The Supreme Court this week agreed to hear a case that could further restrict abortion — even in states where it remains legal. The case to determine the fate of the abortion pill mifepristone is the first major abortion case to come before the court since its overturn of Roe v. Wade in 2022. It could also set a precedent for judges to second-guess scientific rulings by the FDA.

Meanwhile, legislation is finally moving in the House and Senate to renew a long list of health programs that technically expired at the end of the last fiscal year, on Sept. 30. But the bills to fund community health centers and build on programs to fight the opioid epidemic are unlikely to become law until January, at the soonest.

This week’s panelists are Julie Rovner of KFF Health News, Riley Griffin of Bloomberg News, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists

Among the takeaways from this week’s episode:

• The Supreme Court will consider a case challenging access to mifepristone, opting to review FDA decisions in recent years governing the loosening some requirements for distribution and use of the so-called abortion pill — such as the agency’s call allowing pregnant people to obtain the drug without a doctor’s visit. While the drug’s overall approval is not in question in this case, the drug industry argues undermining the FDA’s authority could open the floodgates for challenges to other pharmaceuticals and have a chilling effect on drug development.
• Legal experts say the Texas high court’s ruling blocking the abortion of a pregnant woman whose fetus has a fatal condition calls into question whether doctors are able to identify any medically necessary circumstance under existing legal exceptions. And, in other court news, the Supreme Court will let stand a Washington state law banning conversion therapy.
• On Capitol Hill, lawmakers are bundling an assortment of bipartisan, generally unrelated health measures so they can be approved, possibly as part of a government spending package in January. But can this Congress — which has proved unproductive even by recent standards — finish its work in a presidential election year?
• One piece of legislation under consideration would address the opioid epidemic, renewing grants for state efforts to prevent and treat opioid use disorder. The epidemic has taken a toll, but it is not the only problem contributing to a troubling drop in U.S. life expectancy.
• And cyberattacks are on the upswing in health care, with new revelations about an attack that targeted the Department of Health and Human Services at the onset of the pandemic.

Also this week, Rovner interviews University of Maryland professor and social media superstar Jen Golbeck about her new book, “The Purest Bond,” which lays out the science of the human-canine relationship.

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

Julie Rovner: The Washington Post’s “They Watched Their Husbands Win the Heisman — Then Lost Them to CTE,” by Kent Babb.

Alice Miranda Ollstein: Politico’s “A Deadly Delivery Highlights ‘Falsified’ Heat Records at USPS,” by Ariel Wittenberg.

Lauren Weber: The Washington Post’s “Applesauce Lead Cases in Kids Surge Amid Questions on FDA Oversight,” by Amanda Morris, Teddy Amenabar, Laura Reiley, and Jenna Portnoy.

Riley Griffin: Bloomberg News’ “The Next Blockbuster Drug Might Be Made in Space,” by Robert Langreth.

Also mentioned in this week’s episode:

• The American Prospect’s “The Life-and-Death Cost of Conservative Power,” by Paul Starr.
• Bloomberg Businessweek’s “The Untold Story of a Massive Hack at HHS in Covid’s Early Days,” by Jordan Robertson and Riley Griffin.

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Judgments against patients in these suits can derail someone’s life but, according to experts, they don’t bring hospitals much money.

So why do hospitals do it?

Host Dan Weissmann investigates this practice with The Baltimore Banner and Scripps News and speaks to patients who’ve found themselves on the receiving end of such lawsuits.

Weissmann also speaks with Nick McLaughlin, an entrepreneur who’s making the business case for hospitals to stop trying to collect money from people who simply don’t have it.

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Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

[birds singing]

Dan: Hey there. Starting this episode with a field trip.

[dogs barking]

Dan (from field tape): I hear dogs. I’m in the right place.

Dan: Nick McLaughlin lives outside Kalamazoo, Michigan. The email with his address said: Long gravel driveway, blue house. He’d said he’d be outside with his dogs, enjoying a cup of coffee. This is a big lot, with a pond on one side, a lake on the other, and huge trees all around.

