KFF Health News' 'What the Health?': Harris in the Spotlight
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
As Vice President Kamala Harris appears poised to become the Democratic Party’s presidential nominee, health policy in general and reproductive health issues in particular are likely to have a higher profile. Harris has long been the Biden administration’s point person on abortion rights and reproductive health and was active on other health issues while serving as California’s attorney general.
Meanwhile, Congress is back for a brief session between presidential conventions, but efforts in the GOP-led House to pass the annual spending bills, due by Oct. 1, have run into the usual roadblocks over abortion-related issues.
This week’s panelists are Julie Rovner of KFF Health News, Stephanie Armour of KFF Health News, Rachel Cohrs Zhang of Stat, and Alice Miranda Ollstein of Politico.
Panelists
Stephanie Armour
KFF Health News
Rachel Cohrs Zhang
Stat News
Alice Miranda Ollstein
Politico
Among the takeaways from this week’s episode:
- President Joe Biden’s decision to drop out of the presidential race has turned attention to his likely successor on the Democratic ticket, Vice President Kamala Harris. At this late hour in the campaign, she is expected to adopt Biden’s health policies, though many anticipate she’ll take a firmer stance on restoring Roe v. Wade. And while abortion rights supporters are enthusiastic about Harris’ candidacy, opponents are eager to frame her views as extreme.
- As he transitions from incumbent candidate to outgoing president, Biden is working to frame his legacy, including on health policy. The president has expressed pride that his signature domestic achievement, the Inflation Reduction Act, took on the pharmaceutical industry, including by forcing the makers of the most expensive drugs into negotiations with Medicare. Yet, as with the Affordable Care Act’s delayed implementation and results, most Americans have yet to see the IRA’s potential effect on drug prices.
- Lawmakers continue to be hung up on federal government spending, leaving appropriations work undone as they prepare to leave for summer recess. Fights over abortion are, once again, gumming up the works.
- In abortion news, Iowa’s six-week limit is scheduled to take effect next week, causing rippling problems of abortion access throughout the region. In Louisiana, which added the two drugs used in medication abortions to its list of controlled substances, doctors are having difficulty using the pills for other indications. And doctors who oppose abortion are pushing higher-risk procedures, like cesarean sections, in lieu of pregnancy termination when the mother’s life is in danger — as states with strict bans, like Texas and Louisiana, are reporting a rise in the use of surgeries, including hysterectomies, to end pregnancies.
- The Government Accountability Office reports that many states incorrectly removed hundreds of thousands of eligible people from the Medicaid rolls during the “unwinding” of the covid-19 public health emergency’s coverage protections. The Biden administration has been reluctant to call out those states publicly in an attempt to keep the process as apolitical as possible.
Also this week, Rovner interviews Anthony Wright, the new executive director of the consumer health advocacy group Families USA. Wright spent the past two decades in California, working with, among others, now-Vice President Kamala Harris on various health issues.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: NPR’s “A Study Finds That Dogs Can Smell Your Stress — And Make Decisions Accordingly,” by Rachel Treisman.
Alice Miranda Ollstein: Stat’s “A Pricey Gilead HIV Drug Could Be Made for Dramatically Less Than the Company Charges,” by Ed Silverman, and Politico’s “Federal HIV Program Set To Wind Down,” by Alice Miranda Ollstein and David Lim.
Stephanie Armour: Vox’s “Free Medical School Won’t Solve the Doctor Shortage,” by Dylan Scott.
Rachel Cohrs Zhang: Stat’s “How UnitedHealth Harnesses Its Physician Empire To Squeeze Profits out of Patients,” by Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence.
Also mentioned on this week’s podcast:
- States Newsroom’s “Anti-Abortion Researchers Back Riskier Procedures When Pregnancy Termination Is Needed, Experts Say,” by Sofia Resnick.
- KFF Health News’ “Louisiana Reclassifies Drugs Used in Abortions as Controlled Dangerous Substances,” by Rosemary Westwood, WWNO.
- The New York Times’ “Biden and Georgia Are Waging a Fight Over Medicaid and the Future of Obamacare,” by Noah Weiland.
click to open the transcript
Transcript: Harris in the Spotlight
KFF Health News’ ‘What the Health?’Episode Title: ‘Harris in the Spotlight’Episode Number: 357Published: July 25, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 25, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Rachel Cohrs Zhang of Stat News.
Rachel Cohrs Zhang: Hi, everybody.
Rovner: And we welcome back to the podcast one of our original panelists, Stephanie Armour, who I am pleased to say has now officially joined us here at KFF Health News. Stephanie, so great to have you back.
Stephanie Armour: Great to be back.
Rovner: Later in this episode, we will have my interview with Anthony Wright, the new executive director of the consumer health advocacy group Families USA. Anthony previously spent two decades working on health issues in California so he’s pretty familiar with the health work of the current vice president and soon-to-be Democratic presidential nominee, Kamala Harris, and he’ll share some of that knowledge with us. But first, this week’s news.
So it’s safe to say a lot has changed since the last time we met. In fact, it may be fair to say that just about everything has changed. President Joe Biden announced he would not seek reelection after all, he endorsed his vice president, Kamala Harris, and she proceeded to all but lock up the nomination in less than 48 hours. Obviously, this will be a huge deal for the fight over abortion and reproductive health care, which we will get to in a moment. But how is this going to impact health care, in general, as a campaign issue?
Ollstein: Yeah, it’s interesting because Kamala Harris has been a public figure for a while and has held a bunch of different offices, and so we can glean some clues as to where she is on various health care issues. But she’s been a bit hard to pin down. And when my colleagues and I were talking to a lot of folks throughout the health care industry over the past week, there were a lot of question marks on their end, so we know a few things. We know that she used the powers of the AG [attorney general] office to go after monopolies and consolidation and anticompetitive practices in California.
She did that in the insurance space, in the provider space, in the drug space, and so people are expecting that she would be maybe more aggressive on that front. We know that she did co-sponsor [Sen. Bernie Sanders’] “Medicare for All” bill, but then she also introduced her own, arguably more moderate, one that preserved private health insurance. And then, of course, abortion rights. She’s been very vocal on that front, but since becoming the presumptive nominee, she hasn’t really laid out what, if anything, she would do differently than Joe Biden. So like I said, a lot of question marks.
Rovner: Stephanie, you led our coverage of Harris’ health record. What did you learn?
Armour: Well, I think a number of the people that I’ve talked with really expect that she’ll be a standard-bearer to what Biden has already done, and I think that’s probably true. I don’t think she’s going to go back stumping for Medicare for All right now, for example. What I did find really interesting is, yes, she’s very much made abortion and reproductive rights a cornerstone of her vice presidency and, I assume, will be of her campaign. But based on where abortion is polling right now, a number of the strategists I spoke to said she really needs to do something pretty major on it in order to get a real uptick in terms of galvanizing voters, just because economy and immigration are so high. They’re saying that she really needs to do something like say that she’ll bring back legislation to restore Roe v. Wade, for example, to really make a difference. So I think it’ll be interesting to see how much that can really motivate voters when there’s so much competing for interest right now.
Cohrs Zhang: Oh, there is one other issue that I wanted to bring up. And I think especially from her time in the Senate, she didn’t sit on health care committees, but she did go out of her way to take ownership over concerns about maternal mortality. She was lead Senate sponsor of the Momnibus Act, which included a whole slew of different policies and programs that could help support mothers, especially Black mothers. And I think she has continued that interest in the White House and really championed health equity, which does, again, just draw a very stark contrast. So we haven’t seen a lot of passion or interest in the traditional health policy sense from her outside of abortion, but that is one issue she really has owned.
Rovner: Yeah, I mean, it has not been part of her quote-unquote “portfolio” as vice president, anything except, as I mentioned, reproductive rights, which will obviously be the biggest change from Biden to Harris. The president, as we all know, does not even like to say the word “abortion.” She, on the other hand, has been all over the issue since well before Roe got overturned and obviously particularly since then. Alice, how are advocates on both sides of this issue reacting to this switch at the top of the ticket?
Ollstein: Yeah, honestly, it’s been this interesting convergence because the pro-abortion-rights side is really jazzed. They’ve basically all rushed to endorse her and talk about how they’ve been working with her for years and really know her and trust her, and they believe she’ll be more aggressive than Biden was. But you also have the anti-abortion side being excited to have her as the villain, basically. They’ve had a hard time portraying Biden as extreme on this issue and they think they’ll have an easier time portraying Kamala Harris as extreme on abortion rights. One other thing from her record and background is her fight with the conservatives who recorded sting videos at Planned Parenthood that the anti-abortion movement still brings that up a lot. So yeah, it’ll be really interesting to see for which side this really lights a fire more because we’re hearing claims from both that it will fuel them.
Rovner: And, actually, I think it will actually fuel both sides of this. I would think that the abortion-rights groups were very — I mean everybody was pretty quick to endorse her — but the abortion-rights groups were right there right away, as were the anti-abortion groups saying she is extreme on abortion, which in some ways will fuel the abortion-right side. It’s like, “Oh good. The more the antis don’t like her, the stronger that means she is for us.” I mean, I literally could see this fueling both sides of this issue and …
Armour: Whereas you see Republicans backing away increasingly from abortion like the RNC [Republican National Committee] platform. And so it’s turning out to be still very much a hot-button issue and difficult issue for Republicans.
Rovner: So they say that the vice presidency is not very good for much, and I definitely agree with that. I mean, everybody always says, “The vice president hasn’t done anything.” Because the vice president doesn’t really have a job to do anything. Often the only time the vice president is on TV is when he or she sits behind the president at the State of the Union. But I feel like, in Harris’ case, it’s made her a much more confident and natural and comfortable campaigner. I watched her a lot when she was running for president in 2019 and 2020, and she was, to be kind, a little bit awkward; I mean she was just not one of those natural, had-that-rapport with a crowd, and I feel like that has changed a lot having watched her crisscross the country, particularly on reproductive health. Am I the only one that feels that way? I feel like people are going to see a very different vice president than they think they saw, while she was doing her due diligence as vice president.
Ollstein: Definitely, and I’ve found it interesting that it’s only been a few days since all of this went down, but I have noticed that while she has brought up abortion rights in pretty much every speech and appearance she’s given, she has not given specifics. She has not indicated if she is in the Biden camp of let’s restore Roe v. Wade, or with a lot of the rest of the movement that says Roe was never good enough, we need to aim for something much more expansive. So we didn’t know where she is on that. I mean, largely she’s been just saying, “Oh, I will stop Donald Trump from banning abortion nationally.” And using him as the foil and pledging to stop him. And so we haven’t really seen her make an affirmative case of what she would do on this front.
Rovner: Well, I think that would probably be as difficult for her as it is for the Republicans to try and figure out how far they want to go banning. Because yeah, as you mentioned, I mean, there’s a lot of the abortion-rights movement that think that restoring Roe, even if they could, is not enough because obviously under Roe, many, many types of restrictions were allowed and were in place. That is obviously not where the abortion-rights side wants to end up. And on the other side, as we’ve talked about ad nauseum, do anti-abortion forces, are they OK with state-by-state bans? Do they want a national ban? If so, what would it look like? So that will obviously continue.
Now that we have, relatively, mostly settled who’s going to be at the top of the ticket, we are once again, back to the “Who will be the VP pick?” sweepstakes. Now that we’ve finished the Republican side, we’re back to the Democratic side of the short list. We’ve all been hearing Kentucky Gov. Andy Beshear, North Carolina Gov. Roy Cooper, Arizona Sen. Mark Kelly, and Pennsylvania Gov. Josh Shapiro. They all have significant health records, but mostly on different issues. Who do you think of the people who are being mentioned would make the biggest splash on the health care scene?
Ollstein: I’ve been hearing a lot of people talk about Gov. Beshear’s record on Medicaid expansion and pushing back against work requirements, and also opposing legislation to restrict trans care. And so there’s definitely a lot there. Really, a lot of them have something there, but I’ve been hearing the most about him.
Rovner: And Mark Kelly, of course, is married to Gabrielle Giffords, who was shot at a campaign event and is now a leading voice in the gun control movement. So they all seem to have slightly different major health issues. Roy Cooper in North Carolina got North Carolina to expand Medicaid, which was a very, very, very big deal with a very, very, very Republican legislature. I’m not going to ask anybody to guess who it’s going to be because I can’t imagine that any of us have any major insight into this. Whoever it turns out to be, and I imagine we’ll know in the next week or two, we will go in and examine their health care record. One of the advantages that Vice President Harris will have on the campaign trail is she gets to campaign on the Biden administration’s record, which is fairly accomplished on the health care front without the drag of being in her 80s. Somebody remind us of all the health policies the Biden administration has gotten done. Start with the Inflation Reduction Act.
Cohrs Zhang: The name of the legislation is very general, but I think President Biden, in his goodbye speech last night, did mention the drug pricing portion of that bill. He’s described it as beating Big Pharma. And I think that’s definitely something that he talked about in his State of the Union, that he wanted to expand some of those pricing mechanisms to more people, not just people in Medicare, but people in commercial health plans, too. So I think that’s been something that he has really felt passionate about and Vice President Harris now could certainly use on the campaign trail. It’s a really popular issue and, again, not a huge policy departure, but, certainly, there’s more work to be done there on Democrats’ side.
Armour: And also I think the ACA [Affordable Care Act] extensions in terms of how many more people have been eligible for coverage is something that will definitely be part of Biden’s legacy as well. And the record-low uninsurance that we saw is something I bet that will be remembered, too.
Rovner: Yeah, I mean I’ve been personally surprised at some of the things that he’s gotten done in a Congress with virtually minuscule majority. I mean, one vote in the Senate and, when the Democrats were controlling the House, it was, what, four votes in the House. That takes, I think, a certain kind of legislator to get things passed. I know people walk around and say, “Oh, the Biden administration hasn’t done anything.” And you want to pull your hair out because that’s all we’ve spent the last six years talking about, things that have actually gotten done and not gotten done.
Cohrs Zhang: Right. Well, I mean doing things and communicating well about doing things are different issues, and I think that’s going to be Vice President Harris’ challenge over the next few months.
Rovner: Yeah, and so we’ve seen, and I think the Biden administration has prevented a lot of things from happening, which is always very hard to campaign on. It’s like, “Well, if we hadn’t done this, then this might’ve happened.” I mean, I think that’s true about the pandemic. Things could have gone much, much worse and didn’t and that’s tricky to say, “Hey, we prevented things from getting even more terrible than they were.”
Ollstein: And on the drug pricing front, I mean it just always reminds me of the Affordable Care Act where the payoff is years down the road, and so selling it to voters in the moment when they’re not feeling the effects yet is really hard. So it makes sense that people aren’t aware that they got this major legal change that’s been decades in the making over the finish line because the drugs aren’t cheaper yet for a lot of people.
Rovner: That’s true. And the caps on spending haven’t really kicked in yet. It is a lot like the Affordable Care Act, which took four years from the time of passage to the time it was fully implemented.
Well, in other news, and there is some other news, Congress is back after a break for the Republican [National] Convention, although they’re about to leave again. At the top of the House’s list was passing the spending bills that they didn’t manage to pass last year. So how’s that all going, Rachel?
Cohrs Zhang: I think they’ve just thrown in the towel this week, given up a bit. I think there’s been an attitude of just apathy on the Hill and especially on health care issues that the sense has been, “We’ll return to this in December when we all have a little bit more information about the dynamics going to the lame-duck session.” And I think that clearly has bled over into any will that remains to pass appropriations bills before August recess. I think they’re ready to get out there, ready to be on the campaign trail and put this on the back burner.
Rovner: Yeah, and in an election year, you basically have the six months leading up to the first convention and then almost nothing until they come back after the election. They were going gangbusters on some of these spending bills. They were getting them out of committee even though they were obviously not in the kind of shape that they were going to become law. We talked at some length about all of the riders and all of the funding cuts that the Republicans have put in some of these bills, but they couldn’t even get them through the floor. I mean, Alice we’re hung up on abortion, again!
Ollstein: Oh, as always. And it’s the exact same policy fights as last time. The fight’s going to happen in the ag[riculture] bill, around FDA [Food and Drug Administration] regulation of abortion pills. There’s going to be fights about the provisions helping veterans and active-duty service members access abortion, knowing that these appropriations bills are the only real legislation that has any chance of going anywhere. People are putting all of their policy priorities in as riders. And last round of this, there were anti-abortion provisions tacked onto basically every single spending bill, and almost all of them got stripped out in the end and did not become law. Obviously, they kept long-standing things like the Hyde Amendment, but they didn’t add the new restrictions Republicans wanted to add. That is likely to happen again. We’ll see. This could drag past the election potentially. So the dynamics, depending on the outcome of the election, could be really different than they are today.
Rovner: Yeah, I mean, I guess the House is going out and they won’t be back until September. It used to be there would be an August recess in an election year, and they would come back in September, and they would actually work until the beginning or even the middle of October. And even that seems to have gone away. Now, once they’re gone for the quote-unquote “August recess,” it’s like, bye-bye getting much of anything done.
Well, there’s also some more news on the abortion front: The on-again off-again, on-again, off-again, six-week abortion ban in Iowa appears to be on again, possibly to start as soon as next week. Alice, I think we’ve mentioned this before, but this is going to affect a lot more than just people in Iowa.
Ollstein: Yeah, definitely. I mean, we’re seeing a big erosion of access across the Midwest Great Plains, like that whole area, that whole swath, the Dakotas, et cetera. And there’s already a lot of pressure on Illinois as the destination and clinics there are already overwhelmed with folks coming in from all over. And so this will add to that. As we’ve seen when this has happened in other states, wait times can go up, shortages of providers needed to care for everyone. Telemedicine does relieve some of that, and there are these groups that mail abortion pills into any state regardless of restrictions. But not everyone is comfortable doing that or knows how to do that or wants to do that or can afford to do that. And so this is said to have a big impact, and we’ll have to see what happens.
Rovner: There were two other pieces about abortion that caught my eye this week, and they’re both about things that we’ve talked about before. One is the push by anti-abortion doctors to change medical practice. In Louisiana, the abortion drugs mifepristone and misoprostol, both of which are used for many more things than just abortion, are now on the state’s list of controlled substances. And then from States Newsroom, there’s a piece about how anti-abortion OB-GYNs are trying to get medically necessary abortions that happen later in pregnancy, switched instead to C-sections or having the pregnant person go through and induce labor and delivery. I’ve been covering this issue, as I like to say, for nearly 40 years. This is the most intense effort I’ve ever seen from inside the medical profession to actually change how medicine is practiced in terms of what’s considered the standard of care, both for things like — not even so much mifepristone the abortion pill, but misoprostol, which is used for a lot of things other than abortion.
Armour: Was it initially an ulcer medication?
Rovner: Yes, yes, misoprostol.
Armour: That’s what I thought. Yeah.
Rovner: Cytotec. It was for a long time one of the go-to ulcer medicine. And in fact, the only reason it stopped becoming the go-to ulcer medicine because, if you were pregnant and wanted to be, it could help end your pregnancy. It is known to have that as a side effect, but yes, it’s an ulcer medication.
