One owns a for-profit insurer, a venture capital company, and for-profit hospitals in Italy and Kazakhstan; it has just acquired its fourth for-profit hospital in Ireland. Another owns one of the largest for-profit hospitals in London, is partnering to build a massive training facility for a professional basketball team, and has launched and financed 80 for-profit start-ups. Another partners with a wellness spa where rooms cost $4,000 a night and co-invests with “leading private equity firms.”

Do these sound like charities?

These diversified businesses are, in fact, some of the country’s largest nonprofit hospital systems. And they have somehow managed to keep myriad for-profit enterprises under their nonprofit umbrella — a status that means they pay little or no taxes, float bonds at preferred rates, and gain numerous other financial advantages.

Through legal maneuvering, regulatory neglect, and a large dollop of lobbying, they have remained tax-exempt charities, classified as 501(c)(3)s.

“Hospitals are some of the biggest businesses in the U.S. — nonprofit in name only,” said Martin Gaynor, an economics and public policy professor at Carnegie Mellon University. “They realized they could own for-profit businesses and keep their not-for-profit status. So the parking lot is for-profit; the laundry service is for-profit; they open up for-profit entities in other countries that are expressly for making money. Great work if you can get it.”

Many universities’ most robust income streams come from their technically nonprofit hospitals. At Stanford University, 62% of operating revenue in fiscal 2023 was from health services; at the University of Chicago, patient services brought in 49% of operating revenue in fiscal 2022.

To be sure, many hospitals’ major source of income is still likely to be pricey patient care. Because they are nonprofit and therefore, by definition, can’t show that thing called “profit,” excess earnings are called “operating surpluses.” Meanwhile, some nonprofit hospitals, particularly in rural areas and inner cities, struggle to stay afloat because they depend heavily on lower payments from Medicaid and Medicare and have no alternative income streams.

But investments are making “a bigger and bigger difference” in the bottom line of many big systems, said Ge Bai, a professor of health care accounting at the Johns Hopkins University Bloomberg School of Public Health. Investment income helped Cleveland Clinic overcome the deficit incurred during the pandemic.

When many U.S. hospitals were founded over the past two centuries, mostly by religious groups, they were accorded nonprofit status for doling out free care during an era in which fewer people had insurance and bills were modest. The institutions operated on razor-thin margins. But as more Americans gained insurance and medical treatments became more effective — and more expensive — there was money to be made.

Not-for-profit hospitals merged with one another, pursuing economies of scale, like joint purchasing of linens and surgical supplies. Then, in this century, they also began acquiring parts of the health care systems that had long been for-profit, such as doctors’ groups, as well as imaging and surgery centers. That raised some legal eyebrows — how could a nonprofit simply acquire a for-profit? — but regulators and the IRS let it ride.

And in recent years, partnerships with, and ownership of, profit-making ventures have strayed further and further afield from the purported charitable health care mission in their community.

“When I first encountered it, I was dumbfounded — I said, ‘This not charitable,’” said Michael West, an attorney and senior vice president of the New York Council of Nonprofits. “I’ve long questioned why these institutions get away with it. I just don’t see how it’s compliant with the IRS tax code.” West also pointed out that they don’t act like charities: “I mean, everyone knows someone with an outstanding $15,000 bill they can’t pay.”

Hospitals get their tax breaks for providing “charity care and community benefit.” But how much charity care is enough and, more important, what sort of activities count as “community benefit” and how to value them? IRS guidance released this year remains fuzzy on the issue.

Academics who study the subject have consistently found the value of many hospitals’ good work pales in comparison with the value of their tax breaks. Studies have shown that generally nonprofit and for-profit hospitals spend about the same portion of their expenses on the charity care component.

Here are some things listed as “community benefit” on hospital systems’ 990 tax forms: creating jobs; building energy-efficient facilities; hiring minority- or women-owned contractors; upgrading parks with lighting and comfortable seating; creating healing gardens and spas for patients.

All good works, to be sure, but health care?

What’s more, to justify engaging in for-profit business while maintaining their not-for-profit status, hospitals must connect the business revenue to that mission. Otherwise, they pay an unrelated business income tax.

“Their CEOs — many from the corporate world — spout drivel and turn somersaults to make the case,” said Lawton Burns, a management professor at the University of Pennsylvania’s Wharton School. “They do a lot of profitable stuff — they’re very clever and entrepreneurial.”

The truth is that a number of not-for-profit hospitals have become wealthy diversified business organizations. The most visible manifestation of that is outsize executive compensation at many of the country’s big health systems. Seven of the 10 most highly paid nonprofit CEOs in the United States run hospitals and are paid millions, sometimes tens of millions, of dollars annually. The CEOs of the Gates and Ford foundations make far less, just a bit over $1 million.

When challenged about the generous pay packages — as they often are — hospitals respond that running a hospital is a complicated business, that pharmaceutical and insurance execs make much more. Also, board compensation committees determine the payout, considering salaries at comparable institutions as well as the hospital’s financial performance.

One obvious reason for the regulatory tolerance is that hospital systems are major employers — the largest in many states (including Massachusetts, Pennsylvania, Minnesota, Arizona, and Delaware). They are big-time lobbying forces and major donors in Washington and in state capitals.

But some patients have had enough: In a suit brought by a local school board, a judge last year declared that four Pennsylvania hospitals in the Tower Health system had to pay property taxes because its executive pay was “eye popping” and it demonstrated “profit motives through actions such as charging management fees from its hospitals.”

A 2020 Government Accountability Office report chided the IRS for its lack of vigilance in reviewing nonprofit hospitals’ community benefit and recommended ways to “improve IRS oversight.” A follow-up GAO report to Congress in 2023 said, “IRS officials told us that the agency had not revoked a hospital’s tax-exempt status for failing to provide sufficient community benefits in the previous 10 years” and recommended that Congress lay out more specific standards. The IRS declined to comment for this column.

Attorneys general, who regulate charity at the state level, could also get involved. But, in practice, “there is zero accountability,” West said. “Most nonprofits live in fear of the AG. Not hospitals.”

Today’s big hospital systems do miraculous, lifesaving stuff. But they are not channeling Mother Teresa. Maybe it’s time to end the community benefit charade for those that exploit it, and have these big businesses pay at least some tax. Communities could then use those dollars in ways that directly benefit residents’ health.

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

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

It’s not surprising that the nursing home industry is filing lawsuits to block new Biden administration rules requiring minimum staffing at facilities that accept federal dollars. What is slightly surprising is the pushback against the rules from members of Congress. Lawmakers don’t appear to have the votes to disapprove the rule, but they might be able to force a floor vote, which could be embarrassing for the administration.

Meanwhile, Senate Democrats aim to force Republicans who proclaim support for contraceptive access to vote for a bill guaranteeing it, which all but a handful have refused to do.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

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Rachel Cohrs Zhang
Stat News

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Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• In suing to block the Biden administration’s staffing rules, the nursing home industry is arguing that the Centers for Medicare & Medicaid Services lacks the authority to implement the requirements and that the rules, if enforced, could force many facilities to downsize or close.
• Anthony Fauci, the retired director of the National Institute of Allergy and Infectious Diseases and the man who advised both Presidents Donald Trump and Joe Biden on the covid-19 pandemic, testified this week before the congressional committee charged with reviewing the government’s pandemic response. Fauci, the subject of many conspiracy theories, pushed back hard, particularly on the charge that he covered up evidence that the pandemic began because dangerous microbes escaped from a lab in China partly funded by the National Institutes of Health.
• A giant inflatable intrauterine device was positioned near Union Station in Washington, D.C., marking what seemed to be “Contraceptive Week” on Capitol Hill. Republican senators blocked an effort by Senate Majority Leader Chuck Schumer to force a vote on consideration of legislation to codify the federal right to contraception. Immediately after, Schumer announced a vote for next week on codifying access to in vitro fertilization services.
• Hospitals in London appear to be the latest, high-profile cyberattack victims, raising the question of whether it might be time for some sort of international cybercrime-fighting agency. In the United States, health systems and government officials are still in the very early stages of tackling the problem, and it is not clear whether Congress or the administration will take the lead.
• An FDA advisory panel this week recommended against the formal approval of MDMA, a psychedelic also known as ecstasy, to treat post-traumatic stress disorder. Members of the panel said there was not enough evidence to recommend its use. But the discussion did provide more guidance about what companies need to present in terms of trials and evidence to make their argument for approval more feasible.

Also this week, Rovner interviews KFF Health News’ Bram Sable-Smith, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” feature about a free cruise that turned out to be anything but. If you have an outrageous or baffling 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: Abortion, Every Day’s “EXCLUSIVE: Health Data Breach at America’s Largest Crisis Pregnancy Org,” by Jessica Valenti.
• Alice Miranda Ollstein: The Washington Post’s “Conservative Attacks on Birth Control Could Threaten Access,” by Lauren Weber.
• Rachel Cohrs Zhang: ProPublica’s “This Mississippi Hospital Transfers Some Patients to Jail to Await Mental Health Treatment,” by Isabelle Taft, Mississippi Today.
• Sandhya Raman: Air Mail’s “Roanoke’s Requiem,” by Clara Molot.

Click to open the transcript

Transcript: Nursing Home Staffing Rules Prompt Pushback

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

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, June 6, 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: Sandhya Raman of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: And Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Bram Sable-Smith, who reported and wrote this month’s KFF Health News/NPR “Bill of the Month.” It’s about a free cruise that turned out to be anything but. But first, this week’s news. We’re going to start this week with those controversial nursing home staffing rules.

In case you’ve forgotten, back in May, the Biden administration finalized rules that would require nursing homes that receive federal funding, which is basically all of them, to have nurses on duty 24/7/365, as well as impose other minimum staffing requirements.

The nursing home industry, which has been fighting this effort literally for decades, is doing what most big powerful health industry players do when an administration does something it doesn’t like: filing lawsuits. So what is their problem with the requirement to have sufficient staff to care for patients who, by definition, can’t care for themselves or they wouldn’t be in nursing homes?

Cohrs Zhang: Well, I think the groups are arguing that CMS [Centers for Medicare & Medicaid Service] doesn’t have authority to implement these rules, and that if Congress had wanted these minimum staffing requirements, Congress should have done that and they didn’t. So they’re arguing that they’re overstepping their boundaries, and we are seeing this lawsuit again in Texas, which is a popular venue for the health care industry to try to challenge rules or legislation that they don’t like.

So, I think it isn’t a surprise that we would see these groups sue, given the financial issues at stake, given the fearmongering about facilities having to close, and just the hiring that could have to happen for a lot of these facilities. So it’s not necessarily a surprise, but it will certainly be interesting and impactful for facilities and for seniors across the nation as this plays out.

Rovner: I mean, basically one of their arguments is that there just aren’t enough people to hire, that they can’t get the number of people that they would need, and that seems to be actually pretty persuasive argument at some point, right?

Cohrs Zhang: I mean, there is controversy about why staffing shortages happen. Certainly there could be issues with the pipeline or with nursing schools, education. But I think there are also arguments that unions or workers’ rights groups would make that maybe if facilities paid better, then they would get more people to work for them. Or that people might exit the industry because of working conditions, because of understaffing, and just that makes it harder on the workers who are actually there if their workloads are too much. Or they’re expected to do more work — longer hours or overtime — or their vacation is limited, that kind of thing.

So I think it is a surprisingly controversial issue that doesn’t have an easy answer, but that’s the perspectives that we’re seeing here.

Rovner: I mean, layering onto this, it’s not just the industry versus the administration. Now Congress is getting into the act, which you rarely see. They’re talking about using the Congressional Review Act, which is something that Congress can do. But of course, when you’re in the middle of an administration that’s done it, it would get vetoed by the president. So they can’t probably do anything. Sandhya, I see you nodding your head. These members of Congress just want to make a statement here?

Raman: Yeah. So Sen. James Lankford insured the resolution earlier this week to block the rule’s implementation, and it’s mostly Republicans that have signed on, but we also have [Sen.] Joe Manchin and [Sen.] Jon Tester. But the way it stands, it doesn’t have enough folks on board yet, and it would also need to be taken up. It faces an uphill climb like many of these things.

Rovner: Somebody actually asked me yesterday though, can they do this? And the answer is yes, there is the Congressional Review Act. Yes, Congress with just a majority vote and no filibuster in the Senate can overturn an administration rule. But like I said, it usually happens when an administration changes its hands because it does have to be signed by the president and the president can veto it.

If the president vetoes it, then they would need a veto override majority, which they clearly don’t seem to have in this case. But obviously there is enough concern about this issue. I think there’s been a Congressional Review Act resolution introduced in the House too, right?

Ollstein: It’s really tough because, like Rachel said, these jobs are low-paid. They’re emotionally and physically grueling. It’s really hard to find people willing to do this work. And at the same time, the current situation seems really untenable for patients. There’s been so many reports of really horrible patient safety and hygiene issues and all kinds of stuff in part, not entirely the fault of understaffing, but not helped by understaffing certainly.

I think, like, we see on so many fronts in health care, there are attempts to do something about this situation that has become untenable, but any attempt also will piss off someone and be challenged.

Rovner: Yeah, absolutely. And we should point out that nursing homes are staffed primarily not by nurses, but by nurses aides of various training levels. So this is not entirely about a nursing shortage, it is about a shortage of workers who want to do this, as you say, very grueling and usually underpaid work.

Well, speaking of controversial things, Dr. Tony Fauci, the now-retired head of the NIH’s National Institute of Allergy and Infectious Diseases, and currently the man most conspiracy theorists hold responsible for the entire covid-19 pandemic, testified before the House Select Committee on the pandemic Monday. And not surprisingly, sparks flew. What, if anything, did we learn from this hearing?

Cohrs Zhang: The interesting part of this hearing was watching how Dr. Fauci positioned himself in response to a lot of these criticisms that have been circulating. The committee has been going through different witnesses, and specifically it criticized one of his deputies, essentially, who had some unflattering emails released showing that he appeared to be trying to delete emails or use personal accounts to avoid public records requests from journalists or other organizations …

Rovner: I’m shocked, shocked that officials would want to keep their information away from prying reporters’ eyes.

Cohrs Zhang: It’s not surprising, but it is surprising to see it in writing. But this is, again, everyone is working from home and channels of communication were changing. But I think we did see Dr. Fauci pretty aggressively distancing himself, downplaying the relationship he had with this individual and saying that they worked on research together, but he wasn’t necessarily advising agency policy.

So that’s at least how he was framing the relationship. So he definitely downplayed that. And I think an interesting comment he made — I’m curious to see what you think about this, Julie — was that he didn’t say that the lab leak theory itself was a conspiracy, but his involvement and a cover-up was a conspiracy. And so it did seem that some of the rhetoric has at least changed. He seemed more open-minded, I guess, to a lab leak theory than I expected.

Rovner: I thought he was pretty careful about that. I think it was the last thing he said, which is that we’re never really going to know. I mean, it could have been a lab leak. It could have happened. It could have been an animal from the wet market. The Chinese have not been very forthcoming with information. I personally keep wondering why we keep pounding at this.

I mean, it seems unlikely that it was a lab leak and then a conspiracy to cover it up. It clearly was one or the other, and there’s a lot of differences of opinions. And that was the last thing he said is that it could have been either. We don’t know. That’s always struck me as the, “OK, let’s talk about something else.” Anyway, let’s talk about something else.

Raman: I was just going to add, we did see a personal side to him, which I think we didn’t see as much when he was in his official role when he was talking. It was about the death threats that he and his family have been receiving when responding to a lot of the misinformation going around about that. And I thought that was striking compared to, just juxtaposed, with a lot of the other [indecipherable] with [Rep.] Marjorie Taylor Greene saying, “Oh, you’re not a real doctor.” There’s a lot of colorful protesters. And I just thought that stood out, too.

Rovner: Yeah, he did obviously, I think, relish the chance to defend himself from a lot of the charges that have been leveled at him. And I think … his wife is a prominent scientist in her own right — obviously can take care of herself — but I think he was particularly angry that there had been death threats leveled toward his grown daughters, which probably a bit out of line. Alice, you wanted to add something.