Nick: So yeah, when I said I was sitting out enjoying a cup of coffee, this is a pretty good spot to do it. Pretty cool bird action. We had some neat, red headed woodpeckers going this morning.

Dan: He’s lived in the area since he was in high school. His parents still live nearby. So do his in laws. He’s married to his high school sweetheart — they got married while they were still in college. That’s also when Nick started working in medical collections.

Nick: I just saw a part time job listing in the college job website for a patient financial counselor. Didn’t know what that meant. Uh, and next thing I knew I had a, uh, headset on and was talking to patients about two and three year old hospital bills that they had. And my parents about disowned me. My mom’s a nurse, uh, and my dad’s a PhD environmental scientist. And so, um, Their line was, what are you doing calling sick people asking for money?

Dan: He says they came around. After a couple of years, he quit the call center and ended up in sales for a company called AmeriCollect. As the name suggests, they’re a collection agency. Specifically, medical-bill collections. Hospitals and medical groups are their clients. Nick started as Americollect’s first sales rep in Michigan, then after a year or so, branched out.

Nick: It was Michigan, Indiana. Ohio. Pennsylvania, and then North Carolina and, then we’re just kinda all over.

Dan: You were really good at this. 

Nick: I was good at this.

Dan: Nick spent a decade at AmeriCollect. The company’s slogan was, is — and I swear this is true: “ridiculously nice.” It’s on their website — and Nick says it was part of their pitch to clients.

Nick: The pitch was, we’re going to be more effective in connecting with your people, maintaining your reputation, with them and your community, and, oh, by the way, we’re also effective at recovering the dollars that are owed to you, uh, by being ridiculously nice, was the line.

Dan: I’ve come to Nick for insights on one of the most ridiculously nasty parts of American health care: Because some hospitals and medical providers don’t just send bill collectors — nice or otherwise– after patients. Some hospitals sue their patients over unpaid bills — filing lawsuits by the hundreds, or even thousands, every year. And here’s a twist: These lawsuits don’t bring hospitals much money. So why do they do it? I’ve been interested in this question for years. And this year, I’ve had a lot of help chasing it, working with amazing journalists from two incredible news outlets. We had some ideas when we started — hypotheses, that we tested together. And those hypotheses… they were wrong. But we discovered something along the way that, well, no one else seems to have discovered yet. And for once, it’s actually not-bad news. Surprisingly hopeful. Of course we also learned things that made me super-mad… and the whole inquiry absolutely made clear some ways we can all look out for ourselves and each other. It’s a bunch. So we’re bringing it to you in a two-parter. Strap in.

With Scripps News and the Baltimore Banner, this is “An Arm and a Leg” — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful. Before we get into big trends, numbers, all that– let’s start with just one family’s story.

Casey and Ron Gasior live in South Milwaukee. Our summer intern, Bella Czakowski, met them there in August.

Bella Czajkowski: Hi, Bella, nice to meet you. My husband, Ron.

Dan: Casey and Ron met in a bar almost 20 years ago. He was working there, and

then so was she. They were close– as friends.

Ron: A lot of people thought that we were together because we were so close.

Casey: But we never had anything to do with each other and that’s a sore subject. On his part. Because …

Bella: Because you were interested back then?

Ron: Yes. Yeah. Who knows, I mean, if we would have been together back then, it might not have lasted. She was young, I was older, but I still …I didn’t have my stuff together, you know. Whatever.

Dan: They married other people, drifted apart, and reconnected as friends years later –by which time both marriages were in trouble. Casey and Ron both got divorces, then got together, then bought this house eight months later. They got married in 2017. And then came the wave — waves– of medical issues.

Casey: His back, his knee, my heart.

Dan: Atrial fibrillation. That’s three procedures between them. And time off work to recover, less income. Another two procedures for Casey– carpal tunnel– more time away from work.

Casey: And at that time, too, I was also diagnosed with diabetes. So there was, there was a lot.