Armour: Yeah, this is the first I had seen anywhere, and I could be wrong, but of a real push to try and change the management of late-term medical miscarriages to how it would actually be carried out, which was just very interesting and to see what they were recommending instead.
Rovner: ACOG, the American College of Obstetricians and Gynecologists, has put out guidelines — forever, that’s what they do — about how to handle pregnancy problems later in pregnancy. Generally using the least invasive procedure is considered the safest and, therefore, best for the patient. And that’s not necessarily having a C-section, which is major surgery, or going through labor and delivery. People forget that it’s really dangerous to be pregnant. I mean, it’s amazing that we have all of these kids and happy parents because if you go back and look in history, a lot of women used to die in childbirth. They still do. It’s obviously not as bad as it used to be, but it is not everything-goes-fine-99%-of-the-time thing that I think a lot of people think it is.
Armour: That’s right. Yeah.
Rovner: All right, well, meanwhile, before we bid Congress goodbye for the rest of the summer, the House Oversight Committee, which is usually as partisan a place as there is in this Congress, held a hearing this week on PBMs [pharmacy benefit managers] and there seems to be pretty bipartisan support that something needs to be done. Rachel, I keep asking this question: It seems that just about everybody on Capitol Hill wants to do something to rein in PBM drug price abuse, and yet no one ever does. So are we getting closer yet?
Cohrs Zhang: We are getting closer, I think, as we approach December. My understanding was that lawmakers were pretty close on a deal on PBMs back in March. But I think it was just a symptom of “Appropriations Bill Has to Move.” They want it to be clean. If they add one committee’s extra stuff, they have to let other committees add extra stuff, too, and it gets too complicated on deadline. But it’s wild to me that we’re still seeing new PBM reform bills at this point. But there’s just a huge, huge pile of bills at this point, everyone wants their name on it. And so I really do believe that we’re going to see something in December. I think the big question is how far some of these reforms will reach: whether they’ll be limited to the Medicare program or whether some of these will start to touch private insurance as well. I think that’s what the larger industry is waiting to see. But I think there’s a lot of appetite. I mean with congresswoman Cathy McMorris Rodgers retiring, she’s led a package on this issue …
Rovner: She’s chairman of the House Energy and Commerce Committee, which obviously has the main jurisdiction over this in the House.
Cohrs Zhang: Right. So if we’re thinking about legacy, getting some of these things across the finish line, it does depend how dynamics change in the lame duck. But I think there is a very good chance that we’re going to see some sort of action here.
Rovner: Congressman Jamie Raskin, at that hearing, had maybe my favorite line ever about PBMs, which is, he said, “The more I hear about this, the less I understand it.” It’s like you could put that on a T-shirt.
Ollstein: That’s great. Yeah.
Cohrs Zhang: Yes.
Rovner: The PBM debate in one sentence. All right. Finally, this week we have some Medicaid news, a new report from the GAO [Government Accountability Office] finds pretty much what we already knew: that states have been wrongly kicking eligible people off of their Medicaid coverage as they were, quote, “unwinding from the public health emergency.” According to the report, more than 400,000 people lost coverage because the state looked at the household’s eligibility instead of individual eligibility. Even though Medicaid income thresholds are much higher for many people, like children and pregnant women. So if the household wasn’t eligible, possibly, even probably, the children still were. It’s a pretty scathing report. Is anybody going to do anything about it? I mean, the GAO’s recommendation was that the administration act a little more strongly and the administration says, “We already are.”
Cohrs Zhang: Yeah, I actually had the chance to talk with a White House official about this dynamic, and just, I think there’s only so far that they’re willing to go, and I think might talk about, in a while. I think there’s been clashes between the Biden administration and conservative states, especially on Medicaid programs, and there’s really only so much influence they can exert. And I think without provoking an all-out war, I’m personally expecting them to get much more aggressive in the last six months of their administration, if they weren’t going to do it before, when they really could have potentially made a difference and really made it a calling card in some of these states. So I’m not expecting much change from the White House on this issue.
Rovner: Yeah, I remember the administration was so sensitive about this that when we were first learning about how states were cutting people off who they shouldn’t have been, the administration said, “We’re working with the states.” And we all said, “Which states?” And they said, “We’re not going to tell you.” I mean, that’s literally how sensitive it was. They would not give us the list of the states who they said were incorrectly knocking people off the roll. So yeah, clearly this has been politically sensitive for the administration, but I’m …
Armour: And the Medicaid directors, too. They really pushed back, especially initially, about not wanting it to be too adversarial. I think the administration really took that to heart. Whether that was the right call or not remains to be seen, but there was a lot of tension around that from the get-go.
Rovner: Yeah. Well, also this week, The New York Times has a deep dive into the one remaining Medicaid work requirement in the country, Georgia’s Pathways to Coverage. In case you don’t remember, this was the program that Georgia said would enroll up to 100,000 people, except, so far it’s only managed to sign up about 4,500. It feels relevant again though, because the Heritage Foundation’s Project 2025, which is now all over the campaign trail, would go even further than previous Republican efforts to rein in Medicaid by possibly imposing lifetime caps on coverage. Cutting Medicaid didn’t go very well in 2017 when the Republicans tried to repeal and replace the Affordable Care Act. What makes them think an even bigger cutback would be more popular now?
Armour: Well, the study’s authors say to me that if they’re not cutting Medicaid, which goes back to the original debate back when they were talking about …
Rovner: The Project 2025 authors.
Armour: Yes, authors. Right. And that goes back to the original debate of how do you define it? A little bit of sleight of hand. And the other thing is that would definitely bring back the Medicaid work requirements and some premiums for some, which also turned out not to be super-popular as well. So it does dive right into an issue. But it’s also an issue that conservatives have been, boy, working on for years and years now to try and get this accomplished.
Rovner: Oh yeah, block-granting Medicaid goes back decades.
Armour: Exactly. Yeah.
Rovner: And there’ve been various ways to do it. And then work requirements, obviously Alice, you were the queen of our work requirement coverage in Arkansas because they put in a work requirement and it didn’t go well. Remind us.
Ollstein: Yeah. So this is what a lot of experts and advocates predicted, which is that we know from years of data that pretty much everybody on Medicaid who can work is already working and those who aren’t working are not working because they are a student or they have to care for a relative or they have a disability or there are all these reasons. And so when these work requirements actually went into effect, just a lot of people who should have been eligible fell through the cracks. It was hard to navigate the bureaucracy of it all. And so even people who were working struggled to prove it and to get their benefits. And so people really point to that as a cautionary tale for other states. But this is something conservatives really believe in ideologically, and so I don’t expect it to be going away anytime soon.
Rovner: To swing back to where we started. I imagine we will see more talk about health care on the presidential campaign trail as we go forward.
All right, well that’s as much news for this week as we can fit in. Now we will play my interview with Families USA’s Anthony Wright, and then we’ll come back and do our extra credits.
I am so pleased to welcome to the podcast Anthony Wright, the brand-new executive director of Families USA, one of the nation’s leading consumer health advocacy groups. And a big part of why we even have the ACA. Anthony is no stranger to health care battles. He spent more than 20 years heading up the group Health Access California, where he worked on a variety of health issues, large and small, and encountered someone who is suddenly very much in the news: Vice President Kamala Harris. Anthony Wright, welcome to “What the Health?”
Anthony Wright: Thank you so much for having me. I’m a longtime listener, but first-time caller.
Rovner: Awesome. So, for those who are not familiar with Families USA, tell us about the group and tell us what your immediate priorities are.
Wright: So, Families USA has been a longtime voice for health care consumers in Congress, at the administration, working nationally for the goal of quality, affordable, equitable health care for all Americans. I’m pleased to take on that legacy and to try to uplift those goals. I’m also particularly interested in continuing to uplift and amplify the voices of patients in the public in health policy debates. It’s opaque to try to figure out how normal people engage in the federal health policy discussions so that health reforms actually matter to them. I would like families to do more to provide pathways so that they have an effective voice in those policy discussion tables. There’s so many policy debates where it’s the fight between various parts of the industry, when, in fact, the point of the health care system is patients, is the public, and they should be at the center of these discussions.
Rovner: Yes, and I’m embarrassed to admit that we spend an enormous amount of time talking about the players in the health care debate that are not patients. They are basically the people who stand to make money from it. What’s your biggest priority for this year and next?
Wright: Yeah, I want to take some of the lessons that I’ve learned over the 22 years of working in California, where we had the biggest drop of the uninsured rate of all 50 states, mostly working to implement and improve the Affordable Care Act. And I recognize that some of those lessons will have to be adopted and changed for the different context of [Washington,] D.C., or the 49 other states. But there is work that we can do, and we should do, moving forward. There are things on the plate right now. For example, in the next year, the additional affordability assistance that people have in the exchanges is set to expire. And so we can either have a system where everybody has a guarantee that their premiums are capped at 8.5% of their income or less on a sliding scale, or we can let those enhanced tax credits expire and to have premiums go up by hundreds, or for many people, thousands of dollars literally in the next year or so.
So that’s a very important thing that will be on the ballot this fall, along with a number of other issues and we want to highlight that. But frankly, I’m also interested in the work around expanding coverage, including in those 10 states that haven’t expanded Medicaid yet. In California, we’ve done a lot of work on health equity dealing with racial and ethnic disparities and just meeting the specific needs of specific communities. That was an imperative in California with the diversity and the size and scale of that state. But there’s more we can do both in California, but nationally, with regard to that. And then I think there’s more to work on costs with regard to just how darn expensive health care is and how do we fix the market failures that lead to, not just high, but irrational and inflated health prices.
Rovner: So obviously a big part of what you will or won’t be able to do next year depends on who occupies the White House and who controls Congress. You’re from California and so is Vice President Harris. Tell us about her record on health care.
Wright: Yeah, she actually has a significant record, mostly from her time as attorney general of California. She didn’t have much of a portfolio as district attorney, but when she did become the attorney general — attorney generals have choices about where they focus their time and she made a point to focus more on health care and start an evolution of the attorney general being more involved in health care issues — on issues like reviewing mergers of hospitals and putting conditions to make sure that emergency rooms stayed open, that hospitals continued their commitments to charity care. She worked on broader issues of consolidation, for example, joining the [U.S.] Justice Department in opposing the merger of Anthem and Cigna.
And she took on, whether it’s the insurers or the drug companies or the hospital chains, on issues of pricing and anticompetitive practices, whether it was Bayer and Cipro and other drug companies with regard to pay-for-delay practices, basically schemes to keep the price of drugs inflated. Or on the issue of high hospital prices. She began the investigations that led to a landmark Sutter settlement where that hospital chain paid $575 million in fines, but also agreed to a series of conditions with regard to no longer engaging in anticompetitive contracting practices. And that kind of work is something that we worked on with her, and I think is really relevant to the moment we’re in now where we really do see that consolidation is one of the major drivers of why health care prices are so high. And that kind of experience that she could talk about as she talks about health care costs broadly, medical debt, and some of the issues that are on the campaign trail today.
Rovner: So, obviously, with the exception of reproductive health, health in general has not been a big part of the campaign this year. Do you think it’s going to get bigger now that Harris is at the head of the ticket?
Wright: One of the things that I’m happy with is that, after several weeks where the conversation has much been about the campaign processes, we can maybe focus back on policy and the very real issues that are at stake. Our health care is on the ballot, whether it is reproductive health and abortion care, but also there’s a very easy leap to also talk about the threats, not just to reproductive health, but also to the Affordable Care Act, to Medicaid, to Medicare. There’s very different visions and records of the last two administrations with regard to the Affordable Care Act, whether to repeal it or build upon it, on Medicaid and whether to bolster it or to block-grant it. And even on the question of something like prescription drug negotiation, whether we took some important steps under the Inflation Reduction Act. Do we now expand that authority to cover more drugs for more discounts for more people? Or do we give up that authority to negotiate for the best possible price?
Those are very key issues that are at stake in this election. We are a nonpartisan, non-endorsing organization, but we do want to make sure that health care issues are on people’s minds, and also, frankly, policymakers to make some commitments, including on something like what I was talking about earlier with those enhanced tax credits. Again, at a time when people are screaming about affordability, but we know that they’ve been actually screaming about health care affordability for not just years but decades. And that’s a very specific, concrete thing that literally means hundreds or thousands of dollars in people’s pockets.
Rovner: So then-presidential candidate Kamala Harris was a supporter of Medicare for All in 2020 when she ran. Do you expect that that may have changed, as she’s learned how hard it is even to make incremental change? I haven’t seen anybody ask her yet what her feeling is on systemic health reform.
Wright: I mean, she had a modified proposal that I think was trying to both take seriously the question of how do we get to universal coverage while also recognizing the politics and procedural barriers that exist. And so I think there’s a practical streak of how do we get the most help to the most people and help change, frankly, the financial incentives in our system, which are right now just to get bigger, not to get better. And so I think that there’s some very practical questions on the table right now, like these tax credits, this cap on how much a percentage of your income should go for premium. That’s something that’s front of mind because it literally expires next year. So it’s something that maybe gets dealt with in a lame duck, but hopefully early in the next year, since rates need to be decided early. And so those are the immediate things.
But I do think she’s also, in her record — I’m not going to talk about what may be — but in her record, she’s been supportive of the Affordable Care Act. I mean our biggest actual engagement with then-U.S. Sen. Harris was at a time when we all thought that the Affordable Care Act was a goner. It would be repealed and replaced. She was willing to be loud and proud at our rallies, in front of a thousand people, in front of a Los Angeles public hospital, talking about the need to defend the Affordable Care Act and protections for people with preexisting conditions. And she came again in July and just at a time where we needed that forceful defense of the Affordable Care Act. She was there and we very much appreciated that. I think she would continue to do that as well as want to work to build upon that financing and framework to make additional gains forward.
Rovner: This being Washington, everybody’s favorite parlor game this week is handicapping the vice presidential sweepstakes. And who about-to-be-candidate Harris is going to choose to be her running mate. Are any of the big names in contention more or less important in terms of their health care backgrounds?
Wright: I have my credentials to talk about the Californian on the ticket. I probably have less there. I do know that some of those governors and others have their own records of trying to take the framework of the ACA and adapt it to their state. And I think that would be a useful thing to continue to move forward on the trail. I’m not in a position, again, as a non-endorsing organization, we’re focused on the issues.
Rovner: You’re agnostic about the vice presidential candidate.
Wright: You’re right, I think the point is how can we make sure that people recognize what is at stake for the health care that they depend on and, frankly, the financial piece of it. Affordability has been something that has been talked about a lot and there is no greater source of economic anxiety and insecurity than the health care bill. A hospital bill is the biggest bill that anybody will get in their entire life. So how do you deal with it? And whether it’s a conversation about medical debt and how you deal with it, or what kind of tax credits we can provide to provide some security that you don’t pay more than the percentage of your income. Or how do you deal with the root causes of the market failures in our health care system, whether it’s consolidations and mergers or anticompetitive practices. Those are the things that I think we should have a bigger conversation in this campaign cycle about.
Rovner: Hopefully we’ll be able to do this again as it happens. Anthony Wright, thank you so much.
Wright: Thank you.
Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?
Cohrs Zhang: Sure. There’s a lot of good health journalism out there, but I have to highlight a new project from my colleagues. Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence are looking into UnitedHealth’s business practices, and there’s been a lot of buzz about UnitedHealthcare on the Hill, and the first part of their investigation is headlined “How UnitedHealth Harnesses Its Physician Empire To Squeeze Profits out of Patients.” It focuses on the trend that UnitedHealth has been acquiring so many physician practices and looks at the incentives of what actually happens when an insurer owns a physician practice.
What pressures are they putting on? What’s the patient experience? What’s the physician experience? Their physicians on the record were telling them about their experiences: having to turn through patients; feeling pressure to make patients look sicker on paper so UnitedHealth could get more money from the federal government to pay for them. And just, I mean, the documentation here is just really superb reporting. It’s part one of a series. And I think reporting like this really helps inform Washington about how these things are actually playing out and what’s next in terms of whether action should be taken to rein these practices in.
Rovner: I feel like the behemoth that is UnitedHealthcare is going to keep a lot of health reporters busy for a very long time to come. Alice.
Ollstein: Yeah. So there’s been a lot of news on the PrEP front recently. That’s the drug that prevents transmission of HIV. And so basically two steps forward, one step back. I chose this piece from Stat News [“A Pricey Gilead HIV Drug Could Be Made for Dramatically Less Than the Company Charges”], about a new form of PrEP that is an injection that you get just twice a year that has proven wildly effective in clinical trials. And so folks are really excited about that, and I think it could really make a difference because, as with birth control and as with lots of other medication, the effectiveness rate is only if you use it perfectly, which, you know, we’re humans. And humans don’t always adhere perfectly. And so something like just a couple injections a year that you could get from your doctor would go a long way towards compliance and making sure people are safe with their medications.
But my colleague and I also scooped this week that HHS [the Department of Health and Human Services] is ending one of its big PrEP distribution programs [“Federal HIV Program Set To Wind Down”]. It’s called Ready, Set, PrEP. It debuted under the Trump administration in 2019. And the reason given by HHS for it ending — which, by the way, they were very quiet about and didn’t even tell a lot of providers that it was ending — they said it was because there are all these other ways people can get PrEP now, that didn’t exist back then, like generic versions. And while that’s true, we also heard from a lot of advocates who said the program was just really flawed from the start and didn’t reach even a fraction of the people it should have reached. And so we’ll continue to dig on that front.
Rovner: Good stories. Stephanie.
Armour: Yes. I picked the story by Dylan Scott on Vox about “Free Medical School Won’t Solve the Doctor Shortage.” And it looks at Michael Bloomberg, who is donating a billion dollars to Johns Hopkins to try to pay for medical school for students there. The idea being that, “Look, there’s this doctor shortage and what can we do to help?” And what’s really interesting about the story is it goes beyond just the donation to look at the fact that it’s not really that there’s a doctor shortage, it’s that we don’t have the right kind of doctors and it’s the distribution. Where you don’t have nearly what we need when it comes to psychiatrists, for example. And there’s a real dearth of physicians in areas that are rural or in the Midwest. So I think what it raises is what resources do we want to spend and where? What other steps can we do that would really help drive doctors to where they’re most needed? So it’s a good story. It’s worth a read.
Rovner: Yeah, it is a good story. It is a continuing problem that I continue to harp on. But we now have quote-unquote “free medical school,” mostly in really urban, really expensive places.
Armour: Yes.
Rovner: New York, Los Angeles, Baltimore. That’s nice for the doctors who will now graduate without $200,000 in medical debt. But yeah, as Dylan points out, it’s not exactly solving the problem that we have. Well, I went cute this week. My extra credit this week is from NPR. It’s called “A Study Finds That Dogs Can Smell Your Stress — And Make Decisions Accordingly,” by Rachel Treisman. Now, we’ve known for a fairly long time that dogs’ sensitive noses can detect physical changes in their humans. That’s how alert dogs for epilepsy and diabetes and other ailments actually work.