Ollstein: Yeah, I think it’s also been interesting to see the shift among Democrats on the committee over time. I think they’ve gone from an attitude of Republicans are on a total witch hunt, this is completely political, this is muddying the waters and fueling conspiracy theories and will lead to worse public health outcomes. And I think based on some of the revelations, like Rachel said about emails and such, they have come to a position of, oh, there might be some things that need investigating and need accountability in here.

But I think their frustration seems to be what it’s always been in that how will this lead to making the country better prepared in the future for the next pandemic — which may or may not already be circulating, but certainly is inevitable at some point. Either way, it’s all well and good to hold officials accountable for things they may have done, but how does that lead to making the country more prepared, improving pandemic response in the future? That’s what they feel is the missing piece here.

Rovner: Yeah. I think there was not a lot of that at this hearing, although I feel like they had to go through this maybe to get over to the other side and start thinking about what we can do in the future to avoid similar kinds of problems. And obviously you get a disease that you have no idea what to do about, and people try to muddle through the best they can. All right, now we are going to move on and we’ll talk about abortion where there is always lots of news.

Here in Washington, there is a giant inflatable IUD flying over Union Station Wednesday to highlight what seems to be Contraception Week on Capitol Hill. Not coincidentally, it’s also the anniversary this week of the Supreme Court’s 1965 ruling Griswold v. Connecticut that created the right to birth control. Alice, what are Democrats, particularly in the Senate where they’re in charge, doing to try to highlight these potential threats to contraceptive access?

Ollstein: So this vote that happened that was blocked because only two Republicans crossed the aisle to support this Right to Contraception bill — it’s the two you expect, it’s [Sen.] Lisa Murkowski and [Sen.] Susan Collins — and you’re already seeing Democrats really make hay of this. Both Democrats and their campaign arms and outside allied groups are planning to just absolutely blitz this in ads. They’re holding events in swing states related to it, and they’re going hard against individual Republicans for their votes.

I think the Republicans I talked to who voted no, they had a funny mixed message about why they were voting no on it. They were both saying that the bill was this sinister Trojan horse for forcing religious groups to promote contraception and even abortion and also gender-affirming care somehow. But also, the bill was a pointless stunt that wouldn’t really do anything because there is no threat to contraception. But also Republicans have their own rival bill to promote access to contraception.

So access to contraception isn’t a problem, but please support my bill to improve access to contraception. It’s a tough message. Whereas Democrats’ message is a lot simpler. You can argue with it on the merits, but it’s a lot simpler. They point to the fact that Supreme Court Justice Clarence Thomas has expressed interest and actually called on the court to revisit precedents that protect the right to contraception.

Lots of states have thwarted attempts to enact protections for contraception. And a lot of anti-abortion groups have really made a big push to muddy the waters on medical understanding of what is contraception versus what is abortion, which we can get into later.

Rovner: Yes, which we will. Sandhya, did you want to add something?

Raman: Yeah, and I think that something that I would add to what Alice was saying is just how this is kind of at the same time a little bit different for the Democrats. Something that I wrote about this week was just that after the Dobbs [v. Jackson Women’s Health Organization] decision, we had the then-Democratic House vote on several different bills, but the Democrats have not really been holding this chamber-wide vote on bills related to abortion, contraception for the most part. And so this was the first time that they are stepping into that.

They’ve done the unanimous consent requests on a lot of these bills. And even just a couple months ago when talks are really heating up on IVF, there’s other things that we have to get to, appropriations and things like that, and this would just get bogged down. And they were shying away from taking floor time to do this. So I think that was an interesting move that they’re doing this now and that they’re going to vote on an IVF next week and whatever else next down the line.

Rovner: Yeah, I noticed that as soon as this bill went down, Sen. [Chuck] Schumer teed up the Right to IVF bill for a vote next week. But Alice, as you were alluding to, I mean, where this gets really uncomfortable for Republicans is that fine line between contraception and abortion. Our colleague Lauren Weber has a story about this this week [“Conservative Attacks on Birth Control Could Threaten Access,”], which is your extra credit, so why don’t you tell us about it?

Ollstein: Yeah. So she did a really great job highlighting how, especially at the state level where a lot of these battles are playing out, anti-abortion groups that are very influential are making arguments that certain forms of birth control are abortifacients. This is completely disputed by medical experts and the FDA [Food and Drug Administration] that regulates these products. They say, just to be clear about what we’re talking about, we’re talking about some forms of emergency contraception, which is taken after sex to prevent pregnancy. It is not an abortifacient. It won’t work if you’re already pregnant. It prevents pregnancy. It does not terminate a pregnancy. They are also saying this about some IUDs, intrauterine devices, and even about some hormonal birth control pills.

So there’s been pushback that Lauren detailed in her story, including from some Republicans who are trying to correct the record. But this misinformation is getting really entrenched, and I think it’s something we should all be paying attention to when it crops up, especially in the mouths of people in power.

Rovner: I mean, when I first started writing about it it was not entirely clear. There was thought that one of the ways the morning-after pill worked was by preventing implantation of a fertilized egg, which some people consider, if you consider that fertilization and not implantation, is the beginning of life. According to doctors, implantation is the beginning of pregnancy, among other things, because that’s when you can test for it.

But those who believe that fertilization is the beginning of life — and therefore something that prevents implantation is an abortion — were concerned that IUDs, and mostly progesterone-based birth control that prevented implantation, were abortifacients. Except that in the years since, it’s been shown that that’s not the case.

Ollstein: Right.

Rovner: That in fact, both IUDs and the morning-after pill work by preventing ovulation. There is no fertilized egg because there’s no egg. So they are not abortifacients. On the other hand, the FDA changed the labeling on the morning-after pill because of this. And yet the Hobby Lobby case [Burwell v. Hobby Lobby Stores Inc.] that the decision was written by Justice [Samuel] Alito, basically took that premise, that they were allowed to not offer these forms of contraception because they believed that they were acted as abortifacients, even though science suggests that they didn’t. It’s not something new, and it’s not something I don’t think is going to go away anytime in the near future.

Raman: I would add that it also came up in this week’s Senate Health [Committee] hearing, that line of questioning about whether or not different parts of birth control were abortifacients. Sen. [Patty] Murray did that line of questioning with Dr. Christina Francis, who’s the head of the anti-abortion obstetrician-gynecology group and went through on Plan B, IUDs and different things. And there was a back and forth of evading questions, but she did call IUDs as abortifacients, which goes back to the same thing that we’re saying.

Rovner: Right, which they have done all along.

Ollstein: Yeah. I mean, I think this really spotlights a challenge here, which is that Republicans’ response to votes like this week and things that are playing out in the state level, they’re scoffing and saying, “It’s absolutely ridiculous to suggest that Republicans are trying to ban birth control. This is completely a political concoction by Democrats to scare people into voting for them in November.”

What we’re talking about here are not bans on birth control, but there are policies that have been introduced at both the state and federal level that would make birth control, especially certain forms like we were just talking about, way harder to access. So there are proposals to carve them out of Obamacare’s contraception mandate, so they’re not covered by insurance.

That’s not a ban. You can still go pay out-of-pocket, but I remember all the people who were paying out-of-pocket for IUDs before Obamacare: hundreds and hundreds of dollars for something that is now completely free. And so what we’re seeing right now are not bans, but I think it’s important to think about the ways it would still restrict access for a lot of people.

Rovner: Before we leave the nation’s capital it seems that the Supreme Court’s upcoming decision on the abortion pill may not be the last word on the case. While it seemed likely from the oral arguments that the justices will agree that the Texas doctors who brought the case don’t have standing, there were three state attorneys general who sought to become part of the case when it was first considered back in Texas. So it would go back to Judge [Matthew] Kacsmaryk, our original judge who said that the entire abortion pill approval should be overturned. It feels like this is not the end of fighting about the abortion pill’s approval at the federal level. I mean, I assume that that’s something that the drug industry, among others, won’t be happy about.

Ollstein: Courts could find that the states don’t have standing either, that this policy does not harm them in any real way. In fact, Democratic attorneys general have argued the exact opposite, that the availability of mifepristone helps states: saves a lot of money; it prevents pregnancy; it treats people’s medical needs. So obviously, Kacsmaryk has a very long anti-abortion record and has sided with these challenges in a lot of cases. But that doesn’t mean that this would necessarily go anywhere.

But your bigger point that the Supreme Court’s upcoming ruling on mifepristone is not the end, it certainly is not. There’s going to be a lot more court challenges, some already in motion. There’s going to be state-level policy fights. There’s going to be federal-level policy fights. If Trump is elected, groups want him to do a lot of things through executive order to restrict mifepristone or remove it from the market entirely through the FDA. So yes, this is not going to be over for the foreseeable future.

Rovner: Well, meanwhile, in a case that might be over for the foreseeable future, the Texas Supreme Court last week officially rejected the case brought by 20 women who nearly died when they were unable to get timely care for pregnancy complications. The justices said in their ruling that while the women definitely did suffer, the fault lay with the doctors who declined to treat them rather than the vagueness of the state’s abortion ban. So where does that leave the debate about medical exceptions?

Ollstein: So anti-abortion groups’ response to a lot of the challenges to these abortion bans and stories about women in medical emergencies who are getting denied care and suffering real harm as a result, their response has been that there’s nothing wrong with the law. The law is perfectly clear, and that doctors are either accidentally or intentionally misinterpreting the law for political reasons. Meanwhile, doctors say it’s not clear at all. It’s not clear how honestly close to dead someone has to be in order to receive an abortion.

Rovner: And it’s not just in Texas. This is true in a bunch of states, right? The doctors don’t know …

Ollstein: In many states.

Rovner: … right? …

Ollstein: Exactly.

Rovner: … when they can intervene.

Ollstein: Right. And so I think the upcoming Supreme Court ruling on EMTALA [Emergency Medical Treatment and Active Labor Law], which we’ve talked about, could give some indication either way of what doctors are and are not able to do, but that won’t really resolve it either. There is still so much gray area. And so patients and doctors are going to state courts to plead for clarity. They’re going to their legislatures to plead for clarity. And they’re going to state medical boards, including in Texas, to plead for clarity. And so far, they have not gotten any.

Most legislatures have been unwilling to revisit their bans and clarify or expand the exceptions even as these stories play out on the ground of doctors who say, “I know that providing an abortion for this patient is the right thing medically and ethically to do, but I’m so afraid of being hit with criminal charges that I put the patient on a plane out of state instead.” Yeah, it’s just really tough.

And so what we wrote about it is we keep talking about doctors being torn between conflicting state and federal law, and that’s absolutely true, but what we dug into is that the state law just looms so much larger than the federal laws. So when you’re weighing, should I maybe violate EMTALA or should I maybe violate my state’s ban, they’re not going to want to violate their state’s ban because that means jail time, that means losing their license, that means having their freedom and their livelihood taken away.

Whereas an EMTALA violation may or may not mean a fine somewhere down the road. The enforcement has not been as aggressive at the federal level from the Biden administration as a lot of doctors would like it to be. And so, in that environment, they’re really deferring to the state law, and that means some people are not getting care that they maybe need.

Rovner: I say in the meantime, we had yet another jury just last week about a woman who had a miscarriage and could not get a D&C [dilation and curettage procedure] basically. When she went in there was no fetal heartbeat, but she ended up miscarrying at home and almost dying. She was sent away, I believe, from three different facilities. This continues to happen because doctors are concerned about when it is appropriate for them to intervene. And they seem, you’re right, to be leaning towards the “let’s not get in trouble with the state” law, so let’s wait to provide care as long as we think we can.

Well, moving on, we have two stories this week about efforts to treat post-traumatic stress disorder, particularly in military veterans. On Tuesday, an FDA advisory committee recommended against approval of the psychedelic MDMA, better known as ecstasy, for the treatment of PTSD. My understanding is that the panel didn’t reject the idea outright that this could be helpful, only that there isn’t enough evidence yet to approve it. Was I reading that right? Rachel, you guys covered this pretty closely.

Cohrs Zhang: Yes. Yeah, my colleagues did cover this. Certainly I think what’s a discouraging sign, I don’t think there’s any way around it, for some of these companies that are looking at psychedelics and trying to figure out some sort of approval pathway for conditions like PTSD.

One of my colleagues, Meghana Keshavan, she chatted with a dozen companies yesterday and they were trying to put a positive spin on it, that having some opinion or some discussion of a treatment like this by the advisory committee could lay out more clear standards for what companies would have to present in order to get something approved. So I think obviously they have a vested interest in spinning this positively.

But it is a very innovative space and certainly was a short-term setback. But it certainly isn’t a long-term issue if some of these companies are able to present stronger evidence or better trial design. I think there were some questions about whether trial participants actually could figure out whether they were placebo or not, which if you’re taking psychedelic drugs, yeah, that’s kind of a challenge in terms of trial design.

So I think there are some interesting questions, and I am confident that this’ll be something the FDA and industry is going to have to figure out in a space that’s new like this.

Rovner: Yeah, it’s been interesting to follow. Well, in something that does seem to help, one of the first controlled studies of service dogs to treat PTSD has found that man’s best friend can be a therapist as well. Those veterans who got specially trained dogs showed much more improvement in their symptoms than those who were on the doggy wait list as determined by professionals who didn’t know who had the dogs and who didn’t. So pet therapy for the win here?

Raman: I mean, this is the biggest study of this kind that we’ve had so far, and it seems promising. I think one thing will be interesting is if there’s more research, if this would change policy down the line for the VA [Department of Veterans Affairs] or other agencies to be able to get these kinds of service dogs in the hands of more vets.

Rovner: Yeah, I know there’s a huge demand for these kinds of service dogs. I know a lot of people who basically have started training service dogs for veterans. Obviously they were able to do this study because there was a long wait list. They were able to look at people who were waiting but hadn’t gotten a dog yet. So at least in the short term, possibly some help for some people.

Finally this week, in a segment I’m calling “Misery Loves Company,” it’s not just the U.S. where big health systems are getting cyberhacked. Across the pond, quoting here from the BBC, major hospitals in London have declared a critical incident after a cyberattack led to operations being canceled and emergency patients being diverted elsewhere. This sounds painfully familiar.

Maybe we need an international cybercrime fighting agency. Is there one? Is there at least, do we know, is there a task force working on this? Obviously the bigger, more centralized your health care system, the bigger problem this becomes, as we saw with Change Healthcare belonging to United[Healthcare], and this is now … I guess it’s a contractor that works for the NHS [National Health Service]. You can see the potential for really bad stuff here.

Cohrs Zhang: That’s a good question about some international standards, Julie, but I think what we have seen is Sen. Ron Wyden, who leads the Senate Finance Committee, did write to HHS [Department of Health and Human Services] this week and asked HHS to add to multiple-factor authentication as a condition of participation for some of these facilities to try to institute standards that way.

And again, I think there are questions about how much HHS can actually do, but I think it’s a signal that Congress might not want to do anything or think they can do anything if they’re asking the administration to do something here. But we’re still in the very early stages of systems viewing this as worthy of investment and just education about some of the best practices here.

Yeah, certainly it’s going to be a business opportunity for some consulting firms to help these hospitals increase their cybersecurity measures and certainly will be a global market if we see these attacks continue in other places, too.

Rovner: Maybe our health records will be as protected as our Spotify accounts. It would apparently be a step forward. All right, well, that is the news for this week. Now we will play my “Bill of the Month” interview with Bram Sable-Smith, and then we will come back and do our extra credits.

I am pleased to welcome back to the podcast my KFF Health News colleague Bram Sable-Smith, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” about a free cruise that turned out to be anything but. Welcome back to the podcast, Bram.

Bram Sable-Smith: Thanks for having me.

Rovner: So tell us about this month’s patient, who he is, and what happened to him. This is one of the wilder Bills of the Month, I think.

Sable-Smith: Right. So his name is Vincent Wasney. He lives in Saginaw, Michigan. Never been on an airplane before, neither had his [fiancée], Sarah. But when they bought their first house in 2019, their Realtor, as a gift, gifted them tickets for a cruise. My Realtor gave me a tote bag. So, what a Realtor, first of all! What an incredible gift.

Rovner: My Realtor gave me a wine opener, which I do still use.