Dan: And there were lots of bills. They had insurance, but there’s always “Your portion.” It adds up. Plus Casey’s meds for diabetes and a-fib.

Casey: we would dig little bit out of our hole, and then we’d go right back down. And it to the where we we can’t even pay these

Dan: And then they started falling behind on house payments too.

Casey: There was a few nights in the garage, trying to figure out what our next step was.

Dan: In the garage, where Ron’s teenage daughter couldn’t hear.

Casey: We tried to do all of this without our daughter knowing, you know, cause

you don’t want to stress a kid out.

Dan: They decided the best of their bad options was Chapter 13 bankruptcy: Wrapping all their debts into a giant five-year payment plan. It would let them keep the house and their cars, if they were able to make the payments. It was really tough. The pandemic didn’t help. But in the spring of 2023, they were a couple months away from getting discharged, when they got a letter from a law firm– looking to collect money on a medical bill. It said…

Casey: That I needed to call them to make payment arrangements by a certain date Ron: Well, not to make arrangements. They wanted to payments. To make payments.

Casey: By a certain date. Otherwise, we’d be going to court.

Dan: The bill was three thousand dollars– for a medical procedure that happened before the bankruptcy. But the bill had come after. They say they called the lawyer, explained: Until we’re discharged from bankruptcy — which we will be soon — we’re actually not allowed to pay you. According to Casey and Ron, the lawyer was rude and said, essentially: See you in court. When they did, Casey says, the judge told the lawyer on the other side: These folks aren’t allowed to pay you anything until their bankruptcy is done. And told the Gasiors: When you’re discharged, do make arrangements to pay. So that’s one story– a lawsuit against folks who literally weren’t allowed to pay.

And every story is gonna be different, but the big picture: Lawsuits filed against people who — even without a court order — just couldn’t pay — that’s not a one-off. Lots of folks — reporters, researchers, advocates — have been documenting this phenomenon — hospitals suing patients by the hundreds or even thousands– for a long time. For instance, in Maryland, a study from 2020 found a hundred and forty thousand lawsuits that hospitals had filed against patients over a ten-year period. In New York, a series of reports looked at more than 50,000 lawsuits over just five years. 

Elisabeth Benjamin co-wrote those New York reports. She’s the vice president for health initiatives at the Community Service Society of New York. And one of the findings that shocked her was: how small the amounts were that folks were being sued for– like, compared to a hospital’s bottom line. Or even compared to an average hospital bill.

Elisabeth Benjamin: They’re suing people for pennies. right. The average lawsuit is maybe 1900 bucks. So they’re suing them for chump change, but that $1,900 is like life ruining for the patient.

Dan: Because the people getting sued tend to be people who are just getting by– if they’re even getting by. Elisabeth Benjamin found: People whose wages get garnished to pay medical debts tend to work for low-wage employers. And our colleagues at the Baltimore Banner found that in Maryland, people who get sued over medical bills tend to live in census tracts where poverty is high. Elisabeth Benjamin turned up another finding that surprised her: The hospitals filing the most lawsuits were not always the kinds of places that were hard-up for money. And lots of hospitals that were hard up for money weren’t filing any lawsuits.

Elisabeth Benjamin: In other words, there’s many hospitals that are either making it or not making it, but are not suing people. At least in New York, most hospitals are good guys. I mean, they wouldn’t dream of suing people. And then there’s like this cruddy, top 20, top 15 that are responsible for huge amounts of the lawsuits. And it doesn’t seem like the amounts they’re suing for really has any bearing on any hospitals bottom line. So then it begs the question of, well, what are they doing this for in the first place?

Dan: That’s basically the question I started with. What are they doing this for in the first place? And I just want to underline one of Elisabeth Benjamin’s findings: not all hospitals do this– file lawsuits in bulk. Most hospitals don’t. Other studies have found the same thing. So, it’s not a necessity. It’s a choice. And for the majority of hospitals, it’s a choice that seems to run counter to a pretty important fact: They’re organized as non-profit charities. They pay no taxes, and they give donors big tax write-offs. And they’re legally obligated to provide charity care: To have policies saying how they’ll write off bills for folks who can’t pay. 