But what we didn’t know until now is that if a dog smells a person’s stress, it can change the dog’s emotional reaction. It was a complicated experiment that you can read about if you want, but as somebody who competes with my dogs, and who knows how differently they act when I am nervous, this study explains a lot.
All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner. Alice, where are you?
Ollstein: @AliceOllstein on X.
Rovner: Rachel.
Cohrs Zhang: @rachelcohrs on X.
Rovner: Stephanie.
Armour: @StephArmour1.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Anti-Abortion Hard-Liners Speak Up
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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.
With abortion shaping up as a key issue for the November elections, the movement that united to overturn Roe v. Wade is divided over going further, faster — including by punishing those who have abortions and banning contraception or IVF. Politicians who oppose abortion are already experiencing backlash in some states.
Meanwhile, bad actors are bilking the health system in various new ways, from switching people’s insurance plans without their consent to pocket additional commissions, to hacking the records of major health systems and demanding millions of dollars in ransom.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Rachel Roubein of The Washington Post, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.
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Alice Miranda Ollstein
Politico
Joanne Kenen
Johns Hopkins University and Politico
Rachel Roubein
The Washington Post
Among the takeaways from this week’s episode:
- It appears that abortion opponents are learning it’s a lot easier to agree on what you’re against than for. Now that the constitutional right to an abortion has been overturned, political leaders are contending with vocal groups that want to push further — such as by banning access to IVF or contraception.
- A Louisiana bill designating abortion pills as controlled substances targets people in the state, where abortion is banned, who are finding ways to get the drug. And abortion providers in Kansas are suing over a new law that requires patients to report their reasons for having an abortion. Such state laws have a cumulative chilling effect on abortion access.
- Some Republican lawmakers seem to be trying to dodge voter dissatisfaction with abortion restrictions in this election year. Sen. Ted Cruz of Texas and Sen. Katie Britt of Alabama introduced legislation to protect IVF by pulling Medicaid funding from states that ban the fertility procedure — but it has holes. And Gov. Larry Hogan of Maryland declared he is pro-choice, even though he mostly dodged the issue during his eight years as governor.
- Former President Donald Trump is in the news again for comments that seemed to leave the door open to restrictions on contraception — which may be the case, though he is known to make such vague policy suggestions. Trump’s policies as president did restrict access to contraception, and his allies have proposed going further.
Also this week, Rovner interviews Shefali Luthra of The 19th about her new book on abortion in post-Roe America, “Undue Burden.”
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The 19th’s “What Happens to Clinics After a State Bans Abortion? They Fight To Survive,” by Shefali Luthra and Chabeli Carrazana.
Alice Miranda Ollstein: Stat’s “How Doctors Are Pressuring Sickle Cell Patients Into Unwanted Sterilizations,” by Eric Boodman.
Rachel Roubein: The Washington Post’s “What Science Tells Us About Biden, Trump and Evaluating an Aging Brain,” by Joel Achenbach and Mark Johnson.
Joanne Kenen: ProPublica’s “Toxic Gaslighting: How 3M Executives Convinced a Scientist the Forever Chemicals She Found in Human Blood Were Safe,” by Sharon Lerner; and The Guardian’s “Microplastics Found in Every Human Testicle in Study,” by Damian Carrington.
Also mentioned on this week’s podcast:
- NPR’s “Republicans Try To Soften Stance on Abortion as ‘Abolitionists’ Go Farther,” by Sarah McCammon.
- KFF Health News’ “Biden Leans Into Health Care, Asking Voters To Trust Him Over Trump,” by Phil Galewitz.
- KFF Health News’ “Exclusive: Senator Urges Biden Administration To Thwart Fraudulent Obamacare Enrollments,” by Julie Appleby.
- KFF Health News’ “KHN’s ‘What the Health?’: Un-Trumping the ACA,” featuring an interview with journalist Marshall Allen.
Click to open the Transcript
Transcript: Anti-Abortion Hard-Liners Speak Up
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Mila Atmos: The future of America is in your hands. This is not a movie trailer, and it’s not a political ad, but it is a call to action. I’m Mila Atmos, and I’m passionate about unlocking the power of everyday citizens. On our podcast Future Hindsight, we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday, we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 23, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. We are joined today via a video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Rachel Roubein of The Washington Post.
Rachel Roubein: Hi, thanks for having me.
Rovner: And Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.
Joanne Kenen: Hi, everybody.
Rovner: Later in this episode, we’ll have my interview with podcast panelist Shefali Luthra of The 19th. Shefali’s new book about abortion in the post-Roe [v. Wade] world, called “Undue Burden,” is out this week. But first, this week’s news. We’re going to start with abortion this week with a topic I’m calling “Abolitionists in Ascendance,” and a shoutout here to NPR’s Sarah McCammon with a great piece on this that we will link to in the show notes. It seems that while Republican politicians, at least at the federal level, are kind of going to ground on this issue, and we’ll talk more about that in a bit, those who would take the ban to the furthest by prosecuting women, and/or banning IVF and contraception, are raising their voices. How much of a split does this portend for what, until the overturn of Roe, had been a pretty unified movement? I mean they were all unified in “Let’s overturn Roe,” and now that Roe has gone, boy are they dividing.
Ollstein: Yeah, it’s a lot easier to agree on what you’re against than on what you’re for. We wrote about the split on IVF specifically a bit ago, and it is really interesting. A lot of anti-abortion advocates are disappointed in the Republican response and the Republican rush to say, “No, let’s leave IVF totally alone” because these groups think, some think it some should be banned, some think that there should be a lot of restrictions on the way it’s currently practiced. So not a total ban, but things like you can only produce a certain number of embryos, you can only implant a certain number of embryos, you can only create the ones you intend to implant, and so that would completely upend the way IVF is currently practiced in the U.S.
So, we know the anti-abortion movement is good at playing the long game, and so some of them have told me that they see this kind of like the campaign to overturn Roe v. Wade. They understand that Republicans are reacting for political reasons right now, and they are confident in winning them over for restrictions in the long term.
Rovner: I’ve been fascinated by, I would say, by things like Kristan Hawkins of Students for Life [of America] who’s been sort of the far-right fringe of the anti-abortion movement looking like she’s the moderate now with some of these people, and their discussions of “We should charge women with murder and have the death penalty if necessary.” Sorry, Rachel, you want to say something?
Roubein: This is something that Republicans, they don’t want to be asked about this on the campaign. The more hard-line abolitionist movement is something more mainstream groups have been taking a lot of pains to distance themselves and say that we don’t prosecute women, and essentially nobody wants to talk about this ahead of 2024. GOP doesn’t want to be seen as that party that’s going after that.
Kenen: And the divisions existed when Roe was still the law of the land, and we would all write about the divisions and what they were pushing for, and it was partly strategic. How far do you push? Do you push for legislation? Do you push for the courts? Do you push for 20 weeks for fetal pain? But it was like rape exceptions and under what terms and things like that. So it was sort of much later in pregnancy, and with more restrictions, and the fight was about exactly where do you draw that line. This abolition of all abortion under all circumstances, or personhood, only a couple of years ago, were the fringe. Personhood was sort of like, “Oh, they’re out there, no one will go for that.” And now I don’t think it’s the dominant voice. I don’t think we yet know what their dominant voice is, but it’s a player in this conversation.
At the same time, on the other side, the pro-abortion rights people, there’s polls showing us this many Americans support abortion, but it’s subtler too. Even if people support abortion rights, it doesn’t mean that they’re not, some subset are in favor of some restrictions, or where that’s going to settle. Right now, a 15-week ban, which would’ve seemed draconian a year or two ago, now seems like the moderate position. It has not shaken out, and …
Rovner: Well, let’s talk …
Kenen: It’s not going to shake out for some time.
Rovner: Let’s talk about a few specifics. The Louisiana State Legislature on Tuesday approved a bill that would put the drugs used in medication abortion, mifepristone and misoprostol, on the state’s list of controlled substances. This has gotten a lot of publicity. I’m wondering what the actual effect might be here though since abortion is already banned in Louisiana. Obviously, these drugs are used for other things, but they wouldn’t be unavailable. They would just be put in this category of dangerous drugs.
Ollstein: So, officials know that people in banned states, including Louisiana, are obtaining abortion pills from out of state, whether through telehealth from states with shield laws or through these gray-area groups overseas that are mailing pills to anyone no matter what state they live in or what restrictions are in place. So I think because it would be very difficult to actually enforce this law, short of going through people’s homes and their mail, this is just one more layer of a chilling effect and making people afraid to seek out those mail order services.
Rovner: So it’s more, again, for the appearance of it than the actuality of it.
Ollstein: It also sets up another state versus federal law clash, potentially. We’ve seen this playing out in courts in West Virginia and in North Carolina, basically. Can states restrict or even completely ban a medication that the FDA says is safe and effective? And that question is percolating in a few different courts right now.
Rovner: Including sort of the Supreme Court. We’re still waiting for their abortion pill decision that we expect now next month. Meanwhile, in Kansas, where voters approved a big abortion rights referendum in 2022 — remember, it was the first one of those — abortion providers are suing to stop a new state law enacted over the governor’s veto that would require them to report to the state women’s reasons for having an abortion. Now it’s not that hard to see how that information could be misused by people with other kinds of intents, right?
Ollstein: Well, it also brings up right to free speech issues, compelled speech. I think I’ve seen this pop up in abortion lawsuits even before Dobbs [v. Jackson Women’s Health Organization], this very issue because there have been instances where either doctors are required to give information that they say that they believe is medically inaccurate. That’s an issue in several states right now. And then this demanding information from patients. A lot of clinics that I’ve spoken to are so afraid of subpoenas from officials in-state, from out of state, that they intentionally don’t ask patients for certain kinds of data even though it would really help medically or organizationally for them to have that data. But they’re so afraid of it being seized, they figure well, they can’t seize it if they’re … doesn’t exist in the first place. And so I think this kind of law is in direct conflict with that.
Roubein: It also gets at the question of medical privacy that we’ve been seeing in the Biden administration’s efforts over HIPAA and protecting patients’ records and making it harder for state officials to attempt to seize.
Rovner: Yeah, this is clearly going to be a struggle in a lot of states where voters versus Republican legislatures, and we will sort of see how that all plays out. So even while this is going on in a bunch of the states, a lot of Republicans, including some who have been and remain strongly anti-abortion, are doing what I’m calling ducking-and-covering on a lot of these issues. Case in point, Texas Republican Sen. Ted Cruz and Alabama Republican Sen. Katie Britt this week introduced a bill they say would protect IVF, which is kind of ironic given that both of them voted against a bill to protect IVF back in, checking notes, February. What’s the difference here? What are these guys trying to do?
Kenen: Theirs is narrower. They say that the original bill, which was a Democratic bill, was larded with abortion rights kinds of things. I have not read the entire bill, I just read the summary of it. And in this one, if a state restricts someone who had — someone feel free to correct me if I am missing something here because I don’t have deep knowledge of this bill — but if a state does not protect IVF, they would lose their Medicaid payment. And I was not clear whether that meant every penny of Medicaid, including nursing homes, or if it’s a subsection of Medicaid, because it seems like a big can of worms.
Ollstein: Yeah, so the key difference in these bills is the word ban. The Republican bill says that if states ban IVF, then these penalties kick in for Medicaid, but they say that there can be “health and safety regulations,” and so that is very open to interpretation. That can include the things we talked about before about you can only produce a certain number of embryos, you can only implant a certain number of embryos, and you can’t discard them. And so even what Alabama did was not an outright ban. So even something like that that cut off services for lots of people wouldn’t be considered a ban under this Republican bill. So I think there’s sort of a semantic game going on here where restrictions would still be allowed if they were short of a blanket ban, whereas the democratic bill would also prevent restrictions.
Rovner: Well, and along those exact same lines, in Maryland, former two-term Republican governor Larry Hogan, who’s managed to dodge the abortion issue in his primary run to become the Senate nominee, now that he is the Republican candidate for the open Senate seat, has declared himself, his words, “pro-choice,” and says he would vote to restore Roe in the Senate if given the opportunity. But as I recall, and I live in Maryland, he vetoed a couple of bills to expand abortion rights in very blue Maryland. Is he going to be able to have this both ways? He seems to be doing the [Sen.] Susan Collins script where he gets to say he’s pro-choice, but he doesn’t necessarily have to vote for abortion rights bills.
Kenen: Hogan is a very popular moderate Republican governor in a Democratic state. He is a strong Senate candidate. His opponent, a Democrat, Angela Alsobrooks, has a stronger abortion rights record. I don’t think that’s going to be the decisive issue in Maryland. I think it may help him a little bit, but I think in Maryland, if the Senate was 55-45, a lot of Democrats like Hogan and might want another moderate Republican in the Senate. But given that this is going to be about control of the Senate, abortion will be a factor, I don’t think abortion is going to be the dominant factor in this particular race.
If she were to win and there’s two black women, I mean that would be the first time that two black women ever served in the Senate at once, and I think they would only be number three and number four in history. So race and Affirmative Action will be factors, but I think that Democrats who might otherwise lean toward him, because he was considered a good governor. He was well-liked. This is a 50-50ish Senate, and that’s the deciding thing for anyone who pays attention, which of course is a whole other can of worms because nobody really pays attention. They just do things.
Roubein: I think it’s also worth noting this tact to the left comes as Maryland voters will be voting on an abortion rights ballot measure in 2024. So that all sort of in context, we’ve seen what’s happened with the other abortion measures, abortion rights have won, so.
Rovner: And Maryland is a really blue state, so one would expect it …
Kenen: There’s no question that the Maryland …
Rovner: Yeah.
Kenen: I mean, and all of us would fall flat on our faces if the abortion measure fails in Maryland. But I believe this is the first one on the ballot alongside a presidential election, and some of them have been in special elections. It’s unclear the correlation between, you can vote for a Republican candidate and still vote for a pro-abortion rights initiative. We will learn a lot more about how that split happens in November. I mean, is Kansas going to go for Biden? Unlikely. But Kansas went really strong for abortion rights. If you’re not a single-issue voter, you can, in fact, have it both ways.
Rovner: Yes, and we are already seeing that in the polls. Well, of course then there is the king of trying to have it both ways: former President Trump. He is either considering restrictions on contraception, as he told an interviewer earlier this week, promising a proposal soon, or he will, all caps, as he put on Truth Social, never advocate imposing restrictions on birth control. So which is it?
Ollstein: So this came out of Trump’s verbal tick of saying “We’ll have a plan in a few weeks,” which he says about everything. But in this context it made it sound like he was leaving the door open to restrictions on contraception, which very well might be the case. So what my colleague and I wrote about is he says he would never restrict contraception. A lot of things he did in his first administration did restrict access to contraception. It was not a ban. Again, we’re getting back into the semantics of ban. It was not a ban, but his Title X rule led to a drop in hundreds of thousands of people accessing contraception. He allowed more kinds of employers to refuse to cover their employees’ contraception on their health plans, and the plans his allies are creating in this Project 2025 blueprint would reimpose those restrictions and go even further in different ways that would have the effect of restricting access to contraception. And so I think this is a good instance of look at what people do, not what they say.
Rovner: So now that we’re on the subject of campaign 2024, President Biden’s campaign launched a $14 million ad buy this week that includes the warning that if Trump becomes president again he’ll try to repeal the Affordable Care Act. Maybe health care will be an issue in this election after all? I don’t have a rooting interest one way or the other. I’m just curious to see how much of an issue health will be beyond reproductive rights.
Kenen: Well, as Alice just pointed out, Trump’s promised plans often do not materialize, and we are still waiting to see his replacement plan eight years later. I think he’s being told to sort of go slow on this. I mean, not that you can control what Trump says, but he didn’t run on health care until the end, in 2016. It was a close race, and he ran against Hillary Clinton, and it was the last 10 or so days that he really came down hard because it was right when ACA enrollment was about to begin and premiums came in and they were high. He pivoted. So is this going to be a health care election from day one? And I’m putting abortion aside for one second in terms of my definition of health care for this particular segment. Is it going to be a health care election in terms of ACA, Medicare, Medicaid? At this point, probably not. But is it going to emerge at various times by one or the other side in politically opportune ways? I would be surprised if Biden’s not raising it. The ACA is thriving under Biden.
Rovner: Well, he is. That’s the whole point. He just took out a $14 million ad buy.
Kenen: Right. But again, we don’t know. Is it a health care election or is it a couple ads? We don’t know. So yes, it’s going to be a health care election because all elections are health care elections. How much it’s defined by health care compared to immigration? No, at this point, that’s not what we’re expecting. Compared to the economy? No, at this point. But is it an issue for some voters? Yes. Is it going to be an issue more prominently depending on how other things play out? It’ll have its peaks. We just don’t know how consistent it’ll be.
Roubein: Biden would love to run on the Inflation Reduction Act and politically popular policies like allowing Medicare to negotiate drug prices. One of the problems of that is polls, including from KFF, has shown that the majority of voters don’t know about that. And some of these policies, the big ones, have not even gone into effect. CMS [Centers for Medicare & Medicaid Services] is going through the negotiation process, but that’s not going to hit people’s pocketbooks until after the election.
Kenen: The cliff for the ACA subsidies, which is in 2025, I mean I would imagine Democrats will be campaigning on, “We will extend the subsidies,” and again, in some places more than others, but that’s a time-sensitive big thing happening next year.
Rovner: But talk about an issue that people have no idea that’s coming. Well, meanwhile, for Trump, reproductive health isn’t the only issue where he’s doing a not-so-delicate dance. Apparently worried about Robert F. Kennedy Jr. stealing anti-vax [vaccine] votes from him, Trump is now calling RFK Jr. a fake anti-vaxxer. Except I’m old enough to remember when Trump bragged repeatedly about how fast his administration developed and brought the covid vaccine to market. That used to be one of his big selling points. Now he’s trying to be anti-vax, too?
Kenen: Not only did he brag about bringing it to the market. The way he used to talk about it, it was like he was there in his lab coat inventing it. Operation Warp Speed was a success. It got vaccines out in record time, way beyond what many people expected. Democrats gave him credit for that one policy in health care. He got a vaccine out and available in less than a year, and he got vaccinated and boasted about being vaccinated. He was open about it. Now we don’t know if he’s been boosted. He really backed off. As soon as somebody booed him, and it wasn’t a lot of boos, at one rally when he talked about vaccination and he got pushed back, that was the end.
Rovner: So, yeah, so I expect that to sort of continue on this election season, too.
Kenen: But we don’t expect RFK to flip.
Rovner: No, we do not. Right. Well, moving on to this weekend’s “Cyber Hacks,” a new feature, the fallout continues from the hack of Ascension [health care company]. That’s the Catholic hospital system with facilities in 19 states. In Michigan, patients have been unable to use hospital pharmacies and their doctors have been unable to send electronic prescriptions, so they’re having to write them out by hand. And in Indiana orders for tests and test results are being delayed by as much as a day for hospital patients. Not a great thing.