Sable-Smith: If it sailed to the Caribbean, it’d be equivalent. So their cruise got delayed because of the pandemic, but they set sail in December 2022. And they were having a great time. One of the highlights of their trip was they went to this private island called CocoCay for Royal Caribbean guests, and it included an excursion to go swimming with pigs.

Rovner: Wild pigs, right?

Sable-Smith: Wild pigs, a big fancy water park, all kinds of food. They were having a great time. But it’s also on that island that Vincent started feeling off. And so in the past, Vincent has had seizures. About 10 years earlier, he had had a few seizures. They decided he was probably epileptic, and he was on medicine for a while. He went off the medicine because they were worried about liver damage, and he’d been relatively seizure-free for a long time. It’d been a long time since he’d had a seizure.

But when he was on that island having a great time, it’s when he started to feel off. And when they got back on the cruise ship for the last full day of the cruise, he had a seizure in his room. And he was taken down to the medical center on the cruise ship and he was observed. He was given fluids for a while, and then sent back to his room, where he had a second seizure. Once again, went down to the medical center on the ship, where he had a third seizure. It was time to get him off the boat. He needed to get onto land and go to a hospital. And so they were close enough to land that they were able to do the evacuation by boat instead of having to do something like a helicopter to do a medevac that way. And so a rescue boat came to the ship. He was lowered off the ship. He was in a stretcher and it was lowered down to the rescue boat by a rope.

His fiancée, Sarah, climbed down a rope ladder to get into the boat as well to go with them to land. And then he was taken to land in an ambulance ride to the hospital, et cetera. But, before they were allowed to disembark, they were given their bill and told “It’s time to pay this. You have to pay this bill.”

Rovner: And how much was it?

Sable-Smith: So the bill for the medical services was $2,500. This was a free cruise. They had budgeted to pay for internet, $150 for internet. They had budgeted to pay for their alcoholic drinks. They had budgeted to pay for their tips. So they had saved up a few hundred dollars, which is what they thought would be their bill at the end of this cruise. Now, that completely exploded into this $2,500 bill just for medical expenses alone.

And as they’re waiting to evacuate the ship, they’re like, “We can’t pay this. We don’t have this money.” So that led to some negotiations. They ended up basically taking all the money out of their bank accounts, including their mortgage payment. They maxed out Vincent’s credit card, but they were still $1,000 short. And they later learned once they were on land that Vincent’s credit card had been overdrafted by $1,000 to cover that additional expense.

Rovner: So it turns out that he was uninsured at the time, and we’ll talk about that in a minute. But even if he had had insurance, the cruise ship wasn’t going to let him off the boat until he paid in full, even though it was an emergency? Did I read that right?

Sable-Smith: That’s certainly the feeling that they had at the time. When Vincent was short the $1,000, eventually they were let off the ship, but they did end up, as we said, getting that credit card overdrafted. But I think what’s important to note here is that even though he was uninsured at the time, even if he had had insurance, and even if he had had travel insurance, which he also did not have at the time, which we can talk about, he still would’ve been required to pay upfront and then submit the receipts later to try to get reimbursed for the payments.

And that’s because on the cruise’s website, they explain that they do not accept “land-based health insurance plans” when they’re on the vessel.

Rovner: In fact, as you mentioned, a lot of health insurance doesn’t cover care on a cruise ship or, in fact, anywhere outside the United States. So lots of people buy travel insurance in case they have a medical emergency. Why didn’t they?

Sable-Smith: So travel insurance is often purchased when you purchase the tickets. You’ll buy a ticket to the cruise and then it will prompt you, say, “Hey, do you want some travel insurance to protect you while you’re on this ship?” And that’s the way that most people are buying travel insurance. Well, remember, this cruise was a gift from their realtors, so they never bought the ticket. So they never got that prompting to say, “Hey, time to buy some travel insurance to protect yourself on the trip.”

And again, these were inexperienced travelers. They’d never been on an airplane before. The furthest either one of them had been from Michigan was Vincent went to Washington, D.C., one time on a school trip. And so they didn’t really know what travel insurance was. They knew it existed. But as Vincent explained, he said, “I thought this was for lost luggage and trip cancellations. I didn’t realize that this was something for medical expenses you might incur when you’re out at sea.”

Rovner: And it’s really both. I mean, it is for lost luggage and cancellation, right?

Sable-Smith: And it is for lost luggage and cancellation. Yeah, that’s right.

Rovner: So what eventually happened to Vincent and what eventually happened to the bill?

Sable-Smith: Well, once he got taken to the hospital, he got an additional bill, or actually several additional bills, one from the hospital, two from a couple doctors who saw him at the hospital who billed separately, and also one from the ambulance services. As we know, he had already drained his bank account and maxed out his credit card and had it overdrafted to cover the expenses on the ship. So he was working on paying those off. And then for the additional bills he incurred on land, he had set up payment plans, really small ones, $25, $50 a month, but going to four separate entities.

He actually missed a couple payments on his bill to the hospital, and that ended up getting sent to collections. Again, none of these are charging interest, but these are still quite some burdens. And so he was paying them off bit by bit by bit. He set up a GoFundMe campaign, which is something that a lot of people end up doing who never expect to have to cover these kinds of emergency expenses, or reach out publicly for help like that. And they got quite a bit of help from family and friends. Including, Vincent picked up Frisbee golf during the pandemic, and he’s made quite a lot of good friends that way. And that community really came through for them as well. So with those GoFundMe payments, they were able to make their house payment. It was helpful with some of these bills that they had lingering leftover from the cruise.

Rovner: So what’s the takeaway here, other than that nothing that seems free is ever really free?

Sable-Smith: Yeah, right. Well, the takeaway is to be informed before you leave about a plan for how are you going to cover medical expenses when you’re going traveling. I think this is something that a lot of people are going to be doing this summer, going on vacations. I’ve got vacations planned. What’s your plan for covering medical expenses? And if you’re leaving the country, if you’re going on a cruise, someplace where your land-based American health insurance might not cover you, you should consider travel insurance.

And when you’re considering travel insurance, they come in all sorts of varieties. So you want to make sure that they’re going to cover your particular cases. So some plans, for example, won’t cover pre-existing conditions. Some plans won’t cover care for risky activities like rock climbing. So you want to know what you’re going to be doing during your trip, and you want to make sure when you’re purchasing travel insurance to find a plan that’s going to cover your particular needs.

Rovner: Very well explained. Bram Sable-Smith, thank you very much.

Sable-Smith: Always a pleasure.

Rovner: And 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.  Alice, you’ve gone already. Sandhya, why don’t you go next?

Raman: So my extra credit is “Roanoke’s Requiem,” and it’s an Air Mail from Clara Molot. And this is a really interesting piece. So at least 16 alumni from the classes of 2011 to 2019 of Roanoke have been diagnosed with cancer since 2010, which is a much higher rate when compared to the rate for 20-somethings in the U.S. and 15-times-higher mortality rate. And so the piece does some looking at some of the work that’s being done to uncover why this is happening.

Rovner: It’s quite a scary story. Rachel?

Cohrs Zhang: Yes. So the story I chose, it was co-published by ProPublica in Mississippi Today. The headline is “This Mississippi Hospital Transfers Some Patients to Jail to Await Mental Health Treatment,” by Isabelle Taft. And I mean, truly such a harrowing story of … obviously we know that there’s capacity issues with mental health treatment, but the idea that patients would be involuntarily committed, go to a hospital, and then be transferred to a jail having committed no crime, having no recourse.

I mean, some of these detentions happened. It was like two months long where these patients who are already suffering are then thrown out of their comfortable environments into jail as they awaited county facilities to open up spots for them. And I think the story also did a good job of pointing out that other jurisdictions had found other solutions to this other than placing suffering people in jail. So yeah, it just felt like it was a really great classic example of investigative journalism that’ll have an impact.

Rovner: Local investigative journalism — not just investigative journalism — which is really rare, yet it was a really good piece. Well, my extra credit this week is from Jessica Valenti, who writes a super-helpful newsletter called Abortion, Every Day. Usually it’s an aggregation of stories from around the country, but this week she also has her own exclusive [“EXCLUSIVE: Health Data Breach at America’s Largest Crisis Pregnancy Org,”] about how Heartbeat International, which runs the nation’s largest network of crisis pregnancy centers, is collecting and sharing private health data, including due dates, dates of last menstrual periods, addresses, and even family living arrangements.

Isn’t this a violation of HIPAA, you may ask? Well, probably not, because HIPAA only applies to health care providers and insurers and the vast majority of crisis pregnancy centers don’t deliver medical care. You don’t need a medical license to give a pregnancy test or even do an ultrasound. Among other things, personal health data has been used for training sales staff, and until recently was readily available to anyone on the web without password protection. It’s a pretty eye-opening story.

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

Raman: @SandhyaWrites.

Rovner: Alice?

Ollstein: @AliceOllstein.

Rovner: Rachel?

Cohrs Zhang: @rachelcohrs.

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

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Ballad Health, a 20-hospital system in northeast Tennessee and southwest Virginia, has received A grades and an annual stamp of approval from the Tennessee Department of Health. This has occurred as Ballad hospitals consistently fall short of performance targets established by the state, according to health department documents.

Because the state’s scoring rubric largely ignores the hospitals’ performance, only 5% of Ballad’s final score is based on actual quality of care, and Ballad has suffered no penalty for failing to meet the state’s goals in about 50 areas — including surgery complications, emergency room speed, and patient satisfaction.

“It doesn’t make any sense,” said Ron Allgood, 75, of Kingsport, Tennessee, who said he had a heart attack in a Ballad ER in 2022 after waiting for three hours with chest pains. “It seems that nobody listens to the patients.”

Ballad Health was created six years ago after Tennessee and Virginia lawmakers waived federal anti-monopoly laws so two competing hospital companies could merge. The monopoly agreement established two quality measures to compare Ballad’s care against the state’s baseline expectations: about 17 “target” measures, on which hospitals are expected to improve and their performance factors into their grade; and more than 50 “monitoring” measures, which Ballad must report, but how the hospitals perform on them is not factored into Ballad’s grade.

Ballad has failed to meet the baseline values on 75% or more of all quality measures in recent years — and some are not even close — according to reports the company has submitted to the health department.

Since the merger, Ballad has become the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina. Critics are vocal. Protesters rallied outside a Ballad hospital for months. For years, longtime residents like Allgood have alleged Ballad’s leadership has diminished the hospitals they’ve relied on their entire lives.

“It’s a shadow of the hospital we used to have,” Allgood said.

And yet, every year since the merger, the Tennessee health department has reported that the benefits of the hospital merger outweigh the risks of a monopoly, and that Ballad “continues to provide a Public Advantage.” Tennessee has also given Ballad an A grade in every year but two, when the scoring system was suspended due to the covid-19 pandemic and no grade issued.

The department’s latest report, released this month, awarded Ballad 93.6 of 100 possible points, including 15 points just for reporting the monitoring measures. If Tennessee rescored Ballad based on its performance, its score would drop from 93.6 to about 79.7, based on the scoring rubric described in health department documents. Tennessee considers scores of 85 or higher to be “satisfactory,” the documents state.

Larry Fitzgerald, who monitored Ballad for the Tennessee government before retiring this year, said it was obvious the state’s scoring rubric should be changed.

Fitzgerald likened Ballad to a student getting 15 free points on a test for writing any answer.

“Do I think Ballad should be required to show improvement on those measures? Yes, absolutely,” Fitzgerald said. “I think any human being you spoke with would give the same answer.”

Ballad Health declined to comment. Tennessee Department of Health spokesperson Dean Flener declined an interview request and directed all questions about Ballad to the Tennessee Attorney General’s Office, which also has a role in regulating the monopoly. Amy Wilhite, a spokesperson for the AG’s office, directed those questions back to the health department and provided documents showing it is the agency responsible for how Ballad is scored.

The Virginia Department of Health, which is also supposed to perform “active supervision” of Ballad as part of the monopoly agreement, has fallen several years behind schedule. Its most recent assessment of the company was for fiscal year 2020, when it found that the benefits of the monopoly “outweigh the disadvantages.” Erik Bodin, a Virginia official who oversees the agreement, said more recent reports are not yet ready to be released.

Ballad Health was formed in 2018 after state officials approved the nation’s biggest so-called Certificate of Public Advantage, or COPA, agreement, allowing a merger of the Tri-Cities region’s only two hospital systems — Mountain States Health Alliance and Wellmont Health System. Nationwide, COPAs have been used in about 10 hospital mergers over the past three decades, but none has involved as many hospitals as Ballad’s.

The Federal Trade Commission has warned that hospital monopolies lead to increased prices and decreased quality of care. To offset the perils of Ballad’s monopoly, officials required the new company to agree to more robust regulation by state health officials and a long list of special conditions, including the state’s quality-of-care measurements.

Ballad failed to meet the baseline on about 80% of those quality measures from July 2021 to June 2022, according to a report the company submitted to the health department. The following year, Ballad fell short on about 75% of the quality measures, and some got dramatically worse, another company report shows.

For example, the median time Ballad patients spend in the ER before being admitted to the hospital has risen each year and is now nearly 11 hours, according to the latest Ballad report. That’s more than three times what it was when the monopoly began, and more than 2.5 times the state baseline.

And yet Ballad’s grade is not lowered by the lack of speed in its ERs.

Fitzgerald, Tennessee’s former Ballad monitor, who previously served as an executive in the University of Virginia Health System, said a hospital company with competitors would have more reason than Ballad to improve its ER speeds.

“When I was at UVA, we monitored this stuff passionately because — and I think this is the key point here — we had competition,” Fitzgerald said. “And if we didn’t score well, the competition took advantage.”

Midwest correspondent Samantha Liss contributed to this report.

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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While adopting new technology is obviously a big part of healthcare innovation teams’ work, there are plenty of worthwhile initiatives that don’t involve advanced technologies, pointed out Dan Shoenthal, chief innovation officer at MD Anderson Cancer Center.

The post Innovation Doesn’t Always Have To Involve The Latest Tech, MD Anderson Exec Says appeared first on MedCity 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.

Public health officials are watching with concern since a strain of bird flu spread to dairy cows in at least nine states, and to at least one dairy worker. But in the wake of covid-19, many farmers are loath to let in health authorities for testing.

Meanwhile, another large health company — the Catholic hospital chain Ascension — has been targeted by a cyberattack, leading to serious problems at some facilities.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

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

• Stumbles in the early response to bird flu bear an uncomfortable resemblance to the early days of covid, including the troubles protecting workers who could be exposed to the disease. Notably, the Department of Agriculture benefited from millions in covid relief funds designed to strengthen disease surveillance.
• Congress is working to extend coverage of telehealth care; the question is, how to pay for it? Lawmakers appear to have settled on a two-year agreement, though more on the extension — including how much it will cost — remains unknown.
• Speaking of telehealth, a new report shows about 20% of medication abortions are supervised via telehealth care. State-level restrictions are forcing those in need of abortion care to turn to options farther from home.
• And new reporting on Medicaid illuminates the number of people falling through the cracks of the government health system for low-income and disabled Americans — including how insurance companies benefit from individuals’ confusion over whether they have Medicaid coverage at all.

Also this week, Rovner interviews Atul Grover of the Association of American Medical Colleges about its recent analysis showing that graduating medical students are avoiding training in states with abortion bans and major restrictions.

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

Julie Rovner: NPR’s “Why Writing by Hand Beats Typing for Thinking and Learning,” by Jonathan Lambert.  

Alice Miranda Ollstein: Time’s “‘I Don’t Have Faith in Doctors Anymore.’ Women Say They Were Pressured Into Long-Term Birth Control,” by Alana Semuels.  

Rachel Cohrs Zhang: Stat’s “After Decades Fighting Big Tobacco, Cliff Douglas Now Leads a Foundation Funded by His Former Adversaries,” by Nicholas Florko.  

Sandhya Raman: The Baltimore Banner’s “People With Severe Mental Illness Are Stuck in Jail. Montgomery County Is the Epicenter of the Problem,” by Ben Conarck.  