I mean, even for-profit hospitals tend to have policies like that, without a legal obligation. So, suing people in bulk, … it’s an interesting choice. I wanted to talk with people who were part of the conversations where hospitals give the order: This is how we’re going to collect. And I got to talk with a couple of those people. One of them was Nick McLaughlin. Because Nick says, when a hospital sues patients– especially if they’re filing lawsuits in bulk, by the hundreds or thousands– a lot of the time, they’re not sending a staff attorney, or even picking a lawyer directly. The collection agency handles all that. But as Nick tells me: the strategy, the question of whether or not to sue, how hard to chase people– that all comes from the client, someone like the hospital’s revenue director.

Nick: We had clients at AmeriCollect where, they’d say, collect on it for six months and afterwards cancel it back.

Dan: Cancel it back. Meaning, cancel the assignment. Just don’t even bother trying to collect after six months. We’ll write it off.

Nick: And we’d say, you sure? Six months isn’t very long. And they’d say, “That’s what we want.” it’s more standard to be, two years.

Dan: What’s the recovery like in those intervening 18 months? Like how much more you get?

Nick: Not a ton.

Dan: Because — and this was the part that stuck with me the most– by the time a bill gets sent to a collection agency, it’s unlikely to actually be collected. When Nick was pitching AmeriCollect’s services, the pitch wasn’t, “We collect more than anybody else.” Because: that wasn’t a relevant pitch.

Nick: You’re normally not really gonna move the needle much from one collection agency to another. Meaning one collection agency might collect 10 percent, the next collection agency might collect 12 percent.

Dan: That’s a difference of two percent– but two percent of WHAT? Two percent of what’s already a very narrow slice of hospitals’ income.

I talked with an analyst for a consulting company called Kodiak– they run the numbers on this kind of thing. He said hospitals get about 90 percent of their money from insurance. By the time they send us bills, hospitals have already got 90 percent of their money. And then: a lot of people are able to pay their bills before getting sent to collections. Nick says maybe five or six percent of hospital bills– in dollars– get sent to collections at all. And Nick says, when you’re looking for someone to chase folks for that five or six percent, the difference between one agency and another is… not much.

Nick: One agency is collecting 10 percent of 5 percent and one agency is collecting 12 percent of 5%. We’re talking about a difference of, fractions of a fraction of a percent.

Dan: And even if ALL of the difference — the fractions of a fraction of a percent — is because you went hard after people, took them to court… it really looks like peanuts. 

This lines up with what journalists and advocates have documented in their reports: They compare the total, aggregate amounts hospitals are suing for, and compare it to the institution’s annual surplus. Or pay for top executives. The amounts their suing for– total– always look tiny in comparison. So the decision to do something like sue people in bulk, it doesn’t seem to Nick like it’s based on numbers. In fact, here’s where the mystery gets deeper. Because: You may have noticed, Nick’s been talking about Americollect in the past tense. He doesn’t work there anymore. These days he runs his own business, pitching his old clients — and any other hospital system he can get to listen — on a completely different approach: No matter how ridiculously nice your collections agents may be, he tells them, you should be sending them a lot less business. You’d be better off forgiving those debts, through charity care, before ever sending the first bill. He’s pitching tech to help hospitals do that. And he’s not telling hospitals, you should do this to be nice. He’s telling them: this is better for your bottom line. How he got there, and the pitch he makes now– that’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News– that’s a nonprofit newsroom covering health care in America. They are amazing journalists, and I learn from them all. The. Time. We’ll have a little more information about KFF Health News at the end of this episode.

This part of Nick’s story starts at a family holiday gathering in 2019. And a conversation with his wife’s grandfather, who was 86 at the time.

Nick: He and grandma were on social security and not a whole lot of extra resources. Pretty much your, standard salt of the earth, awesome people that serve everybody else and don’t have a ton. But are just fine with that.

