — such as by banning access to IVF or contraception.
• A Louisiana bill designating abortion pills as controlled substances targets people in the state, where abortion is banned, who are finding ways to get the drug. And abortion providers in Kansas are suing over a new law that requires patients to report their reasons for having an abortion. Such state laws have a cumulative chilling effect on abortion access.
• Some Republican lawmakers seem to be trying to dodge voter dissatisfaction with abortion restrictions in this election year. Sen. Ted Cruz of Texas and Sen. Katie Britt of Alabama introduced legislation to protect IVF by pulling Medicaid funding from states that ban the fertility procedure — but it has holes. And Gov. Larry Hogan of Maryland declared he is pro-choice, even though he mostly dodged the issue during his eight years as governor.
• Former President Donald Trump is in the news again for comments that seemed to leave the door open to restrictions on contraception — which may be the case, though he is known to make such vague policy suggestions. Trump’s policies as president did restrict access to contraception, and his allies have proposed going further.

Also this week, Rovner interviews Shefali Luthra of The 19th about her new book on abortion in post-Roe America, “Undue Burden.”

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

Julie Rovner: The 19th’s “What Happens to Clinics After a State Bans Abortion? They Fight To Survive,” by Shefali Luthra and Chabeli Carrazana. 

Alice Miranda Ollstein: Stat’s “How Doctors Are Pressuring Sickle Cell Patients Into Unwanted Sterilizations,” by Eric Boodman.  

Rachel Roubein: The Washington Post’s “What Science Tells Us About Biden, Trump and Evaluating an Aging Brain,” by Joel Achenbach and Mark Johnson.  

Joanne Kenen: ProPublica’s “Toxic Gaslighting: How 3M Executives Convinced a Scientist the Forever Chemicals She Found in Human Blood Were Safe,” by Sharon Lerner; and The Guardian’s “Microplastics Found in Every Human Testicle in Study,” by Damian Carrington. 

Also mentioned on this week’s podcast:

• NPR’s “Republicans Try To Soften Stance on Abortion as ‘Abolitionists’ Go Farther,” by Sarah McCammon.
• KFF Health News’ “Biden Leans Into Health Care, Asking Voters To Trust Him Over Trump,” by Phil Galewitz.
• KFF Health News’ “Exclusive: Senator Urges Biden Administration To Thwart Fraudulent Obamacare Enrollments,” by Julie Appleby.
• KFF Health News’ “KHN’s ‘What the Health?’: Un-Trumping the ACA,” featuring an interview with journalist Marshall Allen.

Click to open the Transcript

Transcript: Anti-Abortion Hard-Liners Speak Up

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

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 23, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. We are joined today via a video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, thanks for having me.

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

Joanne Kenen: Hi, everybody.

Rovner: Later in this episode, we’ll have my interview with podcast panelist Shefali Luthra of The 19th. Shefali’s new book about abortion in the post-Roe [v. Wade] world, called “Undue Burden,” is out this week. But first, this week’s news. We’re going to start with abortion this week with a topic I’m calling “Abolitionists in Ascendance,” and a shoutout here to NPR’s Sarah McCammon with a great piece on this that we will link to in the show notes. It seems that while Republican politicians, at least at the federal level, are kind of going to ground on this issue, and we’ll talk more about that in a bit, those who would take the ban to the furthest by prosecuting women, and/or banning IVF and contraception, are raising their voices. How much of a split does this portend for what, until the overturn of Roe, had been a pretty unified movement? I mean they were all unified in “Let’s overturn Roe,” and now that Roe has gone, boy are they dividing.

Ollstein: Yeah, it’s a lot easier to agree on what you’re against than on what you’re for. We wrote about the split on IVF specifically a bit ago, and it is really interesting. A lot of anti-abortion advocates are disappointed in the Republican response and the Republican rush to say, “No, let’s leave IVF totally alone” because these groups think, some think it some should be banned, some think that there should be a lot of restrictions on the way it’s currently practiced. So not a total ban, but things like you can only produce a certain number of embryos, you can only implant a certain number of embryos, you can only create the ones you intend to implant, and so that would completely upend the way IVF is currently practiced in the U.S.

So, we know the anti-abortion movement is good at playing the long game, and so some of them have told me that they see this kind of like the campaign to overturn Roe v. Wade. They understand that Republicans are reacting for political reasons right now, and they are confident in winning them over for restrictions in the long term.

Rovner: I’ve been fascinated by, I would say, by things like Kristan Hawkins of Students for Life [of America] who’s been sort of the far-right fringe of the anti-abortion movement looking like she’s the moderate now with some of these people, and their discussions of “We should charge women with murder and have the death penalty if necessary.” Sorry, Rachel, you want to say something?

Roubein: This is something that Republicans, they don’t want to be asked about this on the campaign. The more hard-line abolitionist movement is something more mainstream groups have been taking a lot of pains to distance themselves and say that we don’t prosecute women, and essentially nobody wants to talk about this ahead of 2024. GOP doesn’t want to be seen as that party that’s going after that.

Kenen: And the divisions existed when Roe was still the law of the land, and we would all write about the divisions and what they were pushing for, and it was partly strategic. How far do you push? Do you push for legislation? Do you push for the courts? Do you push for 20 weeks for fetal pain? But it was like rape exceptions and under what terms and things like that. So it was sort of much later in pregnancy, and with more restrictions, and the fight was about exactly where do you draw that line. This abolition of all abortion under all circumstances, or personhood, only a couple of years ago, were the fringe. Personhood was sort of like, “Oh, they’re out there, no one will go for that.” And now I don’t think it’s the dominant voice. I don’t think we yet know what their dominant voice is, but it’s a player in this conversation.

At the same time, on the other side, the pro-abortion rights people, there’s polls showing us this many Americans support abortion, but it’s subtler too. Even if people support abortion rights, it doesn’t mean that they’re not, some subset are in favor of some restrictions, or where that’s going to settle. Right now, a 15-week ban, which would’ve seemed draconian a year or two ago, now seems like the moderate position. It has not shaken out, and …

Rovner: Well, let’s talk …

Kenen: It’s not going to shake out for some time.

Rovner: Let’s talk about a few specifics. The Louisiana State Legislature on Tuesday approved a bill that would put the drugs used in medication abortion, mifepristone and misoprostol, on the state’s list of controlled substances. This has gotten a lot of publicity. I’m wondering what the actual effect might be here though since abortion is already banned in Louisiana. Obviously, these drugs are used for other things, but they wouldn’t be unavailable. They would just be put in this category of dangerous drugs.

Ollstein: So, officials know that people in banned states, including Louisiana, are obtaining abortion pills from out of state, whether through telehealth from states with shield laws or through these gray-area groups overseas that are mailing pills to anyone no matter what state they live in or what restrictions are in place. So I think because it would be very difficult to actually enforce this law, short of going through people’s homes and their mail, this is just one more layer of a chilling effect and making people afraid to seek out those mail order services.

Rovner: So it’s more, again, for the appearance of it than the actuality of it.

Ollstein: It also sets up another state versus federal law clash, potentially. We’ve seen this playing out in courts in West Virginia and in North Carolina, basically. Can states restrict or even completely ban a medication that the FDA says is safe and effective? And that question is percolating in a few different courts right now.

Rovner: Including sort of the Supreme Court. We’re still waiting for their abortion pill decision that we expect now next month. Meanwhile, in Kansas, where voters approved a big abortion rights referendum in 2022 — remember, it was the first one of those — abortion providers are suing to stop a new state law enacted over the governor’s veto that would require them to report to the state women’s reasons for having an abortion. Now it’s not that hard to see how that information could be misused by people with other kinds of intents, right?

Ollstein: Well, it also brings up right to free speech issues, compelled speech. I think I’ve seen this pop up in abortion lawsuits even before Dobbs [v. Jackson Women’s Health Organization], this very issue because there have been instances where either doctors are required to give information that they say that they believe is medically inaccurate. That’s an issue in several states right now. And then this demanding information from patients. A lot of clinics that I’ve spoken to are so afraid of subpoenas from officials in-state, from out of state, that they intentionally don’t ask patients for certain kinds of data even though it would really help medically or organizationally for them to have that data. But they’re so afraid of it being seized, they figure well, they can’t seize it if they’re … doesn’t exist in the first place. And so I think this kind of law is in direct conflict with that.

Roubein: It also gets at the question of medical privacy that we’ve been seeing in the Biden administration’s efforts over HIPAA and protecting patients’ records and making it harder for state officials to attempt to seize.

Rovner: Yeah, this is clearly going to be a struggle in a lot of states where voters versus Republican legislatures, and we will sort of see how that all plays out. So even while this is going on in a bunch of the states, a lot of Republicans, including some who have been and remain strongly anti-abortion, are doing what I’m calling ducking-and-covering on a lot of these issues. Case in point, Texas Republican Sen. Ted Cruz and Alabama Republican Sen. Katie Britt this week introduced a bill they say would protect IVF, which is kind of ironic given that both of them voted against a bill to protect IVF back in, checking notes, February. What’s the difference here? What are these guys trying to do?

Kenen: Theirs is narrower. They say that the original bill, which was a Democratic bill, was larded with abortion rights kinds of things. I have not read the entire bill, I just read the summary of it. And in this one, if a state restricts someone who had — someone feel free to correct me if I am missing something here because I don’t have deep knowledge of this bill — but if a state does not protect IVF, they would lose their Medicaid payment. And I was not clear whether that meant every penny of Medicaid, including nursing homes, or if it’s a subsection of Medicaid, because it seems like a big can of worms.

Ollstein: Yeah, so the key difference in these bills is the word ban. The Republican bill says that if states ban IVF, then these penalties kick in for Medicaid, but they say that there can be “health and safety regulations,” and so that is very open to interpretation. That can include the things we talked about before about you can only produce a certain number of embryos, you can only implant a certain number of embryos, and you can’t discard them. And so even what Alabama did was not an outright ban. So even something like that that cut off services for lots of people wouldn’t be considered a ban under this Republican bill. So I think there’s sort of a semantic game going on here where restrictions would still be allowed if they were short of a blanket ban, whereas the democratic bill would also prevent restrictions.

Rovner: Well, and along those exact same lines, in Maryland, former two-term Republican governor Larry Hogan, who’s managed to dodge the abortion issue in his primary run to become the Senate nominee, now that he is the Republican candidate for the open Senate seat, has declared himself, his words, “pro-choice,” and says he would vote to restore Roe in the Senate if given the opportunity. But as I recall, and I live in Maryland, he vetoed a couple of bills to expand abortion rights in very blue Maryland. Is he going to be able to have this both ways? He seems to be doing the [Sen.] Susan Collins script where he gets to say he’s pro-choice, but he doesn’t necessarily have to vote for abortion rights bills.

Kenen: Hogan is a very popular moderate Republican governor in a Democratic state. He is a strong Senate candidate. His opponent, a Democrat, Angela Alsobrooks, has a stronger abortion rights record. I don’t think that’s going to be the decisive issue in Maryland. I think it may help him a little bit, but I think in Maryland, if the Senate was 55-45, a lot of Democrats like Hogan and might want another moderate Republican in the Senate. But given that this is going to be about control of the Senate, abortion will be a factor, I don’t think abortion is going to be the dominant factor in this particular race.

If she were to win and there’s two black women, I mean that would be the first time that two black women ever served in the Senate at once, and I think they would only be number three and number four in history. So race and Affirmative Action will be factors, but I think that Democrats who might otherwise lean toward him, because he was considered a good governor. He was well-liked. This is a 50-50ish Senate, and that’s the deciding thing for anyone who pays attention, which of course is a whole other can of worms because nobody really pays attention. They just do things.

Roubein: I think it’s also worth noting this tact to the left comes as Maryland voters will be voting on an abortion rights ballot measure in 2024. So that all sort of in context, we’ve seen what’s happened with the other abortion measures, abortion rights have won, so.

Rovner: And Maryland is a really blue state, so one would expect it …

Kenen: There’s no question that the Maryland …

Rovner: Yeah.

Kenen: I mean, and all of us would fall flat on our faces if the abortion measure fails in Maryland. But I believe this is the first one on the ballot alongside a presidential election, and some of them have been in special elections. It’s unclear the correlation between, you can vote for a Republican candidate and still vote for a pro-abortion rights initiative. We will learn a lot more about how that split happens in November. I mean, is Kansas going to go for Biden? Unlikely. But Kansas went really strong for abortion rights. If you’re not a single-issue voter, you can, in fact, have it both ways.

Rovner: Yes, and we are already seeing that in the polls. Well, of course then there is the king of trying to have it both ways: former President Trump. He is either considering restrictions on contraception, as he told an interviewer earlier this week, promising a proposal soon, or he will, all caps, as he put on Truth Social, never advocate imposing restrictions on birth control. So which is it?

Ollstein: So this came out of Trump’s verbal tick of saying “We’ll have a plan in a few weeks,” which he says about everything. But in this context it made it sound like he was leaving the door open to restrictions on contraception, which very well might be the case. So what my colleague and I wrote about is he says he would never restrict contraception. A lot of things he did in his first administration did restrict access to contraception. It was not a ban. Again, we’re getting back into the semantics of ban. It was not a ban, but his Title X rule led to a drop in hundreds of thousands of people accessing contraception. He allowed more kinds of employers to refuse to cover their employees’ contraception on their health plans, and the plans his allies are creating in this Project 2025 blueprint would reimpose those restrictions and go even further in different ways that would have the effect of restricting access to contraception. And so I think this is a good instance of look at what people do, not what they say.

Rovner: So now that we’re on the subject of campaign 2024, President Biden’s campaign launched a $14 million ad buy this week that includes the warning that if Trump becomes president again he’ll try to repeal the Affordable Care Act. Maybe health care will be an issue in this election after all? I don’t have a rooting interest one way or the other. I’m just curious to see how much of an issue health will be beyond reproductive rights.

Kenen: Well, as Alice just pointed out, Trump’s promised plans often do not materialize, and we are still waiting to see his replacement plan eight years later. I think he’s being told to sort of go slow on this. I mean, not that you can control what Trump says, but he didn’t run on health care until the end, in 2016. It was a close race, and he ran against Hillary Clinton, and it was the last 10 or so days that he really came down hard because it was right when ACA enrollment was about to begin and premiums came in and they were high. He pivoted. So is this going to be a health care election from day one? And I’m putting abortion aside for one second in terms of my definition of health care for this particular segment. Is it going to be a health care election in terms of ACA, Medicare, Medicaid? At this point, probably not. But is it going to emerge at various times by one or the other side in politically opportune ways? I would be surprised if Biden’s not raising it. The ACA is thriving under Biden.

Rovner: Well, he is. That’s the whole point. He just took out a $14 million ad buy.

Kenen: Right. But again, we don’t know. Is it a health care election or is it a couple ads? We don’t know. So yes, it’s going to be a health care election because all elections are health care elections. How much it’s defined by health care compared to immigration? No, at this point, that’s not what we’re expecting. Compared to the economy? No, at this point. But is it an issue for some voters? Yes. Is it going to be an issue more prominently depending on how other things play out? It’ll have its peaks. We just don’t know how consistent it’ll be.

Roubein: Biden would love to run on the Inflation Reduction Act and politically popular policies like allowing Medicare to negotiate drug prices. One of the problems of that is polls, including from KFF, has shown that the majority of voters don’t know about that. And some of these policies, the big ones, have not even gone into effect. CMS [Centers for Medicare & Medicaid Services] is going through the negotiation process, but that’s not going to hit people’s pocketbooks until after the election.

Kenen: The cliff for the ACA subsidies, which is in 2025, I mean I would imagine Democrats will be campaigning on, “We will extend the subsidies,” and again, in some places more than others, but that’s a time-sensitive big thing happening next year.

Rovner: But talk about an issue that people have no idea that’s coming. Well, meanwhile, for Trump, reproductive health isn’t the only issue where he’s doing a not-so-delicate dance. Apparently worried about Robert F. Kennedy Jr. stealing anti-vax [vaccine] votes from him, Trump is now calling RFK Jr. a fake anti-vaxxer. Except I’m old enough to remember when Trump bragged repeatedly about how fast his administration developed and brought the covid vaccine to market. That used to be one of his big selling points. Now he’s trying to be anti-vax, too?

Kenen: Not only did he brag about bringing it to the market. The way he used to talk about it, it was like he was there in his lab coat inventing it. Operation Warp Speed was a success. It got vaccines out in record time, way beyond what many people expected. Democrats gave him credit for that one policy in health care. He got a vaccine out and available in less than a year, and he got vaccinated and boasted about being vaccinated. He was open about it. Now we don’t know if he’s been boosted. He really backed off. As soon as somebody booed him, and it wasn’t a lot of boos, at one rally when he talked about vaccination and he got pushed back, that was the end.

Rovner: So, yeah, so I expect that to sort of continue on this election season, too.

Kenen: But we don’t expect RFK to flip.