Also mentioned on this week’s podcast:

• Stat’s “My Rendezvous With the Raw Milk Black Market: Quick, Easy, and Unchecked by the FDA,” by Nicholas Florko.
• The Stamford Advocate’s “Dan Haar: Hackers Stole a Disabled CT Couple’s SNAP Food Aid. Now They’re Out $1,373,” by Dan Haar.
• WKRN’s “‘Chaos’: Nurses, Visitors Describe Conditions Inside Ascension Hospitals After Cyberattack,” by Stephanie Langston.
• KFF Health News’ “Medicaid ‘Unwinding’ Decried as Biased Against Disabled People,” by Daniel Chang.
• KFF Health News’ “Why Medicaid’s ‘Undercount’ Problem Counts,” by Phil Galewitz.

Click to open the transcript

Transcript: Bird Flu Lands as the Next Public Health Challenge

[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 16, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go.

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

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: And we welcome back to the podcast following her sabbatical, Sandhya Raman of CQ Roll Call.

Sandhya Raman: Hi, everyone.

Rovner: Later in this episode we’ll have my interview with Atul Grover of the Association of American Medical Colleges. He’s the co-author of the analysis we talked about on last week’s episode about how graduating medical students are avoiding applying for residencies in states with abortion bans or severe restrictions. But first this week’s news.

Well, I have been trying to avoid it, but I guess we finally have to talk about bird flu, which I think we really need to start calling “cow flu.” I just hope we don’t have to call it the next pandemic. Seriously, scientists say they’ve never seen the H5N1 virus spread quite like this before, including to at least one farmworker, who luckily had a very mild case. And public health officials are, if not actively freaking out, at least expressing very serious concern.

On the one hand, the federal government is providing livestock farmers tens of thousands of dollars each to beef up their protective measures — yes, I did that on purpose — and test for the avian flu virus in their cows, which seems to be spreading rapidly. On the other hand, many farmers are resisting efforts to allow health officials to test their herds, and this is exactly the kind of thing at the federal level that touches off those intra-agency rivalries between FDA [Food and Drug Administration] and USDA [United States Department of Agriculture] and the CDC [Centers for Disease Control and Prevention].

Is this going to be the first test of how weak our public health sector has become in the wake of covid? And how worried should we be both about the bird flu and about the ability of government to do anything about it? Rachel, you wrote about this this week.

Cohrs Zhang: I did, yes. It is kind of wild to see a lot of these patterns play out yet again, as if we’ve learned nothing. We still have a lot of challenges between coordinating with state and local health officials and federal agencies like CDC. We’re still seeing authorities that are exactly the same between USDA and FDA. USDA actually got $300 million from covid relief bills to try to increase their surveillance for these kind of diseases that spread among animals, but people are worried it could all potentially jump to humans.

So I think there was a lot of hope that maybe we would learn some lessons and learn to respond better, but I think we have seen some hiccups and just these jurisdictional issues that have just continued to happen because Congress didn’t really address some of these larger authorities in any meaningful way.

Rovner: I think the thing that worries me the most is looking at the dairy farmers who don’t want to let inspectors onto their farms. That strikes me as something that could seriously hamper efforts to know how widely and how fast this is spreading.

Cohrs Zhang: It could. And USDA does have more authority than they have had in other foodborne disease outbreaks like E. coli or salmonella to get on these farms, according to the experts that I’ve talked to. But we do see sometimes federal agencies don’t always want to use their full statutory authority because then it creates conflict. And obviously USDA has this dual mission of both ensuring food safety and promoting agriculture. And I think that comes into conflict sometimes and USDA just hasn’t been willing to enforce anything mandatory on farms yet. They’ve been kind of trying to use the carrot instead of the stick approach so far. So we’ll see how that goes and how much information they’re able to obtain with the measures they’ve used so far.

Rovner: Alice, you want to add something.

Ollstein: Yeah, I mean, like Rachel said, it’s sort of Groundhog Day for some of the bigger missteps of covid: inadequate testing, inadequate PPE [personal protective equipment]. But it’s also like a scary repeat of some of the specifics of covid, which really hit agricultural workers really hard. And a lot of that wasn’t known at the time, but we know it now. And a lot of workers in these agricultural, meatpacking, and other sectors, were just really devastated and forced to keep working during the outbreak.

This sector in particular has been resistant to public health enforcement and we’re just seeing that repeat once again with a potentially more deadly virus should it make the jump to humans.

Rovner: Basically, from what they can tell, this virus is in a lot of milk. It seems that pasteurization can kill it, but is this maybe what will get people to stop drinking raw milk, which isn’t that safe anyway? And if you need to know why you shouldn’t drink raw milk, I will link to a highly informative and entertaining story by Rachel’s colleague Nick Florko about how easy it is to buy raw milk and how dangerous it can be. This is one of those things where the public looks at the public health and goes, “Yeah, nah.”

Ollstein: Right, yeah. I think, at least anecdotally, the raw milk seller that Nick bought from indicated that business is good for him, business is booming. A lot of the people that maybe weren’t so concerned about covid aren’t so concerned about bird flu, and I think that will continue to drink that. Again, we haven’t seen a lot of data about how exactly that works with bird flu fragments or virus fragments: whether it’s showing up in raw milk?; what happens when people drink it? There’s so many questions we have right now because I think the FDA has been focused on pasteurized milk because that’s what most people drink. But certainly in terms of concern with transitions into humans, I think that’s an area to watch.

Raman: One of the things that struck me was that one of the benefits from what the USDA and HHS [Department of Health and Human Services] were doing was the benefit for workers to get a swab test and do an interview so they can study more and gauge the situation.

If $75 is enough to incentivize people to take off work, to maybe have to do transportation, to do those other things. And if they’ll be able to get some of the data, just as Rachel was saying, to just kind of continue gauging the situation. So I think that’ll be interesting to see.

Because even with when we had covid, there were so many incentives that we did just for vaccines that we hoped would be successful for different populations and money and prizes and all sorts of things that didn’t necessarily move the needle.

Rovner: Although some did. And nice pun there.

All right, well, moving on to less potentially-end-of-the-world health news, Congress is grappling with whether and how to extend coverage of telehealth and, if so, how to pay for it. Telehealth, of course, was practically the only way to get nonemergency health care throughout most of the pandemic, and both patients and providers got used to it and even, dare I say, came to like it. But as a Politico story succinctly put it this week, telehealth “has the potential to reduce expenses but also lead to more visits, driving up costs.”

Rachel, you’ve been watching this also this week. Where are we on these competing telehealth bills?

Cohrs Zhang: Well, we have some news this morning. The [House Committee on] Energy and Commerce Health Subcommittee is planning to mark up their telehealth bill. And the underlying bill will be a permanent extension of some of these Medicare telehealth flexibilities that matter a lot to seniors. But they’re planning to amend it today, so that they’re proposing a two-year extension, which does fall more in line with what the Ways and Means Committee, which is kind of the counterpart that makes policy on health care, marked up …

Rovner: Yes, they shared jurisdiction over Medicare.

Cohrs Zhang: … unanimously passed. They shared, yes, but it is surprising and remarkable for them to come to an agreement this quickly on a two-year extension. Again, I think industry would’ve loved to see a little bit more certainty on this for what these authorities are going to look like, but I think it is just expensive. Again, when these bills pass out of committee, then we’ll actually get formal cost estimates for them, which will be helpful in informing what our end-of-the-year December package is going to look like on health care. But we are seeing some alignment now in the House on a two-year telehealth extension for some of these very impactful measures for Medicare patients.

Rovner: Congress potentially getting things done months before they actually have to! Dare we hope?

Meanwhile, bridging this week’s topics between telehealth and abortion, which we will get to next, a new report from the family planning group WeCount! finds that not only are medication abortions more than half of all abortions being performed these days, but telehealth medication abortions now make up 20% of all medication abortions.

Some of this increase obviously is the pandemic relaxation of in-person medication abortion rules by the FDA, as well as shield laws that attempt to protect providers in states where abortion is still legal, who prescribe the pills for patients in states where abortion is banned.

Still, I imagine this is making anti-abortion activists really, really frustrated because it is certainly compromising their ability to really stop abortions in these states with bans, right?

Ollstein: Well, I think for a while we’ve seen anti-abortion activists really targeting the two main routes for people who live in states with bans to still have an abortion. One is ordering pills and the other is traveling out of state. And so they are exploring different policies to cut off both. Obviously both are very hard to police, both logistically and legally. There’s been a lot of debate about how this would be enforced. You see Louisiana moving to make abortion pills a controlled substance and police it that way. These pills are used for more than just abortions, so there’s some health care implications to going down that route. They’re used in miscarriage management, they’re used for other things as well in health care. And then of course, the enforcement question. Short of going through everyone’s mail, which has obvious constitutional problems, how would you ever know? These pills are sent to people’s homes in discreet packaging.

What we’ve seen so far with anti-abortion laws and their enforcement is that just the chilling effect alone and the fear is often enough to deter people from using different methods. And so that could be the goal. But actually cutting off people from telehealth abortions that, like you said, like the report said, have become very, very widely used, seems challenging.

Raman: And I would say that that really underscores the importance of the case we’d heard this year from the Supreme Court, and that we will get a decision coming up about the regulation of medication abortions. And how the court lands on that could have a huge impact on the next steps for all of these. So it’s in flux regardless of what’s happening here.

Cohrs Zhang: I want to emphasize, too, that mail-order abortion pills have been sort of held up as this silver bullet for getting around bans. And for a lot of people, that seems to be the case. But I really hear from providers and from patients that this is not a solution for everyone. A lot of people don’t have internet access or don’t know how to navigate different websites to find a reliable source for the pills. Or they’re too scared to do so, scared by the threat of law enforcement or scared that they could purchase some sort of counterfeit that isn’t effective or harms them.

Some people, even when they’re eligible for a medication abortion, prefer surgical or procedural because with a medication you take it and then you have to wait a few weeks to find out if it worked. And so some people would rather go into the clinic, make sure it’s done, have that peace of mind and security.

Also, these pills are delivered to people’s homes. Some people, because of a domestic violence situation or because they’re a minor who’s still at home with their parents, they can’t have anything sent to their homes. There’s a lot of reasons why this isn’t a solution for everyone, that I’ve been hearing about, but it is a solution, it seems, for a lot of people.

Rovner: In other abortion news this week, Democrats in the Missouri state Senate this week broke the record for the longest filibuster in history in an effort to block anti-abortion forces from making it harder for voters to amend the state constitution.

Alice, this feels pretty familiar, like it’s just about what happened in Ohio, right? And I guess the filibuster is over, but so far they’ve managed to be successful. What’s happening in Missouri?

Ollstein: So Missouri Democrats, with their filibuster that lasted for days, managed to stop a vote for now on a measure that would’ve made ballot measures harder to pass, including the abortion rights ballot measure that’s expected this fall. It’s not over yet. They sort of kicked it back to committee, but there’s only basically a day left in the legislature session, and so stay tuned over the next day to see what happens.

But what Democrats are trying to do is prevent what happened in Ohio, which is setting up a summer special election on a provision that would make all ballot measures harder to pass in the future. In Ohio, they did hold that summer vote, and voters defeated it and then went on to pass an abortion rights measure. And so even if Republicans push this through, it can still be scuttled later. But there, Democrats are trying to nip it in the bud to make sure that doesn’t happen in the first place.

Rovner: I thought that was very well explained. Thank you very much.

And speaking of misleading ballot measures, next door in Nebraska — and I did have to look at a map to make sure that Nebraska and Missouri do have a border, they do — anti-abortion forces are pushing a ballot measure they’re advertising as enshrining abortion rights in the state constitution, but which would actually enshrine the state’s current 12-week ban.

We’re seeing more and more of this: anti-abortion forces trying to sort of confuse voters about what it is that they’re voting on.

Raman: I mean, I think that that has been something that we have been seeing a little bit more of this. They’ve been trying different tactics to see — the same metaphor of throwing spaghetti at the wall and seeing what sticks. So with Nebraska right now, the proposal is to ban abortions after the first trimester, except in the trio of cases: medical emergencies, rape, incest.

And so that’s definitely different than a lot of the other ballot measures that we’ve seen in the last few years in that it’s being kind of pitched as a little bit of a middle ground and it has the backing of the different anti-abortion groups. But at the same time, it would allow state legislature to put additional bans on top of that. This is just kind of like the mark in the constitution and it would already keep in place the bans that you have in place.

So it’s a little bit more difficult to comprehend, especially if you’re just kind of walking in and checking a box, since there’s more nuance to it than some of the other measures. And I think that a lot of that is definitely more happening in states like that and others.

Rovner: I feel like we’re learning a lot more about ballot measures and how they work. And while we’re in the Great Plains, there’s a wild story out of South Dakota this week about an actual scam related to signatures on petitions for abortion ballot measures. Somebody tease this one apart.

Ollstein: So in South Dakota, they’ve already submitted signatures to put an abortion rights measure on the November ballot. The state is, as happens in most states, going through those signatures to verify it. What’s different than most states is that the state released the names of some of the people who signed the petition, and that enabled these anti-abortion groups to look up all those people and start calling them, and to try to convince them to withdraw their signatures to deny this from going forward.

What happened is that, in doing so, these groups are accused of misrepresenting themselves and impersonating government officials in the way they said, “Hey, we’re the ballot integrity committee of the something, something, something.” And they said it in a way that made it sound like they were with the secretary of state’s office. So the secretary of state put out a press release condemning this and referring it to law enforcement.

The group has admitted to doing this and said it’s done nothing wrong, that technically it didn’t say anything untrue. Of course there’s lying versus misleading versus this versus that. It’s a bit complicated here.

So regardless, I am skeptical that enough people will bother to go through the process of withdrawing their signature to make a difference. It’s a lot more work to withdraw your signature than to sign in the first place. You have to go in person or mail something in. And so I am curious to see if, one, whether this is illegal, and two, whether it makes a difference on the ground.

Rovner: Well, at some point, I think by the end of the summer we’ll be able to make a comprehensive list of where there are going to be ballot measures and what they’re going to be. In the meantime, we shall keep watching.

Let’s move on to another continuing story: health system cyberhacks. This week’s victim is Ascension, a large Catholic system with hospitals in 19 states. And the hack, to quote the AP, “forced some of its 140 hospitals to divert ambulances, caused patients to postpone medical tests, and blocked online access to patient records.”

You would think in the wake of the Change Healthcare hack, big systems like Ascension would’ve taken steps to lock things down more, or is that just me?

Cohrs Zhang: We’re still using fax machines, Julie. What are your expectations here? So cyberattacks have been a theoretical concern of health systems for a long time. I mean, back in 2019, 2020, Congress was kind of sliding provisions into spending bills to help support health systems in upgrading their systems. But again, we’re just seeing the scale. And I think these stories that came out this week really illustrate the human impact of these cyberattacks. And people are waiting longer in an ambulance to get to the hospital.

I mean, that’s a really serious issue. And I’m hoping that health systems will start taking this seriously. But I think it’s just exposing yet another risk that the failure to upgrade these systems isn’t just an inconvenience for people actually using the system. It isn’t just a disservice to all kind of the power of health care data and patients’ information that they could be leveraging better. But it’s also a real medical concern with these attacks. So I am optimistic. We’ll see. Sometimes it takes these sort of events to force change.

Rovner: Well, just before we started to tape this morning, I saw a story out of Tennessee about one of the hospitals that’s being affected. And apparently it is. I believe the word “chaos” was used in the headline and the lead. I mean, these are really serious things. It’s not just what’s going on in the back room, it’s what’s going on with patient care.

In maybe the most depressing hacking story ever, in Connecticut criminals are hacking and stealing the value of people’s electronic food stamp debit card. The Stamford Advocate wrote about one older couple whose card has been now hacked five times and who are out nearly $1,400 they can’t get back because the state can only reimburse people for two hacks. I remember when electronic funds transfers were going to make our lives so much easier. They do seem to be making lives so much easier for criminals.

Finally this week, more on the mess that is the Medicaid unwinding, from two of my colleagues. One story by Daniel Chang is about how people with disabilities, who shouldn’t really have been impacted by the unwinding anyway, are losing critical home care services in all of the administrative confusion. This seems a lot like the cases of eligible children losing coverage because their parents were deemed to have too-high income, even though children have different eligibility criteria.