And just in time, or maybe a little late, the U.S. Department of Health and Human Services, through the newly created ARPA-H [Advanced Research Projects Agency for Health] that we have talked about, this week announced the launch of a new program to help hospitals make security patches and updates to their systems without taking them offline, which is obviously a major reason so many of these systems are so vulnerable to cyberhacking.
Of course, this announcement from HHS is just to solicit ideas for grants to help make that happen. So it’s going to be a while before we get any of these security changes. I’m wondering, how many systems are going to try to build a lot more redundancy into them? In the meantime, are we hearing anything about what they can do in the short term? It feels like the entire health care system is kind of a sitting duck for this group of cyberhackers who think they can get in easily and get ransom.
Kenen: There’s a reason they think that.
Rovner: They can.
Roubein: Thinking about hospitals and doctors using this manually, paper-based system and how that’s delaying getting your results and just there’s been these stories about patients. Like the anxiety that that’s understandably causing patients, and we’ll see sort of whether Congress can grapple with this, and there’s not really much legislation that’s going to move, so …
Kenen: But I was surprised that they were calling on ARPA-H. I mean, that’s supposed to be a biotech- curing-diseases thing, and none of the four of us are cybersecurity experts, and none of us really specialize in covering the electronic side of the digital side of health, but it just seems to me, I just thought that was an odd thing. First of all, some of these are just systems that haven’t been upgraded or individual clinicians who don’t upgrade or don’t do their double authorization. Some of it’s sort of cyberhygiene, and some of it’s obviously like the change thing. They’re really sophisticated criminals, but it’s not something that one would think you can’t get ahead of, right? They’re smart, good-guy technology people. It’s not like the bad guys are the only ones who understand technology. So why are the smart good guys not doing their job? And also, probably, health care systems have to have some kind of security checks on their own members to make sure they are following all the safety rules and some kind of consequences if you’re not, other than being embarrassed.
Rovner: I’ve just been sort of bemused by all of this, how both patients and providers complain loudly and frequently about the frustrations of some of these electronic record systems. And of course, in the places that they’re going down and they’ve had to go back to paper, people are like, “Please give us our electronic systems back.” So it doesn’t take long to get used to some of these things and be sorry when they’re gone, even if it’s only temporarily. It’s obviously been …
Kenen: But like what Rachel said, if you’re in the hospital, you’re sick, and do your clinicians need your lab results? Yes. I mean some of them are more important than others, and I would hope that hospitals are figuring out how to prioritize. But yeah, this is a crisis. If you’re in the hospital and they don’t know what’s wrong with you and they’re trying to figure out do you have X, Y, or Z, waiting until next week is not really a great idea.
Rovner: But it wasn’t that many years ago that their existence …
Kenen: Right, no, no, no.
Rovner: … did not involve …
Kenen: [inaudible 00:21:28].
Rovner: … electronic medical record.
Kenen: Right. Right.
Rovner: They knew how to get test results back and forth even if it was sending an intern to go fetch them. Finally, this week, we have some updates on some stories that we’ve talked about in earlier episodes. First, thanks in part to the excellent reporting of my colleague and sometime-pod-panelist Julie Appleby, the Senate Finance Committee Chairman Ron Wyden is demanding that HHS [U.S. Department of Health and Human Services] officials do more to rein in rogue insurance brokers who are reaping extra commissions by switching patients’ Affordable Care Act plans without their knowledge, often subjecting them to higher out-of-pocket costs and separating them from the providers that they’ve chosen. Sen. Wyden said he would introduce legislation to make such schemes a crime, but in the meantime he wants Biden officials to do more, given that they have received more than 90,000 complaints in the first quarter of 2024 alone about unauthorized switches and enrollments. Criminals go where the money is, right? You can either cyberhack or you can become a broker and switch people to ACA plans so you can get more commissions.
Kenen: I would think there could be a bipartisan, I mean it’s hard to get anything done in Congress. There’s no must-pass bills in the immediate future that are relevant. And the idea that a broker is secretly doing something that you don’t want them to do and that’s costing you money and making them money. I could see, those 90,000 people are from red and blue states and they vote, it’s going to affect constituents nationwide. Maybe they’ll do something. Maybe the industry can also… There is the National Association … I forgot the acronym, but there’s a broker’s organization, that there are probably things that they can also do to sanction. States can also do some things to brokers, but whether there’s a national solution or piecemeal, I don’t know, but it’s so outrageous that it’s not a right-left issue.
Rovner: Yes, one would think that there’ll be at least some kind of congressional action built into something …
Kenen: Something or other, right.
Rovner: … Congress that manages to do before the end of the year. Well, and in one of those seemingly rare cases where legislation actually does what it was intended to do, the White House this week announced that it has approved more than a million claims under the 2022 PACT Act, which made veterans injured as a result of exposure to burn pits and other toxic substances eligible for VA [Veterans Affairs] disability benefits. On the other hand, the VA is still working its way through another 3 million claims that have been submitted. I feel like even if it’s not very often, sometimes it’s worth noting that there are bipartisan things from Washington, D.C., that actually get passed and actually help the people that they’re supposed to help. It’s kind of sad that this is notable as an exception of something that happened and is working.
Roubein: In sort of the, I guess, Department of Unintended Side Effects here, my colleague Lisa Rein had a really interesting story out this morning that talked about the PACT Act, but basically that despite a federal law that prohibits charging veterans for help in applying for disability benefits, for-profit companies are making millions. She did a review of up to like a hundred unaccredited for-profit companies who have been charging veterans anywhere from like $5,000 to $20,000 for helping file disability claims because …
Rovner: That’s the theme of this week. Anyplace that there’s a lot of money in health care, there were people who will want to come in and take what’s not theirs. That’s where we will leave the news this week. Now we will play my interview with Shefali Luthra, then we’ll come back with our extra credits.
I am so pleased to welcome back to the podcast my former colleague and current “What The Health?” panelist Shefali Luthra. You haven’t heard from her in a while because she’s been working on her first book, called “Undue Burden,” that’s out this week. Shefali, great to see you.
Luthra: Thank you so much for having me Julie.
Rovner: So as the title suggests, “Undue Burden” is about the difficulties for both patients and providers in the wake of the overturn of Roe v. Wade. We talk so much about the politics of this issue, and so little about the real people who are affected. Why did you want to take this particular angle?
Luthra: To me, this is what makes this topic so important. Health care and abortion are really critical political issues. They sway elections. They are likely to be very consequential in this coming presidential election. But this matters to us as reporters and to us as people because of the life-or-death stakes and even beyond the life-or-death stakes, the stakes of how you choose to live your life and what it means to be pregnant and to be a parent. These are really difficult stories to tell because of the resources involved. And I wanted to write a book that just got at all of the different reasons why people pursue abortion and why they provide abortion and how that’s changed in the past two years. Because it felt to me like one of the few ways we could really understand just how seismic the implications of overturning Roe has been.
Rovner: And unlike those of us who talk to politicians all the time, you were really on the ground talking to patients and doctors, right?
Luthra: That was really, really important to the book. I spent a lot of time traveling the country, in clinics talking to people who were able to get abortions, who were unable to get abortions, and it was just really compelling for me to see how much access to care had the capacity to change their lives.
Rovner: So what kind of barriers then are we talking about that cropped up? And I guess it wasn’t even just the wake of the overturn of Roe. In Texas we had sort of a yearlong dry run.
Luthra: Exactly, and the book starts before Roe is overturned in Texas when the state enacted SB 8, the six-week abortion ban that effectively cut off access. And the first main character readers meet is this young girl named Tiffany, and she’s a teenager when she becomes pregnant, and she would love to get an abortion. But she is a minor. She lives very far from any abortion provider. She does not know how to self-manage an abortion. She does not know where to find pills. She has no connections into the health care system. She has no independent income. And she absolutely cannot travel anywhere for care. As a result, she has a child before she turns 18. And what this story highlights is that there are just so many barriers to getting an abortion. Many already existed: The incredible cost for procedure not covered by health insurance, the geographic distance, people already had to travel, the extra restrictions on minors.
But the overturning of Roe has amplified these, it is so expensive to get an abortion. It can be difficult to know you’re pregnant, especially if you are not trying to become pregnant. You have a very short time window. You may need to find childcare. You may need to find a car, get time off work, and bring all of these different forces together so that you are able to make a journey that can be days and pay for a trip that can cost thousands of dollars.
Rovner: One of the things that I think surprised me was that states that proclaimed themselves abortion “havens” actually did so little to help their clinics that predictably got swamped by out-of-state patients. Why do you think that was the case, and is it any better now?
Luthra: I think things have certainly changed. We have seen much more action in states, such as Illinois, where we see more people traveling there for care than anywhere else in the country. But it is worth going back to the summer that Roe was overturned. The governor promised to call a special session and put all these resources into making sure that Illinois could be a sanctuary. He never called that special session. And clinics felt like they were hanging out to dry, just waiting to get some support, and in the meanwhile, doing the absolute best they could.
One thing that I think this book really gets at is we are starting to see more efforts from these bluer states, the Illinois, the Californias, the New Yorks, and they talk a lot about wanting to be abortion havens, in part because it’s great politics if you’re a Democrat, but there’s only so much you can do. California has seen also quite a large increase in out-of-state patients. But I’ve spoken to so many people who just cannot conceivably go to California. They can barely go to Illinois. Making that journey when you are young, if you don’t have a lot of money, if you live in South Texas, if you live in Louisiana, it’s just not really feasible. And the places that are set up as these access points just can’t really fill in the gaps that they say they will.
Rovner: As you point out in the book, a lot of this was completely predictable. Was there something in your reporting that actually did surprise you?
Luthra: That’s a great question, and what did surprise me was in part something that we’ve begun to see borne out in the reporting, is there are very effective telemedicine strategies. We have begun to see physicians living in blue states, the New Yorks, Massachusetts, Californias, prescribing and mailing abortion pills to people in states with bans. This is pretty powerful. It has expanded access to a lot of people. What was really striking to me, though, even as I reported about the experiences of patients seeking care, is that while that has done so much to expand access in the face of abortion bans, it isn’t a solution that everyone can use. There were lots of people I met who did not want a medication abortion, who did not feel safe having pills mailed into their homes, or whose pregnancy complications and questions were just too complex to be solved by a virtual consult and then pills being mailed to them to take in the comfort of their house.
Rovner: Aren’t these difficulties exactly what the anti-abortion movement wanted? Didn’t they want clinics so swamped they couldn’t serve everybody who wanted to come, and abortion to be so difficult to get that women would end up carrying their pregnancies to term instead?
Luthra: Yes and no, I would argue. I think you are absolutely right that one of the primary goals of the anti-abortion movement was to make abortion unavailable, to make it harder to acquire, to have more people not get abortions and instead have children. But when I speak to folks in the anti-abortion movement, they are very troubled by how many people are traveling out of state to get care. They see those really long wait times in Kansas, in, until recently, Florida, in Illinois, in New Mexico, as a symptom of something that they need to address, which is that so many people are still finding a way to fight incredible odds to access abortion.
Rovner: Is there one thing that you hope people take away after they’re finished reading this?
Luthra: There are two things that I have spent a lot of time thinking about as I’ve reported this book. The first is just who gets abortions and under what circumstances. And so often in the national press, in national politics, we talk about these really extreme life-or-death cases. We talk about people who became septic and needed an abortion because their water broke early, or we talk about children who have been sexually assaulted and become pregnant. But we don’t talk about most people who get abortions; who are usually mothers, who are usually people of color, who are in their 20s and just know that they can’t be pregnant. I think those are really important stories to tell because they’re the true face of who is most affected by this, and it was important to me that this book include that.
The other thing that I have thought about so often in reporting this and writing this is abortion demands have an unequal impact. That is true if you are poor, if you are a person of color, if you live in a rural area, et cetera. You will in all likelihood see a greater effect. That said, the overturning of Roe v. Wade is so tremendous that it has affected people in every state. It affects you if you can get pregnant. It affects you if you want birth control. It affects you if you require reproductive health care in some form. This is just such a seismic change to our health care system that I really hope people who read this book understand that this is not a niche issue. This is something worthy of our collective attention and concern as journalists and as people.
Rovner: Shefali Luthra, thank you so much for this, and we will see you soon on the panel, right?
Luthra: Absolutely. Thank you, Julie. I’m so glad we got to do this.
Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Joanne, why don’t you go first this week?
Kenen: This was a pair of articles, a long one and a shorter, related one. There’s an amazingly wonderful piece in ProPublica by Sharon Lerner, and it’s called “Toxic Gaslighting: How 3M Executives Convinced a Scientist the Forever Chemicals She Found in Human Blood Were Safe.” I’m going to come back and talk about it briefly in a second, but the related story was in The Guardian by Damian Carrington: “Microplastics Found in Every Human Testicle in Study.” Now, that was a small study, but there may be a link to the declining sperm count because of these forever chemicals.
The ProPublica story, it was a young woman scientist. She worked for 3M. They kept telling her her results was wrong, her machinery was dirty, over and over and over again until she questioned herself and her findings. She was supposed to be looking at the blood of 3M workers who were, it turned out, the company knew all this already and they were hiding it, and she compared the blood of the 3M workers to non-3M workers, and she found these plastic chemicals in everybody’s blood everywhere, and she was basically gaslit out of her job. She continued to work for 3M, but in a different capacity.
The article’s really scary about the impact for human health. It also has wonderfully interesting little nuggets throughout about how various 3M products were developed, some by accident. Something spilled on somebody’s sneaker and it didn’t stain it, and that’s how we got those sprays for our upholstery. Or somebody needed something to find the pages in their church hymnal, and that’s how we got Post-it notes. It’s a devastating but very readable, and it makes you angry.
Rovner: Yeah, I feel like there’s a lot more we’re going to have to say about forever chemicals going forward. Alice.
Ollstein: So I have a pretty depressing story from Stats. It’s called “How Doctors Are Pressuring Sickle Cell Patients Into Unwanted Sterilizations,” by Eric Boodman. And it is about people with sickle cell, and that is overwhelmingly black women, and they felt pressured to agree to be permanently sterilized when they were going to give birth because of the higher risks. And the doctors said, because we’re already doing a C-section and we’re already doing surgery on you, to not have to do an additional surgery with additional risks, they felt pressured to just sign that they could be sterilized right then and there and came to regret it later and really wanted more children. And so, this is an instance of people feeling coerced, and when people think about pro-choice or the choice debate about reproduction they mostly think about the right to an abortion. But I think that the right to have more children, if you want to, is the other side of that coin.
Rovner: It is. Rachel.
Roubein: My extra credit, it’s called “What Science Tells Us About Biden, Trump and Evaluating an Aging Brain,” by Joel Achenbach and Mark Johnson from The Washington Post. And basically, they kind of took a very science-based look at the 2024 election. They basically called it a crash course in gerontology because former President Donald Trump will be 78 years old. President Biden will be a couple weeks away from turning 82. And obviously that is getting a lot of attention on the campaign trail. They talked to medical and scientific experts who were essentially warning that news reports, political punditry about the candidates’ mental fitness, has essentially been marred by misinformation here about the aging process. One of the things they dived into was these gaffes or what the public sees as senior moments and what experts had told them is, that’s not necessarily a sign of dementia or predictive of cognitive decline. There need to be kind of further clinical evaluation for that. But there have been some calls for just how to kind of standardize and require a certain level of transparency for candidates in terms of disclosing their health information.
Rovner: Yes, which we’ve been talking about for a while, and will continue to. My extra credit this week is from our guest, Shefali Luthra, and her colleague at The 19th Chabeli Carrazana, and it’s called “What Happens to Clinics After a State Bans Abortion? They Fight To Survive.” And for all the talk about doctors and other staffers either moving out of or not moving into states with abortion bans, I think less has been written about entire enterprises that often provide far more than just abortion services having to shut down as well. We saw this in Texas in the mid-2010s, when a law that shut down many of the clinics there was struck down by the Supreme Court in 2016. But many of those clinics were unable to reopen. They just could not reassemble, basically, their leases and equipment and staff. The same could well happen in states that this November vote to reverse some of those bans. And it’s not just abortion, as we’ve discussed. When these clinics close, it often means less family planning, less STI [sexually transmitted infection] screening and other preventive services as well, so it’s definitely something to continue to watch.
Before we go this week, I want to note the passing of a health policy journalism giant with the death of Marshall Allen. Marshall, who worked tirelessly, first in Las Vegas and more recently at ProPublica, to expose some of the most unfair and infuriating parts of the U.S. health care system, was on the podcast in 2021 to talk about his book, “Never Pay the First Bill, and Other Ways to Fight the Health Care System and Win.” I will post a link to the interview in this week’s show notes. Condolences to Marshall’s friends and family.
OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner. Joanne, where are you?
Kenen: We’re at Threads @JoanneKenen.
Rovner: Alice.
Ollstein: Still on X @AliceOllstein.
Rovner: Rachel.
Roubein: On X, @rachel_roubein.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Newly Minted Doctors Are Avoiding Abortion Ban States
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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
Joanne Kenen
Johns Hopkins University and Politico
Lauren Weber
The Washington Post
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.
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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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1 year 2 months ago
Courts, Health Care Costs, Health Industry, Insurance, Medicaid, Medicare, Multimedia, Abortion, Doctors, Hospitals, KFF Health News' 'What The Health?', Medical Education, Missouri, Podcasts, reproductive health, texas, Women's Health
La gripe aviar es mala para las aves de corral y las vacas lecheras. No es una amenaza grave para la mayoría de nosotros… por ahora
Los titulares explotaron después que el Departamento de Agricultura confirmara que el virus de la gripe aviar H5N1 ha infectado a vacas lecheras en todo el país.
Las pruebas han detectado el virus en el ganado en nueve estados, principalmente en Texas y Nuevo México, y más recientemente en Colorado, dijo Nirav Shah, director principal adjunto de los Centros para el Control y Prevención de Enfermedades (CDC), en un evento del 1 de mayo.
Otros animales, y al menos una persona en Texas, también se infectaron con el H5N1. Pero lo que más temen los científicos es si el virus se propagara de manera eficiente de persona a persona. Eso no ha sucedido y podría no suceder. Shah dijo que los CDC consideran que el brote de H5N1 “es un riesgo bajo para el público en general en este momento”.
Los virus evolucionan y los brotes pueden cambiar rápidamente. “Como con cualquier brote importante, esto se mueve a la velocidad de un tren bala”, dijo Shah. “De lo que hablamos ahora es de un instantánea de ese tren que se mueve rápidamente”. Lo que quiere decir es que lo que hoy se sabe sobre la gripe aviar H5N1 seguramente cambiará.
Con eso en mente, KFF Health News explica lo que se necesita saber ahora.
¿Quién contrae el virus que causa la gripe aviar?