Rovner: No, we do not. Right. Well, moving on to this weekend’s “Cyber Hacks,” a new feature, the fallout continues from the hack of Ascension [health care company]. That’s the Catholic hospital system with facilities in 19 states. In Michigan, patients have been unable to use hospital pharmacies and their doctors have been unable to send electronic prescriptions, so they’re having to write them out by hand. And in Indiana orders for tests and test results are being delayed by as much as a day for hospital patients. Not a great thing.

And just in time, or maybe a little late, the U.S. Department of Health and Human Services, through the newly created ARPA-H [Advanced Research Projects Agency for Health] that we have talked about, this week announced the launch of a new program to help hospitals make security patches and updates to their systems without taking them offline, which is obviously a major reason so many of these systems are so vulnerable to cyberhacking.

Of course, this announcement from HHS is just to solicit ideas for grants to help make that happen. So it’s going to be a while before we get any of these security changes. I’m wondering, how many systems are going to try to build a lot more redundancy into them? In the meantime, are we hearing anything about what they can do in the short term? It feels like the entire health care system is kind of a sitting duck for this group of cyberhackers who think they can get in easily and get ransom.

Kenen: There’s a reason they think that.

Rovner: They can.

Roubein: Thinking about hospitals and doctors using this manually, paper-based system and how that’s delaying getting your results and just there’s been these stories about patients. Like the anxiety that that’s understandably causing patients, and we’ll see sort of whether Congress can grapple with this, and there’s not really much legislation that’s going to move, so …

Kenen: But I was surprised that they were calling on ARPA-H. I mean, that’s supposed to be a biotech- curing-diseases thing, and none of the four of us are cybersecurity experts, and none of us really specialize in covering the electronic side of the digital side of health, but it just seems to me, I just thought that was an odd thing. First of all, some of these are just systems that haven’t been upgraded or individual clinicians who don’t upgrade or don’t do their double authorization. Some of it’s sort of cyberhygiene, and some of it’s obviously like the change thing. They’re really sophisticated criminals, but it’s not something that one would think you can’t get ahead of, right? They’re smart, good-guy technology people. It’s not like the bad guys are the only ones who understand technology. So why are the smart good guys not doing their job? And also, probably, health care systems have to have some kind of security checks on their own members to make sure they are following all the safety rules and some kind of consequences if you’re not, other than being embarrassed.

Rovner: I’ve just been sort of bemused by all of this, how both patients and providers complain loudly and frequently about the frustrations of some of these electronic record systems. And of course, in the places that they’re going down and they’ve had to go back to paper, people are like, “Please give us our electronic systems back.” So it doesn’t take long to get used to some of these things and be sorry when they’re gone, even if it’s only temporarily. It’s obviously been …

Kenen: But like what Rachel said, if you’re in the hospital, you’re sick, and do your clinicians need your lab results? Yes. I mean some of them are more important than others, and I would hope that hospitals are figuring out how to prioritize. But yeah, this is a crisis. If you’re in the hospital and they don’t know what’s wrong with you and they’re trying to figure out do you have X, Y, or Z, waiting until next week is not really a great idea.

Rovner: But it wasn’t that many years ago that their existence …

Kenen: Right, no, no, no.

Rovner: … did not involve …

Kenen: [inaudible 00:21:28].

Rovner: … electronic medical record.

Kenen: Right. Right.

Rovner: They knew how to get test results back and forth even if it was sending an intern to go fetch them. Finally, this week, we have some updates on some stories that we’ve talked about in earlier episodes. First, thanks in part to the excellent reporting of my colleague and sometime-pod-panelist Julie Appleby, the Senate Finance Committee Chairman Ron Wyden is demanding that HHS [U.S. Department of Health and Human Services] officials do more to rein in rogue insurance brokers who are reaping extra commissions by switching patients’ Affordable Care Act plans without their knowledge, often subjecting them to higher out-of-pocket costs and separating them from the providers that they’ve chosen. Sen. Wyden said he would introduce legislation to make such schemes a crime, but in the meantime he wants Biden officials to do more, given that they have received more than 90,000 complaints in the first quarter of 2024 alone about unauthorized switches and enrollments. Criminals go where the money is, right? You can either cyberhack or you can become a broker and switch people to ACA plans so you can get more commissions.

Kenen: I would think there could be a bipartisan, I mean it’s hard to get anything done in Congress. There’s no must-pass bills in the immediate future that are relevant. And the idea that a broker is secretly doing something that you don’t want them to do and that’s costing you money and making them money. I could see, those 90,000 people are from red and blue states and they vote, it’s going to affect constituents nationwide. Maybe they’ll do something. Maybe the industry can also… There is the National Association … I forgot the acronym, but there’s a broker’s organization, that there are probably things that they can also do to sanction. States can also do some things to brokers, but whether there’s a national solution or piecemeal, I don’t know, but it’s so outrageous that it’s not a right-left issue.

Rovner: Yes, one would think that there’ll be at least some kind of congressional action built into something …

Kenen: Something or other, right.

Rovner: … Congress that manages to do before the end of the year. Well, and in one of those seemingly rare cases where legislation actually does what it was intended to do, the White House this week announced that it has approved more than a million claims under the 2022 PACT Act, which made veterans injured as a result of exposure to burn pits and other toxic substances eligible for VA [Veterans Affairs] disability benefits. On the other hand, the VA is still working its way through another 3 million claims that have been submitted. I feel like even if it’s not very often, sometimes it’s worth noting that there are bipartisan things from Washington, D.C., that actually get passed and actually help the people that they’re supposed to help. It’s kind of sad that this is notable as an exception of something that happened and is working.

Roubein: In sort of the, I guess, Department of Unintended Side Effects here, my colleague Lisa Rein had a really interesting story out this morning that talked about the PACT Act, but basically that despite a federal law that prohibits charging veterans for help in applying for disability benefits, for-profit companies are making millions. She did a review of up to like a hundred unaccredited for-profit companies who have been charging veterans anywhere from like $5,000 to $20,000 for helping file disability claims because …

Rovner: That’s the theme of this week. Anyplace that there’s a lot of money in health care, there were people who will want to come in and take what’s not theirs. That’s where we will leave the news this week. Now we will play my interview with Shefali Luthra, then we’ll come back with our extra credits.

I am so pleased to welcome back to the podcast my former colleague and current “What The Health?” panelist Shefali Luthra. You haven’t heard from her in a while because she’s been working on her first book, called “Undue Burden,” that’s out this week. Shefali, great to see you.

Luthra: Thank you so much for having me Julie.

Rovner: So as the title suggests, “Undue Burden” is about the difficulties for both patients and providers in the wake of the overturn of Roe v. Wade. We talk so much about the politics of this issue, and so little about the real people who are affected. Why did you want to take this particular angle?

Luthra: To me, this is what makes this topic so important. Health care and abortion are really critical political issues. They sway elections. They are likely to be very consequential in this coming presidential election. But this matters to us as reporters and to us as people because of the life-or-death stakes and even beyond the life-or-death stakes, the stakes of how you choose to live your life and what it means to be pregnant and to be a parent. These are really difficult stories to tell because of the resources involved. And I wanted to write a book that just got at all of the different reasons why people pursue abortion and why they provide abortion and how that’s changed in the past two years. Because it felt to me like one of the few ways we could really understand just how seismic the implications of overturning Roe has been.

Rovner: And unlike those of us who talk to politicians all the time, you were really on the ground talking to patients and doctors, right?

Luthra: That was really, really important to the book. I spent a lot of time traveling the country, in clinics talking to people who were able to get abortions, who were unable to get abortions, and it was just really compelling for me to see how much access to care had the capacity to change their lives.

Rovner: So what kind of barriers then are we talking about that cropped up? And I guess it wasn’t even just the wake of the overturn of Roe. In Texas we had sort of a yearlong dry run.

Luthra: Exactly, and the book starts before Roe is overturned in Texas when the state enacted SB 8, the six-week abortion ban that effectively cut off access. And the first main character readers meet is this young girl named Tiffany, and she’s a teenager when she becomes pregnant, and she would love to get an abortion. But she is a minor. She lives very far from any abortion provider. She does not know how to self-manage an abortion. She does not know where to find pills. She has no connections into the health care system. She has no independent income. And she absolutely cannot travel anywhere for care. As a result, she has a child before she turns 18. And what this story highlights is that there are just so many barriers to getting an abortion. Many already existed: The incredible cost for procedure not covered by health insurance, the geographic distance, people already had to travel, the extra restrictions on minors.

But the overturning of Roe has amplified these, it is so expensive to get an abortion. It can be difficult to know you’re pregnant, especially if you are not trying to become pregnant. You have a very short time window. You may need to find childcare. You may need to find a car, get time off work, and bring all of these different forces together so that you are able to make a journey that can be days and pay for a trip that can cost thousands of dollars.

Rovner: One of the things that I think surprised me was that states that proclaimed themselves abortion “havens” actually did so little to help their clinics that predictably got swamped by out-of-state patients. Why do you think that was the case, and is it any better now?

Luthra: I think things have certainly changed. We have seen much more action in states, such as Illinois, where we see more people traveling there for care than anywhere else in the country. But it is worth going back to the summer that Roe was overturned. The governor promised to call a special session and put all these resources into making sure that Illinois could be a sanctuary. He never called that special session. And clinics felt like they were hanging out to dry, just waiting to get some support, and in the meanwhile, doing the absolute best they could.

One thing that I think this book really gets at is we are starting to see more efforts from these bluer states, the Illinois, the Californias, the New Yorks, and they talk a lot about wanting to be abortion havens, in part because it’s great politics if you’re a Democrat, but there’s only so much you can do. California has seen also quite a large increase in out-of-state patients. But I’ve spoken to so many people who just cannot conceivably go to California. They can barely go to Illinois. Making that journey when you are young, if you don’t have a lot of money, if you live in South Texas, if you live in Louisiana, it’s just not really feasible. And the places that are set up as these access points just can’t really fill in the gaps that they say they will.

Rovner: As you point out in the book, a lot of this was completely predictable. Was there something in your reporting that actually did surprise you?

Luthra: That’s a great question, and what did surprise me was in part something that we’ve begun to see borne out in the reporting, is there are very effective telemedicine strategies. We have begun to see physicians living in blue states, the New Yorks, Massachusetts, Californias, prescribing and mailing abortion pills to people in states with bans. This is pretty powerful. It has expanded access to a lot of people. What was really striking to me, though, even as I reported about the experiences of patients seeking care, is that while that has done so much to expand access in the face of abortion bans, it isn’t a solution that everyone can use. There were lots of people I met who did not want a medication abortion, who did not feel safe having pills mailed into their homes, or whose pregnancy complications and questions were just too complex to be solved by a virtual consult and then pills being mailed to them to take in the comfort of their house.

Rovner: Aren’t these difficulties exactly what the anti-abortion movement wanted? Didn’t they want clinics so swamped they couldn’t serve everybody who wanted to come, and abortion to be so difficult to get that women would end up carrying their pregnancies to term instead?

Luthra: Yes and no, I would argue. I think you are absolutely right that one of the primary goals of the anti-abortion movement was to make abortion unavailable, to make it harder to acquire, to have more people not get abortions and instead have children. But when I speak to folks in the anti-abortion movement, they are very troubled by how many people are traveling out of state to get care. They see those really long wait times in Kansas, in, until recently, Florida, in Illinois, in New Mexico, as a symptom of something that they need to address, which is that so many people are still finding a way to fight incredible odds to access abortion.

Rovner: Is there one thing that you hope people take away after they’re finished reading this?

Luthra: There are two things that I have spent a lot of time thinking about as I’ve reported this book. The first is just who gets abortions and under what circumstances. And so often in the national press, in national politics, we talk about these really extreme life-or-death cases. We talk about people who became septic and needed an abortion because their water broke early, or we talk about children who have been sexually assaulted and become pregnant. But we don’t talk about most people who get abortions; who are usually mothers, who are usually people of color, who are in their 20s and just know that they can’t be pregnant. I think those are really important stories to tell because they’re the true face of who is most affected by this, and it was important to me that this book include that.

The other thing that I have thought about so often in reporting this and writing this is abortion demands have an unequal impact. That is true if you are poor, if you are a person of color, if you live in a rural area, et cetera. You will in all likelihood see a greater effect. That said, the overturning of Roe v. Wade is so tremendous that it has affected people in every state. It affects you if you can get pregnant. It affects you if you want birth control. It affects you if you require reproductive health care in some form. This is just such a seismic change to our health care system that I really hope people who read this book understand that this is not a niche issue. This is something worthy of our collective attention and concern as journalists and as people.

Rovner: Shefali Luthra, thank you so much for this, and we will see you soon on the panel, right?

Luthra: Absolutely. Thank you, Julie. I’m so glad we got to do this.

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. Joanne, why don’t you go first this week?

Kenen: This was a pair of articles, a long one and a shorter, related one. There’s an amazingly wonderful piece in ProPublica by Sharon Lerner, and it’s called “Toxic Gaslighting: How 3M Executives Convinced a Scientist the Forever Chemicals She Found in Human Blood Were Safe.” I’m going to come back and talk about it briefly in a second, but the related story was in The Guardian by Damian Carrington: “Microplastics Found in Every Human Testicle in Study.” Now, that was a small study, but there may be a link to the declining sperm count because of these forever chemicals.

The ProPublica story, it was a young woman scientist. She worked for 3M. They kept telling her her results was wrong, her machinery was dirty, over and over and over again until she questioned herself and her findings. She was supposed to be looking at the blood of 3M workers who were, it turned out, the company knew all this already and they were hiding it, and she compared the blood of the 3M workers to non-3M workers, and she found these plastic chemicals in everybody’s blood everywhere, and she was basically gaslit out of her job. She continued to work for 3M, but in a different capacity.

The article’s really scary about the impact for human health. It also has wonderfully interesting little nuggets throughout about how various 3M products were developed, some by accident. Something spilled on somebody’s sneaker and it didn’t stain it, and that’s how we got those sprays for our upholstery. Or somebody needed something to find the pages in their church hymnal, and that’s how we got Post-it notes. It’s a devastating but very readable, and it makes you angry.

Rovner: Yeah, I feel like there’s a lot more we’re going to have to say about forever chemicals going forward. Alice.

Ollstein: So I have a pretty depressing story from Stats. It’s called “How Doctors Are Pressuring Sickle Cell Patients Into Unwanted Sterilizations,” by Eric Boodman. And it is about people with sickle cell, and that is overwhelmingly black women, and they felt pressured to agree to be permanently sterilized when they were going to give birth because of the higher risks. And the doctors said, because we’re already doing a C-section and we’re already doing surgery on you, to not have to do an additional surgery with additional risks, they felt pressured to just sign that they could be sterilized right then and there and came to regret it later and really wanted more children. And so, this is an instance of people feeling coerced, and when people think about pro-choice or the choice debate about reproduction they mostly think about the right to an abortion. But I think that the right to have more children, if you want to, is the other side of that coin.

Rovner: It is. Rachel.

Roubein: My extra credit, it’s called “What Science Tells Us About Biden, Trump and Evaluating an Aging Brain,” by Joel Achenbach and Mark Johnson from The Washington Post. And basically, they kind of took a very science-based look at the 2024 election. They basically called it a crash course in gerontology because former President Donald Trump will be 78 years old. President Biden will be a couple weeks away from turning 82. And obviously that is getting a lot of attention on the campaign trail. They talked to medical and scientific experts who were essentially warning that news reports, political punditry about the candidates’ mental fitness, has essentially been marred by misinformation here about the aging process. One of the things they dived into was these gaffes or what the public sees as senior moments and what experts had told them is, that’s not necessarily a sign of dementia or predictive of cognitive decline. There need to be kind of further clinical evaluation for that. But there have been some calls for just how to kind of standardize and require a certain level of transparency for candidates in terms of disclosing their health information.

Rovner: Yes, which we’ve been talking about for a while, and will continue to. My extra credit this week is from our guest, Shefali Luthra, and her colleague at The 19th Chabeli Carrazana, and it’s called “What Happens to Clinics After a State Bans Abortion? They Fight To Survive.” And for all the talk about doctors and other staffers either moving out of or not moving into states with abortion bans, I think less has been written about entire enterprises that often provide far more than just abortion services having to shut down as well. We saw this in Texas in the mid-2010s, when a law that shut down many of the clinics there was struck down by the Supreme Court in 2016. But many of those clinics were unable to reopen. They just could not reassemble, basically, their leases and equipment and staff. The same could well happen in states that this November vote to reverse some of those bans. And it’s not just abortion, as we’ve discussed. When these clinics close, it often means less family planning, less STI [sexually transmitted infection] screening and other preventive services as well, so it’s definitely something to continue to watch.

Before we go this week, I want to note the passing of a health policy journalism giant with the death of Marshall Allen. Marshall, who worked tirelessly, first in Las Vegas and more recently at ProPublica, to expose some of the most unfair and infuriating parts of the U.S. health care system, was on the podcast in 2021 to talk about his book, “Never Pay the First Bill, and Other Ways to Fight the Health Care System and Win.” I will post a link to the interview in this week’s show notes. Condolences to Marshall’s friends and family.