I know the Biden administration has been trying to soft-pedal its pushes to some of these states. Rachel, you were talking about the USDA trying not to push too hard, but it does seem like in Medicaid a lot of eligible people are falling between the cracks.

Raman: Yeah, I mean states, as we’ve seen, have been really trying to see how fast that they can go to kind of reverify this huge batch of folks because it will be a cost saver for them to have fewer folks on the rolls. But as you’re saying, that a lot of people are falling through the cracks, especially when it’s unintentionally getting pulled from the program like your colleague’s story. And people with a lot of chronic disabilities already qualify for Medicaid, don’t need to be reverified each time because they’re continually qualified for it. And so there are some cases that have been filed already by the National Health Law Program in Colorado, and [Washington,] D.C., and Texas. And so we’ll kind of see as time goes on, how those go and if there’s any changes made to stop that.

Rovner: Also on the Medicaid beat, my colleague Phil Galewitz has a story that’s kind of the opposite. According to a study in the policy journal Health Affairs, a third of those enrolled in Medicaid in 2022, didn’t even know it. That’s 26 million people. And 3 million people actually thought they were uninsured when they in fact had Medicaid. That not only meant lots of people who didn’t get needed health services because they thought they couldn’t afford them because they thought they didn’t have insurance, but also managed-care companies who got paid for these enrollees who never got any care, and conveniently never bothered to inform them that they were covered. Rachel, you had a comment about this?

Cohrs Zhang: I did, yes. One part I really liked about this story is how Phil highlighted that it’s in insurance companies’ best interests for these people not to know that they can get health care services. Because a lot of Medicaid, they’re getting a payment for each member, capitated payments. And so if people aren’t using it, then the insurance companies are making more money. And so I think there has been some more, I think, political conversation about the incentives that capitated payments create especially in the Medicaid population. And so I think that was certainly just a disservice. I mean, these people have been done a disservice by someone. And I think that it’s a really interesting question of who should have been reaching them. And we’ll just, I guess, never know how much care they could have gotten and how their lives could be different had they known.

Rovner: It’s funny, we’ve known for a long time when they do the uninsured statistics that people don’t always know what kind of insurance they have. And they’ll say when they started asking a follow-up question, the Census Bureau started asking a follow-up question about insurance, suddenly the number of uninsured went down. This is the first time I’ve seen a study like this though, where people actually had insurance but didn’t know it. And it’s really interesting. And you’re right, it has real policy ramifications.

All right, well that’s the news for this week. Before we get to our interview, Sandhya, you’ve been gone for the last couple of months on sabbatical. Tell us what you saw in Europe.

Raman: Yeah, so it’s good to be back. I was gone for six weeks mostly to France, improving my French to see how I could get better at that and hopefully use it in my reporting at some point. It was interesting because I was trying to tune out of the news a little bit and stay away from health care. And of course when you try to do that, it comes right back to you. So I would be in my French class and we’d do a practice, let’s read an article or learn a historical thing, and lo and behold, one of the examples was about abortion politics in France over the years.

It was interesting to have to explain to my classmates, “Yes, I’m very familiar with this topic, and how much do you want me to talk about how this is in my country? But let me make sure I know all of those words.” So it pops up even when you think you’re going to sneak away from it.

Rovner: Yes, and we’re very obviously U.S.-centric here, but when you go to another country you realize none of their health systems work that well either. So the frustration continues everywhere.

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

I am so pleased to welcome to the podcast Dr. Atul Grover, executive director of the Association of American [Medical] Colleges’ Research and Action Institute. I bet you have a very long business card.

And I want to offer him a public apology for not having him on sooner. Atul is the co-author of the report we talked about on last week’s episode on how graduating medical students are less likely to apply for residency in states with abortion bans and restrictions. Welcome at last to “What the Health?”

Grover: Better late than never.

Rovner: So there seems to be some confusion, at least in social media land, about some of the numbers here. Tell us what your analysis found.

Grover: First, Julie, is there ever not confusion in social media land? The numbers basically bear out the same thing that we saw last year — making it a very short but real trend — which is that when we look at where new U.S. medical school graduates are applying for residencies, and they apply to any number of programs, what they’re doing, it appears, is selectively avoiding those states in which abortion is either completely banned or severely restricted. And that’s not just in reproductive health-heavy specialties like OB-GYN, but it seems to be across the board.

Rovner: Now, can you explain why all of the numbers seem to be going down? It’s not that the number of applicants are falling, it’s the number of applications.

Grover: There’s about 20,000 people that graduate from U.S. MD [medical degree] schools every year. There are another 15[,000] to 20,000 applicants for residency positions that are DO [doctor of osteopathic medicine] graduates domestically or international graduates. Could be U.S. citizens or foreign citizens.

But what we’ve tried to do for a number of years is encourage applicants to apply to a fewer number of residency programs because we found that they were out-applying, they were over-applying. Where we did some data analyses a couple of years back on diminishing returns where we said, “Look, once you apply to 15, 20, 30 programs, your likelihood of matching, I know you’re nervous, but the likelihood of matching is not going to go up. You’re going to do fine. You don’t need to apply to 60, 70, 80 programs.”

So the good news is we’re actually seeing those numbers come down by about, for U.S. medical grads, about 7% this year, which is really the first time that I can remember in the last 10 years that this has happened. So that is good news.

Rovner: And that was an explicit goal.

Grover: That was an explicit goal. We want to make this cheaper, easier, and more rational for applicants and for programs, as they have to screen people and figure out who really wants to come to their program.

So overall, we were really pleased to see that the average applicant, as they applied to programs, applied to a few less programs, which meant that in many cases they were maybe not applying to one or two states that the average applicant might’ve applied to last year. So on average, each state saw about a 10% decrease in the number of unique applicants. But that decrease was much higher when we looked at those states that had banned abortion or severely limited it.

Rovner: Eventually, all these residency positions fill though, right, because there are more applicants as you point out, more graduating medical students and incoming graduates from other countries than there are slots. So why should we care, if all of these programs are filling?

Grover: So, I think you should always care about the number of residency spots, and I know you have a long history here, as do I, in that that is the bottleneck where we have to deal with why we have physician shortages, or one of the reasons why across the board we just don’t train enough physicians.

We have increased the number of medical school spots. We have people that are graduating from DO schools, as I said, international graduates. More are applying every year than we have space for. Which means that, yes, right now every spot will fill, because if the alternative for somebody applying is, look, I either won’t get in and actually be able to train in my specialty of choice. Or, I may have to go to my third choice or 10th choice or 50th choice or 100th choice. I’d rather go to someplace than no place at all.

So yes, everything is filling, but our look at the U.S. MD seniors was in part because we believe that they are the most competitive applicants, and in some ways the most desirable applicants. They have a 95% success in the match year after year. And so we thought they would be the most sensitive to look at in terms of, hey, I’ve got a little more choice here. Maybe I won’t apply to that state where I don’t feel like I can practice medicine freely for my patients.

And I think that’s a potential problem for a lot of these states and a lot of these programs is, if the people who might’ve been applying if the laws were different, who happened to be a better match for your program, for your specialty and your community, aren’t choosing to apply there, yes, you can fill it, but maybe not with the ideal candidate. And I think that’s going to affect patients and populations and local communities in the years to come.

Rovner: When we saw the beginning of this trend last year most of the talk was about a potential shortage of OB-GYNs going forward, since physicians often stay in practice where it is that they do their residency. But now, as you mentioned, we’re seeing a decrease in applications and specialties across the board. Why would that be?

Grover: So this is an informed opinion as to why people across specialties are choosing not to apply to residencies in these states. We didn’t ask the specific people who are matching this past year, “Why did you choose to apply or not to apply to this state?”

So what we know, though, from asking questions in other surveys is that about 70% of all health professions and health profession students believe that abortion should be legal at some point during a pregnancy. If you look at some specialties like adolescent medicine, that number goes up to 96%. So No. 1, I think it’s a potential violation of what people believe should be some freedom between doctors and patients as to allowing them to have the full range of reproductive health care.

No. 2, I think the potential penalties and the laws are often viewed as being incredibly punitive and somewhat unclear. And as much as doctors hate getting sued, we really don’t want to be indicted. I know some people are fine getting indicted. We really don’t want to be indicted. And that has implications because if we’re indicted, if we’re convicted of any kind of criminal offense, we could lose our license and not be able to care for patients. And we have a long investment in trying to do so.

The third thing that I think is relevant is certainly some of the specialties we’re looking at are heavily populated by women physicians, so OB-GYN, pediatrics. But again, across the board, it’s 50% women. So I think for the women themselves that happen to be applying, there is this issue of, think about their ages, 26, 27, 28 to the mid-30s, for the most part, and there are outliers on either end. But for the most part, they are of reproductive age, and I think they want to have control over their own lives and their own health care, and make sure that all services are available to them and their families if they need it. And I think even if it’s not relevant to you as an individual, it probably is relevant to your spouse or partner or somebody else in your family. And I think that makes a huge difference when people make these choices.

Rovner: So in the end, assuming these trends continue, I mean there really is concern for what the health professional community will look like in some of these states, right?

Grover: Yeah, and I think one of the things that I tried to look at last year in an editorial for JAMA was trying to overlay the states that have already significant challenges in recruiting and retaining physicians. They tend to be a lot of the heavily rural states, Southern states, parts of the Midwest. You overlay that on a map of the 14 states now that have basically banned abortion, and there’s a pretty close match.

So I think it’s critically important for state, local officials, legislatures, governors to think about their own potential impact of passing these laws on something that they may think is critically important, which is recruiting and retaining health professionals. And as you said, about half of people who train in a state will end up staying there to practice.

And for these pipeline programs, I know places like Mississippi and Alabama will really try and recruit individuals from underserved communities, get them through high school, get them into college, get them to stay in the state for med school, stay in the state for residency. They’re 80% likely to stay in those states. You lose them at any point along the way and they’re a lot less likely to come back.

So without even telling these states, I can’t tell you what’s good for you, but you should at least figure out how to collect the data at a local level to understand the implications of your policies on the health of everybody in a state, not just women of reproductive age.

Rovner: And I assume that we’ll be hearing more about this.

Grover: I would think so, yes.

Rovner: And asking more students about it.

Grover: Yes, we will. And we get to administer something called the Graduation Questionnaire every year for all these MD students. One of the questions we just added, and hopefully we’ll have some data, my colleagues will have that by probably August or so, is asking them specifically: What role did laws around some of these social issues have in your choice of where to do your residency? And again, there is some overlap here of states that have restricted reproductive rights, transgender care, and some other issues that are probably all kind of mixed in.

Rovner: Great. We’ll have you back to talk about it then.

Grover: Great. And I’m happy to come back and talk about market consolidation, about life expectancy, the quality of U.S. health, or anything else you want.

Rovner: Atul Grover, thank you so much.

Grover: Thanks for having me.

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

Sandhya, why don’t you go ahead and go first this week?

Raman: Great. So my story is from Ben Conarck at The Baltimore Banner, and it’s called “People With Severe Mental Illness Are Stuck in Jail. Montgomery County Is the Epicenter of the Problem.”

This is a really sad and impactful story about Montgomery County, Maryland, which is just outside of  D.C., and how they are leading to this problem in this state. And many people are on the wait list for beds and psychiatric facilities, but they’re serving pretty short sentences of 90 days or less, and just a lot of the issues there. And just the problems for criminal defendants waiting in facilities for months on end for treatment.

Rovner: And I would add, because I live there, Montgomery County, Maryland, is one of the wealthiest counties in the country, and it’s kind of embarrassing that there are people who are not where they should be because they don’t have enough beds. Alice.

Ollstein: I have a piece from Time magazine called “‘I Don’t Have Faith in Doctors Anymore.’ Women Say They Were Pressured Into Long-Term Birth Control.” And it’s about something that I’ve been hearing about from providers for a bit now, which is that IUDs are this very effective form of birth control. It’s a device implanted in the uterus, and it was supposed to be this amazing way to help people avoid unwanted pregnancies. But as with many things, it is being used coercively, according to this report.

Because a physician has to implant it and remove it, people say that, one, they were pressured into having one often right after giving birth when they were sort of not in a place to make that kind of big decision. And then people who were given one struggled to have someone remove it when they wanted that done in the future.

And so I think it’s a good reminder that these tools are not inherently good or inherently bad. They can be used unethically or ethically by providers.

Rovner: And all reproductive health care is fraught. Rachel?

Cohrs Zhang: Yes. So Nick has been on quite the tear this week. My colleague Nick Florko at Stat and I wanted to highlight a profile that he wrote. The headline is, “After Decades Fighting Big Tobacco, Cliff Douglas Now Leads a Foundation Funded by His Former Adversaries.”

And I think it just has so much nuance into just a figure who fought Big Tobacco to bring to light what they were doing over decades. And now he’s chosen to take over this organization that had, in the past, been entirely funded by a tobacco company. And so I think it’s this really interesting … what we see all the time in Washington, how people contort themselves to make that transition into the private sector, or what they choose to do with their careers after public service. This is a nontraditional public service, obviously, being an advocate in this way. But I think it will be a really interesting dynamic to watch to see how much he chooses to change the direction of the organization, how long that arrangement lasts, if he chooses to do that.

I learned a lot reading this profile, and I think it’s even more rare to see people sit down for lengthy interviews for an old-fashioned profile. So I really enjoyed the piece.

Rovner: Full disclosure, I’ve known Cliff Douglas since the 1980s when he was just a young advocate starting out on his antismoking career. It really is good piece. I also thought Nick did a really good job.

Well, my story this week is from the NPR Shots blog. It’s by Jonathan Lambert and it’s called “Why Writing by Hand Beats Typing for Thinking and Learning.” And it made me feel much better for often being the only person in a room taking notes by hand in a notebook when everyone else is on their laptop. In fact, I can type as fast as anyone, and I can definitely type faster than I can write in longhand, but I actually find I take better notes if I have to boil down what I’m listening to. And it turns out there’s science that bears that out. Now, if only we could get the schools to go back to teaching cursive, but that’s a whole different issue.

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. And happy birthday today to half of my weekly live audience: Aspen the corgi turns 4 today.

As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X or Twitter, whatever you want to call it, @jrovner. Sandhya, where are you?

Raman: @SandhyaWrites.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Rachel.

Cohrs Zhang: @rachelcohrs.

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.

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.

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.

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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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— Nearly a half-million health workers who stand to benefit from California’s nation-leading $25 minimum wage law could be in for a rude awakening if hospitals and other health care providers follow through on potential cuts to hours and benefits.

A medical industry challenge to a new minimum wage ordinance in one Southern California city suggests layoffs and reductions in hours and benefits, including cuts to premium pay and vacation time, could be one result of a state law set to begin phasing in in June. However, some experts are skeptical of that possibility.

The California Hospital Association brought a partly successful legal challenge to Inglewood’s $25 minimum wage ordinance, which barred employers from taking those sorts of steps to offset their higher costs.

“Layoffs, reductions in premium pay rates, reductions in non-wage benefits, reductions in hours, and increased charges are consequences of an employer having less money to spend—which will necessarily be the case given the significant increase in spending on wages due to the minimum wage,” the association said in its lawsuit. Additional examples include reducing health coverage and charging for parking or work-related equipment.

Inglewood voters approved the ordinance in November 2022, nearly a year before California legislators enacted a $25 minimum wage for health workers. Those statewide higher wages are to be phased in starting in June under California’s first-in-the-nation law, but Gov. Gavin Newsom has since said they are too expensive as the state faces a deficit estimated between $38 billion and $73 billion. It’s unclear if lawmakers will agree to a delay or take other steps to reduce the cost.

U.S. District Judge Dale S. Fischer agreed with the hospital industry in a March 11 tentative ruling when he shot down the portion of Inglewood’s ordinance banning layoffs and clawbacks by employers, while allowing the rest of the ordinance to remain in effect. He gave the sides time to object to his preliminary decision, though none did.

The California Hospital Association represents more than 400 hospitals and was a key backer of the state’s carefully crafted compromise law, which notably contains none of the employee safeguards included in the Inglewood ordinance.