Principalmente las aves. Sin embargo, en los últimos años, el virus de la gripe aviar H5N1 ha estado saltando cada vez más de las aves a los mamíferos en todo el mundo. La creciente lista, de más de 50 especies, incluye focas, cabras, zorrinos, gatos y perros salvajes en un zoológico en el Reino Unido. Al menos 24,000 leones marinos murieron en brotes de gripe aviar H5N1 en Sudamérica el año pasado.
Lo que hace que el brote actual en el ganado sea inusual es que se está propagando rápidamente de vaca a vaca, mientras que los otros casos, excepto las infecciones de leones marinos, parecen limitados. Los investigadores saben esto porque las secuencias genéticas de los virus H5N1 extraídos de las vacas este año eran casi idénticas entre sí.
El brote de ganado también preocupa porque agarró al país desprevenido. Los investigadores que examinan los genomas del virus sugieren que originalmente se transmitió de las aves a las vacas a finales del año pasado en Texas, y desde entonces se ha propagado entre muchas más vacas de las que se han examinado.
“Nuestros análisis muestran que esto ha estado circulando en vacas durante unos cuatro meses, bajo nuestras narices”, dijo Michael Worobey, biólogo especializado en evolución de la Universidad de Arizona en Tucson.
¿Es este el comienzo de la próxima pandemia?
Aún no. Pero es algo que vale la pena considerar porque una pandemia de gripe aviar sería una pesadilla. Más de la mitad de las personas infectadas por cepas anteriores del virus de la gripe aviar H5N1 de 2003 a 2016 murieron.
Incluso si las tasas de mortalidad resultan ser menos severas para la cepa H5N1 que circula actualmente en el ganado, las repercusiones podrían implicar muchas personas enfermas y hospitales demasiado abrumados para manejar otras emergencias médicas.
Aunque al menos una persona se infectó con el H5N1 este año, el virus no puede provocar una pandemia en su estado actual.
Para alcanzar este horrible estatus, un patógeno necesita enfermar a muchas personas en varios continentes. Y para lograrlo, el virus H5N1 necesitaría infectar a toneladas de personas. Eso no sucederá a través de saltos ocasionales del virus de los animales de granja a las personas. Más bien, el virus debe adquirir mutaciones para propagarse de persona a persona, como la gripe estacional, como una infección respiratoria transmitida principalmente por el aire cuando las personas tosen, estornudan y respiran.
Como aprendimos de covid-19, los virus transmitidos por el aire son difíciles de frenar.
Eso aún no ha sucedido. Sin embargo, los virus H5N1 ahora tienen muchas oportunidades para evolucionar a medida que se replican dentro de los organismos de miles de vacas. Como todos los virus, mutan a medida que se replican, y las mutaciones que mejoran la supervivencia del virus se transmiten a la próxima generación. Y debido a que las vacas son mamíferos, los virus podrían estar mejorando en reproducirse dentro de células más cercanas a las nuestras que las de las aves.
La evolución de un virus de gripe aviar listo para una pandemia podría facilitarse por una especie de superpoder que poseen muchos virus. Es decir, a veces intercambian sus genes con otras cepas en un proceso llamado recombinación.
En un estudio publicado en 2009, Worobey y otros investigadores rastrearon el origen de la pandemia del virus de la gripe porcina H1N1 en eventos en los que diferentes virus que causaban esta gripe, la gripe aviar y la gripe humana mezclaban y combinaban sus genes dentro de cerdos que se estaban infectando simultáneamente. Los cerdos no necesitan estar involucrados esta vez, advirtió Worobey.
¿Comenzará una pandemia si una persona bebe leche contaminada con el virus?
Aún no. La leche de vaca, así como la leche en polvo y la fórmula infantil, que se venden en tiendas se consideran seguras porque la ley requiere que toda la leche vendida comercialmente sea pasteurizada. Este proceso de calentar la leche a altas temperaturas mata bacterias, virus y otros microorganismos.
Las pruebas han identificado fragmentos de virus H5N1 en la leche comercial, pero confirman que los fragmentos del virus están muertos y, por lo tanto, son inofensivos.
Sin embargo, la leche “cruda” no pasteurizada ha demostrado contener virus H5N1 vivos, por eso la Administración de Drogas y Alimentos (FDA) y otras autoridades sanitarias recomiendan firmemente a las personas que no la tomen, porque podrían enfermarse de gravedad o algo peor.
Pero, aún así, es poco probable que se desate una pandemia porque el virus, en su forma actual, no se propaga eficientemente de persona a persona, como lo hace, por ejemplo, la gripe estacional.
¿Qué se debe hacer?
¡Mucho! Debido a la falta de vigilancia, el Departamento de Agricultura (USDA) y otras agencias han permitido que la gripe aviar H5N1 se propague en el ganado, sin ser detectada. Para hacerse cargo de la situación, el USDA recientemente ordenó que se sometan a pruebas a todas las vacas lecheras en lactancia antes que los ganaderos las trasladen a otros estados, y que se informen los resultados de las pruebas.
Pero al igual que restringir las pruebas de covid a los viajeros internacionales a principios de 2020 permitió que el coronavirus se propagara sin ser detectado, testear solo a las vacas que se mueven entre estados dejaría pasar muchos casos.
Estas pruebas limitadas no revelarán cómo se está propagando el virus entre el ganado, información que los ganaderos necesitan desesperadamente para frenarlo. Una hipótesis principal es que los virus se están transfiriendo de una vaca a la siguiente a través de las máquinas utilizadas para ordeñarlas.
Para aumentar las pruebas, Fred Gingrich, director ejecutivo de la American Association of Bovine Practitioners, dijo que el gobierno debería ofrecer fondos a los ganaderos para que informen casos y así tengan un incentivo para hacer pruebas. De lo contrario, dijo, informar solo daña la reputación por encima de las pérdidas financieras.
“Estos brotes tienen un impacto económico significativo”, dijo Gingrich. “Los ganaderos pierden aproximadamente el 20% de su producción de leche en un brote porque los animales dejan de comer, producen menos leche, y parte de esa leche es anormal y no se puede vender”.
Gingrich agregó que el gobierno ha hecho gratuitas las pruebas de H5N1 para los ganaderos, pero no han presupuestado dinero para los veterinarios que deben tomar muestras de las vacas, transportar las muestras y presentar los documentos. “Las pruebas son la parte menos costosa”, explicó.
Si las pruebas en las granjas siguen siendo esquivas, los virólogos aún pueden aprender mucho analizando secuencias genómicas del virus H5N1 de muestras de ganado. Las diferencias entre las secuencias cuentan una historia sobre dónde y cuándo comenzó el brote actual, el camino que recorre y si los virus están adquiriendo mutaciones que representan una amenaza para las personas.
Sin embargo, esta investigación vital se ha visto obstaculizada porque el USDA publica los datos incompletos y con cuentagotas, dijo Worobey.
El gobierno también debería ayudar a los criadores de aves de corral a prevenir brotes de H5N1, ya que estos matan a muchas aves y representan una amenaza constante de potenciales saltos de especies, dijo Maurice Pitesky, especialista en enfermedades de aves de la Universidad de California-Davis.
Las aves acuáticas como los patos y los gansos son las fuentes habituales de brotes en granjas avícolas, y los investigadores pueden detectar su proximidad mediante el uso de sensores remotos y otras tecnologías. Eso puede significar una vigilancia rutinaria para detectar signos tempranos de infecciones en aves de corral, usar cañones de agua para ahuyentar a las bandadas migratorias, reubicar animales de granja o llevarlos temporalmente a cobertizos. “Deberíamos estar invirtiendo en prevención”, dijo Pitesky.
Bien, no es una pandemia, pero ¿qué podría pasarle a las personas que contraigan la gripe aviar H5N1 de este año?
Realmente nadie lo sabe. Solo una persona en Texas fue diagnosticada con la enfermedad este año, en abril. Esta persona trabajaba con vacas lecheras, y tuvo un caso leve con una infección en el ojo. Los CDC se enteraron de esto debido a su proceso de vigilancia. Las clínicas deben alertar a los departamentos de salud estatales cuando diagnostican a trabajadores agrícolas con gripe, utilizando pruebas que detectan virus de la influenza en general.
Los departamentos de salud estatales luego confirman la prueba y, si es positiva, envían una muestra de la persona a un laboratorio de los CDC, donde se verifica específicamente la presencia del virus H5N1. “Hasta ahora hemos recibido 23”, dijo Shah. “Todos menos uno resultaron negativos”.
Agregó que funcionarios del departamento de salud estatal también están monitoreando a alrededor de 150 personas que han pasado tiempo alrededor de ganado. Están en contacto con estos trabajadores agrícolas con llamadas telefónicas, mensajes de texto o visitas en persona para ver si desarrollan síntomas. Y si eso sucede, les harán pruebas.
Otra forma de evaluar a los trabajadores agrícolas sería testear su sangre en busca de anticuerpos contra el virus de la gripe aviar H5N1; un resultado positivo indicaría que podrían haberse infectado sin saberlo. Pero Shah dijo que los funcionarios de salud aún no están haciendo este trabajo.
“El hecho de que hayan pasado cuatro meses y aún no hayamos hecho esto no es una buena señal”, dijo Worobey. “No estoy muy preocupado por una pandemia en este momento, pero deberíamos comenzar a actuar como si no quisiéramos que sucediera”.
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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1 year 2 months ago
Health Industry, Noticias En Español, Public Health, Rural Health, Colorado, FDA, Food Safety, New Mexico, texas
Toxic Gas Adds to a Long History of Pollution in Southwest Memphis
MEMPHIS, Tenn. — For many years, Rose Sims had no idea what was going on inside a nondescript brick building on Florida Street a couple of miles from her modest one-story home on the southwestern side of town.
Like other residents, she got an unwelcome surprise in October 2022 at a public forum held by the Environmental Protection Agency at the historic Monumental Baptist Church, known for its role in the civil rights movement. The EPA notified the predominantly Black community that Sterilization Services of Tennessee —which began operations in the brick building in the 1970s — had been emitting unacceptably high levels of ethylene oxide, a toxic gas commonly used to disinfect medical devices.
Airborne emissions of the colorless gas can increase the risk of certain medical conditions, including breast cancer. Sims, who is 59 and Black, said she developed breast cancer in 2019, despite having no family history of it, and she suspects ethylene oxide was a contributing factor.
“I used to be outside a lot. I was in good health. All of a sudden, I got breast cancer,” she said.
Local advocates say the emissions are part of a pattern of environmental racism. The term is often applied when areas populated primarily by racial and ethnic minorities and members of low-socioeconomic backgrounds, like southwest Memphis, are burdened with a disproportionate amount of health hazards.
The drivers of environmental racism include the promise of tax breaks for industry to locate a facility in a heavily minority community, said Malini Ranganathan, an urban geographer at American University in Washington, D.C. The cheaper cost of land also is a factor, as is the concept of NIMBY — or “not in my backyard” — in which power brokers steer possible polluters to poorer areas of cities.
A manager at Sterilization Services’ corporate office in Richmond, Virginia, declined to answer questions from KFF Health News. An attorney with Leitner, Williams, Dooley & Napolitan, a law firm that represents the company, also declined to comment. Sterilization Services, in a legal filing asking for an ethylene oxide-related lawsuit to be dismissed, said the use of the gas, which sterilizes about half the medical devices in the U.S., is highly regulated to ensure public safety.
Besides southwest Memphis, there are nearly two dozen locales, mostly small cities — from Athens, Texas, to Groveland, Florida, and Ardmore, Oklahoma — where the EPA said in 2022 that plants sterilizing medical devices emit the gas at unusually high levels, potentially increasing a person’s risk of developing cancer.
The pollution issue is so bad in southwest Memphis that even though Sterilization Services planned to close shop by April 30, local community leaders have been hesitant to celebrate. In a letter last year to a local Congress member, the company said it has always complied with federal, state, and local regulations. The reason for its closure, it said, was a problem with renewing the building lease.
But many residents see it as just one small win in a bigger battle over environmental safety in the neighborhood.
“It’s still a cesspool of pollution,’’ said Yolonda Spinks, of the environmental advocacy organization Memphis Community Against Pollution, about a host of hazards the community faces.
The air in this part of the city has long been considered dangerous. An oil refinery spews a steady plume of white smoke. A coal plant, which is now closed, leaked components of coal ash, such as arsenic, into the ground and groundwater, according to a corrective action report from the Tennessee Valley Authority. The TVA is proposing to gut an existing gas plant and replace turbines in the facility with new ones. A continual stream of heavy trucks chug along nearby highways and roads. Other transportation sources of air pollution include the Memphis International Airport and barge traffic on the nearby Mississippi River.
Lead contamination is also a concern, not just in drinking water but in the soil from now-closed lead smelters, said Chunrong Jia, a professor of environmental health at the University of Memphis. Almost all the heavy industry in Shelby County — and the associated pollutants — are located in southwest Memphis, Jia added.
Sources of pollution are often “clustered in particular communities,” said Darya Minovi, a senior analyst with the Union of Concerned Scientists, a nonprofit that advocates for environmental justice. When it comes to sterilizing facilities that emit ethylene oxide, areas inhabited largely by Black, Hispanic, low-income, and non-English-speaking people are disproportionately exposed, the group has found.
Four sites that the EPA labeled high-risk are in low-income areas of Puerto Rico. Seven sterilizer plants operate in that U.S. territory.
The EPA, responding to public concerns and to deepened scientific understanding of the hazards of ethylene oxide, recently released rules that the agency said would greatly reduce emissions of the toxic gas from sterilizing facilities.
KeShaun Pearson, who was born and raised in south Memphis and has been active in fighting environmental threats, said he is frustrated that companies with dangerous emissions are allowed to create “toxic soup” in minority communities.
In the area where the sterilization plant is located, 87% of the residents are people of color, and, according to the Southern Environmental Law Center, life expectancy there is about 10 years lower than the average for the county and state. The population within 5 miles of the sterilizer plant is mostly low-income, according to the Union of Concerned Scientists.
Pearson was part of Memphis Community Against the Pipeline, a group formed in 2020 to stop a crude oil pipeline that would have run through Boxtown, a neighborhood established by emancipated slaves and freedmen after the signing of the Emancipation Proclamation of 1863.
That campaign, which received public support from former Vice President Al Gore and actress-activist Jane Fonda, succeeded. After the ethylene oxide danger surfaced in 2022, the group changed the last word of its name from “pipeline” to “pollution.”
Besides breast and lymphoid cancers, animal studies have linked inhaling the gas to tumors of the brain, lungs, connective tissue, uterus, and mammary glands.
Last year, with the help of the Southern Environmental Law Center, the south Memphis community group urged the Shelby County Health Department to declare the ethylene oxide situation a public health emergency and shut down the sterilizing plant. But the health department said the company had complied with its existing air permit and with the EPA’s rules and regulations.
A health department spokesperson, Joan Carr, said Shelby County enforces EPA regulations to ensure that companies comply with the federal Clean Air Act and that the agency has five air monitoring stations around the county to detect levels of other pollutants.
When the county and the Tennessee Department of Health did a cancer cluster study in 2023, the agencies found no evidence of the clustering of high rates of leukemia, non-Hodgkin lymphoma, or breast or stomach cancer near the facility. There were “hot and cold spots” of breast cancer found, but the study said it could not conclude that the clusters were linked to the facility.
Scientists have criticized the study’s methodology, saying it did not follow the Centers for Disease Control and Prevention’s recommendations for designing a cancer cluster investigation.
Meanwhile, several people have sued the sterilizing company, claiming their health has been affected by the ethylene oxide emissions. In a lawsuit seeking class-action status, Reginaé Kendrick, 21, said she was diagnosed with a brain tumor at age 6. Chemotherapy and radiation have stunted her growth, destroyed her hair follicles, and prevented her from going through puberty, said her mother, Robbie Kendrick.
In response to proposed stricter EPA regulations, meanwhile, the Tennessee attorney general helped lead 19 other state AGs in urging the agency to “forgo or defer regulating the use of EtO by commercial sterilizers.”
Sims said she’s glad her neighborhood will have one less thing to worry about once Sterilization Services departs. But her feelings about the closure remain tempered.
“Hope they don’t go to another residential area,” she said.
[Clarification: This article was updated at 3:15 p.m. ET on May 1, 2024, to specify which substances leaked into the ground and groundwater and what changes will occur related to the Tennessee Valley Authority’s activities in Shelby County, Tennessee.]
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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1 year 3 months ago
Public Health, Race and Health, States, Disparities, Environmental Health, Florida, Oklahoma, Tennessee, texas, Virginia
Rare human case of highly contagious bird flu confirmed in Texas
The Centers for Disease Control and Prevention announced Monday that a person in Texas has tested positive for highly pathogenic avian influenza, otherwise known as H5N1 bird flu.
The Centers for Disease Control and Prevention announced Monday that a person in Texas has tested positive for highly pathogenic avian influenza, otherwise known as H5N1 bird flu.
"This person had exposure to dairy cattle in Texas presumed to be infected with HPAI A(H5N1) viruses. The patient reported eye redness (consistent with conjunctivitis), as their only symptom, and is recovering," the CDC said in a statement. "The patient was told to isolate and is being treated with an antiviral drug for flu."
The CDC said this is the second case of a human testing positive for H5N1 in the United States, after a previous case was observed in Colorado in 2022.
"This infection does not change the H5N1 bird flu human health risk assessment for the U.S. general public, which CDC considers to be low," it added. "However, people with close or prolonged, unprotected exposures to infected birds or other animals (including livestock), or to environments contaminated by infected birds or other animals, are at greater risk of infection."
US TUBERCULOSIS CASES IN 2023 WERE AT HIGHEST LEVEL IN A DECADE, CDC SAYS
Last week, dairy cows in Texas and Kansas were reported to be infected with bird flu – and federal agriculture officials later confirmed infections in a Michigan dairy herd that had recently received cows from Texas.
This bird flu was first identified as a threat to people during a 1997 outbreak in Hong Kong, according to the Associated Press. More than 460 people have died in the past two decades from bird flu infections, the World Health Organization says.
PUERTO RICO HEALTH OFFICIALS DECLARE DENGUE FEVER A PUBLIC HEALTH EMERGENCY
Texas officials did not identify the newly infected person, nor release any details about what brought them in contact with the cows.
The CDC said it is "working with state health departments to continue to monitor workers who may have been in contact with infected or potentially infected birds/animals and test those people who develop symptoms."
"Human illnesses with H5N1 bird flu have ranged from mild (e.g., eye infection, upper respiratory symptoms) to severe illness (e.g., pneumonia) that have resulted in death in other countries," the CDC also said.
The Associated Press contributed to this report.
1 year 4 months ago
infectious-disease, texas, Health
Why Covid Patients Who Could Most Benefit From Paxlovid Still Aren’t Getting It
Evangelical minister Eddie Hyatt believes in the healing power of prayer but “also the medical approach.” So on a February evening a week before scheduled prostate surgery, he had his sore throat checked out at an emergency room near his home in Grapevine, Texas.