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

Kenen: We’re at Threads @JoanneKenen.

Rovner: Alice.

Ollstein: Still on X @AliceOllstein.

Rovner: Rachel.

Roubein: On X, @rachel_roubein.

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

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Julie Rovner
KFF Health News

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

A new analysis finds that graduating medical students were less likely to apply this year for residency training in states that ban or restrict abortion. That was true not only for aspiring OB-GYNs and others who regularly treat pregnant patients, but for all specialties.

Meanwhile, another study has found that more than 4 million children have been terminated from Medicaid or the Children’s Health Insurance Program since the federal government ended a covid-related provision barring such disenrollments. The study estimates about three-quarters of those children were still eligible and were kicked off for procedural reasons.

This week’s panelists are Julie Rovner of KFF Health News, Lauren Weber of The Washington Post, Joanne Kenen of the Johns Hopkins University schools of nursing and public health and Politico Magazine, and Anna Edney of Bloomberg News.

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• More medical students are avoiding applying to residency programs in states with abortion restrictions. That could worsen access problems in areas that already don’t have enough doctors and other health providers in their communities.
• New threats to abortion care in the United States include not only state laws penalizing abortion pill possession and abortion travel, but also online misinformation campaigns — which are trying to discourage people from supporting abortion ballot measures by telling them lies about how their information might be used.
• The latest news is out on the fate of Medicare, and a pretty robust economy appears to have bought the program’s trust fund another five years. Still, its overall health depends on a long-term solution — and a long-term solution depends on Congress.
• In Medicaid expansion news, Mississippi lawmakers’ latest attempt to expand the program was unsuccessful, and a report shows two other nonexpansion states — Texas and Florida — account for about 40% of the 4 million kids who were dropped from Medicaid and CHIP last year. By not expanding Medicaid, holdout states say no to billions of federal dollars that could be used to cover health care for low-income residents.
• Finally, the bankruptcy of the hospital chain Steward Health Care tells a striking story of what happens when private equity invests in health care.

Also this week, Rovner interviews KFF Health News’ Katheryn Houghton, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” feature, about a patient who went outside his insurance network for a surgery and thought he had covered all his bases. It turned out he hadn’t. If you have an outrageous or incomprehensible 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: The Nation’s “The Abortion Pill Underground,” by Amy Littlefield.

Joanne Kenen: The New York Times’ “In Medicine, the Morally Unthinkable Too Easily Comes to Seem Normal,” by Carl Elliott.

Anna Edney: ProPublica’s “Facing Unchecked Syphilis Outbreak, Great Plains Tribes Sought Federal Help. Months Later, No One Has Responded,” by Anna Maria Barry-Jester.

Lauren Weber: Stat’s “NYU Professors Who Defended Vaping Didn’t Disclose Ties to Juul, Documents Show,” by Nicholas Florko.

Also mentioned on this week’s podcast:

• KFF Health News’ “Medical Residents Are Increasingly Avoiding States With Abortion Restrictions,” by Julie Rovner and Rachana Pradhan.
• CNBC’s “Abortion Bans Drive Away up to Half of Young Talent, New CNBC/Generation Lab Youth Survey Finds,” by Jason Gewirtz.
• The Washington Post’s “Texas Man Files Legal Action To Probe Ex-Partner’s Out-of-State Abortion,” by Caroline Kitchener.

Click to open the transcript

Transcript: Newly Minted Doctors Are Avoiding Abortion Ban States

[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, May 9, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Lauren Weber of The Washington Post.

Lauren Weber: Hello. Hello.

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

Joanne Kenen: Hi, everybody.

Rovner: And Anna Edney of Bloomberg News.

Anna Edney: Hi there.

Rovner: Later in this episode we’ll have my interview with KFF Health News’ Katheryn Houghton, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” This month’s patient went out of network for surgery and thought he did everything right. Things went wrong anyway. But first, this week’s news. We are going to start again with abortion this week with a segment I’m calling, “The kids are all right, but they don’t want to settle in states with abortion bans.”

This morning we got the numbers from the Association of American Medical Colleges on the latest residency match. And while applications for residency positions were down in general — more on that in a minute — for the second year in a row, they were down considerably more in states with abortion bans, and to a lesser extent, in states with other abortion restrictions, like gestational limits. And it’s not just in OB-GYN and other specialties that interact regularly with pregnant people. It appears that graduating medical students are trying to avoid abortion ban states across the board. This could well play out in ways that have nothing to do with abortion but a lot more to do with the future of the medical workforce in some of those states.

Edney: I think that’s a really good point. We know that even on just a shortage of primary care physicians and if you’re in a rural area already and you aren’t getting enough of those coming — because you could end up dealing with these issues in primary care and ER care and many other sections where it’s not just dealing with pregnant women all the time, but a woman comes in because it’s the first place she can go when she’s miscarrying or something along those lines. So it could lower the workforce for everybody, not just pregnant women.

Rovner: A lot of these graduating medical students are of the age where they want to start their own families. If not them, they’re worried about their partners. Somebody also pointed out to me — this isn’t even in my story — that graduating medical students tend to wait longer to have their children, so they tend to be at higher risk when they are pregnant. So that’s another thing that makes them worry about being in states where if something goes wrong, they would have trouble getting emergency care.

Weber: I would just add, I mean, you know, a lot of these states also overlap with states that have severe health professional shortages as well. You know, my reporting in St. Louis for KFF Health News — we did a lot of work on how there are just huge physician shortages to start with. So the idea that you’re combining massive gaps in primary care or massive gaps in reproductive health deserts with folks that are going to choose not to go to these places is really a double whammy that I don’t necessarily think people fully grasp at this current point in time.

Rovner: I promised I would explain the reason that applications are down. This is something that’s happening on purpose. There are still more graduating medical students from MD programs and DO [Doctor of Osteopathy] programs and international medical graduates than there are residency slots, but graduating students had been applying to literally dozens and dozens of residencies to make sure they got matched somewhere, and they’re trying to deter that. So now I think students are applying to an average of 30 programs instead of an average of 60 programs.

That’s why it takes so long for them to crunch the numbers because everybody’s doing multiple applications in multiple states and it’s hard to sort the whole thing out. Of course, it may be that they don’t need all of those doctors. Because according to a separate survey from CNBC and Generation Lab, 62% of those surveyed said they probably wouldn’t or definitely wouldn’t live in a state that banned abortion. Seriously, at some point, these states are going to have to balance their state economies against their abortion positions. Now we’re talking about not just the medical workforce, but the entire workforce, at least for younger people.

Edney: Yeah. I was thinking about this recently because during the pandemic you had tech or Wall Street companies looking at Texas or Florida for where they wanted to move their headquarters or move a substantial amount of their company. And then when Dobbs [v. Jackson Women’s Health Organization] happened, how is the workforce going to play out? I’m curious what that ends up looking like because many of the people that might want to work for those companies might not want to live there in those states, and I think it could affect how the country is made up at some point. I think what’s still to play out is that over 60% that wouldn’t want to move to a state with abortion restrictions, whether that is something that plays out or whether some people say, “Well, that job’s really good, so maybe I do want to go make a lot more money in this place or whenever.” I’m curious how all of this I think, you know, over the next five years or something, plays out.

Rovner: Yeah. I mean, at some point, this something is better than nothing, that’s true of the residency numbers, too. If the only place you can match is in a state that you’d rather not go, I think most people would rather go somewhere than not be able to pursue their career, and I suspect that’s true for people in other lines of work as well. Well, meanwhile, anti-abortion states are continuing to push the envelope as far as they can. In Louisiana, legislation is moving, it passed the Senate already, to criminalize the act of ordering abortion pills from out of state. It’s scheduling mifepristone and misoprostol in the same category as opioids and other addictive drugs.

Simple possession of either abortion drug without a prescription could result in a $5,000 fine or five years in prison. And in a wild story out of Texas, the ex-partner of a woman who traveled to Colorado for an abortion is attempting to pursue wrongful death claims against anyone who helped her, by helping her with travel or providing money or anything else associated with the abortion. Both of these cases seem like they’re trying to more chill people from attempting to obtain abortions than they are really actually pursuing legal action, right?

Kenen: Well, in that case, he’s pursuing legal action. We don’t know how that’s playing out, but I mean, it’s this accumulation of barriers and threats and making it both more difficult and more risky to obtain an out-of-state abortion or obtain medication abortion in-state. But there’s a big thicket and a lot of it, because it’s in court and it takes years to straighten things out, we don’t know what the final landscape’s going to look like, but obviously the trend is toward greater restriction.

Rovner: And I would point out that the lawyer who’s representing the ex-partner who’s trying to find everyone involved with the ex-partner’s abortion is the lawyer who brought us SB 8 [Senate Bill 8] the law, the “bounty hunter law,” that makes it a crime for people to aid and abet somebody getting an abortion in Texas. Lauren.

Weber: Yeah. I just would add too that tactics like this, whether or not — however they do play out in court, they do have a deterrence effect, right? There’s no way to absolutely tell someone XYZ is legally safe or not. At the end of the day, that can lead to a heck of a lot of misinformation, misconceptions, and different life choices. So I mean, I think the different things that Joanne and Julie are describing lead to people making different choices as all this plays out.

Kenen: I think one of the stories that Julie shared this week — there was an interesting little aside about disinformation, which is the petition to get an abortion rights ballot initiative in, I think it was Missouri. And one of the things in that article was that the anti-abortion forces were telling people that if you sign this petition, you’re vulnerable to identity theft. Now, so that is not true, but it’s just like this misinformation world we’re living in is spilling over into things like, you know, democratic issues of, “Can you get something on the ballot in your state?” It may lose. Missouri is a very conservative state. I don’t know what the threshold is for passage there. I don’t know that it’s as high as the 60% in Florida. But who knows what’s going to happen?

Rovner: That story was interesting, though, because it was the anti-abortion groups were trying to get people not just to not sign the petition.

Kenen: Unsign.

Rovner: Right. They were trying to get people to take their signatures off. And when all was said and done, they had twice as many signatures as they needed to get it on the ballot, so it will be on the ballot. I don’t know either what the threshold is in Missouri ’cause they were playing with that. Lauren, do you know?

Weber: I don’t know what the threshold is, but I will say what I found interesting about that story was that they said they were going to activate the Catholic Church. And as someone who is Catholic and went to Mass during the Missouri eras of Todd Akin and the stem cell fights, activating the Catholic Church could be very effective on changing how the abortion ballot plays out because I’ve seen what that looks like. So I’ll be very curious to see how that plays out in the weeks and months to come.

Kenen: Right. States doing physician-assisted suicide, aid-in-dying bills, have also — people fighting them have activated the church and they’re quite effective.

Rovner: Yeah. But I think Ohio also activated the Catholic Church and it didn’t work out. So I mean, we obviously know from polling Catholics, they’re certainly in favor of contraception and more American Catholics are in favor of abortion rights than I think their priests would like to know, at least that’s what they tell pollsters.

Edney: I also think that activating the church, whatever church it is, is at least a above-the-board tactic where in a lot of ways you never know, but this was so scary because they’re really going out and, not assaulting, but like verbally trying to keep these people from even being able to get signatures, saying that why should we let people vote on something that’s bad for them. Like not giving the electorate the right to make their voices heard. It was pretty scary to see that because of things like Ohio and other abortion rights movements that won that this is what they’re resorting to to try to make sure Missouri goes a different way.

Rovner: Yeah. I think this is going to be a really interesting year to watch because there are so many of them. Well, in abortion travel news, a federal district judge in Alabama green-lighted a suit by abortion rights groups against the state’s attorney general, who was threatening to prosecute those who “aid and abet” Alabama residents trying to leave the state for an abortion. “The right to interstate travel is one of our most fundamental constitutional rights,” Judge Myron Thompson wrote. On the other hand, Idaho was in federal appeals court in Seattle this week arguing just the opposite. They want to have an injunction lifted on its law that would make it a crime to help a minor cross state lines for an abortion. So I guess this particular fight about whether states can have control over their residents’ trying to leave the state for reproductive health care is a fight that’s going to continue for a while.

Edney: I mean, I think that — and sure it’ll continue for a while — you know, my thought when hearing about these cases is sort of just like, I know people that, when there wasn’t really gambling in Maryland, that would get in the bus and the seniors would all go to Delaware and go to the casino and go gambling. Like, we do this all the time. We go to other states for other things — for alcohol, in some cases. It’s just interesting that now they’re trying to make sure that people can’t do that when it comes to women’s rights.

Rovner: Yeah. I know. I mean, there are lots of things that are legal in some states and not legal in others.

Edney: Right.

Rovner: This seems to be, again, pushing the envelope to places we have not yet seen. Well, moving on, it is May, which means it’s time for the annual report of the Medicare and Social Security trustees about the financial solvency of the trust funds, and the news is good, sort of. Medicare’s Hospital Insurance Trust Fund can now pay full benefits until 2036. That’s five years more than the trustees estimated last year, thanks largely to a strong economy, more people paying payroll taxes, and fewer people seeking expensive medical care. But of course, Washington being Washington, good news is also bad news because it makes it less likely that Congress will take on the distasteful task of figuring out how to keep the program solvent for the long term. Are we ever going to get to this or is Congress just going to kick the can down the road until it’s like next year that the trust fund’s going bankrupt?

Kenen: I mean, of all the can-kicking — you know, we’ve used that phrase about Congress frequently — this is the distillation of the essence of kicking the can when it comes to entitlements, right? Both Social Security and Medicare need congressional action to make them viable and sustainable and secure for decades, not years, and we don’t expect that to happen. I mean, even when things are less partisan than they are now, because obviously we’re in a hyperpartisan era, even when Washington functioned better, this was still a kick-the-can issue. Not only was it kick the can, but everybody fought over how to kick the can and where to kick the can and who could kick it furthest. So five extra years is a long time. I mean, it is. But again, the economy changes. Tax revenues change. It’s a cyclical economy. Next year, we could lose the five years or lose two years or gain one year. Who knows? But in terms of a sustained, bipartisan, sensible — no, I’m not holding my breath, because I would get very, very red, very fast.

Rovner: Yeah. And also, I mean, the thing about fixing both Medicare and Social Security is that somebody has to pay more. Either there will be fewer benefits or more taxes, or in the case of Medicare, providers will be paid less. So somebody ends up unhappy. Usually in these compromises, everybody ends up a little bit unhappy. That’s kind of the best possible world. Lauren, you wanted to add something?

Weber: Yeah. I mean, I just wanted to add that if it goes insolvent by 2036, it’s not looking very good for my ability to access these programs.

Kenen: But they always fix it. They always fix it. They just fix it at the last minute.

Weber: That’s true. I mean, I think that’s a fair point, but I do think overall, the concern, it does seem like something will have to change. I don’t think that when I — hope, God willing — live long enough to access this Medicare benefits, that I think they’ll look very different. Because when there is a compromise or there is something like this, there’s just no way the program can continue as it is, currently.

Kenen: The other thing though is this Medicare date probably means there’ll be less campaign. You know, it was beginning to bubble up a little bit on the presidential campaign. I mean, there were plenty of other health care issues to fight about, but it probably means that there’ll be a little bit of token talk about saving Medicare and so forth, but unlikely that there will become a really hot-button issue with either Trump or Biden putting out a detailed plan about it. There’ll be some verbal, “Yes, I’ll protect Medicare,” but I don’t think it’ll be elevated. If it was the other way, if it had lost five years or lost three years, then we would’ve had yet another Medicare election. I think probably we won’t.

Rovner: Yeah. I think that’s exactly right. If the insolvency date had gotten closer, it would’ve been a bigger issue.

Kenen: And remember that the trend toward Medicare Advantage, which is more than people had anticipated, I mean, it is revolutionizing what Medicare looks like. It’s more than half the people now. So there’s many, many sub-cans to kick on that, with private equity and access and prior authorization. I mean, there’s a million things going on there, and payment rates and everything, but that is a slow-motion, dramatic change to Med[icare], not so slow, but that is a dramatic change to Medicare.

Rovner: We’re figuring out how to do sort of a special episode just on Medicare Advantage because there’s so much there. But meanwhile, let’s catch up on Medicaid, ’cause it’s been a while. As one of my colleagues put it on Slack this week, it was a swing and a miss in Mississippi, where some pretty serious efforts to expand Medicaid came to naught as the legislature closed the books on its 2024 session last week. Mississippi is one of the 10 remaining states that have not expanded Medicaid under the Affordable Care Act, which could expand health coverage to an estimated 200,000 low-income residents there who lack it now. It feels like these last states, mostly in the South, are going to hold out as long as they can, even though they’re basically giving up a gigantic handout from the federal government.

Edney: It’s billions of dollars they’re leaving on the table and it doesn’t really make sense. This seemed to maybe come down to a work requirement. Maybe there was more there. It was more of a poison pill in that Senate bill instead, but it doesn’t seem to make sense. I mean, even one of the earlier bills the Senate in Mississippi had come up with would have left billions of dollars on the table as well. So I think the idea of this being the central part of Obamacare is still strong in some places.