Spokesperson Jan Emerson-Shea said the association doesn’t know how providers will react once the state law takes effect. “We don’t have any insights,” she said.

“The challenge for any health care organization is figuring out how to pay for the higher wages,” said Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco. “Since labor costs are the largest part of any health care organization’s costs, it’s hard to figure out how to reduce spending without looking at labor costs.”

Providers can try to increase revenues by bargaining for higher reimbursements from commercial insurers, she said. Public hospitals, nursing homes, and community clinics get most of their money through Medi-Cal, the state’s Medicaid program.

Providers could reduce the services they offer, pare back charity care, and cut or delay capital investments, Spetz said. In the long term, she expects some combination of spending cuts and revenue increases.

Both the state law and local ordinance cover far more than doctors and nurses, with a definition of health worker that includes janitors, housekeepers, groundskeepers, security guards, food service workers, laundry workers, and clerical staff.

The most recent estimate by the Health Care Program at the University of California-Berkeley Labor Center is that as many as 426,000 health workers would make an average of $6,400 extra in the law’s first year, a 19% average pay bump mainly benefiting lower-income workers of color and women. State finance officials project that well over 500,000 workers will benefit.

Researchers didn’t include layoffs and other potential staffing and benefit reductions when they projected the state law’s costs and benefits, said Laurel Lucia, the program’s director. But she pointed to initial projections by hospitals, doctors, and business and taxpayer groups that the wage hike would cost $8 billion annually, thereby imperiling services and resulting in higher premiums and higher costs for state and local governments.

“It seems like a contradiction to say this law’s going to cost billions of dollars while at the same time saying it’s going to reduce workers’ total compensation,” said Lucia, who projects a far lower price tag.

She added that state finance officials had anticipated that Medi-Cal reimbursements would reflect the increased labor costs, while Medicare would eventually at least partially compensate for the higher labor costs.

Michael Reich, chair of the Center on Wage and Employment Dynamics at UC Berkeley’s Institute for Research on Labor and Employment, and affiliated economist Justin Wiltshire recently argued that California’s new $20 minimum wage law for fast-food workers won’t result in mass layoffs and price increases, as some have predicted.

Health care is much different than fast food, Reich acknowledged, but he argued for much the same positive result.

“A higher minimum wage will make it easier and cheaper for hospitals to recruit and retain these workers. The cost savings, and the productivity benefits of more experienced workers, could offset much of the labor cost increase,” Reich said.

The hospital association filed its lawsuit against Inglewood’s ordinance in July, while it was still opposing early versions of the statewide minimum wage legislation. Among many other provisions, the statewide law put on hold an initiative to cap hospital executives’ salaries in Los Angeles.

The hospital association’s legal challenge referenced in part layoffs and reduced working hours imposed by Centinela Hospital Medical Center after Inglewood’s ordinance took effect.

But Centinela said the reduction was entirely unrelated to the ordinance and that all staff were offered alternate positions, which many accepted.

“Centinela Hospital also has since added many more jobs in new clinical positions above minimum wage scale,” the hospital said in a statement.

Service Employees International Union-United Healthcare Workers West, the prime backer of both the local ordinance and the statewide law, sued the hospital in April 2023 alleging that it cut workers’ hours to offset the higher minimum wage. The case is still pending.

The union did not respond to repeated requests for comment.

In a court filing, however, the union and city of Inglewood said similar employer restrictions in previous minimum wage laws have survived.

The ordinance “merely sets the backdrop for collective bargaining negotiations,” and does not bar employers from locking out employees or hiring replacement workers during a strike. Employers can still lay off workers or reduce their hours, they said, so long as they don’t do so to fund the higher minimum wage.

But Fischer agreed with the hospital association that layoffs and reductions in employees’ total compensation packages are “obvious responses by an employer to rising compensation costs.”

Restricting employers’ options would violate federal labor relations rules, he said.

“The minimum wage an employer has to pay its employees will invariably affect the total amount of compensation it is able or willing to pay,” he wrote “This will then invariably affect the number of employees it can retain and the number of hours those employees will be scheduled to work.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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“Estamos trabajando de buena fe con Oxford para alcanzar un nuevo acuerdo justo”, decía la carta, continuando con la frase tranquilizadora: “Sus médicos seguirán siendo parte de la red y debería mantener sus citas con sus proveedores”.

En los meses siguientes, llegaron una avalancha de comunicaciones sobre la disputa tanto del hospital como de la aseguradora. Pasaban de “tienes que preocuparte” a “no tienes que preocuparte'”, contó Feldman.

A fines de febrero, finalmente cayó la bomba: desde el 1 de marzo, el Mount Sinai ya no estaría en la red de la aseguradora de Feldman.

“De repente tuve que cambiar todos mis médicos, gran estrés”, dijo Feldman. Eso incluía no solo a un querido médico de atención primaria, sino también a un ginecólogo, un ortopedista y un fisioterapeuta.

Uno de los aspectos más injustos del seguro médico, en un sistema que a menudo parece diseñado para la frustración, es este: los pacientes solo pueden cambiar de seguro durante los períodos de inscripción abierta al final del año o cuando experimentan “eventos de vida” que califican para una inscripción especial, como un divorcio o un cambio de trabajo.

Pero los contratos de las aseguradoras con médicos, hospitales y farmacéuticas (o sus intermediarios, los llamados administradores de beneficios farmacéuticos) pueden cambiar abruptamente de la noche a la mañana.

Esto es particularmente irritante para los pacientes porque, ya sea que tengan cobertura a través de un empleador o compren un seguro en el mercado, generalmente eligen un plan en función de si cubre a sus médicos y hospitales preferidos, o a un medicamento costoso que necesitan.

Resulta que esa cobertura particular podría desaparecer en cualquier momento durante el término de la póliza.

Los consumidores están en riesgo, según un informe reciente de la Robert Wood Johnson Foundation, en la creciente guerra de precios entre grandes sistemas hospitalarios y mega aseguradoras en un mercado despiadado.

Estas disputas de contratos están aumentando rápidamente, el sitio web Becker’s Hospital Review cita 21 enfrentamientos entre aseguradoras y proveedores en el tercer trimestre de 2023, un aumento del 91% comparado con el mismo período el año anterior.

Por ejemplo, en septiembre pasado, los médicos de Baptist Health en Kentucky cortaron abruptamente la relación con los pacientes inscritos en los planes de Medicare Advantage de Humana, y los médicos de Vanderbilt Health en Tennessee rompieron los contratos lo hicieron con varios planes de Humana, en abril.

En ambos casos los pacientes desesperados tuvieron que buscar frenéticamente nuevos médicos dentro de la red en otros sistemas hospitalarios.

Y expertos predicen más cancelaciones de contratos en un mercado cruel. (las cancelaciones que ocurren dentro del período de inscripción, generalmente entre noviembre y enero por lo menos permite que los pacientes abandonados busquen un nuevo plan que cubra sus médicos y medicamentos).

“La respuesta humana correcta es que esto es horrible”, dijo Allison Hoffman, profesora de derecho de la Universidad de Pennsylvania, incluso si la práctica, por ahora, es “probablemente legal”.

Hoffman dijo que encontró una cláusula “enterrada” en la página 32 de su propio plan médico, de 60 páginas, que sugería que los contratos entre proveedores y aseguradoras pueden cambiar en cualquier momento.

Los reguladores estatales y federales tienen la autoridad para regular las redes de aseguradoras y podrían poner fin a la práctica, dijo Hoffman. Pero hasta ahora “no ha habido regulación federal sobre la continuidad de la cobertura”, especialmente sobre cómo definirla. Sospecha que el aparente aumento en disputas de contratos entre aseguradoras y proveedores se deriva de las regulaciones sobre la transparencia de los precios hospitalarios, que entraron en vigencia en 2022 y han permitido a los hospitales comparar tasas de reembolso entre sí.

De hecho, el Mount Sinai dijo que exigía un mejor reembolso de UnitedHealthcare porque descubrió que estaba recibiendo pagos considerablemente más bajos que otras “instituciones similares”.

Muchas aseguradoras dicen que continuarán pagando por un período después de que termine un contrato —en general de entre 60 a 90 días— o para completar un “episodio de atención” particular, como un embarazo.

Pero, por ejemplo, con el cáncer, ¿eso significaría una ronda de quimioterapia o el curso completo de un tratamiento, que podría durar muchos años? ¿Es continuidad de cobertura si un paciente debe cambiar de oncólogo en medio de una terapia, o si tiene que dejar a un terapeuta eficaz?

Erin Moses, que trabaja para una pequeña organización sin fines de lucro, encontró a un nuevo terapeuta que le gustó después que ella y su esposo se mudaron a la Costa Central de California en febrero del año pasado. En septiembre, recibió una factura de la práctica que decía que había terminado su contrato con Anthem porque la aseguradora era lenta con sus reembolsos. Esto la dejó con una factura de $814.

“No es que no pudiéramos pagarlo, pero mi esposo y yo estamos tratando de ahorrar para una casa, y eso es mucho dinero”, dijo.

A menudo, a los pacientes los toma desprevenidos, sin saber qué hacer. Cuando Laura Alley se cayó de una escalera en septiembre de 2020 y necesitó cirugía para reparar su pelvis quebrada, el hospital y el cirujano estaban en la red.

Alley escribió al proyecto “Bill of the Month” de KFF Health News y NPR y dijo: “Lo que no podía saber de ninguna manera era que el grupo que proporcionaba la anestesia estaba en disputa con el proveedor de seguros de nuestra firma, y que desde el 30 de julio de 2020, ya no estaban en la red”.

Se sintió “como un títere”, dijo. “Mientras trabajo para recuperarme de una lesión traumática, estoy atrapada en medio de una disputa entre una enorme compañía de seguros y un gran grupo de médicos”.

Alley es dueña de una pequeña firma de arquitectura con su esposo, y terminaron pagando “casi $10,000” por servicios de anestesia fuera de la red. (Este tipo de factura fuera de la red para el paciente ahora estaría prohibido por el No Surprises Act, vigente desde 2022).

Nada de esto será noticia para Feldman, la paciente del Mount Sinai que fue una inocente espectadora en la disputa del sistema hospitalario con Oxford Health Plans. Los padres de Feldman la llamaron recientemente, diciendo que recibieron una carta de su aseguradora, Anthem, diciendo que el 1 de mayo podría terminar su contrato con el Hospital NewYork-Presbyterian, en donde la madrastra de Feldman recibe tratamiento por un cáncer de mama.

Es malo para la salud —y para la cordura— de los pacientes que las promesas percibidas de atención en sus planes de seguro puedan desaparecer repentinamente a mitad de año. Y los reguladores pueden hacer algo al respecto: obligar a los proveedores y aseguradoras a mantener sus contratos entre sí durante todo el término de las pólizas de los pacientes, para que ninguno quedé atrapado en una guerra con la que no tienen nada que ver.

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

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The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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

The Alabama Supreme Court’s groundbreaking ruling last week that frozen embryos have legal rights as people has touched off a national debate about the potential fallout of the “personhood” movement. Already the University of Alabama-Birmingham has paused its in vitro fertilization program while it determines the ongoing legality of a process that has become increasingly common for those wishing to start a family. 

Meanwhile, former President Donald Trump is reportedly leaning toward endorsing a national, 16-week abortion ban. At the same time, former aides are planning a long agenda of reproductive health restrictions should Trump win a second term.

This week’s panelists are Julie Rovner of KFF Health News, Lauren Weber of The Washington Post, Rachana Pradhan of KFF Health News, and Victoria Knight of Axios.

Panelists

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Rachana Pradhan
KFF Health News

@rachanadpradhan

Read Rachana's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• The Alabama Supreme Court’s decision on embryonic personhood could have wide-ranging implications beyond reproductive health care, with potential implications for tax deductions, child support payments, criminal law, and much more.
• Donald Trump is considering a national abortion ban at 16 weeks of gestation, according to recent reports. It is unclear whether such a ban would go far enough to please his conservative supporters, but it would be far enough to give Democrats ammunition to campaign on it. And some are looking into using a 19th-century anti-smut law, the Comstock Act, to implement a national ban under a new Trump presidency — no action from Congress necessary.
• New reporting from KFF Health News draws on many interviews with clinicians at Catholic hospitals about how the Roman Catholic Church’s directives dictate the care they may offer patients, especially in reproductive health. It also draws attention to the vast number of religiously affiliated hospitals and the fact that, for many women, a Catholic hospital may be their only option.
• Questions about President Joe Biden’s cognitive health are drawing attention to ageism in politics — as well as in American life, with fewer people taking precautions against the covid-19 virus even as it remains a serious threat to vulnerable people, especially the elderly. The mental fitness of the nation’s leaders is a valid, relevant question for many voters, though the questions are also fueled by frustration with a political system in which many offices are held by older people who have been around a long time.

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

Julie Rovner: Stat’s “New CMS Rules Will Throttle Access Researchers Need to Medicare, Medicaid Data,” by Rachel M. Werner.

Lauren Weber: The Washington Post’s “They Take Kratom to Ease Pain or Anxiety. Sometimes, Death Follows,” by David Ovalle.

Rachana Pradhan: Politico’s “Red States Hopeful for a 2nd Trump Term Prepare to Curtail Medicaid,” by Megan Messerly.

Victoria Knight: ProPublica’s “The Year After a Denied Abortion,” by Stacy Kranitz and Kavitha Surana.

Also mentioned on this week’s podcast:

• The New York Times’ “Trump Privately Expresses Support for a 16-Week Abortion Ban,” by Maggie Haberman, Jonathan Swan, and Lisa Lerer.
• The New York Times’ “Trump Allies Plan New Sweeping Abortion Restrictions,” by Lisa Lerer and Elizabeth Dias.
• Politico’s “Trump Allies Prepare to Infuse ‘Christian Nationalism’ in Second Administration,” by Alexander Ward and Heidi Przybyla.
• KFF Health News’ “The Powerful Constraints on Medical Care in Catholic Hospitals Across America,” by Rachana Pradhan and Hannah Recht.
• The Washington Post’s “Tax Records Reveal the Lucrative World of Covid Misinformation,” by Lauren Weber.
• KFF Health News’ “Do We Simply Not Care About Old People?” by Judith Graham.
• Stat’s “A Neuropsychologist Clarifies Science on Aging and Memory in Wake of Biden Special Counsel Report,” by Annalisa Merelli.

click to open the transcript

Transcript: Alabama Court Rules Embryos Are Children. What Now?

KFF Health News’ ‘What the Health?’Episode Title: Alabama Court Rules Embryos Are Children. What Now?Episode Number: 335Published: Feb. 22,2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 22, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Lauren Weber of The Washington Post.

Lauren Weber: Hello, hello.

Rovner: Victoria Knight of Axios.

Victoria Knight: Hello, everyone.

Rovner: And my KFF Health News colleague Rachana Pradhan.

Rachana Pradhan: Hi, there. Good to be back.

Rovner: Congress is out this week, but there is still tons of news, so we will get right to it. We’re going to start with abortion because there is lots of news there. The biggest is out of Alabama, where the state Supreme Court ruled last week that frozen embryos created for IVF [in vitro fertilization] are legally children and that those who destroy them can be held liable. In fact, the justices called the embryos “extrauterine children,” which, in covering this issue for 40 years, I never knew was a thing. There are lots of layers to this, but let’s start with the immediate, what it could mean to those seeking to get pregnant using IVF. We’ve already heard that the University of Alabama’s IVF clinic has ceased operations until they can figure out what this means.

Pradhan: I think that that is the immediate fallout right now. We’ve seen Alabama’s arguably flagship university saying that they are going to halt. And I believe some of the coverage that I saw, there was even a woman who was about to start a cycle or was literally about to have embryos implanted and had to encounter that extremely jarring development. Beyond the immediate, and of course, Julie, I’m sure we’ll talk about this, a bit about the personhood movement and fetal rights movement in general, but a lot of the country might say, “Oh, well, it’s Alabama. It’s only Alabama.” But as we know it, it really just takes one state, it seems like these days, to open the floodgates for things that might actually take hold much more broadly across the country. So that’s what I’m …

Rovner: It’s funny, the first big personhood push I covered was in 2011 in Mississippi, so next door to Alabama, very conservative state, where everybody assumed it was going to win. And one of the things that the opposition said is that this would ban most forms of birth control and IVF, and it got voted down in Mississippi. So here we are, what, 13 years later. But I mean, I think people don’t quite appreciate how IVF works is that doctors harvest as many eggs as they can and basically create embryos. Because for every embryo that results in a successful pregnancy, there are usually many that don’t.