A doctor confirmed that Hyatt had covid-19 and sent him to CVS with a prescription for the antiviral drug Paxlovid, the generally recommended medicine to fight covid. Hyatt handed the pharmacist the script, but then, he said, “She kept avoiding me.”
She finally looked up from her computer and said, “It’s $1,600.”
The generally healthy 76-year-old went out to the car to consult his wife about their credit card limits. “I don’t think I’ve ever spent more than $20 on a prescription,” the astonished Hyatt recalled.
That kind of sticker shock has stunned thousands of sick Americans since late December, as Pfizer shifted to commercial sales of Paxlovid. Before then, the federal government covered the cost of the drug.
The price is one reason Paxlovid is not reaching those who need it most. And patients who qualify for free doses, which Pfizer offers under an agreement with the federal government, often don’t realize it or know how to get them.
“If you want to create a barrier to people getting a treatment, making it cost a lot is the way to do it,” said William Schaffner, a professor at Vanderbilt University School of Medicine and spokesperson for the National Foundation for Infectious Diseases.
Public and medical awareness of Paxlovid’s benefits is low, and putting people through an application process to get the drug when they’re sick is a non-starter, Schaffner said. Pfizer says it takes only five minutes online.
It’s not an easy drug to use. Doctors are wary about prescribing it because of dangerous interactions with common drugs that treat cholesterol, blood clots, and other conditions. It must be taken within five days of the first symptoms. It leaves a foul taste in the mouth. In one study, 1 in 5 patients reported “rebound” covid symptoms a few days after finishing the medicine — though rebound can also occur without Paxlovid.
A recent JAMA Network study found that sick people 85 and older were less likely than younger Medicare patients to get covid therapies like Paxlovid. The drug might have prevented up to 27,000 deaths in 2022 if it had been allocated based on which patients were at highest risk from covid. Nursing home patients, who account for around 1 in 6 U.S. covid deaths, were about two-thirds as likely as other older adults to get the drug.
Shrunken confidence in government health programs is one reason the drug isn’t reaching those who need it. In senior living facilities, “a lack of clear information and misinformation” are “causing residents and their families to be reluctant to take the necessary steps to reduce covid risks,” said David Gifford, chief medical officer for an association representing 14,000 health care providers, many in senior care.
The anti-vaxxers spreading falsehoods about vaccines have targeted Paxlovid as well. Some call themselves anti-paxxers.
“Proactive and health-literate people get the drug. Those who are receiving information more passively have no idea whether it’s important or harmful,” said Michael Barnett, a primary care physician at Brigham and Women’s Hospital and an associate professor at Harvard, who led the JAMA Network study.
In fact, the drug is still free for those who are uninsured or enrolled in Medicare, Medicaid, or other federal health programs, including those for veterans.
That’s what rescued Hyatt, whose Department of Veterans Affairs health plan doesn’t normally cover outpatient drugs. While he searched on his phone for a solution, the pharmacist’s assistant suddenly appeared from the store. “It won’t cost you anything!” she said.
As Hyatt’s case suggests, it helps to know to ask for free Paxlovid, although federal officials say they’ve educated clinicians and pharmacists — like the one who helped Hyatt — about the program.
“There is still a heaven!” Hyatt replied. After he had been on Paxlovid for a few days his symptoms were gone and his surgery was rescheduled.
About That $1,390 List Price
Pfizer sold the U.S. government 23.7 million five-day courses of Paxlovid, produced under an FDA emergency authorization, in 2021 and 2022, at a price of around $530 each.
Under the new agreement, Pfizer commits to provide the drug for the beneficiaries of the government insurance programs. Meanwhile, Pfizer bills insurers for some portion of the $1,390 list price. Some patients say pharmacies have quoted them prices of $1,600 or more.
How exactly Pfizer arrived at that price isn’t clear. Pfizer won’t say. A Harvard study last year estimated the cost of producing generic Paxlovid at about $15 per treatment course, including manufacturing expenses, a 10% profit markup, and 27% in taxes.
Pfizer reported $12.5 billion in Paxlovid and covid vaccine sales in 2023, after a $57 billion peak in 2022. The company’s 2024 Super Bowl ad, which cost an estimated $14 million to place, focused on Pfizer’s cancer drug pipeline, newly reinforced with its $43 billion purchase of biotech company Seagen. Unlike some other recent oft-aired Pfizer ads (“If it’s covid, Paxlovid”), it didn’t mention covid products.
Connecting With Patients
The other problem is getting the drug where it is needed. “We negotiated really hard with Pfizer to make sure that Paxlovid would be available to Americans the way they were accustomed to,” Department of Health and Human Services Secretary Xavier Becerra told reporters in February. “If you have private insurance, it should not cost you much money, certainly not more than $100.”
Yet in nursing homes, getting Paxlovid is particularly cumbersome, said Chad Worz, CEO of the American Society of Consultant Pharmacists, specialists who provide medicines to care homes.
If someone in long-term care tests positive for covid, the nurse tells the physician, who orders the drug from a pharmacist, who may report back that the patient is on several drugs that interact with Paxlovid, Worz said. Figuring out which drugs to stop temporarily requires further consultations while the time for efficacious use of Paxlovid dwindles, he said.
His group tried to get the FDA to approve a shortcut similar to the standing orders that enable pharmacists to deliver anti-influenza medications when there are flu outbreaks in nursing homes, Worz said. “We were close,” he said, but “it just never came to fruition.” “The FDA is unable to comment,” spokesperson Chanapa Tantibanchachai said.
Los Angeles County requires nursing homes to offer any covid-positive patient an antiviral, but the Centers for Medicare & Medicaid Services, which oversees nursing homes nationwide, has not issued similar guidance. “And this is a mistake,” said Karl Steinberg, chief medical officer for two nursing home chains with facilities in San Diego County, which also has no such mandate. A requirement would ensure the patient “isn’t going to fall through the cracks,” he said.
While it hasn’t ordered doctors to prescribe Paxlovid, CMS on Jan. 4 issued detailed instructions to health insurers urging swift approval of Paxlovid prescriptions, given the five-day window for the drug’s efficacy. It also “encourages” plans to make sure pharmacists know about the free Paxlovid arrangement.
Current covid strains appear less virulent than those that circulated earlier in the pandemic, and years of vaccination and covid infection have left fewer people at risk of grave outcomes. But risk remains, particularly among older seniors, who account for most covid deaths, which number more than 13,500 so far this year in the U.S.
Steinberg, who sees patients in 15 residences, said he orders Paxlovid even for covid-positive patients without symptoms. None of the 30 to 40 patients whom he prescribed the drug in the past year needed hospitalization, he said; two stopped taking it because of nausea or the foul taste, a pertinent concern in older people whose appetites already have ebbed.
Steinberg said he knew of two patients who died of covid in his companies’ facilities this year. Neither was on Paxlovid. He can’t be sure the drug would have made a difference, but he’s not taking any chances. The benefits, he said, outweigh the risks.
Reporter Colleen DeGuzman 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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1 year 4 months ago
COVID-19, Pharmaceuticals, Public Health, Misinformation, Pandemic Disparities, texas
Pregnancy Care Was Always Lacking in Jails. It Could Get Worse.
It was about midnight in June 2022 when police officers showed up at Angela Collier’s door and told her that someone anonymously requested a welfare check because they thought she might have had a miscarriage.
Standing in front of the concrete steps of her home in Midway, Texas, Collier, initially barefoot and wearing a baggy gray T-shirt, told officers she planned to see a doctor in the morning because she had been bleeding.
Police body camera footage obtained by KFF Health News through an open records request shows that the officers then told Collier — who was 29 at the time and enrolled in online classes to study psychology — to turn around.
Instead of taking her to get medical care, they handcuffed and arrested her because she had outstanding warrants in a neighboring county for failing to appear in court to face misdemeanor drug charges three weeks earlier. She had missed that court date, medical records show, because she was at a hospital receiving treatment for pregnancy complications.
Despite her symptoms and being about 13 weeks pregnant, Collier spent the next day and a half in the Walker County Jail, about 80 miles north of Houston. She said her bleeding worsened there and she begged repeatedly for medical attention that she didn’t receive, according to a formal complaint she filed with the Texas Commission on Jail Standards.
“There wasn’t anything I could do,” she said, but “just lay there and be scared and not know what was going to happen.”
Collier’s experience highlights the limited oversight and absence of federal standards for reproductive care for pregnant women in the criminal justice system. Incarcerated people have a constitutional right to health care, yet only a half-dozen states have passed laws guaranteeing access to prenatal or postpartum medical care for people in custody, according to a review of reproductive health care legislation for incarcerated people by a research group at Johns Hopkins School of Medicine. And now abortion restrictions might be putting care further out of reach.
Collier’s arrest was “shocking and disturbing” because officers “blithely” took her to jail despite her miscarriage concerns, said Wanda Bertram, a spokesperson for the Prison Policy Initiative, a nonprofit organization that studies incarceration. Bertram reviewed the body cam footage and Collier’s complaint.
“Police arrest people who are in medical emergencies all the time,” she said. “And they do that regardless of the fact that the jail is often not equipped to care for those people in the way an emergency room might be.”
After a decline during the first year of the pandemic, the number of women in U.S. jails is once again rising, hitting nearly 93,000 in June 2022, a 33% increase over 2020, according to the Department of Justice. Tens of thousands of pregnant women enter U.S. jails each year, according to estimates by Carolyn Sufrin, an associate professor of gynecology and obstetrics at Johns Hopkins School of Medicine, who researches pregnancy care in jails and prisons.
The health care needs of incarcerated women have “always been an afterthought,” said Dana Sussman, deputy executive director at Pregnancy Justice, an organization that defends women who have been charged with crimes related to their pregnancy, such as substance use. For example, about half of states don’t provide free menstrual products in jails and prisons. “And then the needs of pregnant women are an afterthought beyond that,” Sussman said.
Researchers and advocates worry that confusion over recent abortion restrictions may further complicate the situation. A nurse cited Texas’ abortion laws as one reason Collier didn’t need care, according to her statement to the standards commission.
Texas law allows treatment of miscarriage and ectopic pregnancies, a life-threatening condition in which a fertilized egg implants outside the uterus. However, different interpretations of the law can create confusion.
A nurse told Collier that “hospitals no longer did dilation and curettage,” Collier told the commission. “Since I wasn’t hemorrhaging to the point of completely soaking my pants, there wasn’t anything that could be done for me,” she said.
Collier testified that she saw a nurse only once during her stay in jail, even after she repeatedly asked jail staffers for help. The nurse checked her temperature and blood pressure and told her to put in a formal request for Tylenol. Collier said she completed her miscarriage shortly after being released.
Collier’s case is a “canary in a coal mine” for what is happening in jails; abortion restrictions are “going to have a huge ripple effect on a system already unequipped to handle obstetric emergencies,” Sufrin said.
‘There Are No Consequences’
Jail and prison health policies vary widely around the country and often fall far short of the American College of Obstetricians and Gynecologists’ guidelines for reproductive health care for incarcerated people. ACOG and other groups recommend that incarcerated women have access to unscheduled or emergency obstetric visits on a 24-hour basis and that on-site health care providers should be better trained to recognize pregnancy problems.
In Alabama, where women have been jailed for substance use during pregnancy, the state offers pregnancy tests in jail. But it doesn’t guarantee a minimum standard of prenatal care, such as access to extra food and medical visits, according to Johns Hopkins’ review.
Policies for pregnant women at federal facilities also don’t align with national standards for nutrition, safe housing, and access to medical care, according to a 2021 report from the Government Accountability Office.
Even when laws exist to ensure that incarcerated pregnant women have access to care, the language is often vague, leaving discretion to jail personnel.
Since 2020, Tennessee law has required that jails and prisons provide pregnant women “regular prenatal and postpartum care, as necessary.” But last August a woman gave birth in a jail cell after seeking medical attention for more than an hour, according to the Montgomery County Sheriff’s Office.
Pregnancy complications can quickly escalate into life-threatening situations, requiring more timely and specialized care than jails can often provide, said Sufrin. And when jails fail to comply with laws on the books, little oversight or enforcement may exist.
In Louisiana, many jails didn’t consistently follow laws that aimed to improve access to reproductive health care, such as providing free menstrual items, according to a May 2023 report commissioned by state lawmakers. The report also said jails weren’t transparent about whether they followed other laws, such as prohibiting the use of solitary confinement for pregnant women.
Krishnaveni Gundu, as co-founder of the Texas Jail Project, which advocates for people held in county jails, has lobbied for more than a decade to strengthen state protections for pregnant incarcerated people.
In 2019, Texas became one of the few states to require that jails’ health policies include obstetrical and gynecological care. The law requires jails to promptly transport a pregnant person in labor to a hospital, and additional regulations mandate access to medical and mental health care for miscarriages and other pregnancy complications.
But Gundu said lack of oversight and meaningful enforcement mechanisms, along with “apathy” among jail employees, have undermined regulatory protections.
“All those reforms feel futile,” said Gundu, who helped Collier prepare for her testimony. “There are no consequences.”
Before her arrest, Collier had been to the hospital twice that month experiencing pregnancy complications, including a bladder infection, her medical records show. Yet the commission found that Walker County Jail didn’t violate minimum standards. The commission did not consider the police body cam footage or Collier’s personal medical records, which support her assertions of pregnancy complications, according to investigation documents obtained by KFF Health News via an open records request.
In making its determination, the commission relied mainly on the jail’s medical records, which note that Collier asked for medical attention for a miscarriage once, in the morning on the day she was released, and refused Tylenol.
“Your complaint of no medical care is unfounded,” the commission concluded, “and no further action will be taken.”
Collier’s miscarriage had ended before she entered the jail, argued Lt. Keith DeHart, jail lieutenant for the Walker County Sheriff’s Office. “I believe there was some misunderstanding,” he said.
Brandon Wood, executive director of the commission, wouldn’t comment on Collier’s case but defends the group’s investigation as thorough. Jails “have a duty to ensure that those records are accurate and truthful,” he said. And most Texas jails are complying with heightened standards, he said.
Bertram disagrees, saying the fact that care was denied to someone who was begging for it speaks volumes. “That should tell you something about what these standards are worth,” she said.
Last year, Chiree Harley spent six weeks in a Comal County, Texas, jail shortly after discovering she was pregnant and before she could get prenatal care, she said.
I was “thinking that I was going to be well taken care of,” said Harley, 37, who also struggled with substance use.
Jail officials put her in the infirmary, Harley said, but she saw only a jail doctor and never visited an OB-GYN, even though she had previous pregnancy complications including losing multiple pregnancies at around 21 weeks. This time she had no idea how far along she was.
She said that she started leaking amniotic fluid and having contractions on Nov. 1, but that jail officials waited nearly two days to take her to a hospital. Harley said officers forced her to sign papers releasing her from jail custody while she was having contractions in the hospital. Harley delivered at 23 weeks; the baby boy died less than a day later in her arms.
The whole experience was “very scary,” Harley said. “Afterwards we were all very, very devastated.”
Comal County declined to send Harley’s medical and other records in response to an open records request. Michael Shaunessy, a partner at McGinnis Lochridge who represents Comal County, said in a statement that, “at all times, the Comal County Jail provided Chiree Harley with all appropriate and necessary medical treatment for her and her unborn child.” He did not respond to questions about whether Harley was provided specialized obstetric care.
‘I Trusted Those People’
In states like Idaho, Mississippi, and Louisiana that installed near-total abortion bans after the Supreme Court eliminated the constitutional right to abortion in 2022, some patients might have to wait until no fetal cardiac activity is detected before they can get care, said Kari White, the executive and scientific director of Resound Research for Reproductive Health.
White co-authored a recent study that documented 50 cases in which pregnancy care deviated from the standard because of abortion restrictions even outside of jails and prisons. Health care providers who worry about running afoul of strict laws might tell patients to go home and wait until their situations worsen.
“Obviously, it’s much trickier for people who are in jail or in prison, because they are not going to necessarily be able to leave again,” she said.
Advocates argue that boosting oversight and standards is a start, but that states need to find other ways to manage pregnant women who get caught in the justice system.
For many pregnant people, even a short stay in jail can cause lasting trauma and interrupt crucial prenatal care.
Collier remembers being in “disbelief” when she was first arrested but said she was not “distraught.”
“I figured I would be taken care of, that nothing bad was gonna happen to me,” she said. As it became clear that she wouldn’t get care, she grew distressed.
After her miscarriage, Collier saw a mental health specialist and started medication to treat depression. She hasn’t returned to her studies, she said.
“I trusted those people,” Collier said about the jail staff. “The whole experience really messed my head up.”
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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1 year 5 months ago
States, Alabama, Idaho, Louisiana, Mississippi, Pregnancy, Prison Health Care, Tennessee, texas, Women's Health
Ouch. That ‘Free’ Annual Checkup Might Cost You. Here’s Why.
When Kristy Uddin, 49, went in for her annual mammogram in Washington state last year, she assumed she would not incur a bill because the test is one of the many preventive measures guaranteed to be free to patients under the 2010 Affordable Care Act.
The ACA’s provision made medical and economic sense, encouraging Americans to use screening tools that could nip medical problems in the bud and keep patients healthy.
So when a bill for $236 arrived, Uddin — an occupational therapist familiar with the health care industry’s workings — complained to her insurer and the hospital. She even requested an independent review.
“I’m like, ‘Tell me why am I getting this bill?’” Uddin recalled in an interview. The unsatisfying explanation: The mammogram itself was covered, per the ACA’s rules, but the fee for the equipment and the facility was not.
That answer was particularly galling, she said, because, a year earlier, her “free” mammogram at the same health system had generated a bill of about $1,000 for the radiologist’s reading. Though she fought that charge (and won), this time she threw in the towel and wrote the $236 check. But then she dashed off a submission to the KFF Health News-NPR “Bill of the Month” project:
“I was really mad — it’s ridiculous,” she later recalled. “This is not how the law is supposed to work.”
The ACA’s designers might have assumed that they had spelled out with sufficient clarity that millions of Americans would no longer have to pay for certain types of preventive care, including mammograms, colonoscopies, and recommended vaccines, in addition to doctor visits to screen for disease. But the law’s authors didn’t reckon with America’s ever-creative medical billing juggernaut.
Over the past several years, the medical industry has eroded the ACA’s guarantees, finding ways to bill patients in gray zones of the law. Patients going in for preventive care, expecting that it will be fully covered by insurance, are being blindsided by bills, big and small.
The problem comes down to deciding exactly what components of a medical encounter are covered by the ACA guarantee. For example, when do conversations between doctor and patient during an annual visit for preventive services veer into the treatment sphere? What screenings are needed for a patient’s annual visit?
A healthy 30-year-old visiting a primary care provider might get a few basic blood tests, while a 50-year-old who is overweight would merit additional screening for Type 2 diabetes.
Making matters more confusing, the annual checkup itself is guaranteed to be “no cost” for women and people age 65 and older, but the guarantee doesn’t apply for men in the 18-64 age range — though many preventive services that require a medical visit (such as checks of blood pressure or cholesterol and screens for substance abuse) are covered.