Kenen: And it also is worth pointing out that these are states not just with the gap in coverage, but most of these states don’t have great health status. They have a lot of chronic disease, a lot of obesity, a lot of addiction, a lot of diabetes, etc. The se are not the healthiest states in the country. You’re not just leaving money on the table; you’re leaving an opportunity to get people care on the table and —

Rovner: And exacerbating health inequities that we already have.

Kenen: Yes. Yes. And when North Carolina decided to, which took many years of arguing about it — that’s a purple state; there were some people who thought it would be a domino: OK, North Carolina stopped holding out; the rest of the South will now. I, never having reported in North Carolina on that, you know, having spent time in the state, I never thought it was a domino. I thought it was just something that went on in North Carolina. Do I think eventually most or all of them will accept Medicaid? Yes. But, you know, we’ve mentioned this before: It took almost 20 years for the original Medicaid to go to all 50 states.

And it’s not just — because North Carolina is North Carolina and South Carolina is different. They have different dynamics. And it’s not over by any means, and there’s no … Mississippi got close. Are they going to pick up where they left off and sort it out next year? Who knows? There’s elections between now and then. We don’t know what the makeup and who is the driver of this, and which chamber there, and who’s retiring, and who’s going to get reelected. We just don’t know exactly. It’s not going to be a dramatic shift, but in these close fights, a couple of seats shifting in state government can change things.

Rovner: That’s what happened in Kansas, although Wyoming came close, I think it was a couple of years ago, and then there I haven’t seen any action either, so.

Kenen: You still hear talk about Wyoming considering it. Like, that’s not off the … I don’t think any of us would be totally shocked if Wyoming is the next one, but I mean it didn’t happen this year, so.

Rovner: Well the other continuing Medicaid story is the “unwinding,” dropping those from coverage who were kept on during the pandemic emergency by a federal requirement. A new report from the Georgetown Center for Children and Families finds that as of the end of 2023, the number of children covered by Medicaid or the Children’s Health Insurance Program was down by 10%, or about 4 million. Yet an estimated three-quarters of those kids are actually still eligible. They were struck from the rolls because of a breakdown in paperwork. Texas alone was responsible for more than a million of those disenrollments, a quarter of the total. Texas and Florida together accounted for nearly 40% of those dropped. And Texas and Florida are also the largest states that haven’t expanded Medicaid to the working poor. At some point the problem with the uninsured is going to be back on our radar, right? I mean, we haven’t talked about it for a while because we haven’t sort of needed to talk about it for a while because uninsurance rate has been the lowest it’s been since we’ve been keeping track.

Weber: I just can’t get over that three-quarters of kids lost their coverage due to paperwork issues. I mean, I know we talk about it many times on this podcast, but just to go back to it again: I miss mail. We all miss mail. I’m not someone also that’s moving frequently. That would make it easier to miss mail. I mean, that is just …

Kenen: You speak English.

Weber: Yeah, and I speak English. That is a wild stat, that 75% of these children lost this coverage because of paperwork issues. And as that report discusses, you know, some states did work to mitigate that and other states worked to not mitigate it. And I think that’s an important distinction to be clear about.

Rovner: And I will link to the report because the report shows the huge difference in states, the ones that sort of did it slowly and carefully. I think the part of it that made my hair stand on end was not so much the kids who came off because, you know, the whole family did, because the paperwork issues, but it’s the kids, particularly kids in CHIP who were still eligible when their parents aren’t. And there were some states that just struck families entirely because the parents were no longer eligible without realizing in their own state that parents’ eligibility and kids’ eligibility isn’t the same. And that apparently happened in a lot of cases. And I think the federal government tried to intercede in some of those because those were kids who, by definition of how these programs work, would still be eligible when their parents were not.

Kenen: The one thing it’s always good to remind people that, I mean, this is an extraordinary mess. I mean, it’s not the unwinding, it’s the unraveling. But unlike employer-sponsored insurance and the Obamacare exchanges, there’s no enrollment season for Medicaid. You can get in if you qual … so it can be the unwinding could be rewound. If a child gets sick and they are in an ER or they’re in a hospital or in a doctor’s or whatever, they can get back in quickly. It is a 365-day, always-open, for both Medicaid and CHIP in I believe every state. There may be an exception I’m not aware of, but I think it’s everywhere.

Rovner: I think it’s everywhere. I think it’s a requirement that it’s everywhere.

Kenen: I think it’s federal, right. So yes, it’s a mess, but unlike many messes in health care, it is a mess that can be improved. Although of course not everybody knows that and somebody will be afraid to go to the doctor ’cause they can’t pay, etc., etc. I’m not minimizing what a mess it is. But if you get word out, you can get word out to people that, you know, if you’re sick, go to the doctor. You’re still being taken care of.

Rovner: And also when people do go to the doctor, at the same time they’re told, uh-oh, your Medicaid’s been canceled, they can be reenrolled if they’re still eligible.

Kenen: Yeah, right. I mean, community health clinics know that. Hospitals know that. I don’t know that all private physicians’ offices know that, but …

Rovner: Although they should —

Kenen: They should.

Rovner: — because that’s how they’ll get paid.

Kenen: They should.

Rovner: So I suspect — providers have an incentive to know who’s eligible because otherwise they’re not going to get paid.

Kenen: So that should be the next public campaign. If you lost your Medicaid, here’s how you get it back. And we don’t see enough of that.

Rovner: Last week we talked about a lot of health-related regulations the Biden administration is trying to finalize. If it seems they’re all happening at once, there is an actual reason for that. It’s called the Congressional Review Act. Basically the CRA lets a new Congress and administration easily undo regulations put in place by an earlier administration towards the end of a presidential term. Basically that means any regulations the Biden administration doesn’t want easily overturned by the next Congress and president, should it return to Republican hands, those regulations need to be completed roughly by the end of this month. Towards that end, and as I said, speaking of looking at the problem of the uninsured, last week the administration finalized a rule that would give people here under DACA, that’s the Deferred Action for Childhood Arrivals immigration program, access to subsidized coverage under the Affordable Care Act.

These are about 100,000 so-called Dreamers, those who are not here legally but were brought over as children. In general, those who are not in the country legally are not able to access Affordable Care Act coverage. That was a gigantic fight when the Affordable Care Act was being passed. In some ways, though, I feel like this addition of Dreamers to the ACA is an acknowledgement that they’re not going to get full legal status anytime soon, which has also been a fight that’s been going on for years and years.

Kenen: Yes. And I was wondering, like, who’s going to sue to stop this or introduce legislation? I mean, somebody will do something. I’m not sure what yet. I mean, I would be surprised if nobody tries to block this because there’s obviously controversy about normalizing the status of the Dreamers or the DACA population and it’s been going on for years. We’ll see. I mean, it’s just another, I mean, immigration is such a flash point in this year’s election. Maybe people will say, “OK, this portion of the Dreamers has legal status and they can get health insurance” and people won’t fight about it. But usually nowadays people fight about — I mean, if the intersection of health care and immigration, I would think somebody will fight about it.

Rovner: Yeah. I would, too. And also, I mean obviously the people who are preventing legislation from getting through to legalize the Dreamers’ status, there seems to be, I believe, there is overwhelming support in both houses, but not quite enough to get it through. I suspect those people on the other side might not be very happy about this. Well, finally this week in business, or more specifically this week in private equity in health care, the multistate hospital chain Steward Health [Care] filed for bankruptcy this week, putting up for sale all 31 of its hospitals, which normally wouldn’t be really big news. Lots of hospitals are having trouble keeping their doors open. But in this case, we’re talking about a chain that was pretty large and stable until it was bought by Cerberus Capital Management, a private equity firm.

Cerberus sold off the land the hospitals were on, requiring them to pay rent to yet another company, and then Cerberus got out. The details of the many transactions that took place are still kind of murky, but it appears that many investors did quite well, including acquisitions of some private yachts, while the hospitals, well, did not do so well. This all has yet to play out fully. But this seems to be pretty much how private equity often works, right? They buy something, take the profit that they can, and leave the rest to the whims of the marketplace, or in this case billions of dollars in debt now owed by these hospitals.

Weber: Yeah. I mean, I think when you look at private equity the question is always when is the multipliers going to run out? Like, when are you going to run out of things to sell to get the multipliers out? And the question is, when you do this with health care, you know, we’ve seen some emerging research show that the patient outcomes for private equity-owned health care systems can be impacted by infection rates and so on. And I mean, I thought it was particularly interesting at the end of this Wall Street Journal story, they also noted how UnitedHealthcare, there is some investigations over —

Rovner: They’re tangentially involved.

Weber: They’re tangentially involved, but the government appeared — the story seems to allude to the government is interested in whether there’s some antitrust concerns on selling the doctors’ practices, which is obviously an ongoing issue as well as we talk about health care and acquisitions and consolidation in the country. So, 31 hospitals’ being insolvent is a lot of hospitals in a lot of states.

Rovner: Yeah. And I mean, the idea, I think, was that one of the ways they were going to pay off some of their debts was by selling the doctor practices to United. United, of course, now under the microscope for antitrust, might not be such an eager buyer, which leaves Steward holding the bag again with all of this debt. They owe literally billions of dollars to this company that now owns the land that their hospitals are on. It is quite the saga.

Kenen: It’s very complicated. I mean, I had to read everything more than once to understand it, and I’m not sure I totally understood all of it. It’s also sort of like the, you know, if you were writing, if you were teaching business school about what can go wrong when private equity buys a health system, this would be your final exam question. It is very complicated, extremely damaging, and the critics of PE in health care — I mean this is everything they warn about. And I would also, since all of us are journalists, I mean the same thing is going on with private equity in owning newspapers or newspaper chains: wreckage. Not everyone is a bad actor. There’s wreckage in health care and there’s wreckage in the media.

Rovner: Yeah. We will watch this one to see how it plays out. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Katheryn Houghton and then we will be back with our extra credits. I am pleased to welcome to the podcast my KFF Health News colleague, in person, here in our Washington, D.C., studio, Katheryn Houghton, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” It’s about an out-of-network surgery the patient knew would be expensive, but not how expensive it would be. Welcome, Katheryn.

Houghton: Hi.

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

Houghton: So I spoke with Cass Smith-Collins. He’s a 52-year-old transgender man from Vegas, and he wanted to get surgery to match his chest to his gender identity, so he got top surgery.

Rovner: This was a planned surgery and he knew he was going to go out of network. So what kind of steps did he take in preparation to make sure that the surgery would be at least partially covered by his health insurance?

Houghton: Well, he actually took a really key step that some patients miss, and it’s making sure that you get prior authorization from insurance, so a letter from them saying we’re going to cover this. And he got that. He also talked with his surgeon beforehand, saying what do I need to do to make sure we can submit a claim with insurance? And he signed paperwork saying how that would happen.

Rovner: Then, as we say, the bill came. What went awry?

Houghton: Yeah. Or in this case the reimbursement didn’t come. For Cass’ case there are two key things that kind of went awry here. First off, covered doesn’t necessarily mean the entire bill. So what insurance says is a fair price is not going to match up with what the surgeon always says is a fair price. So when Cass saw that his procedure was covered, it didn’t say the entire amount. It didn’t say how much was covered. The second thing is that that provider agreement that he signed with the surgeon beforehand actually says you’re not guaranteed reimbursement. And that provider agreement also stated there are two different bills here. One is the cost that Cass paid up-front for his surgery, and the other was the bill submitted to insurance.

Rovner: And how much money are we actually talking about here?

Houghton: We’re talking about $14,000. And he expected to get about half of that back.

Rovner: Because he assumed that when he got to his out-of-network maximum the insurance would cover, right?

Houghton: Exactly.

Rovner: And that’s not what happened.

Houghton: Not at all.

Rovner: How much did the surgeon end up charging for the surgery and what did his insurance say about that?

Houghton: If you’re looking at both bills, the surgeon charged more than $120,000 for the surgery and insurance said ah, no, we’re not going to cover that. And it was a little over $4,000 that insurance said, this is the fair price.

Rovner: So that’s a big difference.

Houghton: A very big difference.

Rovner: Was Cass expected to pay the rest?

Houghton: He could have. The agreement that he signed actually said that he could be on the hook for whatever insurance didn’t cover. That being said, he didn’t get a bill this time around.

Rovner: So what eventually happened?

Houghton: So eventually, when KFF Health News started asking questions about this, insurance increased how much that they paid the provider. And with that increased reimbursement, which was $97,000, the provider gave Cass a reimbursement of about $7,000.

Rovner: So he ended up paying about $7,000 out-of-pocket.

Houghton: It was more towards the line of what he was expecting to pay for this.

Rovner: Right. I was just going to say that was about what his out-of-pocket maximum was. But in this case he was kind of just lucky, right?

Houghton: Yes. I mean the paperwork that he signed in advance — it was really confusing paperwork. We had several experts look over this and say, yeah, there are things in this we don’t fully understand what it means.

Rovner: What’s the takeaway here? A lot of people want to go to a particular provider who may be very good at what they do but don’t take insurance. Is there any way that he could have better prepared for this financially or that somebody looking at a similar kind of situation and doesn’t want to end up having someone say, oh, you owe us $80,000?

Houghton: Right. Yeah. So for this case it was really important for Cass to go to a surgeon that he felt like he could trust. And so if you do have that out-of-network provider, there are a few steps you can actually take. There’s still no guarantees, but there are steps. First off, patients should always ask their insurance company what covered actually means. Are you talking the entire bill here? Are you talking just a portion of it? Try to get that outlined. You can also ask your insurance company to spell out the dollar amount that they’re willing to pay for this. That’s a really helpful step. And lastly, on the provider side, you can also say, “Hey, whatever insurance deems as a fair payment, can we count that as the total bill?” You can always ask that. They’re not required, but it’s worth checking.

Rovner: Yeah. So at least you go in with your eyes open knowing what your maximum is going to be.

Houghton: Exactly. Especially if you’re paying out-of-pocket to begin with. You really want to know what is insurance reimbursing for this? What is the provider going to charge me more at the end of this?

Rovner: Well, I’m glad this one had a happy ending. Katheryn Houghton, thank you very much.

Houghton: Thank you so much.

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

Edney: Sure. So mine is from ProPublica by Anna Maria Barry-Jester and it’s “Facing Unchecked Syphilis Outbreak, Great Plains Tribes Sought Federal Help. Months Later, No One Has Responded.” And I think we have even heard over the last few years the story of syphilis rates rising and in this specific look at the Great Plains, there are Native Americans there, that the syphilis rates are even worse. And this is resulting in deaths of babies, like wanted children. And it seems like the federal government has been pretty lackluster in its response, to put it mildly, sending a few CDC [Centers for Disease Control and Prevention] workers for a couple of weeks, and the tribes have been asking for basically a national emergency so they can get more help. And they’ve gone straight to HHS [Health and Human Services] Secretary [Xavier] Becerra, and at least in the last several weeks as this was being reported, they haven’t gotten any response or any help. So I think it’s an important story to spread far and wide.

Rovner: It is. Joanne?

Kenen: There was a very interesting op-ed in The New York Times this week by Dr. Carl Elliott, who is a physician and bioethicist at the University of Minnesota: “In Medicine, the Morally Unthinkable Too Easily Comes to Seem Normal.” It’s a little hard to summarize, but it’s very subtle. It’s the culture of medicine, of being a medical student or a resident, and the things you see, so much of what you see, shocks you anyway because it’s something you have to get used to. But there are outrages. He begins, the opening anecdote is a woman is unconscious and anesthetized before her surgery and the doctor in charge invites all the med students to come and like, “Oh, why don’t you come touch her cervix? She’ll never know. See what it’s like.”

And to that, to really the larger, even larger questions about how did Willowbrook [State School] survive for all those years? How did the Tuskegee studies go on for all those years? You know, at what point, what are the sort of cultural and peer pressure and dynamics of these outrages, big and large, becoming normalized? And, you know, as we know, like recently HHS just said you have to have a written consent for a pelvic exam, particularly if you’re going to be unconscious. But that’s only one example — it was a very disturbing piece actually.

Rovner: Yeah. It really was. Lauren?

Weber: I chose Nicholas Florko’s piece on how “NYU Professors Who Defended Vaping Didn’t Disclose Ties to Juul, Documents Show,” in Stat. Great piece. He dug through a bunch of the Juul legal documents that have been revealed to show how two prominent NYU public health professors were communicating with Juul about their comments in both a congressional hearing and then public comments to many, many journalists defending vaping and saying that, you know, it had public health benefits because it got people off of cigarettes. And it raises up a lot of thorny questions about conflict of interest. These public health officials say they were not paid by Juul, but they did accept dinners. And the question is, you know, a lot of the studies they submitted, one of them they even sent to Juul. It’s a lot of thorny questions about academic review and disclosures. It’s a great piece, too, and a warning for all journalists of who are you interviewing, what are their ties, and what are the disclosures that they may or may not be sharing? It was a great story.