Dan: But now grandpa had a 750 dollar hospital bill. Not so fine.

Nick: He said, Hey Nick, I know you know a lot about hospital bills. That’s a lot of money for an old guy like me. Do you know if there are any options ? And I said, Well, sure, Grandpa.Have you ever, looked into financial assistance? And he looked at me and said, What’s that?

Dan: Financial assistance — also known as charity care — is when a hospital agrees to reduce your bill, or just write it off, because you don’t make enough money to pay it.

And Nick knew all about charity care because since he’d started working at Americollect, having a charity care policy had become a legal obligation for nonprofit hospitals — which is to say, the majority of American hospitals — thanks to a provision in the Affordable Care Act.

Nick’s company, AmeriCollect, had kept on top of that new law, and he says they helped hospitals make sure they were complying with it.

Nick: We put together policy templates and sample financial assistance policies and application forms

Dan: He says it was, in its way, a long-game sales strategy. If you develop a reputation among hospitals as someone who’s trustworthy and helpful and smart, then next time they need a new bill collector, they’ll keep you in mind. Anyway, when Nick’s grandpa said, “What’s financial assistance?” Nick was ready to go.

Nick: I said, let’s see if you qualify um, so I pulled up, the hospital’s website and pulled up their financial assistance policy, um, which was 16 pages long. And I thought to myself, how in the world would grandpa get an answer to the question, do I qualify for financial assistance?

Dan: Nick has looked at a lot of super-long financial-assistance forms since then, and he can rattle off the kinds of questions they ask:

Nick: What kind of cars do you drive? Your make and model. How much do you think that it’s worth? And how much do you owe on it? What is the value of your primary residence? How much are you spending each month on house payment, car payment, groceries, cell phone bill, a breakdown of a monthly budget?

Dan: In other words, a LOT. Nick says some of the detailed questions were put there in anticipation of proposed federal laws and regulations that never got adopted. So, Nick was super well versed in all this stuff. He’d helped hospitals design their charity care policies.

Nick: But I hadn’t spent a whole lot of time thinking about what it would be like from the patient’s perspective to try to navigate a hospital’s financial assistance program.

Dan: He was like, before jumping into all this, Grandpa, let’s just figure out if it’s worth it. Are you likely to qualify? And Nick knew how to get an answer: Because he knew, the way hospital charity-care policies work is: They compare your income to a multiple of the federal poverty level. At this hospital it was 250 percent. Nick learned what grandma and grandpa got from social security, compared it to that federal poverty number.

Nick: And so I was like, all right, well, hey grandpa, it looks like you’re going to qualify for financial assistance, let’s print out an application and start filling it out. It was bare because it was a beast of an application. But eventually he was approved for Medicaid and never received another hospital bill for the rest of his life.

Dan: And the 750 bucks? 

Nick: Disappeared.

Dan: It got Nick thinking about a presentation he’d seen a couple of years before. This was when a lot of hospitals were first rolling out their charity-care policies to comply with the new law. One of the national Catholic hospital chains was giving a talk about their policy.

Nick: We offer 75 percent discounts up to 400 percent of the federal poverty level. And I just kind of sat back in my chair and thought, 400 percent of the federal

poverty level.

Dan: That sounded like it might cover a lot of people. Like, how many people in this country make less than that? Maybe a lot. He looked it up later, and I did too:

4 times the federal poverty level for a single person is about 58 thousand a year. And almost 60 percent of Americans make less than that.

Nick: So the next logical step is, Okay, well, uh, People that hospitals send to collections, would you imagine that they have higher incomes or lower incomes than your average American? I think it’s fair to say that we can guess that they’re lower on the income scale than the average American.