No wonder what’s covered under the umbrella of prevention can look very different to medical providers (trying to be thorough) and billers (intent on squeezing more dollars out of every medical encounter) than it does to insurers (who profit from narrower definitions).
For patients, the gray zone has become a billing minefield. Here are a few more examples, gleaned from the Bill of the Month project in just the past six months:
Peter Opaskar, 46, of Texas, went to his primary care doctor last year for his preventive care visit — as he’d done before, at no cost. This time, his insurer paid $130.81 for the visit, but he also received a perplexing bill for $111.81. Opaskar learned that he had incurred the additional charge because when his doctor asked if he had any health concerns, he mentioned that he was having digestive problems but had already made an appointment with his gastroenterologist. So, the office explained, his visit was billed as both a preventive physical and a consultation. “Next year,” Opasker said in an interview, if he’s asked about health concerns, “I’ll say ‘no,’ even if I have a gunshot wound.”
Kevin Lin, a technology specialist in Virginia in his 30s, went to a new primary care provider to take advantage of the preventive care benefit when he got insurance; he had no physical complaints. He said he was assured at check-in that he wouldn’t be charged. His insurer paid $174 for the checkup, but he was billed an additional $132.29 for a “new patient visit.” He said he has made many calls to fight the bill, so far with no luck.
Finally, there’s Yoori Lee, 46, of Minnesota, herself a colorectal surgeon, who was shocked when her first screening colonoscopy yielded a bill for $450 for a biopsy of a polyp — a bill she knew was illegal. Federal regulations issued in 2022 to clarify the matter are very clear that biopsies during screening colonoscopies are included in the no-cost promise. “I mean, the whole point of screening is to find things,” she said, stating, perhaps, the obvious.
Though these patient bills defy common sense, room for creative exploitation has been provided by the complex regulatory language surrounding the ACA. Consider this from Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services, in an emailed response to queries and an interview request on this subject: “If a preventive service is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of the preventive item or service, then the plan issuer may impose cost sharing for the office visit.”
So, if the doctor decides that a patient’s mention of stomach pain does not fall under the umbrella of preventive care, then that aspect of the visit can be billed separately, and the patient must pay?
And then there’s this, also from Montz: “Whether a facility fee is permitted to be charged to a consumer would depend on whether the facility usage is an integral part of performing the mammogram or an integral part of any other preventive service that is required to be covered without cost sharing under federal law.”
But wait, how can you do a mammogram or colonoscopy without a facility?
Unfortunately, there is no federal enforcement mechanism to catch individual billing abuses. And agencies’ remedies are weak — simply directing insurers to reprocess claims or notifying patients they can resubmit them.
In the absence of stronger enforcement or remedies, CMS could likely curtail these practices and give patients the tools to fight back by offering the sort of clarity the agency provided a few years ago regarding polyp biopsies — spelling out more clearly what comes under the rubric of preventive care, what can be billed, and what cannot.
The stories KFF Health News and NPR receive are likely just the tip of an iceberg. And while each bill might be relatively small compared with the stunning $10,000 hospital bills that have become all too familiar in the United States, the sorry consequences are manifold. Patients pay bills they do not owe, depriving them of cash they could use elsewhere. If they can’t pay, those bills might end up with debt-collection agencies and, ultimately, harm their credit score.
Perhaps most disturbing: These unexpected bills might discourage people from seeking preventive screenings that could be lifesaving, which is why the ACA deemed them “essential health benefits” that should be free.
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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1 year 6 months ago
Health Care Costs, Health Industry, Legislation, Minnesota, Obamacare Plans, Preventive Services, texas, Virginia, Washington
KFF Health News' 'What the Health?': New Year, Same Abortion Debate
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
It’s a new year, but the abortion debate is raging like it’s 2023, with a new federal appeals court ruling that doctors in Texas don’t have to provide abortions in medical emergencies, despite a federal requirement to the contrary. The case, similar to one in Idaho, is almost certainly headed for the Supreme Court. Meanwhile, Congress returns to Washington with only days to avert a government shutdown by passing either full-year or temporary spending bills. And with almost no progress toward a spending deal since the last temporary bill passed in November, this time a shutdown might well happen.
This week’s panelists are Julie Rovner of KFF Health News, Lauren Weber of The Washington Post, Shefali Luthra of The 19th, and Victoria Knight of Axios.
Panelists
Victoria Knight
Axios
Shefali Luthra
The 19th
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- New year, same Congress. It’s likely lawmakers will fall short of their early-year goals to pass necessary spending bills, prompting another government shutdown or yet another short-term extension. And funding for pediatric medical training is among the latest casualties of the clash over gender-affirming care, raising the odds of a political fight over the federal health budget.
- The emergency abortion care decision out of Texas this week underscores the difficult position health care providers are in: Now, a doctor could be brought up on charges in Texas for performing an abortion in a medical emergency — or brought up on federal charges if they abstain.
- A new law in California makes it easier for out-of-state doctors to receive reproductive health training there, a change that could benefit medical residents in the 18 states where it is effectively impossible to be trained to perform an abortion. But some doctors say they still fear breaking another state’s laws.
- Another study raises questions about the quality of care at hospitals purchased by private equity firms, an issue that has drawn the Biden administration’s attention. From the Journal of the American Medical Association, new findings show that those private equity-owned hospitals experienced a 25% increase in adverse patient events from three years before they were purchased to three years after.
- And “This Week in Medical Misinformation”: Robert F. Kennedy Jr. earned PolitiFact’s 2023 Lie of the Year designation for his “campaign of conspiracy theories.” The anti-vaccination message he espouses has been around a while, but the movement is gaining political traction — including in statehouses, where more candidates who share RFK Jr.’s views are winning elections.
Also this week, Rovner interviews Sandro Galea, dean of the Boston University School of Public Health, about how public health can regain the public’s trust.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Politico’s “Why Democrats Can’t Rely on Abortion Ballot Initiatives to Help Them Win,” by Alice Miranda Ollstein, Jessica Piper, and Madison Fernandez.
Lauren Weber: The Washington Post’s “Can the Exhausted, Angry People of Ottawa County Learn to Live Together?” by Greg Jaffe.
Victoria Knight: Politico’s “Georgia Offered Medicaid With a Work Requirement. Few Have Signed Up.” by Megan Messerly and Robert King.
Shefali Luthra: Stat News’ “Medical Marijuana Companies Are Using Pharma’s Sales Tactics With Little of the Same Scrutiny,” by Nicholas Florko.
Also mentioned in this week’s episode:
- Law Dork’s “ADF Is Providing Free Legal Representation to Idaho in Anti-Abortion, Anti-Trans Cases,” by Chris Geidner.
- JAMA Network Open’s “Barriers to Family Building Among Physicians and Medical Students,” by Zoe King, Qiang Zhang, Jane Liang, et al.
- The Journal of the American Medical Association’s “Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition,” by Sneha Kannan, Joseph Dov Bruch, and Zirui Song.
- KFF Health News’ “RFK Jr.’s Campaign of Conspiracy Theories Is PolitiFact’s 2023 Lie of the Year,” by Madison Czopek, PolitiFact, and Katie Sanders, PolitiFact.
click to open the transcript
Transcript: New Year, Same Abortion Debate
KFF Health News’ ‘What the Health?’Episode Title: New Year, Same Abortion DebateEpisode Number: 328Published: Jan. 4, 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, Happy New Year, 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, Jan. 4, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this, so here we go. Today we are joined via video conference by Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: Victoria Knight of Axios News.
Victoria Knight: Hey, everyone.
Rovner: And Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: An entire panel of KFF Health News alums. I’m pretty sure that is a first. Later in this episode, we’ll have my interview with Boston University School of Public Health dean Dr. Sandro Galea. He has a new and pretty provocative prescription for how public health can regain public trust. But first, there was plenty of news over the holiday break, in addition to my Michigan Wolverines going to the national championship — sorry, Lauren — plenty of health news, that is. So we shall get to it. We will start on Capitol Hill, where Congress is poised to come back into session — apparently no closer to a deal on the appropriations bills that keep the government open than they were when they left for Christmas, and now it’s only two weeks until the latest continuing resolution ends. Victoria, are we looking at a shutdown again?
Knight: I was texting a lot of people yesterday trying to feel out the vibes. I think a lot of people think a shutdown seems pretty likely. A reminder that we have another member of Congress that is leaving on the Republican side in the House, so now the Republicans can only lose two votes if they’re trying to pass a bill. So when you have House Freedom Caucus members saying, “Hey, we don’t want to agree to any appropriations bills without doing something about the border,” and Democrats unlikely to agree to any border demands that the Freedom Caucus is wanting, it seems like we may be at a standstill. I know there is some reporting this morning that possibly they may just do another fiscal year continuing resolution until …
Rovner: You mean like the last couple of years we’ve done a full-year CR?
Knight: Yeah, exactly. So …
Rovner: The thing they swore they wouldn’t do.
Knight: And [House] Speaker [Mike] Johnson said, he promised he wouldn’t do that, so it’ll be interesting to see how that all plays out. As far as I’ve heard the latest, there’s no top-line funding number, but it does seem like a shutdown may be looming.
Rovner: Well, assuming there is a spending deal at some point, and the fact that 2024 is an election year where not much gets passed, a lot of lawmakers have a lot of things they would like to attach to a moving spending train, assuming there is a moving spending train. What’s the outlook for the bill that we were talking about all of December on PBMs [pharmacy benefit managers] and health transparency and some extensions of some expiring programs That’s still kicking around, right?
Knight: Yeah. That’s definitely still kicking around. So there are some extenders like for community health centers and averting some cuts to safety-net hospitals. Those are really high priority for lawmakers. I think those will make their way onto any kind of deal most likely. What seems more up in the air is the transparency measures for PBMs and for hospitals and for insurers. That was the big, as you mentioned, the big pass the House in December. The Senate has introduced their own versions of the bill and there’s talk that maybe some of that could ride onto if there is some kind of funding deal, but it’s also possible that maybe it’s more likely to be punted to the lame duck session. So, post-election, when Republicans are trying in the House and Senate Democrats are trying to do their last hurrah before the new Congress comes in. So we’ll see. Latest I heard yesterday there were some negotiations around the transparency stuff, so it’s still possible, but who knows?
Rovner: Congress is the ultimate college student. They don’t do anything until they have a deadline. Meanwhile, we have yet another health program caught up in the culture wars, this time the Children’s Hospital Graduate Medical Education [Payment] program. Because most medical residencies are funded by Medicare and because Medicare doesn’t have a lot of patients in children’s hospitals, this program was created in 1999 to remedy that. Yes, I covered it at the time. Republicans in the House are happy to reauthorize it or just to fund it through the appropriations process, which keeps the money flowing, but only if it bans funding for children’s hospitals that don’t provide gender-affirming care for transgender minors. It appears that has killed the reauthorization bill that was moving for this year. Is that the kind of thing that could also threaten the HHS [Department of Health and Human Services] spending bill?
Knight: Yeah, I mean there are provisions within the HHS bill to ban Medicare, Medicaid paying for gender-affirming care. I don’t know. We haven’t done much debate on the Labor-HHS bill. It’s been the one that’s been put to the side. It hasn’t even gone through the full committee, so we haven’t …
Rovner: In the House, right?
Knight: Yeah, in the House, yes. Yeah. But yeah, I think it’s definitely possible. Just broader picture, this is an issue that Republicans are trying to make a bigger thing that they’re running on in different congressional districts, talking about banning gender-affirming care. So I think even if we don’t see it now, it’s probably something that we’re going to continue seeing.
Rovner: Well, we will obviously talk more as Congress comes back and tries to do things. So new year, same old abortion debate. This week’s big entry is a decision by a panel of the 5th Circuit Court of Appeals ruling that EMTALA, the federal law that requires hospitals to at least screen and provide stabilizing care to anyone who presents in their emergency room, does not supersede Texas’ abortion ban. In other words, if a pregnant woman needs an abortion to stabilize her condition, she’d also have to meet one of the exceptions in the Texas abortion ban. Given that we don’t really know what the Texas exceptions are, since we’ve had litigation on that, that could be a tall order, right, Shefali?
Luthra: Yes. Doctors have basically said that the Texas exceptions in the state law are unworkable. And I think it’s worth noting that what EMTALA would require and what is in effect in other states with abortion bans is again very narrow. We are talking about the smallest subset of abortions, the smallest subset of medical emergency abortions, because this doesn’t apply to someone with a fetal anomaly who cannot give birth to a viable child. This doesn’t apply to someone who maybe is undergoing chemotherapy and can’t stay pregnant. This is for people who have situations such as sepsis or preterm premature membrane rupture. These are really, really specific instances, and even then, Texas is arguing and the 5th Circuit says, hospitals don’t have to provide care that would by all accounts be lifesaving.
Rovner: This puts doctors, particularly in Texas, in an untenable situation where if a woman presents, say, with an ectopic pregnancy, which is neither going to produce a live baby and is likely or could definitely kill the woman, if they perform that abortion, they could be brought up on charges in Texas, but if they don’t perform the abortion, they could be brought up on federal charges.
Luthra: And this is the bind that doctors have found themselves in over and over again. And I do want to reiterate that this isn’t actually unique to Texas because even in states where the EMTALA guidance is in effect, doctors and hospitals remain very afraid of coming up against the very onerous abortion penalties that their laws have. I was talking to a physician from Tennessee earlier this week, and she made the point that what your doctor feels safe doing, it comes down to luck in a lot of ways. Which city you happen to live in, which hospital you happen to go to, what the lawyers on that hospital staff happen to think the law says. It’s really untenable for physicians, for hospitals, and more than anyone else for patients.
Rovner: Now, despite Justice [Samuel] Alito’s hope in his Dobbs opinion overturning Roe that the Supreme Court would no longer have to adjudicate this issue, that’s exactly what’s going to happen. There’s already an emergency petition at SCOTUS from Idaho wanting to reverse a 9th Circuit ruling, preventing them from enforcing their abortion ban over EMTALA. In other words, the 9th Circuit basically said, no, we’re going to put this Idaho ban on hold to the extent that it conflicts with EMTALA until it’s all the way through the courts. Not to mention the mifepristone case that could roll back availability of the abortion pill. Is it fair to say that Justice Alito’s reasoning backfired here, or was he being disingenuous when he … did he know this was going to come back to the court?
Luthra: Not one of us can see inside any individual justice’s heart or mind, but I think we can say that anyone who seriously thought that overturning Roe v. Wade, which had been in effect for almost 50 years, would bring up no legal questions to be answered again and again by the courts clearly hadn’t thought this through. I was talking to scholars this week who think that we’ll be spending the next decade answering through the courts all of the new questions that have been instigated by the decision.
Rovner: Yeah, that’s definitely not going to lower their workload. Well, speaking of Idaho, the “Law Dork” blog has an interesting story this week about how the Alliance Defending Freedom — it’s a self-identified Christian law firm that represents mostly anti-abortion and other conservative groups in court — is now providing free representation to the state of Idaho in its effort to keep its state abortion ban in place. ADF is also representing Idaho in a case about bathroom use by transgender people. Now, conservative organizations and states often work together on cases, as do liberal organizations in states, that is not rare. But in this case, ADF is actually representing the state, which poses all kinds of conflicts-of-interest questions, right? Lauren, you’re nodding.
Weber: Yeah, I mean it’s pretty wild to see this kind of overlap. As you pointed out, Julie, it’s not rare for attorney general’s offices to seek outside legal help, that happens all the time. They’re understaffed. There’s a lot of problems they can address. But to fully turn over a case essentially to an ideological group is something different altogether because it also implies that that group is giving a gift to the government. It implies that they may be able to take on more cases because if it’s for free, then who knows? And I want to point out that this group really is at the forefront of many of the battles that we’re seeing play out in health issues legally across the country. I mean, they’re involved in a lot of the gender-affirming care cases and even in dealing with some of the groups that are promoting some of the legislation in places across the country. So this is quite a novel step and something to definitely be on the lookout for as we pay attention to many court cases that are going to play out over the next couple of years.
Rovner: Yeah, this was something I hadn’t really focused on until I saw this story and I was like, “Oh, that is a little bit different from what we’ve seen.” Well, while we were on the subject of doctors and lawsuits and the 5th Circuit Court of Appeals, a panel there kept alive a case filed by three doctors against the FDA, charging that it overstepped its authority by recommending that doctors not prescribe ivermectin, an anti-parasite drug, for covid. We’ve talked a lot about how the mifepristone case could undermine FDA’s drug approval process. Obviously, if anyone can sue to effectively get a drug approval reversed, this case could basically stop the FDA from telling the public about evidence-based research, couldn’t it?
Weber: This case is quite wild. I mean, as someone that covers misinformation and disinformation and has extensively covered the ivermectin sagas over the last couple of years, the idea that the FDA cannot come out and say, “Look, this drug is not recommended,” it would be a severe restricting of its authority. I mean, government agencies are known to give advice, which does not always have to be neutral. Historically, that is what has been considered just the status quo legally. And so for the court to restrict the FDA’s authority in this way — if this does, it’s obviously still up for appeal, so who knows? But if it were to be successful, essentially everything the FDA ever put out would have to say, “But go talk to your physician,” which would lead to a little bit more of a wild, wild West when it comes to evidence-based medicine as we know it today.
Rovner: Back on the abortion beat, the news isn’t all about bans in California. The new year is bringing several new laws aimed at making abortion easier to access. Shefali, tell us about some of those.
Luthra: California is really interesting because they really position themselves as the antithesis of states banning abortion. And the law that you’re discussing here, Julie, this is part of a real concern that a lot of physicians have, which is that in states with abortion bans, it’ll be harder for medical residents to be trained in appropriate health care. That means providing abortion care. It means providing comprehensive OB-GYN care in general, right? Miscarriage management, you learn how to do that in part by providing abortions. California has implemented a law this year that would try to help more out-of-state doctors come to California to get trained in how to provide this kind of care.
I think where this gets tricky and where doctors I’ve spoken to remain concerned, confused, it’s not a panacea, is the concern about whether any single state in and of itself can do enough to rectify what is happening in 18 states across the country. That’s a very, very tall order, and it comes with other concerns of: Will residents feel safe, able to come to California? Will their institutions want to send them? These are all open questions, and I think this California law, this project that they’re taking on, is incredibly interesting. I think it’ll take some time for us to see both what the impact is and what the kinks and challenges are that emerge along the way.
Rovner: I was also interested in a California law that says that California officials don’t have to cooperate with out-of-state investigations into doctors prescribing abortion pills or gender-affirming care.
Luthra: This is, again, really interesting, and I mean, I think what we are going to see is individual state laws continuing to run up against each other and questions over whose authority applies in what situations. This has come up for doctors constantly, right? The ones who live in states with abortion protections but want to provide care in other states. What happens if they are flying across the country and have a layover in a state with an abortion ban? What happens if they have a medical emergency in a state that they have maybe broken the law of, whose law applies there? These are things that have left a lot of doctors really concerned. I know I’ve spoken to physicians who say that even despite the legal protections in their states, in a state like California for instance, they still don’t feel safe actively breaking another state’s laws. And again, this is just one of those questions we’re going to keep watching and seeing play out. Who ultimately is able to decide what happens and what role would the federal government eventually have to play?