Rovner: Yeah. Super thought-provoking. I will say, every time I speak — and we don’t take money for speaking — all of my speeches are for free. But I constantly, you know, they now have to fill out that, “Do you have any conflicts of interest?” And it’s like, no, I don’t take any money from any industry. But it’s all basically self-reported, and I think that’s one of the big problems with this whole issue. Well, my story this week is from The Nation. It’s by Amy Littlefield. It’s called “The Abortion Pill Underground.” And it’s not the first story like this, but it’s a very comprehensive look at the fight that’s shaping up between blue states that are passing shield laws to protect doctors who are providing abortion medication to patients in red states where, as we discussed earlier, prosecutors would like to reach back to punish those blue-state providers. It’s a fairly small group of providers operating in what is still a legally gray area.

As we mentioned, this is all still under — in court, in various places at various levels — but I do think it’s one of the next big battles that are shaping up in reproductive health. It’s a really good piece. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at Twitter, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Joanne, are you hanging anywhere on social media?

Kenen: A little bit on Twitter @JoanneKenen, not even that much. But more on Threads @joannekenen1.

Rovner: Anna?

Edney: @annaedney on Twitter and @anna_edneyreports on Threads.

Rovner: Lauren?

Weber: Still only on Twitter, @LaurenWeberHP. HP is for health policy.

Rovner: Don’t apologize. You can find us all if you really want to. We will be back in your feed next week. Until then, be healthy.

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

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

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

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

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Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Rachana Pradhan
KFF Health News

@rachanadpradhan

Read Rachana's stories.

Among the takeaways from this week’s episode:

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

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

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

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

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

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

Also mentioned on this week’s podcast:

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

Click to open the Transcript

Transcript: Abortion Access Changing Again in Florida and Arizona

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

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

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

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

Alice Miranda Ollstein: Hello.

Rovner: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: And my KFF Health News colleague Rachana Pradhan.

Rachana Pradhan: Hello.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: I have it for my Facebook account!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Right, good story. Sarah?

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

Rovner: Alice?

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

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

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

Rachana, where are you hanging these days?

Pradhan: I am also on X, @rachanadpradhan.

Rovner: Sarah?

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

Rovner: Alice?

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

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

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

Some justices suggested the Supreme Court had said its piece on abortion law when it overturned Roe v. Wade in 2022. This term, however, the court has agreed to review another abortion case. At issue is whether a federal law requiring emergency care in hospitals overrides Idaho’s near-total abortion ban. A decision is expected by summer.

Meanwhile, the Centers for Medicare & Medicaid finalized the first-ever minimum staffing requirements for nursing homes participating in the programs. But the industry argues that there are not enough workers to hire to meet the standards.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins University’s nursing and public health schools and Politico Magazine, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Tami Luhby
CNN

@Luhby

Read Tami's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• This week’s Supreme Court hearing on emergency abortion care in Idaho was the first challenge to a state’s abortion ban since the overturn of the constitutional right to an abortion. Unlike previous abortion cases, this one focused on the everyday impacts of bans on abortion care — cases in which pregnant patients experienced medical emergencies.
• Establishment medical groups and doctors themselves are getting more vocal and active as states set laws on abortion access. In a departure from earlier political moments, some major medical groups are campaigning on state ballot measures.
• Medicaid officials this week finalized new rules intended to more closely regulate managed-care plans that enroll Medicaid patients. The rules are intended to ensure, among other things, that patients have prompt access to needed primary care doctors and specialists.
• Also this week, the Federal Trade Commission voted to ban most “noncompete” clauses in employment contracts. Such language has become common in health care and prevents not just doctors but other health workers from changing jobs — often forcing those workers to move or commute to leave a position. Business interests are already suing to block the new rules, claiming they would be too expensive and risk the loss of proprietary information to competitors.
• The fallout from the cyberattack of Change Healthcare continues, as yet another group is demanding ransom from UnitedHealth Group, Change’s owner. UnitedHealth said in a statement this week that the records of “a substantial portion of America” may be involved in the breach.

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

Julie Rovner: NBC News’ “Women Are Less Likely To Die When Treated by Female Doctors, Study Suggests,” by Liz Szabo.  

Alice Miranda Ollstein: States Newsroom’s “Loss of Federal Protection in Idaho Spurs Pregnant Patients To Plan for Emergency Air Transport,” by Kelcie Moseley-Morris.  

Tami Luhby: The Associated Press’ “Mississippi Lawmakers Haggle Over Possible Medicaid Expansion as Their Legislative Session Nears End,” by Emily Wagster Pettus.  

Joanne Kenen: States Newsroom’s “Missouri Prison Agency To Pay $60K for Sunshine Law Violations Over Inmate Death Records,” by Rudi Keller.  

Also mentioned on this week’s podcast:

• American Economic Review’s “Is There Too Little Antitrust Enforcement in the U.S. Hospital Sector?” by Zarek Brot-Goldberg, Zack Cooper, Stuart Craig, and Lev Klarnet.
• KFF Health News’ “Medical Providers Still Grappling With UnitedHealth Cyberattack: ‘More Devastating Than Covid,” by Samantha Liss.

CLICK TO OPEN THE TRANSCRIPT

Transcript: Abortion — Again — At the Supreme Court

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

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

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

Alice Miranda Ollstein: Hello.

Rovner: Tami Luhby of CNN.

Tami Luhby: Hello.

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

Joanne Kenen: Hi, everybody.

Rovner: No interview this week, but wow, tons of news, so we are going to get right to it. We will start at the Supreme Court, which yesterday heard oral arguments in a case out of Idaho over whether the federal Emergency Medical Treatment and Active Labor Act, or EMTALA, trumps Idaho’s almost complete abortion ban. This is the second abortion case the high court has heard in as many months and the first to actively challenge a state’s abortion ban since the overturn of Roe v. Wade in 2022. Last month’s case, for those who have forgotten already, was about the FDA approval of the abortion pill mifepristone. Alice, you and I both listened to these arguments. Did you hear any hints on which way the court might be leaning here?

Ollstein: The usual caveat that you can’t always tell by the questions they ask. Sometimes they play devil’s advocate or it’s not indicative of how they will rule on the case, but it did seem that at least a couple of the court’s conservatives were interested in really taking a tough look at Idaho’s argument. Obviously, some of the other conservatives were very much in support of Idaho’s argument that its doctors should not be compelled to perform abortions for patients experiencing a medical emergency. It really struck me from the arguments how much it focused on what’s actually going on on the ground.

That was a huge departure from a lot of other Supreme Court arguments and a lot of Supreme Court arguments on abortion where it’s a lot of hypotheticals and getting into the legal weeds. This was just like they were reading these concrete, reported stories of what’s been happening in Idaho and other states because of these abortion bans. People turned away while they were actively miscarrying, people being flown across state lines to receive timely care. I think whether that will make a difference that the justices are sort of being confronted with the concrete ramifications of the Dobbs [v. Jackson Women’s Health Organization] decision or not remains to be seen.

Rovner: I thought one of the things that it looked like very much like last month’s argument is that the women justices were very much about real details and talking about medical conditions, about ectopic pregnancies and premature rupture of membranes and things that none of the men mentioned at all. The men were sort of very legalistic and the women, including Amy Coney Barrett, who voted to overturn Roe v. Wade, were very much all about, as you said, what’s going on on the ground and what this distinction means. I mean, where we are is that Idaho has an exception in its abortion ban, but only for the life of the woman. Whereas EMTALA says you have to stabilize someone in an emergency situation and it’s been interpreted by the federal government to say sometimes that stabilization means terminating a pregnancy, as in the case of premature rupture of membranes or an ectopic pregnancy or a case where the woman is going to hemorrhage and is actively hemorrhaging.

That question of where that line is, between what’s an immediate threat to life and what’s just a threat to health or a threat to life soon, was the crux of this case. And it really does feel uncomfortably like we have nine Supreme Court justices making, really, medical decisions.

Ollstein: Yeah, it struck me how Amy Coney Barrett seemed to get pretty frustrated with Idaho’s attorney at a couple points. Idaho’s attorney was saying kind of, “Nothing to see here. There’s no problem. Since we allow lifesaving abortions and that’s what is required under EMTALA, there’s no conflict.” So Amy Coney Barrett was like, “Well, why are you here then? Why are you before us?” The reason is that they’re trying to get this lower-court injunction lifted even though it’s not in effect right now. The other point she got kinda testy was when Idaho was saying that their law is clear, doctors know what to do, and Amy Coney Barrett asked, “Well, couldn’t a prosecutor come in later and disagree and said, “Oh, you performed an abortion you said was to save someone’s life, but I don’t think it was necessary to save her life and I’m going to charge you criminally?” And the Idaho attorney conceded that that could happen.

So I think her vote could potentially be in play, but I don’t know if it’s going to be enough to overcome the court’s conservatives who are very skeptical that EMTALA should compel states to do anything.

Rovner: So the medical community has been quite outspoken in this case. The American Medical Association, American College of Obstetricians and Gynecologists and the American College of Emergency Physicians have all filed briefs saying the Idaho ban could require them to violate professional ethics, wrote the immediate president of the AMA, Jack Resnick, in an op-ed. “It is reckless for Idaho to tell emergency physicians that they must ignore their moral and ethical standards and stand by while a septic patient begins to lose kidney function or when a hemorrhaging patient faces only a 30% chance of death.” But I feel like the medical profession has long since lost control of the abortion issue. I mean, is there any chance here that they might prevail? I have to say this week I’ve gotten so many emails from so many doctor groups saying, “Oh my goodness, look what’s happening. They’re going to put us in this impossible situation.” To which I want my response to be, “Where have you been for the last 20 years?”

Ollstein: I mean, I think it is notable that these establishment medical groups are becoming more vocal. I mean, some might say better late than never, and I think in some instances they are having an impact at the state level. They have pushed some state legislatures to add or expand exemptions to abortion bans. But a lot of times Republican lawmakers have rejected calls from state medical associations to do that, and so I think filing amicus briefs is a way to have your say, lobbying at the state level is a way to have your say. Some doctors are even running for office specifically on this issue. And also, medical groups are campaigning hard on these state abortion referendums. I reported on doctor groups door-knocking in Ohio, for instance, before that referendum won big.

I think it’s really interesting to see the medical community get a lot more vocal on something they’ve either tried to stay out of or been vocal on the other side on in the past, but we’ll have to see how much impact that actually has.

Rovner: Well, one thing this case highlights is how pregnant women who experience complications that can threaten their health or future fertility, but are not immediately life-threatening, can end up in really terrible circumstances, as we heard in a number of anecdotes at the oral arguments. The Associated Press “FOIA’d”[requested Freedom of Information Act] EMTALA pregnancy complaint records from several states with abortion bans and found some pretty horrific examples, including one woman who miscarried in the emergency room lobby restroom after she was turned away from the registration desk. Another who was turned away and ended up giving birth in a car on the way to another hospital. That baby died. These are not people who go to the emergency room in search of abortions. They’re women who are trying to maintain pregnancies. Is the concept that people ending up in the most horrific situations are often those who most want children, is that finally getting through here?

Ollstein: What struck me most about that reporting is that the documents they got were just from the first few months after Roe v. Wade was overturned, so we have no idea what’s happening now. It could be better, it could be much worse, it could be the same. I think that lack of transparency makes this really hard to report on accurately. And the fact that it took The AP a year to even get those few heavily redacted documents speaks to the challenge here. We want an accurate picture of how these bans are impacting the provision of health care around the country, and it’s really hard to get.

Rovner: I know the Biden administration has been kind of trying to keep this quiet. I mean, not out there sort of blaring what’s happening. They’ve been sort of leaving that to the politics side and this is obviously the policy side. Obviously on the politics side, the Biden administration is getting bolder about using abortion as a campaign issue. The president himself gave a speech in Florida where a six-week ban is set to take effect next week and pinned all the abortion restrictions directly on former President Trump, who he pointed out has taken credit for them. Biden actually said the word abortion twice in that speech. I was listening very closely and went back and counted. I think that’s a first. They’re definitely stepping up the pressure politically, right?

Ollstein: Yes. The Biden campaign is leaning very hard on this. Even in states where it’s debatable whether they have a chance, like Florida, I think that there’s an interest, especially after seeing all of these referendums and ballot measures win big. It’s really shown Democrats that this is a very popular issue to run on, that they shouldn’t be afraid of it, that they should lean into it. I think you are seeing attempts to do that. It’s not always the language that the abortion rights advocacy community wants to hear, but it’s definitely more than we’ve heard from the Biden administration in the past.

I think you’re also seeing an attempt to sort of take the air out of Trump’s “Let’s leave it to states. I am reasonable and moderate” sort-of pitch. By highlighting what’s happening on the ground in certain states, it’s an attempt to say, “OK, you want to leave it to states? Then you own all of this. You own every woman being turned away from a hospital while she’s miscarrying. You own every instance of a ban going into effect and people having to travel across state lines,” et cetera. But whether just blaming Trump and arguing that he would be worse is enough versus saying what Biden would actually do and continue to do, I think that’s what we’ve heard people want to hear more of. Although there has been some action from the Biden administration recently.

Rovner: That was just going to be my next question. The one policy change the Biden administration did do this week was finalized a rule expanding the health records protections under HIPAA to abortion information. Why was this important? It sounds pretty nerdy.

Ollstein: This has been in the works for more than a year. A lot of people have been wondering why it’s been taking so long and worried that if it took even longer, it would be easier to get rid of it if a new administration takes over. But essentially this is to make it harder for states to reach across state lines to try to obtain information and use it to prosecute for having an abortion. It’s an attempt to better protect that data and so we heard a lot of praise after the announcement came out from abortion rights groups and some medical groups, and I would anticipate some groups on the right would sue. I’ve seen some complaints saying this will prevent law enforcement from investigating actual crimes against people, and so I expect to see some legal challenges soon.

Kenen: There are all sorts of efforts to stop both travel for abortion. There are also laws on books already, there have been for a number of years, about helping a minor cross state lines for abortion. There’s the attempts to stop the shipment of abortion pills from a legal state into a state that has a ban. There’s all sorts of things where, whether the intent is to actually prosecute a woman or a pregnant person, versus collecting evidence for some kind of larger crackdown or prosecution, this is potentially a piece … patient records are potentially a piece of that. We’ve talked a few weeks ago, maybe a month or two ago by now, about some Texas communities that wanted to say, “If you drive on the road in our town on the way to an abortion, we’re going to arrest you.” How they figure out logistically and practically … What are you going to do? Stop everybody on the road and give them a pregnancy test?

I mean, I don’t know how you enforce that, but just that these ideas are out there and on the books through this privacy shield. We have privacy under HIPAA, all of us, so to interpret it this way, or reinforce it depending on your political point of view, undermine excessively, whatever, but this is sort of pivotal because there’s so many ways these records could be used in various kinds of legislative and prosecutorial ways.

Rovner: As you point out, it’s not theoretical. We’ve seen attorneys general — Indiana and Kansas — and some other states, actually, and Texas say that they want to go after these records, so it’s not …

Kenen: Right and we’ve seen cases of the child rape victim and the prosecutor, what happened with the doctor, and so it’s not theoretical. It’s not widespread right now, but it’s not theoretical. Whether the pregnancy was planned and wanted or it was unplanned and ended up being wanted, going through a pregnancy loss is not just medically difficult, depending on when in pregnancy it occurs and under what circumstances. It can be medically quite complicated and it’s emotionally devastating. So to just get pulled into these political legal fights when you’ve already been bleeding in the parking lot or whatever, or having lost a pregnancy, it’s like you forget these are human beings. These are people going through medical crises.

Rovner: Indeed. Well, abortion is far from the only big health news this week. On Monday, the Biden administration finalized more long-awaited rules regarding staffing in nursing homes that participate in Medicare or Medicaid. Tami, what’s in these rules and why is the concept that nursing homes should have nurses on duty so controversial?

Luhby: It is very controversial and it’s also very consequential. So on Monday, as you said, the Biden administration finalized the first-ever minimum staffing rules at nursing homes involved in Medicare and Medicaid, and they say it’s crucial for patient safety and quality of care. It requires that all nursing homes provide a total of at least 3.48 hours of nursing care per resident per day, including defined periods of care from registered nurses and from nurses’ aides. Plus, nursing homes must have a registered nurse on-site at all times, which is different than the rules now. Now, CMS [Centers for Medicare & Medicaid Services] is giving the nursing homes some time to staff up. The mandate will be phased in over three years with rural communities having up to five years and they’re also giving temporary exemptions for facilities in areas with workforce shortages that demonstrate a good faith effort to hire. When I spoke to [Department of Health and Human Services] Secretary [Xavier] Becerra about the nursing home industry’s vocal concerns that this could cause a lot of nursing homes to close or limit admissions, he said, “Well, a business model that is based on understaffing is not a very good business model and is dangerous for patients.”