Dan: So it would seem like most people who get sent to collections… would’ve qualified for financial assistance. And since, according to industry consultants, most BILLS that get sent to collections never get collected it also seems like: A lot of people who are getting chased by collections agents, maybe getting sued, would have qualified for charity care. Which, duh, maybe. I mean, a lot of reporters and advocates have written a lot of reports showing exactly that. To a lot of people, it looks like an outrage. But with Nick’s knowledge of hospital revenue departments, he saw it as something else: An opportunity. By spending all that effort on chasing folks who wouldn’t and couldn’t pay, hospitals were WASTING MONEY on that effort. And– again, because Nick really knows the nerdy details– he figured hospitals were also leaving other money on the table. Like from Medicaid, which would be paying for Grandpa’s hospital bills– not just for that first 750 dollar charge, but on every bill for the rest of his life. That’s money the hospital would’ve had a hard time getting from grandpa. And Nick thought: A guy could build a business helping hospitals save money over here and pick up money over there. So he quit his job at AmeriCollect to start that business. I asked him to do his pitch for me.

Nick: Uh, pitch. Are you looking for basically what we present to hospitals and stuff like that? Yeah.

Dan: He does this at conferences a few times a year. He pulled up PowerPoint, put it in Presenter View.

Nick: Love presenter view. Hey, let me just fire away. Yeah.

Dan: And we were off.

Nick: So, as the host mentioned, I spent my first 12 years in the industry in the hospital billing and collections world.

Dan: Nick skipped a few details– actually, looking over his shoulder I noticed a key one.

Dan (from field tape): this paragraph that you skipped, like, the cost of sending those bills, you’re saying, like, 2 dollars per.

Nick: Oh, yeah

Dan: Two bucks out of pocket. Even though it’s all automated, you’re spending a lot on the machines, the software, the paper– not to mention postage. And if someone’s headed to collections, you’re not just sending them one bill.

Nick: if you think about three statements and a final notice, and customer service cost for supporting all of that, it’s not insignificant.

Dan: Oh yeah: Customer service cost. That’s the call center. So that’s savings. Then there’s money you pick up. Nick proposes that hospitals basically just ask people their income up front, along with their insurance information. He’s offering them an easy web form to give patients. And he says when hospitals use that form, like ten percent of patients turn out to be eligible for Medicaid. He tells hospitals:

Nick: These are great opportunities to help them get on the Medicaid program, and help you get paid for the care that you provided.

Dan: And Nick says Medicaid isn’t the only opportunity to get paid. Lots of people with regular insurance also have deductibles and other “patient responsibilities” that can get into the thousands of dollars. Which makes a lot of people think twice about going in for care, if they can avoid it. And: Not only could a lot of those people meet the income requirements for charity care– remember, almost 60 percent could meet those requirements at some hospitals — hospitals can adopt charity-care policies that cover people who do have insurance. Which, Nick argues can be a money-making opportunity.

Nick: Um, a question I like to pose is: If a low income patient is on the fence about getting a procedure at your hospital, for example, a knee replacement, that will get you paid 15,000 by their insurance…

Dan: … then wouldn’t it be smart to offer them charity care so they don’t worry about their deductible? You’d be unlocking that 15 thousand dollars from their insurance company. Nick’s pitch sounded pretty solid to me. He’s got some clients, and a backer — a bigger company that’s investing in his work. He says people chat him up after he gives these talks… but he does hear some — not pushback, exactly. More like…

Nick: Eh, we’ll do what we need to do to be compliant, but we’ve got other things to deal with that, we’re not really going to worry about this too much.

Dan: In other words, it’s not a priority. Maybe not where the big money is. But then, lawsuits — especially lawsuits against people who can’t pay– aren’t where the big money is either. Why do these folks allow themselves to be literally party to them?

Nick: It’s really, I would say philosophically-based.

Dan: Philosophically-based. Up to the philosophy of the collection agency and the hospital revenue director. In part two of this story, we’ll hear from someone in the collections world who’s ready to argue, philosophically, that it’s OK to sue people for medical bills they just can’t pay.

Scott Purcell: If you just sued somebody who can’t pay, they’re not out any money. So you made a bad business decision. But truly Dan, what is the harm they’re experiencing?

Dan: And we’ll hear about the case of the disappearing lawsuits’

Ryan Little: So on September 18th, I said, Maryland hospitals are dot, dot, dot…

Basically not suing anyone for medical debt anymore. 