And of course, couples who are trying to have babies using IVF tend to have more embryos than they might need, and, generally, those embryos are destroyed or donated to research, or, in some cases — I actually went back and looked this up — in the early 2000s there was a push, and it’s still there, there’s an adoption agency that will let you adopt out your unused embryos for someone else to carry to term. And apparently, all of this, I guess maybe not the adoption, but all the rest of this could theoretically become illegal under this Alabama Supreme Court ruling.

Pradhan: And one thing I just want to say, too, Julie, piggybacking on that point too is not just in each cycle that someone goes through with IVF — as you said, there are multiple embryos — but it often takes two people who want to start a family, it often takes multiple IVF cycles to have a successful pregnancy from that. It’s not like it’s a one-time shot, it usually takes a long time. And so you’re really talking about a lot of embryos, not just a one-and-done situation.

Rovner: And every cycle is really expensive. I know lots of people who have both successfully and unsuccessfully had babies using IVF and it’s traumatic. The drugs that are used to stimulate the extra eggs for the woman are basically rough, and it costs a lot of money, and it doesn’t always work. It seems odd to me that the pro-life movement has gotten to the point where they are stopping people who want to get pregnant and have children from getting pregnant and having children. But I guess that is the outflow of this. Lauren, you wanted to add something?

Weber: Yeah, I just wanted to chime in on that. I mean, I think we’re really going to see a lot of potential political ramifications from this. I mean, after this news came down, and just to put in context, the CDC [Centers for Disease Control and Prevention] reported in 2021 that there were 91,906 births via IVF. So that’s almost 92,000 families in 2021 alone. You have a political constituency of hundreds of thousands of parents across the U.S. that feel very strongly about this because they have received children that they paid a lot of money for and worked very hard to get. And it was interesting after this news came down — I will admit, I follow a lot of preppy Southern influencers who are very apolitical and if anything conservative, who all were very aggressively saying, “The only reason I could have my children is through this. We have to make a stand.”

I mean, these are not political people. These are people that are — you could even argue, veering into tradwife [traditional wife] territory in terms of social media. I think we’re really going to see some political ramifications from this that already are reflected in what Donald Trump has recently been reported as feeling about how abortion limits could cost him voters. I do wonder if IVF limits could really cause quite an uproar for conservative candidates. We’ll see.

Rovner: Yeah. Well, Nikki Haley’s already gotten caught up in this. She’s very pro-life. On the other hand, she had one of her children using IVF, which she’s been pretty frank about. She, of course, got asked about this yesterday and her eyes had the deer-in-the-headlights look, and she said, “Well, embryos are children,” and it’s like, “Well, then what about your extra embryos?” Which I guess nobody asked about. But yeah, I mean clearly you don’t have to be a liberal to use IVF to have babies, and I think you’re absolutely right. I want to expand this though, because the ruling was based on this 2018 constitutional amendment approved by voters in Alabama that made it state policy to, quote, “Recognize and support the sanctity of unborn life and the rights of unborn children.”

I should point out that this 2018 amendment did not directly try to create fetal personhood in the way that several states tried — and, as I mentioned, failed — in the 2010s, yet that’s how the Alabama Supreme Court interpreted it. Now, anti-abortion advocates in other states, Rachana, you mentioned this, are already trying to use this decision to apply to abortion bans and court cases there. What are the implications of declaring someone a person at the moment of fertilization? It obviously goes beyond just IVF, right?

Knight: Well, and I think you mentioned already, birth control is also the next step as well. Which basically they don’t want you to have a device that will stop a sperm from reaching an egg. And so I think that could have huge ramifications as well. So many young women across the U.S. use IUDs or other types of birth control. I know that’s one application that people are concerned about. I don’t know if there are others.

Rovner: Yeah, I’ve seen things like, if you’re pregnant, can you now drive in the HOV [high-occupancy vehicle] lane because you have another person?

Pradhan: I think that’s one of the more benign, maybe potential impacts of this. But I mean, if an embryo is a child, I mean it would affect everything from, I think, criminal laws affecting murder or any other … you could see there being criminal law impacts there. I think also, as far as child support, domestic laws, involving families, what would you — presumably maybe not everyone that I imagine who are turning to fertility treatments to start a family or to grow a family may not have a situation where there are two partners involved in that decision. I think it could affect everything, frankly. So much of our tax estate laws are impacted by whether people have children or not, and so …

Rovner: And whether those children have been born yet.

Pradhan: … tax deductions, can you claim an embryo as a dependent? I mean, it would affect everything. So I think they’re very wide, sweeping ramifications beyond the unfortunate consequences that some people might face, as Lauren said, which is that they’re just trying to start a family and now that’s being jeopardized.

Rovner: I think Georgia already has a law that you can take a tax deduction if you’re pregnant. I have been wondering, what happens to birthdays? Do they cease to mean anything? It completely turns on its head the way we think about people and humans, and I mean obviously they say, “Well, yeah, of course it is a separate being from the moment of fertilization, but that doesn’t make it a legal person.” And I think that’s what this debate is about. I did notice in Alabama — of course, what happened, what prompted this case was that some patient in a hospital got into the lab where the frozen embryos were kept and took some out and literally just dropped them on the floor and broke the vial that they were in. And the question is whether the families who belong to those embryos could sue for some kind of recourse, but it would not be considered murder because, under Alabama’s statutes, it has to be a child in utero.

And obviously frozen embryos are not yet in utero, they’re in a freezer somewhere. In that sense it might not be murder, but it could become — I mean, this is something that I think people have been thinking about and talking about obviously for many years, and you wonder if this is just the beginning of we’re going to see how far this can go, particularly in some of the more conservative states. Well, meanwhile, The New York Times reported last week that former President Trump, who’s literally been on just about every side of the abortion debate over the years, is leaning towards supporting a 16-week ban — in part, according to the story, because it’s a round number. Trump, of course, was a supporter of abortion rights until he started running for president as a Republican.

And, in winning the endorsement of skeptical anti-abortion groups in 2016, promised to appoint only anti-abortion judges and to reimpose government restrictions from previous Republican administrations. He did that and more, appointing the three Supreme Court justices who enabled the overturn of Roe v. Wade. But more recently, he’s seen the political backlash over that ruling and the number of states that have voted for abortion rights, including some fairly red states, and he’s been warning Republicans not to emphasize the issue. So why would he fail to follow his own advice now, particularly if it would animate voters in swing states? He keeps saying he’s not in the primaries anymore, that he’s basically running a general-election campaign.

Knight: I mean, I think to me, it seems like he’s clearly trying to thread the needle here. He knows some of the more social conservative of his supporters want him to do something about abortion. They want him to take a stand. And so he decided on allegedly 16 weeks, four months, which is less strict than some states. We saw Florida was 10 weeks. And then some other states …

Rovner: I think Florida is six weeks now.

Knight: Oh, sorry, six weeks. OK.

Rovner: Right. Pending a court decision.

Knight: Yeah. And then other states, in Tennessee, complete abortion ban with little room for exceptions. So 16 weeks is longer than some other states have enacted that are stricter. Roe v. Wade was about 24 weeks. So to me, it seems like he’s trying to find some middle ground to try to appease those social conservatives, but not be too strict.

Rovner: Although, I mean, one of the things that a 16-week ban would not do is protect all the women that we’ve been reading about who are with wanted pregnancies, who have things go wrong at 19 or 20 or 21 weeks, which are before viability but after 16 weeks. Well, unless they had — he does say he wants exceptions, and as we know, as we’ve talked about every week for the last six months, those exceptions, the devil is in the details and they have not been usable in a lot of states. But I’m interested in why Trump, after saying he didn’t want to wade into this, is now wading into this. Lauren, you wanted to add something?

Weber: Yeah, I wanted to echo your point because I think it’s important to note that 16 weeks is not based, it seems like, on any scientific reason. It sounds like to me, from what I understand from what’s out there, that 20 weeks is more when you can actually see if there’s heart abnormalities and other issues. So it sounds like from the reporting the Times did, was that he felt like 16 weeks was good as,  quote, “It was a round number.” So this isn’t exactly, these weak timing of bans, as I’m sure we’ve discussed with this podcast, are not necessarily tied towards scientific development of where the fetus is. So I think that’s an important thing to note.

Rovner: Yes. Rachana.

Pradhan: I mean, I think, and we’ve talked about this, but it’s the perennial danger in weighing in on any limit, and certainly a national limit, but any limit at all, is that 16 weeks, of course as the anti-abortion movement and I think many more people know now, the CDC data shows that the vast majority of abortions annually occur before that point in pregnancy. And so there are, of course, some anti-abortion groups that are trying to thread the needle and back a more middle-ground approach such as this one, 15 weeks, 16 weeks, banning it after that point. But for many, it’s certainly not anywhere good enough. And I think if you’re going to try to motivate your conservative base, I still have a lot of questions about whether they would find that acceptable. And I think it depends on how they message it, honestly.

If they say, “This is the best we can do right now and we’re trying,” that might win over some voters. But on the flip side, it’s still enough for Democrats to be able to run with it and say any national ban obviously is unacceptable to them, but it gives them enough ammunition, I think, to still say that former President Trump wants to take your rights away. And I think, as Lauren noted, genetic testing and things these days of course can happen and does happen before 16 weeks. So there might be some sense of whether there might be, your child has a lethal chromosomal disorder or something like that, that might make the pregnancy not viable. But the big scan that happens about midway through pregnancy is around 20 weeks, and that’s often when you, unfortunately, some people find out that there are things that would make it very difficult for their baby to survive so …

Rovner: Well, it seems that no matter what Trump does or says he will do if he’s elected in November, it’s clear that people close to him, including former officials, are gearing up for a second term that could go way further than even his very anti-abortion first term. According to Politico, a plan is underway for Trump to govern as a, quote, “Christian nationalist nation,” which could mean not just banning abortion, but, as Victoria pointed out, contraception, too, or many forms of contraception. A separate planning group being run out of the Heritage Foundation is also developing far-reaching plans about women’s reproductive health, including enforcement of the long-dormant 19th century Comstock Act, which we have talked about here many times before. But someone please remind us what the Comstock Act is and what it could mean.

Weber: I feel like you’re the expert on this. I feel like you should explain it.

Rovner: Oh boy. I don’t want to be the expert on the Comstock Act, but I guess I’ve become it. It’s actually my favorite tidbit about the Comstock Act is that it is not named after a congressman. It is named after basically an anti-smut crusader named Anthony Comstock in the late 1800s. And it bans the mailing of, I believe the phrase is “lewd or obscene” information, which in the late 1880s included ways to prevent pregnancy, but certainly also abortion. When the Supreme Court basically ruled that contraception was legal, which did not happen until the late 1960s — and early 1970s, actually —, the Comstock Act sort of ceased to be. And obviously then Roe v. Wade, it ceased to be.

But it is still in the books. It’s never been officially repealed, and there’s been a lot of chatter in anti-abortion movements about starting to enforce it again, which could certainly stop if nothing else, the distribution of the abortion pill in its tracks. And also it’s anything using the mail. So it could not just be the abortion pill, but anything that doctors use to perform abortions or to make surgical equipment — it seems that using Comstock, you could implement a national ban without ever having to worry about Congress doing anything. And that seems to be the goal here, is to do as much as they can without even having to involve Congress. Yes.

Pradhan: Julie, I’m waiting for the phrase “anti-smut crusader” to end up on a campaign sign or bumper sticker, honestly. I feel like we might see it. I don’t think this election has gotten nearly weird enough yet. So we still have nine months to go.

Rovner: Yeah. I’m learning way more about the Comstock Act than I really ever wanted to know. But meanwhile, Rachana, it does not take state or federal action to restrict access to reproductive health care. You have a story this week about the continuing expansion of Catholic hospitals and what that means for reproductive health care. Tell us what you found.

Pradhan: Well, yes, I would love to talk about our story. So myself and my colleague Hannah Recht, we started reporting the story, just for background, before the Supreme Court’s Dobbs decision, obviously anticipating that that is what was going to happen. And our story really digs into, based on ample interviews with clinicians, other academic experts, reading lots of documents about what the ethical and religious directives for Catholic health care services, which is what all, any health facility, a hospital, a physician’s office, anything that deems itself Catholic, has to abide by these directives for care, and they follow church teaching. Which we were talking about fertility treatments and IVF earlier actually, so in vitro fertilization is also something that the Catholic Church teaches is immoral. And so that’s actually something that they oppose, which many people may not know that.

But other things that the ERDs [ethical and religious directives] so to speak, impact are access to contraception, access to surgeries that would permanently prevent pregnancy. So for women that would be removing or cinching your fallopian tubes, but also, for men, vasectomies. And then, of course, anything that constitutes what they would call a direct abortion. And that affects everything from care for ectopic pregnancies, how you can treat them, to managing miscarriages. The lead story or anecdote in our story is about a nurse midwife who I spoke with, who used to work at a Catholic hospital in Maryland and talked to me about, relayed this anecdote about, a patient who was about 19 or 20 weeks pregnant and had her water break prematurely.

At that point, her fetus was not viable and that patient did not want to continue her pregnancy, but the medical staff there, what they would’ve done is induce labor with the intent of terminating the pregnancy. And they were unable to do that because of ERDs. And so, we really wanted to look at it systemically, too. So we looked at that combined with state laws that protect, shield hospitals from liability when they oppose providing things like abortions or even sterilization procedures on religious grounds. And included fresh new data analysis on how many women around the country live either nearby to a Catholic hospital or only have Catholic hospitals nearby. So we thought it was important.

Rovner: That’s a little bit of the lead because there’s been so much takeover of hospitals by Catholic entities over the last, really, decade and a half or so, that women who often had a choice of Catholic hospital or not Catholic hospital don’t anymore. That Catholic hospital may be the only hospital anywhere around.

Pradhan: Right and if people criticize the story, which we’ve gotten some criticism over it, one of the refrains we’ll hear is, “Well, just go to a different hospital.” Well, we don’t live in a country where you can just pick any hospital you want to go to — even when you have a choice, insurance will dictate what’s in-network versus what’s not. And honestly, people just don’t know. They don’t know that a hospital has a religious affiliation at all, let alone that that religious affiliation could impact the care that you would receive. And so there’s been research done over the years showing the percentage of hospital beds that are controlled by Catholic systems, et cetera, but Hannah and I both felt strongly that that’s a useful metric to a point, but beds is not relatable to a human being. So we really wanted to boil it down to people and how many people we’re talking about who do not have other options nearby. How many births occur in Catholic hospitals so that you know those people do not have access to certain care if they deliver at these hospitals, that they would have in other places.

Rovner: It’s a continuing story. We’ll obviously post the link to it. Well, I also want to talk about age this week. Specifically the somewhat advanced age of our likely presidential candidates this year. President [Joe] Biden, currently age 81, and former President Trump, age 77. One thing voters of both parties seem to agree on is that both are generically too old, although voters in neither party seem to have alternative candidates in mind. My KFF Health News colleague Judy Graham has a really interesting piece on increasing ageism in U.S. society that the seniors we used to admire and honor we now scorn and ignore. Is this just the continuing irritation at the self-centeredness of the baby boomers or is there something else going on here that old people have become dispensable and not worth listening to? I keep thinking the “OK, boomer” refrain. It keeps ringing in my ears.

Weber: I mean, I think there’s a mix of things going on here. I mean, her piece was really fascinating because it also touched upon the fact — which all of us here reported on; Rachana and I wrote a story about this back in 2021 — on how nursing homes really have been abandoned to some extent. I mean, folks are not getting the covid vaccine. People are dying of covid, they die of the flu, and it’s considered a way of life. And there is almost an irritation that there would be any expectation that it would be any differently because it’s a “Don’t infringe upon my rights” thought. And I do think her piece was fascinating because it asks, “Are we really looking at the elderly?”