So, it’s going to be a heavy lift for nursing homes. According to HHS, 75% of them will have to hire staff, including 12,000 registered nurses and 77,000 aides. And also, 22% of them will need to hire registered nurses to meet the around-the-clock mandate. The nursing home operators, not surprisingly, have strongly pushed back on this rule even back when it was first proposed in September, saying that they’re already having staffing problems amid a nationwide shortage of nurses. The American Health Care Association called the mandate an unreasonable standard that only threatens to shut down more nursing homes, displace hundreds of thousands of residents, and restrict seniors’ access to care.

Rovner: We should point out the American Health Care Association is the lobbying group for nursing homes.

Luhby: Yes. What’s interesting also, though, is that on the other side, you have advocacy groups that are saying that it doesn’t go far enough and they’re citing a 2001 CMS study that found that nursing home residents need at least 4.1 hours of daily care. To add to all of this, if it’s not complicated and controversial enough, Congress is getting involved and is also split over the rules. Some lawmakers, like Sens. Elizabeth Warren and Bob Casey, generally support it, but nearly a hundred House members from both parties wrote to HHS Secretary Becerra expressing their concern that the mandate could lead to nursing home closures. And there’s a bipartisan Senate bill and a House Republican bill that would prohibit HHS from finalizing the rule. So we have time before this goes into effect. It goes into effect in phases, and we’ll see if lawmakers move to block the mandate or if the courts do, but it’s going to be interesting to watch how this plays out.

Rovner: Joanne wanted to add something.

Kenen: Well, first of all, as we say frequently, there’s always lawsuits. We have a health care/lawsuit system, so it’s not over. But I think the other thing is I think families who put a loved one in a nursing home don’t understand how little nursing, let alone doctoring, goes on. The name is “nursing” home and people expect there to be a nurse there, meaning a registered nurse. I think people often think there’s a doctor there, where the doctors are not there very much. That’s one reason the lack of medical care on-site, not only could there be emergencies, but I mean even things that could be treated in place if there is a physician. I mean, it’s just dial 911 and put them in an ambulance and send them to the hospital. And we do have this problem with hospital readmission, which is not just a cost problem and a regulatory problem, it’s really bad for patients to … the continuity of care is good and lack of continuity and handoffs and change, sending people back-and-forth is not good for them.

Obviously, there are times there’s an emergency and you need to send someone to a hospital, but not always. If there was a doctor or nurse, there’s some things that you don’t have to call 911 for. Because you don’t know or don’t learn about nursing homes until you have a relative there or until you’re a reporter who has to write about them. You don’t realize that they’re very custodial and there’s not a lot of taken care of in terms of getting assistance in bathing and walking and things like that. There’s less medical care, including nursing care, than people realize until your loved one is there. I mean, when I covered them the first time, I was really shocked. I mean, it’s 20 years ago the first time I wrote about it, but my assumption of what was there and what is actually there was a big gap.

Rovner: Tami.

Luhby: One thing also, though is … I mean, yes, that is definitely true about the medical care, but we’re also talking about just the care, not only the nursing. But that’s why so many aides need to be hired because you also have situations in nursing homes where people aren’t getting help to go to the bathroom, aren’t getting showered regularly, aren’t being watched. Maybe they’re trying to go to the bathroom themselves and they’re falling because they have to go. I mean, unfortunately, I’ve had experience with nursing homes with my family and I’ve seen this. But also I think it’s been pretty well reported in a lot of publications and studies and such. But there are a lot of problems in nursing homes, in general, and staffing.

Rovner: Well, just to talk about how long this is going on, former Sen. David Pryor died this week. When he was a House member, he rather famously went undercover at a nursing home to try and spotlight. That was when we first started to hear about some of the conditions in nursing homes. He was instrumental in doing the work that got the original federal nursing home standards passed in 1987, which was the first time I covered this issue, and even then there was a big fight in 1987 about should there be a staffing mandate? It’s like, hello, if we’re going to improve care in nursing homes, maybe we should make sure there are enough people to provide care. Even then the nursing home industry was saying, “But we have a shortage. We can’t hire enough people to actually do this if you give us a staffing mandate.” So literally, this has gone back-and-forth since 1987. And, as Joanne points out, it’s still in all likelihood not over, but one could sort of think, gee, they’ve had two generations now to come up with enough people to work in these nursing homes. Maybe Becerra is right. Maybe there’s something wrong with the business model?

Luhby: I was going to say, we know the business model is also moving more towards private equity, which is not necessarily going to be as concerned with the staffing levels. We know that the staffing levels … I think there’ve been studies that show that staffing levels are generally lower in investor-owned nursing homes. So there’s that.

Kenen: There’ve been a lot of demographic changes. I mean, you live longer, but you don’t always live healthier. We have families that are spread out. Not everybody’s living in the same town anymore. I mean, they haven’t for a number of decades now, but your daughter-in-law is 3,000 miles away. She can’t come to your house every day. At the same time, we do have a push and it’s not brand-new, it’s a number of years now, to do more home- and community-based care, but there are shortages and waiting lists and problems there, too. So there are a lot of people who need institutional care. Whether they wanted to have that or not, that’s where they go because either there’s not enough community support or they don’t have the family to fill in the gaps or they’re too medically complicated or whatever. Given the demographic trends and the degree of chronic disease and disability, this is not going away. It’s like Julie said, it’s way overdue. We need to figure it out. There are workforce shortages to train more CRNAs [certified registered nurse anesthetists] like the trained aides. It’s not a five-, six-year program. I mean, this can be done and is done somewhere in community colleges. You can do this. You can improve at all levels. You need more nurse RNs, nurses or advanced practice nurses, but you also need more of everything else. People who go to work in these jobs, by and large, do want to provide quality, compassionate care, and it’s hard to do if there are not enough of you.

Rovner: But they’re also super hard jobs and super stressful and super physically demanding.

Kenen: Hoisting and …

Rovner: Yeah, yeah. And not well-paid.

Kenen: Keeping track of a lot of stuff.

Rovner: Well, in a related move, the Biden administration this week also finalized rules that will attempt to make the quality of Medicaid managed-care plans more transparent. Among other things, the rules establish national wait time limits for certain types of medical care and require states to conduct secret shopper surveys of insurance provider networks to make sure there are enough practitioners available to serve the patient population. The administration says these rules are needed because so many Medicaid patients are now in managed care and regulations just haven’t kept up. Will these be enough to actually protect these often very vulnerable populations? I mean, obviously these people are not quite as vulnerable as people in nursing homes, but they’re kind of the next level down.

Kenen: Well, I think that we’ve seen a history of waves of regulation. Then whatever the status quo becomes, it doesn’t stay the status quo. Whether, as Tami mentioned, there’s more private equity or there’s monopolization and consolidation or just new state regulation. I mean, it’s not static. Do we know how this move is going to play out? No. Do we assume that the bad actors who don’t want to comply will find new ways of doing things that in five years we’ll have another set of regulations that we’ll be talking about? I mean, unfortunately, that’s the way things work. Some regulatory approaches or legal approaches work and others just sort of morph. There’s a lot of history of innovative great actors and lousy bad actors.

Rovner: I say it’s been a big week for federal regulation because we also have breaking news from the Federal Trade Commission, of all places. On Tuesday, the commissioners voted to finalize rules banning most noncompete clauses in employment contracts. At an event here at KFF, the FTC chair, Lina Kahn, said a surprisingly large number of comments about that proposed rule came from health care workers. Here’s a snippet from that conversation.

Lina Khan: There were a whole bunch of comments that said, “I signed this, but it’s not like I was exercising real choice. It felt coercive.” We also heard a lot about the effect of these noncompetes and the way that, especially in rural areas, if you want to switch employers and there’s really only one other option locally, if a noncompete is barring you from taking a job with that other hospital, practically to change jobs you have to leave the state. Right? And just how destructive and devastating that is for people and their families, especially if they’re choosing between staying in a job where the employer realizes that this is a captive employee and they don’t really have to compete in offering them better opportunities, better wages, and having to instead think about uprooting their family. We also heard from doctors who did not uproot their families, but instead just commuted hours and hours a day driving. People saying, “For five years I didn’t really see my kids at all awake, ever, because I was always on the road because of this noncompete.” So just really vivid stories from people.

Rovner: So even though the vote was less than 48 hours ago, the U.S. Chamber of Commerce has already filed suit to block the rules as have some smaller business groups. Why do businesses think they need to prevent workers from changing jobs near where they live? I mean, you could see it for people who’ve invented something. You don’t want them to walk out the door with proprietary secrets, but baristas at Starbucks and even nurses are not walking out with trade secrets.

Kenen: Well, I mean, this is common in doctors’ employment contracts, nurses, it’s everything. I think it’s partly because there are provider shortages in some places and they want to keep the workforce they have instead of having them be lured across town to a competitor where they could be paid more and then you have to pay even more to hire the next one. So that’s part of it. It’s economic. A lot of it’s economic. I mean, there’s some fear of patients going with a certain beloved provider, a doctor goes somewhere else. But I think it’s basically they don’t want churn. They don’t want to have to keep paying more. Somebody gets a job offer across the street and they don’t want to take it. They like where they are, but they’re going to ask for more money. It’s largely economic in a market where there’s scarcity of some specialties and certainly nursing. I mean, there’s questions about are there are not enough nurses? Or are we just putting them in the wrong places? But speaking generally, there’s a nursing shortage and physicians, we don’t have enough primary care providers. We certainly don’t have enough geriatricians. We don’t have enough mental health providers. We don’t have enough of a lot of things. This helps the employer, in this case, the health system, usually.

Rovner: I have to say it was only in the last couple of years that I even became aware there were noncompetes in health care. I mean, I knew about them for weathercasters on local stations. It’s like if you leave, you have to go to another station in another city. I had absolutely no idea that they were so common, as you point out, for so many economic reasons. Obviously this has also already been challenged in court, so we’ll have to see how that plays out.

Also this week on the antitrust front, we have a paper from three health economists published in the American Economic Review who calculated that if the Federal Trade Commission had been more aggressive about flagging and potentially blocking hospital mergers just between 2010 and 2015, health care prices could have been 5% lower. Researchers blame the FTC’s limited budget, but you have to wonder if that budget is limited because business has so much clout in Washington and really doesn’t want eager regulators snooping into their potentially anticompetitive practices. I mean, the FTC has been around for 120-some years now. Occasionally it tries to do big things like with these noncompetes, but mostly it doesn’t do as much as obviously economists and people who study it think that it could do. I mean, we certainly have problems with lack of competition in health care.

Ollstein: I think we have an unusually aggressive FTC right now, so it’ll be really interesting to see what they can accomplish in whatever time this administration has remaining to it, which remains to be seen. I have seen some more aggressive action from the agency in the past on things like payday lending and some of these other sort of maybe more fringy sectors of the economy. So to take on health care, which is so central and such a behemoth and, like you said, there’s so much political power behind it, as Joanne said, guarantee of lawsuits and coverage from us forever basically.

Kenen: The other point that’s worth making, I don’t think any of us have said this, it doesn’t apply to nonprofit hospitals or health systems, and that’s a lot of … market-dominant health care systems that are nonprofits, nominally their tax status is nonprofit. It’s a very confusing term to normal people, but these bans on noncompetes do not apply to the nonprofit sector, which is a lot of health care.

Rovner: Yet still it’s set off quite a conflagration since they passed this on Tuesday. Well, finally this week, speaking of big health care business, we are still seeing ramifications from that Change Healthcare hack back in February. While UnitedHealth Group, which owns Change, says things are approaching normality, that’s not the case for providers who still can’t submit bills or collect payments except doing it on paper. Meanwhile, in what’s going to be some kind of movie or miniseries someday, a second group is now demanding ransom after publishing some of the stolen data. If you’ve been following this story along with us, you’ll remember that United reportedly already paid a ransom of $22 million, except that it appears that the group that got that money stiffed the group that actually has control of the pirated data.

Oh, and buried in UnitedHealthcare’s news “update” posted on its website, it says protected health information, “which could cover a substantial proportion of people of America,” is involved in the hack. Can this get any worse?

Kenen: Snakes? I don’t think any of us journalists can quite comprehend. I mean, we understand intellectually, but I don’t think we understand what it’s like to be the billing clerk at a major practice right now trying to figure out what’s where and how to get paid and what it means for patients and what’s next. I mean, this is a tremendous hack, but it’s not the last.

Rovner: Yeah, and the idea that I think — what did they say? — 1 out of every 3 health care transactions goes through Change, I certainly wasn’t aware of. I think most reporters who are covering this weren’t aware of. I think certainly none of the public was aware of, that there’s that much of the money-changing that goes on from one, as we now know, vulnerable organization is a little bit scary.

Luhby: It shows the power of UnitedHealth[care] in the market. I mean, it’s the largest insurer and people think of it, “OK, I have insurance through it,” but they don’t realize all of the other tentacles that are attached.

Kenen: It also shows that there’s hack after hack after hack after hack. This company knew that they were big and powerful and central, and many of us never heard of them or barely knew what they were. But they knew what they were and despite all the warnings of the need for better and higher protection, cybersecurity protections, these things are going on still. I don’t have the technical expertise to know, well, OK, everybody’s doing everything they’re supposed to do as a health system, but the hackers are just always a step ahead. Or whether they’re really not doing everything they’re supposed to do and weak links in their own chains. Is it the diabolical geniuses? Or is it people still not taking this seriously enough?

Rovner: I will add that in our discussion with FTC Chair Lina Kahn, she did talk about cybersecurity as something that the FTC is going to be looking at in deciding whether there is unfair competition going on. Also, she has promised to come on the podcast, so hopefully we will get her in the next several weeks.

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

Luhby: Well, my extra credit is an AP story by Emily Wagster Pettus titled “Mississippi Lawmakers Haggle Over Possible Medicaid Expansion as Their Legislative Session Nears End.” This story brings us up to date on the negotiations between the House and Senate in Mississippi over expanding Medicaid. Just a quick refresher for listeners: Mississippi is one of 10 states that hasn’t expanded Medicaid yet, and this is the first time, and it’s really very consequential that the Republican-led legislature has seriously considered doing so. The problem is the House and Senate versions are very, very different. The House bill is more like a traditional Medicaid expansion, providing coverage for those earning up to 138% of the poverty level, although it would also try to institute a work requirement, and about 200,000 people would gain coverage. But the Senate version would only extend coverage to those earning up to 100% of the poverty level, which the Senate Medicaid committee chair thought would add about 40,000 to the program, and it would also come with a very strict work requirement.

So on Tuesday, lawmakers met to try to hash out a compromise. They did so in public. It was a public meeting recorded, which was very unusual, and apparently there were people waiting hours to get in. It was standing room only. The House offered a plan that would cover people earning up to 100% of the poverty level under Medicaid, while those earning between 100% and 138% would receive subsidies to buy insurance through the ACA exchange. But the Senate did not offer a proposal nor immediately respond to the one in the House. There are more meetings scheduled. I think there was another one yesterday. It remains to be seen what will happen, but the clock is ticking. The state legislature only is in session until May 5, and it doesn’t give them much time.

Another wrinkle is that it’s important to note that Gov. Tate Reeves, a Republican, has repeatedly voiced his opposition to Medicaid expansion in recent months and is likely to veto any bill. So if lawmakers do eventually agree on a compromise, they may very well also have to vote on whether to override the veto by the governor. This happened in Kansas in 2017 where the legislature did pass Medicaid expansion, Republican governor vetoed it, and the legislature was not able to override the veto and it never got that far again.

Rovner: So yes, we will keep our eyes on Mississippi. Thank you for the update. Alice, why don’t you go next?

Ollstein: I have a piece from States Newsroom related to the Supreme Court arguments on Idaho’s abortion ban and its impact on pregnant patients. The piece [“Loss of Federal Protection in Idaho Spurs Pregnant Patients To Plan for Emergency Air Transport”] is about the increase in patients being airlifted out of the state on these Life Flight [Network] emergency transports and the situation and doctors’ hesitancy to provide abortion care, even when they feel it’s medically necessary, is leading to this increase in flying patients to Oregon and Washington and Utah and neighboring states. It’s getting to the point where some doctors are even recommending people who are pregnant or planning to be pregnant purchase memberships in these flight companies, which normally is only recommended for people who do extreme outdoor sports who may need to be rescued or who ride motorcycles. So the fact that just being pregnant is becoming a category in which you are recommended to have this kind of insurance is pretty wild.

Rovner: Yeah. Welcome to 2024. Joanne.

Kenen: This is a piece from the Missouri Independent, which is also part of the States Newsroom, by Rudi Keller, and the headline is “Missouri Prison Agency To Pay $60K for Sunshine Law Violations Over Inmate Death Records.” That doesn’t sound quite as dramatic as this story really is. It’s about a mother who’s been trying to find out how her son was left unprotected, and he died by suicide, hanged himself in solitary confinement, when he had a history of mental illness. He was serving time for robbery. He wasn’t a murderer. I mean, he was obviously in prison. He had done something wrong, very wrong. He had had a 13-year sentence. But he had a history of mental illness. He had a history of past suicide attempts. He had been taken off some of his drugs, and she has been trying to find out what happened. But it’s not just her. There are other cases. The number of deaths in Missouri prisons has actually gone up in the last few years, even though the prison population itself has gone down. The headline is sort of the tip of a rather sad iceberg.