Rovner: I think these were things, these were the kinds of questions that I don’t think the Supreme Court really considered when they overturned Roe. There’s so many ramifications that we just didn’t expect. I mean, there were some that we did, but this seems to be an extent that it’s gone to that was not anticipated.
Luthra: It’s just a whole mess of, if not undesired, then perhaps unanticipated or not fully planned-for questions and concerns that are now emerging.
Rovner: So I wanted to call out a survey in the Journal of the American Medical Association about reproduction more broadly, not about abortion. How hard it is for medical students and young doctors to build families early in their careers — a time when most people are building their families. Medical training takes so long in many cases that women, in particular, may find it much more difficult or impossible to get pregnant if they wait until after their training is done. And the pace of medical care delivery and the patriarchal structure of most medical practice frowns on women doing things like getting pregnant and having babies and trying to raise children. I vividly remember a doctor retreat I spoke at in 2004 when a 30-something OB-GYN said that when she got pregnant, her residency adviser accused her of wasting a residency spot that could have gone to someone who wasn’t going to take time out of their career. I think things have progressed since then, but apparently not all that much, according to this survey.
Luthra: And this, I think, is really interesting because especially after the covid pandemic, we saw obviously, health care workers leave the field in droves. We saw more women leave the field than men. And what that spoke to was, in part, that working through covid was really taxing. Women were more often in positions that were on the front lines, but what it also spoke to is that the culture of medicine has long been very unfriendly toward the family-building burdens that often fall on women, and that hasn’t gotten better. If anything, it’s gotten worse because child care is even harder to come by. Moms, in particular, have way more to juggle and to balance than they once did. And the support, it’s not even fair to say it hasn’t caught up. It was never there to begin with.
Weber: And just to add on that, I mean, I find it — that study is great, and I will say I have family members that struggle with this currently. It’s wild to me that the American Academy of Pediatrics recommends a 12-week parental leave, and you possibly couldn’t finish your residency or qualify for a surgery residency if you take more than six weeks. I mean, I think that, in itself, that factoid really says exactly what Shefali was getting at. The culture of medicine is not at all friendly to folks that are considering this whatsoever.
Rovner: There’s so many women in medicine now. Now it’s making a problem not just for the women in medicine, but for everybody who wants medical care. So maybe that will get some attention paid to it. Moving on to “This Week in Private Equity,” we have another study from the Journal of the American Medical Association. It found that hospitals that were bought by private equity firms had a 25% increase in adverse events in the three years following their acquisition. Adverse events include things like falls, hospital-acquired infections, and other harm that, in theory, could or should have been prevented. It’s not really hard to connect the dots here, right? Private equity wants to raise more money, and that tends to want to cut staff, so bad things happen. I see you nodding, Victoria.
Knight: Yeah, I mean, I think this is an ongoing issue. It’s something that the Biden administration has said they want to look into, just decreasing quality of care in places that are taken over by private equity. I’m not sure there’s a really good solution to it at this point in time. And I think it also speaks to the broader issues of consolidation among the health care industry and the business of health care and what that means in regards to quality for patients. But yeah, I think this study is just another piece in building up a case of why sometimes private equity doesn’t always seem to equate to the best care for patients.
Luthra: If we go back in time a little bit, there is more evidence that shows the role that private equity has played in not only reduction in quality of care, but in the opposition between the health care industry and consumers. And the example I’m thinking of is air ambulances and surprise billing by those ER staffing firms, all of which were eventually owned by private equity firms that have their own set of incentives that is at odds with the goal of providing care that people can afford and can access, and that keeps them healthy.
Rovner: Indeed. Well, following “This Week in Private Equity,” we have “This Week in Health Misinformation.” My winner this week is Robert F. Kennedy Jr., who was awarded the “Lie of the Year” from PolitiFact for not just his repeated and repeatedly debunked claims about vaccines, but other fanciful conspiracy theories about covid-19, mass shootings, and the rise in gender dysphoria. I will post the link so I don’t have to repeat all of those things here. Which brings us to the story I asked Lauren here to talk about, how the anti-vax movement is quietly gaining a foothold in state houses. Lauren, tell us what you found.
Weber: Well, I found that it’s becoming very politically advantageous, to some extent. Political clout around anti-vaccine movement is growing. So you’re seeing more and more state legislators get elected that have anti-vaccine or vaccine-skeptical views. And I went down to Baton Rouge and 29 folks that were supported by Stanford Health Freedom, which is against vaccine mandates, got elected in this year’s off-cycle elections. So who knows what will happen next year, but you’re already seeing this reflected in other states. In Iowa, legislators this year stopped the requirement that you can talk about the HPV vaccines in schools. In Tennessee, home-schooled kids no longer have vaccine requirements. In Florida, they banned any possible requiring of covid vaccines, which experts said they worry if you just strike “covid” from that, that could lead to the banning of other requirements for vaccines. You’re seeing this momentum grow, and as you mentioned, Julie, RFK Jr. has played a role in this.
As I talk about in my story, back in 2021, he went down to Louisiana and really riled up some anti-vaccine fever in a legislative hearing about the covid vaccine. And so it’s a combination of things. People are reacting to a lot of misinformation that was spread during covid about the covid vaccine. And that distrust of the covid vaccine is seeping into childhood vaccinations. I mean, this year we saw data that came out that said in the 2022-2023 school year, we saw the highest rate of exemption rates for kindergartners getting their vaccinations. That’s a bad trend for the United States when it comes to herd immunity to protect against things like measles or other preventable diseases. So we will see how the next year plays out legislatively, but as it stands right now, I expect to see much more anti-vaccine movement in the statehouses in 2024.
Rovner: I’ve been covering the anti-vax movement for, I don’t know, 25, 30 years. There’s always been an anti-vax movement. It’s actually this combination of people on the far left and people on the far right, they tend to both be anti-vax, but I think this is the first time we’ve really seen it come into actual legislating way. In fact, the trend over the last couple of years has been to get rid of things like religious exemptions for families getting their children vaccinated in order to attend public school. So now we’re expecting to see the reverse, right?
Weber: Yeah, as you said, this is a horseshoe political issue that it’s been far left, far right, but now it’s really seeped into the far-right conservative consciousness in a way that has become a political advantage for some candidates. And so you’re seeing stuff that would previously be, not even make it to the floor for a vote, have to be vetoed, make it out of a committee, where previously some of these things would’ve looked at the signs and said, this is just not true. Now there’s more political power behind the ideology of some of these anti-mandate freedom pushes. So it’s really going to be something to track in this upcoming year.
Rovner: I think the other trend we’re seeing is actual health officials talking about these kinds of things, led by the Florida Surgeon General, Dr. [Joseph] Ladapo. He’s now moved on beyond recommending that young men not get the covid vaccine, right?
Weber: Yeah. So yesterday he sent out a health bulletin, and I just want to take a step back to say this is incredibly unprecedented because this is a state health officer sending out a bulletin to the state saying that he does not recommend anyone … he wants to halt the use of mRNA covid vaccinations. Now, that is not a position that any other state health officer has taken. It’s not a position that any national health agency has taken. He made it based on claims that have been debunked. He primarily based it on a study that several of the experts I talked to said it is not one that they would base assumptions on.
His claims were implausible, but needless to say, I mean, he’s the health director for the third-largest state in the union. I mean, his words carry weight, and his political patron is Ron DeSantis. Now, DeSantis has not commented publicly yet on this, but oftentimes it seems that they both have worked hand in hand to fight against vaccine mandates and to cause a ruckus around things like this. So it needs to be seen the politicization of this as this continues to play out.
Rovner: Well, that is a wonderful segue into our interview this week with Dr. Sandro Galea about the future of public health. So we will play that now and then we will come back and do our extra credits.
I am pleased to welcome to the podcast Dr. Sandro Galea, dean of the Boston University School of Public Health. Longtime listeners will know I’ve been concerned about the state of public health since even before the pandemic. Dr. Galea has a new book of essays called “Within Reason: A Liberal Public Health for an Illiberal Time” that takes a pretty provocative look at what’s gone wrong for public health and how it might win back the support of the actual public. Dr. Galea, thank you so much for joining us.
Sandro Galea: Thank you for having me.
Rovner: So I want to start with your diagnosis of what it is that ails public health in 2024.
Galea: Well, I suppose I start from the data, and the data show that there is a tremendous loss of trust in science broadly, in public health more specifically. Data from Pew that came out just a few months ago show, really, a 25-point drop in trust in medicine and in health from before the pandemic. So the question becomes why is that? What’s going on? And what I try to do in the book is to identify a number of things that I think have really hurt us, and I could numerate those. No. 1, it is we took a very narrow approach to our perception of what should have been done without leaving space for a plurality of voices that weigh different inputs differently.
No. 2, that through the mediation of social media as a way of extending our voice, we were perhaps inhabited false certitude much more than we ever meant to or much more than we do when we think about our science. And No. 3, we allowed ourselves to become politicized in a way that’s unhealthy. Perhaps partisanized is an even better term because public health is always political, but we allowed ourselves to become blue versus red, and that doesn’t serve anybody because public health should be there to serve the whole public. And I think those three big buckets, obviously in the book I write about them in much more detail, but I think they capture the fundamental problems that then have resulted in this loss of trust we face right now.
Rovner: So I’ve had experts note that the lack of public trust in public health isn’t necessarily because of anything the public health community has done. It’s because of a broader pushback against elites and people in power of all kinds. Do you think that’s the case, or has public health also contributed to its own, I won’t say downfall, but lack of status?
Galea: I feel like the answer to that is “and,” meaning that, yes, there’s no question that there are forces that have tried to undermine public health, forces that tried to undermine science. And in the book, I’m very clear that I do realize there are outside forces that have had mal intent, that they have not acted in good faith and they have tried to undermine public health and science, but that’s not what the book is about. I say that is there, I recognize it’s there, but I wanted to write about public health from within public health. It would be shortsighted of us not to realize that we are contributing to how public perceives us. In many respects, I feel like we should have the agency and the confidence to say, well, there are things that we are doing that we should look at. And now, after the acute phase of the pandemic, is the time to look at that.
I was clear in my other writing that I did not write this book in 2021 or 2022 intentionally, because it was too close. But I feel like now that we’re over the acute phase of the pandemic, now is the time to ask hard questions and to say, “What should we be learning?” And I do that in the book, very much looking forward. I’m not naming names, I’m not pointing fingers. All I’m simply saying is we now have the benefit of time passing. Let us see what we should have done better so we can learn how to be better in future.
Rovner: One of the things I think that frustrated me as a journalist, as somebody who communicates to a lay audience for a living, is that public health and science in general during the pandemic seemed unable to say that yes, as we learn more, we’re going to change what we recommend. It becomes, to the public, well, they said this and now they’re saying that, so they were wrong. Does public health need to show its work more?
Galea: This is the term that I use, which is false certitude, which is that we conveyed confidence when we should not have conveyed confidence. Now, there are many reasons for that. Things were happening quickly. It was a fast-moving pandemic. Everybody was scared. And, also, our communication was mediated through social media, which was a new medium for communication of public health. And that does not leave space for the asterisk, for the caveat. And I think our mistake was not recognizing how much harm it was going to do and not being upfront about this is what we know today, but tomorrow we may know more, and we may then have to change our recommendations. And as one pauses and thinks about how should we do better, surely this is front and center to learn how to communicate by saying, “Today, based on what we know, this is what we think is best, but we reserve the right to come back tomorrow and be clear, tell you that the data have changed, hence the recommendations have changed.”
Rovner: Do you think public health has been slow to embrace things like social media? I mean, there are organizations on social media. I think one that comes to mind is the Consumer Product Safety Commission, the National Park Service. I mean that they’re very cheeky, but they get out really important information in a very quick and understandable way. Is that something that public health needs to be doing better?
Galea: Perhaps. I’m not sure I’m willing to say that public health is any worse than the National Park Service on social media. I think we are all, as a society, struggling with communicating important facts rapidly in a time of crisis. One analogy, which I use in the book, is the analogy to 9/11, meaning in 9/11, it was the first national crisis that was lived through in a time of 24/7 cable news. And as a result, there was a lot of noise on cable news that was happening that was distorting how we dealt with the event. Similarly, covid-19 was the first national crisis that was lived through the lens of social media, and we did not really know how to use it. So, at the same time as I’m labeling this as a real challenge that public health faced, I’m also trying to understand and have the compassion to realize that in public health we were struggling to learn how to do this as everybody else was.
Rovner: So let’s turn to the future. What should public health do first to try and regain some of the trust that it’s lost?
Galea: Well, I suppose first we should be having this conversation, and I’m grateful to you for having a conversation, but I actually mean that, at a large scale, I actually think that I meant my book to be a place marker. And I say in it clearly, I expect people will disagree with elements of the book, and that’s OK. And I hope that the book encourages others to write their books that talks about the things, how they see it. Because I do think that this conversation should open up space for public health to say, what are the things that we didn’t do well? What are the things that we should do better? Because from that is going to emerge a new consensus about how we should act.
If the only thing that emerges is simply this, what you and I just talked about, which is communicating with due humility, recognizing the complexity of rapidly evolving facts, and being clear with the population that things may change. If that’s the only thing that emerges, we’ve already made progress. So I think the first thing that should happen is having the conversation, opening this up, being honest that there are things that public health did that it should do better. That is going to lead us to a new consensus about how we should do better.
Rovner: And beyond the conversation, is there one thing that you wish that policymakers could do that could help public health regain its prominence and its trust? I mean, there really is no other word here.
Galea: I think the one thing that I would want to see in policy is a moving away from abolishing of the notion that we can “follow the science.” One of my least favorite things that happened during the pandemic was this notion that we could “follow the science.” Now, why do I say that? I’m a scientist! But I say that because “follow the science” implies that science leads to linear answers, to linear solutions. And that phrase, “follow the science,” became a fig leaf for policymakers, saying, “Well, the science says we should do X, therefore we’re going to do X.” That is simply false. Policymaking should rest on multiple inputs, science being one of them, but also values, but also the importance of other sectors of the economy.
And I would like us to see as a society being honest about that, that policymaking shouldn’t take science into account centrally. I agree with that. As I said, it’s my bread and butter, it’s what I do. But to pretend that science has the answer is simply wrong. We elect people in elected positions, and there are people who are appointed in decision-making positions in other circumstances. It is their job to weigh all the inputs, science being one of those inputs.
Rovner: Well, Dr. Galea, thank you so much. I will do my part to keep the conversation going. I’m sure you will do yours as well.
Galea: I will. And thank you for doing the part you’re doing.
Rovner: OK. We are back and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week?
Luthra: Sure. My story is from Stat by Nicholas Florko. The headline is “Medical Marijuana Companies Are Using Pharma’s Sales Tactics With Little of the Same Scrutiny.” And I think this is such a smart investigation, and I’m so grateful that Nicholas wrote it. It really gets into the fact that medical marijuana is a tremendous industry now, right? It’s not just in the Colorados or the Californias or Massachusetts that you think of. It’s all over the country and it’s a huge business. And because it’s so new, it hasn’t gotten the same scrutiny in terms of how it markets its products to consumers, the relationship it has with providers, et cetera. I think this is just a really important topic, and it’s something that we should all be paying attention to as the industry continues to grow in the coming years.
Rovner: Indeed. Victoria?
Knight: Yeah. So my extra credit this week is a Politico story by Megan Messerly and Robert King titled “Georgia Offered Medicaid With a Work Requirement. Few Have Signed Up.” And so it’s talking about just the rollout of Georgia implementing a work requirement for their Medicaid program, which they did expand Medicaid, but they included a work requirement. So I thought this was just really stunning. It said through the first four months, only 1,800 people have enrolled when the governor, Brian Kemp, expected 31,000 people to sign up.
Rovner: Contrast that with North Carolina, which expanded Medicaid without the work requirement and got, like, 200,000 people to sign up.
Knight: Yeah. So that’s just a stunning number. And they’re talking about in the story there. They’re not sure why all the reasons are, but part of it is that there is a lot of paperwork involved. And so I think it was just a really interesting example. Obviously, we have seen work requirements play out before, but we haven’t seen it in a while. And so it’s interesting to see how difficult it can be for people to access Medicaid if this is put in place. And I also think it’s important to remind people that last year, in 2023, during the debt ceiling debate, Republicans did for a while talk about wanting to implement work requirements in Medicaid again. And so, if this was something that they put into place, it would mean probably a lot of people would drop off the rolls. So it’s an idea that resurfaces. So just important to remember that.
Rovner: Indeed. Lauren.
Weber: I was obsessed with Greg Jaffe story from The Washington Post titled “Can the Exhausted, Angry People of Ottawa County Learn to Live Together?” And it’s this incredible portrait of this Michigan county where the county public health officer, Adeline Hambley, has come under tremendous pressure and threat from the conservative county board. And this is a story we have seen play out in different iterations all around the country in the wake of covid. It’s the “we don’t believe in masks, we don’t believe in shutdowns” versus the county public health folks who are trying to follow the science and how does that play out at a people level, which Greg just does a fantastic way of showing. And it’s interesting, the board was so fed up with her and making such political statements that they offered her $4 million to quit. Now this fell apart because the county doesn’t seem to have the money that would affect them, et cetera.
But it just goes to show how deep the divisions are between what used to be a very non-politicized, normal government job of being a public health officer who keeps your water safe and tries to keep you from catching bad diseases at restaurants, to the post-covid era, where [they’re] just absolutely vilified and hated, really, it seems in some of these comments in the story — so much so that they would be paid this much money to quit. So I think this speaks a lot to the tension that we see in America around public health today, and I really recommend everybody to give it a read.
Rovner: Yeah, it’s a really remarkable story. Well, my extra credit this week is from our podcast pal Alice [Miranda] Ollstein, along with her colleagues Jessica Piper and Madison Fernandez at Politico. It’s called Why Democrats Can’t Rely on Abortion Ballot Initiatives to Help Them Win.” And it’s a warning for Democrats not to get too smug about the popularity and success of abortion rights ballot measures around the country. They dug into the numbers and found that in many of those states, the very same voters who supported the abortion rights measures also turned around and voted for Republican candidates. As usual, in politics, things are rarely as simple as they seem.
All right, that is our show for this first week of 2024. 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, my fellow Wolverine, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Shefali, where are you these days?
Luthra: I am @shefalil on X and Blue Sky, and then on Threads, I’m @shefali.luthra.
Rovner: Victoria.
Knight: I’m @victoriaregisk on X and Threads.
Luthra: Lauren.
Weber: And then I’m @LaurenWeberHP on X and clearly still need to work on my social media game.
Rovner: We will be back in your feed next week. Until then, be healthy.
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