I mean, I think that’s very different when we talk about politicians. I mean, the Biden bit is a bit different. I mean, I think there is some frustration in the American populace with the age of politicians. I think that reached a bit of a boiling point with the Sen. [Dianne] Feinstein issue, that I think is continuing to boil over in the current presidential election. But that said, we’re hurtling towards an election with these two folks. I mean, that’s where we’re at. So I think they’re a bit different, but I do think there is a national conversation about age that is happening to some degree, but is not happening in consideration to others.

Well, I was going to say, I think the other aspect is that these people are in the public all the time, or they’re supposed to be. President Biden is giving speeches. Potential candidate President Trump, GOP main candidate, he’s in the spotlight all the time, too. And so you can actually see when they mess up sometimes. You can see potentially what people are saying is signs of aging. And so I think it’s different when they’re literally in front of your eyes and they’re supposed to be making decisions about the direction of this country, potentially. So I think it’s somewhat a valid conversation to have when the country is in their hands.

Rovner: Yeah, and obviously the presidency ages you. [Barack] Obama went in as this young, strong-looking guy and came out with very gray hair, and he was young when he went in. Bill Clinton, too, was young when he was elected and came out looking considerably older. And so Biden, if people have pointed out, looks a lot older now than he did when he was running back in 2020. But meanwhile, despite what voters and some special councils think — including the one who said that Biden was what a kindly old man with a bad memory — neuroscientists say that it’s actually bunk that age alone can determine how mentally fit somebody is, and that even if memory does start to decline, judgment and wisdom may improve as you age. Why is nobody in either party making this point? I mean, the people supporting Biden are just saying that he’s doing a good job and he deserves to continue doing a good job. I mean, talk about the elephant in the room and nobody’s talking about it at all with Trump.

Pradhan: Yeah, I mean, I think probably the short answer is that it’s not really as politically expedient to talk about those things. I thought it was really interesting. Yeah, I really appreciated Stat News had this really interesting Q&A article. And then also there was this opinion piece in The New York Times that, this line struck me so much about, again, both about Biden’s age and his memory. And this line I thought was so fascinating because it just is telling how people’s perceptions can change so much depending on the discourse. So it pointed out that Joe Biden is the same age as Harrison Ford, Paul McCartney, Martin Scorsese. He’s younger than Berkshire Hathaway CEO Warren Buffett, who is considered to be one of the shrewdest and smartest investors, I think, and CEOs of modern times. And no one is saying, “Well, they’re too old to be doing their jobs” or anything. I’m not trying to suggest that people who have concerns about both candidates’ age[s] are not valid, but I think we sometimes have to double-check why we might be being led to think that way, and when it’s not really the same standards are not applied across the board to people who are even older than they are.

Rovner: I do think that some of the frustration, I think, Lauren, you mentioned this, is that in recent years, the vast majority of leadership positions in the U.S. government have been held by people who are, shall we say, visibly old. I mean Nancy Pelosi is still in Congress, but she at least figured out that she needed to step down from being speaker because I think the three top leaders in the House were all in their either late 70s or early 80s. The Senate has long been the land of very old people because you get elected to a six-year term. I mean, Chuck Grassley is 90 now, is he not? Feinstein wasn’t even, I don’t think, the oldest member of the Senate. So I think it’s glaring and staring us in the face. Rachana, you wanted to add something before we moved on.

Pradhan: Well, I think probably, and a lot of that too is just I think probably a reflection of voters’ broader gripes or concerns about the fact that we have people who hold office for an eternity, to not exaggerate it. And so people want to see new leadership, new energy, and when you have public officeholders who hold these jobs for … they’re career politicians, and I think that that is frustrating to a lot of people. They want to see a new generation, even regardless of political party, of ideas and energy. And then when you have these octogenarians holding onto their seats and run over and over and over again, I think that that’s frustrating. And people don’t get energized about those candidates, especially when they’re running for president. They just don’t. So it’s a reflection of just, I think, broader concerns.

Knight: And I think one more thing too was, I mean, Sen. Feinstein died while she was in office. I mean, people also may be referencing Ruth Bader Ginsburg on the Supreme Court, and it’s the question of, should you be holding onto a position that you may die in it, and not setting the way for the new person to take over and making that path available for the next people? Is that the best way to lead in whatever position you’re in? I think, again, Rachana said that’s frustrating for a lot of people.

Rovner: And I think what both parties have been guilty of, although I think Democrats even more than Republicans, is preparing people, making sure that that next generation is ready, that you don’t want to go from these people with age and wisdom and experience to somebody who knows nothing. You need those people coming up through the ranks. And I think there’s been a dearth of people coming up through the ranks lately, and I think that’s probably the big frustration.

Pradhan: I’m not sure if this is still true now, but I certainly remember, I think when Paul Ryan was speaker of the House, I remember the average age of the House Republican conference was significantly younger than that of Democrats. And they would highlight that. They would say, “Look, we are electing a new generation of leaders and look at these aging Democrats over here.” And that might still be true, but I certainly remember that that was something that they tried to capitalize on, oh-so-long ago.

Rovner: As we talked about last week, there are now a lot of those not-so-young Republicans, but not really old, who are just getting out because it is no fun anymore to be in Congress. Which is a good segue because … oh, go ahead.

Knight: Oh, I was just saying one thing Republicans do do in the House, at least they do have term limits on the chairmanships to ensure people do not hold onto those leadership positions forever. And Democrats do not have that. That’s at least in the House.

Rovner: But then you get the expertise walking out the door. It’s a double-edged sword.

Knight: Which is, not all the ones that are leaving have reached their term limits, which is the interesting thing actually. But yes, that expertise can walk out the door.

Rovner: Well, speaking of Congress, here in Washington, as I mentioned at the top, Congress is in recess, but when they come back, they will have I believe it is three days before the first raft of temporary spending bills expire. Victoria, is this the time that the government’s going to actually shut down, or are we looking at yet another round of short-term continuing resolutions? And at some point automatic cuts kick in, right?

Knight: Yeah, the eternal question that we’ve had all of this Congress, I think both sides do not want to shut down. I saw some reporting this morning that was saying [Senate Majority Leader] Chuck Schumer is talking to [House Speaker] Mike Johnson, but he also, Schumer did not want to commit to a CR [continuing resolution] yet either. So it’s possible, but we said that every time and they’ve pulled it off. I think they just know a shutdown is so, not even maybe necessarily politically toxic, but potentially —because I don’t know how much the public understands what that means …

Rovner: Because they don’t understand who’s at fault.

Knight: Right. Who’s at fault …

Rovner: … when it does shut down. They just know that the Social Security office is closed.

Knight: Right, but I just know they know it’s dysfunctional or it just can make things messy when that happens; it’s harder for agencies and things like that. So we’ll see. So the deadline is next Friday for the first set of bills. It’s just four bills then, and then the next deadline is March 8 for the other eight bills. There’s some talk that we may see a package over the weekend, but it’s Mike Johnson’s deciding moment. Again, he’s getting pressure from the House Freedom Caucus to push for either spending cuts or policy riders that include anti-abortion riders, anti-gender-affirming care, a lot. There’s a whole list of things that they sent yesterday they want in bills, and so he’s going to have to …

Rovner: Culture wars is the shorthand for a lot of those.

Knight: Yes, exactly. And so House Freedom Caucus sent a letter yesterday, and so Mike Johnson’s going to have to decide does he want to acquiesce to any House Freedom Caucus demands or does he want to work? But if he doesn’t want to do that, then he’s going to have to pass any funding bills with Democratic votes because he does not have enough votes with the Republicans alone, if Freedom Caucus people and people aligned in that direction don’t vote for any funding bills. If he does that, if he works with Democrats, then there is talk that they might file a motion to vacate him out of the speakership. So it’s the same problem that Kevin McCarthy had. The one thing going for Johnson is that he doesn’t have the baggage that Kevin McCarthy had, a lot of political baggage. A lot of people had ill will towards him, just built up over the years. Johnson doesn’t seem to have that as much, and also Republicans, do they want to be leadership-less again?

Rovner: Because that worked so well the first two times.

Knight: Right, so he has got to decide again who he wants to work with. And it doesn’t seem like we know yet how that’s going to go, and that will determine whether the government shuts down or not.

Rovner: But somebody also reminded me that on April 1, if they haven’t done full-year funding, that automatic cuts kick in. I had forgotten that. So I mean, they can’t just keep rolling these deadlines indefinitely. This presumably is the last time they can roll a deadline without having other ramifications.

Knight: Absolutely. And Freedom Caucus, actually, I think that’s partly why they don’t want to agree to something, because they want the 1% cuts across the board. So that was part of the deal made last year under Kevin McCarthy was, if they don’t come up with full funding bills by April 1, there will be a 1% cut put into place. And so the more hard-liners [are] like, “Great, we’re going to cut funding, so we want to do that.” And then Democrats don’t want that to happen. And so yeah, it’s the last time that they can potentially do a CR before that.

Rovner: Yeah, just a reminder, for those who are not keeping track, that April 1 is six months, halfway through the fiscal year for them to have not finished the fiscal year spending bills.

Knight: And one more note is that usually they’re starting on this coming year spending bills by this point in Congress. So we’re still working on FY24 bills. We should be working on FY25 bills already. So they’re already behind. It’s dysfunctional.

Rovner: I think it’s fair to say the congressional budget process has completely broken down. Well, moving on to “This Week in Medical Misinformation,” we have a case of doing well by doing no good. Lauren, tell us about your story looking into the profits that accrued to anti-vaccine and anti-science groups during the pandemic.

Weber: So I took a look at a bunch of tax records, and what I found is that four major nonprofits that rose to prominence during the covid pandemic by capitalizing on the spread of misinformation collectively gained more than $118 billion from 2020 to 2022. And were able to deploy that money to gain influence in statehouses, courtrooms, and communities across the country. And it’s a pretty staggering figure to tabulate all together. And what was particularly interesting is there was four of these different groups that I was directed to look at by experts in the field, and one of them includes Children’s Health Defense, which was founded by Robert F. Kennedy Jr., and they received, in 2022, $23.5 million in contributions, grants, and other revenue. That was eight times what they got before the pandemic. And that kind of story was reflected in these other groups as well. And it just shows that the fair amount of money that they were able to collect during this time as they were promoting content and other things.

Rovner: Yeah, I mean literally misinformation pays. While we’re on this subject, I would also note that this week there’s a huge multinational study of 99 million people vaccinated against covid that confirmed previous studies showing an association between being vaccinated and developing some rare complications. But a number of stories, at least I thought, overstated the risks of the study that it actually identified. Most failed to include the context that almost every vaccine has the possibility of causing adverse reactions in some very small number of people. The question of course, when you’re evaluating vaccines, is if the benefit outweighs the benefit of protecting against whatever this disease or condition outweighs the risk of these rare side effects.

I would also point out that this is why the U.S. actually has something called the [National] Vaccine Injury Compensation Program, which helps provide for people, particularly children, who experience rare complications to otherwise mandatory vaccines. Anyway, that is the end of my rant. I was just frustrated by the idea that yes, yes, we know vaccines sometimes have side effects. That’s the nature of vaccines. That’s one of the reasons we study them.

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

Knight: So my extra credit this week is a story in ProPublica called “The Year After a Denied Abortion.” It’s by [photographer] Stacy Kranitz and [reporter] Kavitha Surana. And it was a very moving photo essay and story about a woman who was denied an abortion in Tennessee literally weeks to a month after Roe v. Wade was overturned in June 2022, and this was in July 2022. She got pregnant and was denied an abortion. And so it followed her through the next year of her life after that happened. And in Tennessee, it’s one of the strictest abortion bans in the nation. Abortion is banned and there are very rare exceptions. And so this woman, Mayron Michelle Hollis, she already had some children that had been taken out of her care by the state, and so she was already fighting custody battles and then got pregnant. And Tennessee is also a state that doesn’t have a very robust safety-net system, so it follows her as she has a baby that’s born prematurely, has a lot of health issues, doesn’t have a lot of state programs to help her.

She was afraid to go through unemployment because she had had issues with that before. The paperwork situation’s really tough. There’s just so much stress involved also with the situation. She eventually ends up kind of relapsing, starting drinking too much alcohol, and she ends up in jail at the end of the story. And so it just talks about how if there is not a robust safety net in a state, if you’re kind of forced to have a pregnancy that you maybe are not able to take care of, it can be really tough financially and psychologically and tough for the mother and the child. So it was a really moving story and there were photos following her through that year.

Rovner: Lauren.

Weber: I wanted to shout out my colleague who I actually sit next to, David Ovalle, who is wonderful at The Washington Post. He wrote an article called “They Take Kratom to Ease Pain or Anxiety. Sometimes, Death Follows.” And, as our addiction reporter for the Post, he did a horribly depressing but wonderful job actually calculating how many kratom deaths or deaths associated with kratom have happened in recent years. And what he found through requests is that at least 4,100 deaths in 44 states and D.C. were linked to kratom between 2020 and 2022, which is public service journalism at its best. I mean, I think people are clear that there is more risks with this, but I think that it’s emerging actually how those risks are. And he catalogs through the hard numbers, which is often what it requires for folks to pay attention, that this is something that is interactive with other medications which is causing death, in some cases, on death certificates. So pretty moving story, he talked to a lot of the families of folks that have died and it really makes you wonder about the state of regulation around kratom.

Rovner: Yeah, and then, I mean, all food diet supplements that are basically unregulated by the FDA because Congress determined in the 1990s that they should be unregulated because the supplement industry lobbied them very heavily and we will talk about that at some other time. Rachana.

Pradhan: My extra credit is a story in Politico by Megan Messerly. It’s titled “Red States Hopeful for a 2nd Trump Term Prepare to Curtail Medicaid.” The short version is work requirements are in, again. There was an effort previously that Republicans wanted to impose employment as a condition of receiving Medicaid benefits, and then they were very quickly, a couple of states, were sued. Only one program really got off the ground, Arkansas. And what happened as a result is because of the paperwork burdens and other things, thousands of people lost coverage. So currently the Biden administration, of course, is not OK at all with tying any type of work, volunteer service, you name it, to Medicaid benefits. But I think Republicans would be — the story talks about how Republicans would be eager to go and pursue that policy push again and curtail enrollment as a result of that.

So I thought that was, it’s an interesting political story. One thing it did make me wonder though, just as an aside is, there’s also been discussion on the flip side, the states in the story, which focus on South Dakota and Louisiana, states that many of them have already expanded coverage to cover the ACA [Affordable Care Act] population, but there are also still states that have not expanded Medicaid under the ACA’s income thresholds. And those conservative states might find it slightly more palatable to do so if you allow them to impose these types of conditions on the program. And so I think we will see what happens.

Rovner: Although, as we talked about not too long ago, Georgia, one of the states that has not expanded Medicaid under the Affordable Care Act now has a work requirement for Medicaid. And they’ve gotten something in the neighborhood, I believe, of like 2,700 people who’ve signed up out of a potential 100,000 people who could be covered if they actually expanded Medicaid. So another space that we will watch.

Well, my extra credit this week is from Stat News and, warning, it’s super nerdy. It’s called “New CMS Rules Will Throttle Access Researchers Need to Medicare, Medicaid Data.” It’s by Rachel Werner, who’s a physician researcher at the University of Pennsylvania, and it’s about a change recently announced by the Centers for Medicare & Medicaid Services that will make it more difficult and more expensive for researchers to work with the program’s data, of which there is a lot. Since the new policy was announced earlier this month, according to CMS, in response to an increase in data breaches, I’ve heard from a lot of researchers who are worried that critical research won’t get done and that new researchers won’t get trained if these changes are implemented because only certain people will have access to the data because you’ll have to pay every time somebody else gets access to the data. Again, it’s an incredibly nerdy issue, but also really important. So the department is taking comment on this and we’ll see if they actually follow through.

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

Pradhan: Still on X, hanging on, @rachanadpradhan.

Rovner: Victoria.

Knight: I’m also on X @victoriaregisk.

Rovner: Lauren?

Weber: Still on X @LaurenWeberHP.

Rovner: I think people have come sort of slithering back. We will be back in your feed next week. Until then, be healthy.

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