Rovner: Prison health care, I think, is something that people are starting to look at more closely, but there’s a lot of stories there to be done. Well, my story this week is from my friend and former colleague Liz Szabo, and it’s called “Women Are Less Likely To Die When Treated by Female Doctors, Study Suggests.” Now, this was a study of women on Medicare who were hospitalized, so not everybody, and the difference was small, but statistically significant. Those women treated by women doctors were slightly less likely to die in the ensuing 30 days than those treated by male doctors. It’s not entirely clear why, but at least part of it is that women tend to take other women’s problems more seriously, and women patients may be more likely to open up to other women doctors.

It’s another data point in trying to close the gap between women and men and the gap between people of color and white people when it comes to health care. So more studies to come.

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

Kenen: Occasionally on X @JoanneKenen, but not very much, and on threads @joannekenen1.

Rovner: Tami?

Luhby: Best place is cnn.com.

Rovner: There you go. Alice?

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

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

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

The Arizona Supreme Court shook up the national abortion debate this week, ruling that a ban originally passed in 1864 — before the end of the Civil War and decades before Arizona became a state — could be enforced. As in some other states, including Florida, voters will likely have the chance to decide whether to enshrine abortion rights in the state constitution in November.

The Arizona ruling came just one day after former President Donald Trump declared that abortion should remain a state issue, although he then criticized the ruling as having gone “too far.”

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Rachel Roubein of The Washington Post, and Rachel Cohrs Zhang of Stat.

Panelists

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories.

Rachel Cohrs Zhang
Stat News

@rachelcohrs

Read Rachel's stories.

Among the takeaways from this week’s episode:

• Former President Donald Trump’s remarks this week reflect only the latest public shift in his views on abortion access. During an appearance on NBC’s “Meet the Press” in 1999, he described himself as “very pro-choice,” but by the 2016 presidential campaign, he had committed to nominating conservative Supreme Court justices likely to overturn the constitutional right to an abortion. Trump later blamed Republican losses in the 2022 elections on the overturning of that right.
• Arizona officials, as well as doctors and patients, are untangling the ramifications of a state Supreme Court ruling this week allowing the enforcement of a near-total abortion ban dating to the Civil War. Yet any ban — even one that doesn’t last long — can have lasting effects. Abortion clinics may not survive such restrictions, and doctors and residents may factor them into their decisions about where to practice medicine.
• Also in abortion news, an appeals court panel in Indiana unanimously ruled that the state cannot enforce its abortion ban against a group of non-Christians who sued, siding with mostly Jewish plaintiffs who charged that the ban violates their religious freedom rights.
• A discouraging new study finds that paying off an individual’s medical debt once it has reached collections doesn’t offer them much financial — or mental health — benefit. One factor could be that the failure to pay medical debt is only a symptom of larger financial difficulties.

Also this week, Rovner interviews KFF Health News’ Molly Castle Work, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” feature about an air-ambulance ride for an infant with RSV that his insurer deemed not to be medically necessary. If you have an outrageous or baffling medical bill 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 that they think you should read, too:

Julie Rovner: Stat’s “Your Dog Is Probably on Prozac. Experts Say That Says More About the American Mental Health Crisis Than Pets,” by Sarah Owermohle.

Rachel Cohrs Zhang: KFF Health News’ “Ten Doctors on FDA Panel Reviewing Abbott Heart Device Had Financial Ties With Company,” by David Hilzenrath and Holly K. Hacker.

Alice Miranda Ollstein: The Texas Tribune’s “How Texas Teens Lost the One Program That Allowed Birth Control Without Parental Consent,” by Eleanor Klibanoff.

Rachel Roubein: The Washington Post’s “As Obesity Rises, Big Food and Dietitians Push ‘Anti-Diet’ Advice,” by Sasha Chavkin, Caitlin Gilbert, Anjali Tsui, and Anahad O’Connor.

Also mentioned on this week’s podcast:

• Live Action’s “Hi, My Name’s Olivia” video.
• The New York Times’ “Insurers Reap Hidden Fees by Slashing Payment. You May Get the Bill,” by Chris Hamby.
• The Nation Bureau of Economic Research’s “The Effects of Medical Debt Relief: Evidence From Two Randomized Experiments,” by Raymond Kluender, Neale Mahoney, Francis Wong, and Wesley Yin.
• USA Today’s “The Database You Don’t Want to Need: Check to See if Your Health Data Was Hacked,” by Cecilia Garzella.

Click to open the transcript

Transcript: Arizona Turns Back the Clock on Abortion Access

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 11, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go.

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

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: And we welcome back from her leave Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, happy to be here.

Rovner: Later in this episode we’ll have my interview with my KFF Health News colleague Molly Work about the latest KFF Health News-NPR “Bill of the Month,” about yet another very expensive air-ambulance ride that an insurer deemed “unnecessary.” As you will hear, that is hardly the case.

But first, this week’s news, and there is lots of it. We start again this week with abortion because, again, that’s where the biggest news is. I want to do this chronologically because there were a lot of things that happened and they all built on each piece before them. So on Monday, former President [Donald] Trump, as promised, issued his long-awaited statement on abortion, a four-minute video posted on his platform Truth Social, in which he took credit for appointing the justices who overturned Roe v. Wade, but then kind of declared the job done because abortion is now up to the individual states. And while he didn’t say so directly, that strongly suggested he would not be supporting efforts by anti-abortion groups to try to pass a federal 15-week ban, should Republicans retake the presidency and both houses of Congress. That alone was a big step away from some of his strongest anti-abortion supporters like the SBA List [Susan B. Anthony Pro-Life America], which helped got him elected in 2016, right, Alice? I see you nodding.

Ollstein: Yes. He kind of left himself some wiggle room. He made a statement that, at first, people could sort of read into it what they wanted. And so you had several anti-abortion groups going, “Well, he didn’t advocate for a national ban, but he also didn’t rule it out.” But then, as I’m sure we’ll get to, he was asked follow-up questions and he kind of did rule it out. He kind of did say, “No, I wouldn’t sign a national ban if it were presented to me.” And so the little crumbs of hope anti-abortion groups were picking up on may or may not be there. But it was both notable for what he did say and what he didn’t say. There are still a lot of unanswered questions about what he would do in office, both in terms of legislation, which is really a remote possibility that no one thinks is real, but he didn’t say anything.

Rovner: It would need 60 votes in the Senate.

Ollstein: Exactly.

Rovner: Legislation.

Ollstein: Exactly. And no one really on the right or left thinks that is going to happen, but he didn’t say anything about what he would do with executive powers, which, as we’ve discussed, could go a long, long way towards banning abortion nationwide.

Rovner: One of the things that sort of fascinates me, I’ve been covering abortion for a long time, longer than some of you have been alive, and I have seen lots of politicians switch sides on this. I mean, Joe Biden started out as very anti-abortion, now very in favor of abortion rights. So I’ve seen politicians go both ways, but the general rule has always been you get to switch once. You get to either go from being pro-life to pro-choice or being pro-choice to pro-life. You don’t get to go back and forth and yet that seems to be very much what Trump has done. He seems to have taken every conceivable position there is on this extraordinarily binary issue and gotten away with it.

Ollstein: One last thing I wanted to flag in the statement was that he kind of said the quiet part out loud and that he directly said that this is about winning elections. So he’s saying, “This is what we need to say in order to win,” which leaves open what he really believes or what he really would do.

Roubein: Yeah, I mean, going back to Trump’s shifting view on abortion, because that’s really important and that’s something that the anti-abortion movement is sort of looking towards. I mean, in 1999 in an interview in “Meet the Press,” he called himself “very pro-choice,” and then we kind of saw by 2016, he had committed to naming justices who had anti-abortion views. And as Alice mentioned then, after the midterms in 2022, he blamed Republican losses on that.

Rovner: Yeah, I assume that makes it hard for people who try to follow him. I know [Sen.] Lindsey Graham came out, Lindsey Graham, who’s been sort of the major backer of the 15-week abortion ban in Congress for some time now, and suddenly Lindsey Graham, who has been nothing but loyal to Trump, finds himself on the other side of a big, important issue. I mean, Trump seems to get away with it. The question is, are his followers going to get away with having different positions on this?

Cohrs Zhang: Oh, I also just wanted to say that I think it’ll be interesting to see who Trump chooses as his running mate on this because obviously his opinion and his position is very important, but I think we saw kind of last time around with him leaning on Mike Pence a little bit for credibility with the anti-abortion movement. So I think it’ll be interesting to see whether he chooses someone again who can mend some of these relationships or whether he’s just going to carry on and make those decisions himself and lean less on his VP.

Rovner: Well, let’s move on to Tuesday because on Tuesday the Trump abortion doctrine got a pretty severe test from the Arizona Supreme Court, which ruled that an almost absolute abortion ban that was passed in 1864, before Arizona was a state, before the end of the Civil War, can be enforced. Alice, what’s this law and when might it take effect?

Ollstein: So the Supreme Court kicked some of those issues back down to the lower court and so it’s still being worked out. Currently, abortion is banned after 15 weeks of pregnancy. The total ban could go into effect in a little over a month, but it’s really uncertain. And so you’re seeing a lot of the same fear and confusion that we saw in the immediate aftermath of Dobbs [v. Jackson Women’s Health Organization], where providers and patients don’t know what’s legal and whether they can provide or receive care and are, in some instances, over-complying and holding off on doing things that are still legal.

And so just a great example of how Trump and these national political figures, they can take whatever position they want, but that often gets overtaken by events. And so you saw Trump come out and say, “States should decide.” This is arguably an instance of states deciding, although the Supreme Court upholding a law from when no one was currently alive, was part of that, the law was implemented when women couldn’t vote, when Arizona wasn’t even a state yet. So whether this is an example of “will of the people,” that can be debated. But this is an example of “leave it to states.” And then Trump was asked about the Arizona decision, whether it went too far, and he said “Yes, it did go too far.” So it’s like should states be allowed to decide or not?

Rovner: It’s like, “Leave it to states unless they go too far.”

Roubein: And who decides what too far is, because a lot of anti-abortion groups were very complimentary of the Arizona ruling and said it was the right thing to do. So depends who you ask.

Rovner: So this obviously scrambles politics beyond just the presidential race, although I think it’s pretty clear to say that it puts Arizona, which had been teetering as being sort of purple state-ish, right back in play, but it’s going to affect things down the ballot and in other states, right?

Ollstein: I mean just looking at Arizona, I mean abortion rights and Democrats have really been pushing ballot measures here, and, I think as Julie was alluding to, there’s a ballot measure effort in Arizona, and I believe the organizers have said that they have enough signatures to qualify, then there’s steps to actually qualifying. So that’s going to really put a spotlight on Arizona. But, we’ve seen ballot measures in other states, Florida. Democrats really want Florida to be in play now that there’s been a Florida state Supreme Court ruling and there’s a ballot measure there. The threshold’s higher, it’s 60%, but all around the country it’s going to be putting increasing emphasis on this ballot measure effort.

Rovner: So the Republicans now really have no place to hide. I saw there was a Senate candidate in Wisconsin who had been very completely anti-abortion, now seems to be a lot less anti-abortion. I mean Republicans have spent a lot of time putting Democrats on the spot about not wanting to be specific on their abortion position, and that’s what leads to the, “You support abortion up until the ninth month,” which isn’t a thing. But now I feel like it’s a chance for Democrats to turn this on Republicans saying, “Now you have to say exactly what your position is rather than just you are ‘anti-abortion’ or ‘100% pro-life,’ which for many, many elections was plenty and all the candidates needed to say.

Cohrs Zhang: Just as we talk about all of these different, how this is playing out, certainly I think the instance you brought up was an example of a position on the larger issue of what a candidate is going to support generally, but I think there are these kind of tangential local issues too that candidates are going to have to take positions on. I think if we look back, like IVF, that’s something that candidates have never really had to weigh in on, and I think it is going to become local in a new way, which just seeing all these offshoot rulings and court decisions. And I think that it was an excellent catch, and, certainly, it’ll be interesting to see how candidates move across the spectrum as we see some more and more extreme local cases coming up even beyond the national standard.

Rovner: And as Alice points out, this is more than just political. This affects health care on the ground. Doctors either not wanting to train in states that have strict bans or doctors in some cases picking up and leaving states, not wanting to be threatened with jail or loss of license. So that affects what other kinds of women’s health care is available. Alice, you wanted to add something?

Ollstein: Yeah, I’ve been seeing a lot of people saying, both with the Florida ruling and with the Arizona ruling, so in both of these instances, a very sweeping abortion ban is expected to go into effect, but then there’s going to be a ballot referendum in the fall where voters will have the opportunity to get rid of those bans. And so you’re seeing a lot of people saying, “OK, well this is only temporary. Voters will be so outraged over this that they’ll vote to support these ballot measures to overturn it.” But I think it’s important to remember that a lot of the impacts will linger for a long time if these clinics can’t hang on even a few months under a near-total ban and shut their doors. You can’t just flip a switch and turn that back on. It’s incredibly hard to open a new abortion clinic.

Rovner: Or even to reopen one that you’ve closed down “temporarily.”

Ollstein: Exactly. And like you said, medical students and residents and doctors are making decisions about where to live and where to practice that could have impacts that last for years and years. And so people saying, “Oh, well, it’s not that important if these bans go into effect now because in November voters will have their say.” Even a few months can have a very long effect in a state.

Rovner: Yeah. I just want to continue to reiterate this is about more than politics. This is actually about health care on the ground.

Well, in other abortion news, a three-judge panel of the Indiana Court of Appeals ruled last week that the state cannot enforce its abortion ban against a group of plaintiffs who are non-Christians and charge that the ban violates their freedom of religion because some religions, notably Judaism but others too, include tenets that prioritize the life and health of the pregnant woman over that of the fetus. This is obviously not the last word on this case. It could still go to the Indiana Supreme Court or even the U.S. Supreme Court, but it does seem significant. I think it’s the first decision we’ve seen on one of these cases, and it was unanimous. And interestingly, it turns a lot of the recent decisions protecting religious freedom for Christians right back on those who would ban abortion. Alice, there are more of these … awaiting hearing, right?

Ollstein: Yes. There’s ones going on really around the country that are testing these legal theories, and part of it is that state-level religious freedom laws are often more expansive and protective than federal religious freedom laws. And so they’re leaning on that. And yeah, it’s a really fascinating test case of, were these religious freedom laws intended to only protect one particular religion that has hegemonic power in the United States right now or were they designed to protect every one of every religion? And I think Judeo-Christian values is a term that’s thrown out a lot, and this really shows that there are very different beliefs when it comes to pregnancy and abortion and which life to prioritize between the mother and the child. And when it even counts as an abortion, when it even counts as life beginning, that is a lot more muddled.

And look, in this case it was led by Jewish plaintiffs challenging, but I’ve been tracking cases that draw from many different religions, and these protections even apply to avowed atheists in some instances. And so I think this is definitely something to keep an eye on. In addition to Indiana, the other case I’ve been following most closely is in Missouri, so it’ll be really fascinating to see what happens.

Rovner: There was one in Kentucky, too. Did anything ever happen with that one? I think that was the first one we talked about.

Ollstein: They’re still waiting.

Rovner: Like two years ago.

Ollstein: Yeah. The wheels of justice turn slowly.

Rovner: Indeed, they do. Well, finally, Tennessee is on the verge of enacting a bill that would require students to be shown a three-minute video on fetal development and strongly recommends one made by the anti-abortion group Live Action. Not surprisingly, medical experts say the video is inaccurate and manipulative. I will post a link to it so you can watch it and judge for yourself. What jumped out to me in this story is that one Tennessee lawmaker, himself a physician, said, and I quote, “Whether all of the exact details are correct, I don’t think that is important.” Is that where we have come with this debate these days, that facts are no longer important?

Cohrs Zhang: I mean, I thought it was interesting that there was an amendment rejected that would’ve allowed parents to opt out of it. And I just feel like there’s so many permission slips in schools these days for any book or movie that something like this would be mandated is just kind of like an interesting twist on that. So again, we’ll be interested to see if it actually takes effect, but …

Rovner: I mean, it’s a pretty benign video. It’s basically purporting to show fetal development from the moment of fertilization up to birth. The big complaint about it is it’s misleading on the timing because it’s counting from a different place than doctors count from. It’s counting from the moment of fertilization. Doctors generally count pregnancy from the last missed period because it’s hard to tell. You don’t know when the moment of fertilization was. But when we talk about first trimester or however many weeks, medically you’re talking about weeks since last missed period. So this makes everything look like it happened earlier than it actually does in common parlance. Have I explained that right, Alice?

Ollstein: Yes. And we are seeing efforts on this front both to make these educational mandates for students, but we’re also seeing them mandated for doctors’ education in some states as well. Part of this is to address what everyone on all sides acknowledges is a problem, which is that doctors don’t understand when the exemptions to these abortion bans apply in terms of life and health of the parent coming into play. Oftentimes these bans are written with nonmedical language talking about serious threats. What’s serious? Talking about harm to a major bodily function. What’s major? So, you are seeing doctors holding off from providing abortions even in cases that they think should be exempt, these emergency situations, and so anti-abortion groups are pushing these bills mandating certain curricula for doctors to try to address this confusion. The medical groups I’ve spoken to don’t think this is a solution, but it’s interesting as an attempt.

Rovner: In some states, it has to be an affirmative defense. So as you, a doctor, consider an emergency, you perform the abortion and then instead of not getting charged, you get charged and you have to go hire a lawyer and go to court and say, “I decided that this was an emergency.” And that’s not something that’s very attractive to doctors either. And Rachel, you wanted to add …

Roubein: Oh yeah, I was just going to say I think one of the things that stuck out to me about this particular video, one of my colleagues, Dan Rosen, so I [inaudible 00:16: 52] in February, and he said that this is Live Action, which is the group that came under the spotlight in 2011 for releasing undercover videos seeking to discredit Planned Parenthood, but Live Action had been playing the Baby Olivia to legislative audiences, including at an influential conservative group, American Legislative Exchange Council. So just kind of looking at who’s kind of seeking to get this video into classrooms.

Rovner: All right, well now it is time for our weekly dive into why health care costs so darn much. We begin with a fascinating and infuriating investigation from The New York Times about another one of those third-party contractors most of us had never heard of, kind of like Change Healthcare before it got hacked. This one is called MultiPlan, and its job is to recommend how much insurers and/or employers, in self-insured plans, should pay providers. Except it turns out that MultiPlan has an incentive to pay providers less than they charge. It pockets part of the “savings.” And in most of the cases, these out-of-network charges are not covered by the surprise-billing law. I think because patients know they are going out-of-network, that part is not entirely clear to me. And of course, often patients have no other available providers, so they have no choice but to go out-of-network.

Sometimes indeed providers do overcharge outrageously. We’ve talked about that a lot. But in this case, it seems that a lot of these recommendations are to underpay outrageously. The firm told one therapist that her fair payment should be half of what Medicaid pays. Medicaid, traditionally the lowest payer of everyone. I feel like this story’s going to have legs, as they say. Apparently, the American Hospital Association has already asked the U.S. Department of Labor to investigate MultiPlan. Why do I feel like we’re all pawns in this huge competition between health care providers and insurers about who can pay who less or more and pocket the differences?

Cohrs Zhang: Yeah, I think we first heard about MultiPlan, kind of in the conversation around surprise billing, because that was just a different category of these out-of-network bills where patients were getting stuck in the middle. And I think over time we’ve seen more stories come out about loopholes in those protections. And this is another example where MultiPlan is … they have to fix their business model. And the arbitration process for these surprise bills is so backed up, in these certain cases, which are more emergency care, I think, and if patients don’t necessarily have control or knowledge of their provider being out-of-network.

But certainly, people, if you’re looking for a certain specialist or want to go to a certain place to have a procedure done, then you may just elect an out-of-network provider. And I think the part I found really interesting about this reporting, that I think we’ve seen reflected in larger trends on business reporting, is really understanding these business models better and the incentives. And I love the graphics, I think, where you’re showing that if MultiPlan can lowball these providers and manage to squeeze a little bit more of a discount for payers, then they’re taking a cut of that discount, and patients can be left on the hook for these too.

So I think, as with anything, these surprise-billing protections are going to be an iterative process. And certainly I think there’s more to be done in so many different individual cases to protect patients from some of these games that providers and insurers are engaged in and the firms that kind of specialize in brokering these negotiations.

Rovner: It feels very whack-a-mole, every time they sort of put a band-aid on one problem, another one pops up, that it’s just sort of this is what happens when a fifth of your economy goes to health care is that everybody says, “Oh, I can make money doing X.” And then, there’s an awful lot of people making money doing X, which is not necessarily having anything to do with providing or receiving medical care.

Cohrs Zhang: Absolutely. And correct me if I’m wrong, I think MultiPlan, it may be publicly traded as well. So if you look at some of these incentives here to kind of meet those quarterly targets and how that aligns with patients, I think that’s also just something we keep in mind.

Rovner: And there was private equity involved on both sides, too, which I didn’t even want to try to explain. You should really read the story, which is really very complicated and very well explained. Because this is how it works: They make it complicated so you can’t figure out what’s going on.

Well, meanwhile, in a sad payment story of the week, a new study has found that paying off people’s medical debt doesn’t actually fix their financial problems. According to a National Bureau of Economic Research working paper, paying off debts that have already gone to collection did not improve the financial status of the people who owed the money, nor their mental health, nor did it make it more likely that they would be able to pay future medical bills. One thing it did do was help their credit ratings. The researchers said that they hope maybe paying off debt before it reaches the collection status might be more helpful, but that would also be more expensive. What makes it easy to pay off medical debt after it’s gone to collections is they sell it for pennies on the dollar. And of course, the U.S. is already moving towards taking medical debt off of people’s credit report. So obviously we’re talking about patients getting stuck with these huge bills and they end up with this medical debt and now we can’t seem to figure out how to fix the medical debt problem either.

Cohrs Zhang: When I first saw the study, obviously I trust that Sarah Kliff edited her studies, but I scrolled right down to the conflict-of-interest section to see who funded this. And yeah, it was a very depressing study. But I think it’s important to keep in mind that a failure to pay medical debt is a symptom of larger economic problems. Certainly there may be cases where medical debt is the only outstanding debt somebody has or is a shocking surprise or is a lien on their home, something like that that might have just these massive consequences.

But I think one of the points that was brought up in the story was that when you have medical debt, sure, you have collections calls, you have bad impact on your credit, but you’re not getting evicted from your home. And we’ve heard about cases where providers have held outstanding balances against patients, but I don’t think that’s a general practice. You’re supposed to be seen if you go in for medical care. So I think just like the day-to-day challenges of poverty, of debt, are so overwhelming that it is a little discouraging to hear that these individual payments may not have changed someone’s life. But I think there may be anecdotal cases that would be different from that larger trend, but it was not an encouraging study.

Rovner: No. And speaking of conflict of interest, there was the opposite of conflict of interest. It was conducted in part by the group RIP Medical Debt, which was created to help pay off people’s medical debt. And they did say, obviously there are cases in this does make huge differences in individual people’s lives. It was just that, overall, apparently the model by which they are paying off people’s debt is not helping them as much as I guess they had hoped to. So they have to look on to other things.

Moving on to this week in health data security, or lack thereof, it seems that another cyberattack group is trying to get Change Healthcare to pay ransom. This is after the company reportedly paid $22 million. So it seems that after paying, the company didn’t get all of its stolen records back. Meanwhile, it seems that even though we’re not hearing as much about this as we were, there are still lots of providers that aren’t getting paid. I mean, Rachel, this thing as we predicted, has a really long tail.

Roubein: Absolutely does. Yeah, I think we’re seeing these multiple ransomware groups trying to extort money out of UnitedHealthcare. I mean, they have deep pockets. It’s such a mess. I think, who’s to say what’s true about what data they have as well. So it’s kind of hard to report on these kind of things. And I think only UnitedHealthcare has the answers to those questions. But I think we are going to see some more congressional oversight on this issue. I know providers, hospitals, and physician groups were absolutely using these arguments on Capitol Hill during the appropriations negotiations. They’re saying, “We’re in such financial distress.” Going to their lawmakers talking about how it wouldn’t be a good idea to cut provider payments or implement site-neutral payments for hospitals, all these long-term things that lawmakers have been thinking about. There were other political problems, too, but I think it’s definitely seeped into Washington how difficult this has been, how cumbersome some of the workarounds are for providers, large and small, I think who are trying to work around this fiasco.

Rovner: Yeah, I read one story, I mean it really does feel like a spy movie that they’re assuming that maybe the company that got the ransom that was supposed to split it with the company that actually did the hacking didn’t and made off with the money. And now the company that actually did the hacking is trying to get its own ransom and oh my goodness. I mean, again, this is what happens when a fifth of the economy goes through the health care system. But I mean, I want to keep on this story because this story really does keep on impacting the back-room goings-on, which keep the health care system functioning in some ways.

And while we are on the subject of health care data breaches, USA Today has now a searchable tool for you to find out if you’re one of the 144 million Americans whose medical information was stolen or exposed in the last year. Yay? I think? I suppose this is a necessary evil. It’s hard for me to imagine 10 years ago. It’s like, “Wow, you can take some time and find out if your medical information’s been exposed.”

Roubein: It’s better than not knowing because you can change your passwords, you can do some credit monitoring, you could protect your information in some ways. But it’s not the same as better protections for the breaches happening in the first place.

Rovner: I know Congress is talking about a privacy bill, but apparently it is in truly embryonic stages at this point because I don’t think Congress really knows what to do about this either. They just know that they probably should do something.

All right, that is the news for this week. Now we will play my bill of the month interview with Molly [Castle] Work. Then we will come back and do our extra credits.

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

Molly Castle Work: Thanks so much, Julie.

Rovner: So this month’s bill, like last month’s bill, is for an air-ambulance ride, a bill that should have been prevented by the federal No Surprises Act. But we’ll get to that in a minute. First, who is our patient this month?

Work: So our patient is Amari Vaca. He was a 3-month-old baby at the time from Salinas, California.

Rovner: And what happened to him?

Work: When Amari was a 3-month-old baby, he had issues with his breathing. His mother took him to a local ER and pretty quickly his team of doctors decided that he needed more specialized care at a larger hospital in San Francisco. So they organized an emergency transport.

Rovner: Via helicopter, yes?

Work: It was actually by air ambulance. So like a small airplane.

Rovner: Ah. OK. And before we get too far, he’s OK now, right?

Work: Yes, he is OK. Unfortunately, he was transported to the hospital. He was there for three weeks. They diagnosed him with RSV, but he’s fortunately doing well, now.

Rovner: Well, and then as we say, the bill came. And how much was it?

Work: It was $97,599.

Rovner: Of which the insurance paid how much?

Work: Zero.

Rovner: Now, as I mentioned at the top, the federal surprise-billing law should have prevented the patient from getting a big bill like this, except it didn’t in this case. So why not?

Work: Yeah, so this was really interesting. Cigna, which was Amari’s health plan at the time, decided that the care was not medically necessary. Their argument was that he could have taken a ground ambulance. There was nothing to prove that he had to take this emergency airplane. And so, because of this, Cigna was able to avoid No Surprises Act and they didn’t pay for any of the bill.

Rovner: And, therefore, the patient was left on the hook.

Work: Yes. Amari and his family were left on the hook for the entire bill.

Rovner: So this feels like something that should have been taken care of with a phone call. The insurer calls the doctor and says, “Hey, why’d you order an air ambulance when the hospital’s only 100 miles away?” And the doctor says, “Because it was an infant on a ventilator.” But that would’ve been too easy, right?

Work: Yeah, exactly. There’s a lot of issues with this. First off, one of the best things about No Surprises Act is it’s supposed to take patients out of this. It’s supposed to make it so health plans and providers deal with all these negotiations before it even goes to a patient. But because of how this was handled, instead, Amari’s family is having to do all these negotiations. They’re the ones who are writing letters, using his medical records, to Cigna, and doing multiple appeals.

Rovner: And so far, has there been any progress or is the bill still outstanding?

Work: It’s still outstanding. His mother, Sara, has done two internal appeals. So that means she applied to have the bill changed within Cigna. They denied her both times. Right now she’s working on an external appeal, where an outside provider helps evaluate, and she’s still waiting to hear back on that.

Rovner: So what’s the takeaway here? I mean, obviously you take your critically ill child to a hospital, and they say he has to go, he needs a higher level of care, and recommends an air ambulance. Are you supposed to say, “Wait, I have to call my insurer first to make sure they’re not going to deem this medically unnecessary?”

Work: Yeah, that’s what’s so frustrating because obviously if any of us were in that situation, we would’ve done the same thing. If our baby was sick, we would do the emergency air ambulance, or what we would do what the doctors told us to do. I think what I’ve been hearing from people is that, first off, hospitals should become better acquainted with what plans cover. Of course, we can only hope. But the hospital, for example, should have checked which air-ambulance providers are covered by Cigna before they made the call, because the one they did call was out-of-network for Amari’s family. As patients, what you can really do is you just need to advocate for yourself. It’s easy to be intimidated, but there are lots of times that hospitals just get the medical bill wrong or insurance companies. So do what Sara is doing and appeal. If internal appeals don’t work, go push for that external appeal as well.

Rovner: Yes, these days it helps to know your rights and to try to exercise them when you have them. Molly Work, thank you so much.

Work: 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. Rachel, Rachel Zhang. Why don’t you go first this week? Yep. We have both Rachels.

Cohrs Zhang: Yes. Confusing. So I chose a story in KFF Health News actually, and the headline is “Ten Doctors on FDA Panel Reviewing Abbott Heart Device Had Financial Ties With Company.” And I think this was just a really illuminating explanation of some of the loopholes in conflict-of-interest disclosures with FDA advisory committees. There’s a lot of controversy over what role these committees should play, when they should meet. But we’re seeing them play some very high-profile roles in drug approvals as well. But we have a medical device reporter on our team, and we just think it’s such an important coverage area as we’re looking at the money that the medical device industry spends. And I mean, you’re looking at some of these advisory board members who’ve received, on Open Payments, $200,000 from this company, and they’re not disclosing it because it’s not directly related to this individual device.

And I think it’s fair to say that some of them argued, “It was for a clinical study. The university got the money. I wasn’t spending it on a fancy car or something.” But nonetheless, I think there’s a good argument in this piece for some more stringent requirements for conflict of interest, especially if this data is publicly available.

Rovner: Yes, I was kind of taken this week about how very many good stories there were about investigations into conflicts of interest. Speaking of which, Rachel, other Rachel, why don’t you go next?

Roubein: My extra credit this week is titled “As Obesity Rises, Big Food and Dietitians Push ‘Anti-Diet’ Advice” and it’s a joint investigation by The Washington Post and The Examination, which is a new nonprofit newsroom that’s specializing in global health. And I thought it was a really fascinating window into the food industry and its practices at a time when the FDA and its commissioner wants to crack down, make front-of-package labeling more prevalent. And so basically the story dives into this anti-diet movement, which began as an effort to combat weight stigma and unhealthy obsession with thinness. And the movement has now become kind of a behemoth on social media, and basically food marketers are kind of trying to cash in here. The story kind of focused on one company in particular, General Mills, and its cereal, and the investigation found that the company launched a multipronged campaign to capitalize on the anti-diet movement and giveaways to registered dietitians who promote the cereals online. And I just thought it was kind of a fascinating exploration of all of these dynamics.

Rovner: Yes. Good journalism at work. Alice.

Ollstein: Yeah, I have a story from the Texas Tribune [“How Texas Teens Lost the One Program That Allowed Birth Control Without Parental Consent“] by Eleanor Klibanoff about the impact of the court ruling that said that Title X federal family planning clinics that all across the country have a policy of dispensing contraception, prescribing contraception to teens, whether or not they have parental consent, and doing that in a … advancing privacy and protecting them in that way. There was just a recent court ruling that said, just in Texas, the state’s parental consent laws override that. And they found that at a lot of these clinics, instances of teens coming in and seeking contraception have really fallen off. These are teens, the story documents, who don’t feel comfortable going to their parents. There’s instances of parents even getting violent with their kids when they find out about this. And so it really shows the effect of this, and this is something we should be continuing to track because it went to the 5th Circuit and it could go to the Supreme Court. We don’t know yet.

Rovner: Yeah, we talked about this case a couple of weeks ago. It was another of those cases that was very much aimed at a particular judge that they were confident would rule in their favor, who indeed did rule in their favor.

All right, well, my extra credit this week is not an investigation, it’s just a story I really liked from Stat News from Rachel’s colleague Sarah Owermohle, and it’s called “Your Dog Is Probably on Prozac. Experts Say That Says More About the American Mental Health Crisis Than Pets.” And full disclosure, that is one of my dogs in the background messing with a bone. My dogs are not on Prozac, but I am, and we are all three the better for it. It’s a serious story, though, about how our mental health impacts that of our pets, not just vice versa, and about how so few new medicines there are for anxiety and depression. And as an officer of a dog training club, I will say that it’s more than humans’ projections. We are definitely seeing more dogs with behavioral issues than at any time that I can remember, and I’ve owned dogs all my life.

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

Ollstein: I’m at @AliceOllstein on X, and @alicemiranda on Bluesky.

Rovner: Rachel Zhang?

Cohrs Zhang: I’m at @rachelcohrs on X and also spending more time on LinkedIn these days. 

Rovner: Rachel Roubein?

Roubein: @rachel_roubein on X.

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

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