Dan: Yep!

Meanwhile, this is a GREAT time to make a donation to keep this show going. Projects like this take a TON of time and money. And right now, every dollar you give is being MATCHED by other “Arm and a Leg” listeners.

The NewsMatch program from the Institute for Nonprofit News has matched as much as they can for this year, and a few super-generous listeners have put up MORE matching funds. Go take them up on it!

There’s a link in the show notes, wherever you’re listening, or head to arm-and-a-leg-show, dot com, slash, support. (https://armandalegshow.com/support/)

Thank you so much! Your help makes a huge difference. We’ll be back in two weeks with part two. 

Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Bella Czakowski and  Emily Pisacreta in partnership with the Scripps News, the Baltimore Banner, and the McGraw Center for Business Journalism at the Craig Newmark Graduate School of Journalism at the City University of New York.

Our work on this story is supported by the Fund for Investigative Journalism, and edited by Ellen Weiss.

Daisy Rosario is An Arm and a Leg’s consulting managing producer.

Gabrielle Healy is our managing editor for audience — she edits the First Aid Kit newsletter.

Sarah Ballema is our Operations Manager. 

Bea Bosco is our Consulting Director of Operations.

An Arm and a Leg is produced in partnership with KFF Health News.

That’s a national newsroom producing in-depth journalism about health care in America, and a core program at KFF — an independent source of health policy research, polling, and journalism.

You can learn more about KFF Health News at arm and a leg show dot com, slash KFF. (https://armandalegshow.com/about-x/partners-and-supporters/kaiserhealthnews/)

Zach Dyer is senior audio producer at KFF Health News. He is editorial liaison to this show.

Thanks to the INSTITUTE FOR NONPROFIT NEWS for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about INN at I-N-N dot org. (https://inn.org/)

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If you haven’t yet, we’d love for you to pitch in to join us. Again, the place for that is arm and a leg show dot com, slash support.(https://armandalegshow.com/support/)

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

This episode was produced in partnership with Scripps News, The Baltimore Banner, and the McGraw Center for Business Journalism at the Craig Newmark Graduate School of Journalism at the City University of New York.

Work by “An Arm and a Leg” on this article is supported by the Fund for Investigative Journalism.

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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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This story can be republished for free (details).

With other GOP presidential candidates following Donald Trump’s lead in calling for an end to the Affordable Care Act, Democrats are jumping on an issue they think will favor them in the 2024 elections. The Biden administration almost immediately rolled out a controversial proposal that could dramatically decrease the price of drugs developed with federally funded research dollars. The drug industry and the business community at large are vehemently opposed to the proposal, but it is likely to be popular with voters.

Meanwhile, the Supreme Court hears arguments in a case to decide whether the Sackler family should be able to shield billions of dollars taken from its bankrupt drug company, Purdue Pharma, from further lawsuits regarding the company’s highly addictive drug OxyContin.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico, and Rachana Pradhan of KFF Health News.

Panelists

Among the takeaways from this week’s episode:

• The ACA may end up back on the proverbial chopping block if Trump is reelected. But as many in both parties know, it is unlikely to be a winning political strategy for Republicans. ACA enrollment numbers are high, as is the law’s popularity, and years after a failed effort during Trump’s presidency, Republicans still have not unified around a proposal to replace it.
• Democrats are eager to capitalize on the revival of “repeal and replace.” This week, the Biden administration announced plans to exercise so-called “march-in rights,” which it argues allow the government to seize certain patent-protected drugs whose prices have gotten too high and open them to price competition. The plan, once largely embraced by progressives, could give President Joe Biden another opportunity to claim his administration has proven more effective than Trump’s heading into the 2024 election.
• The Senate voted to approve more than 400 military promotions this week, effectively ending the 10-month blockade by Republican Sen. Tommy Tuberville of Alabama over a Pentagon policy that helps service members travel to obtain abortions. At the state level, the Texas courts are considering cases over its exceptions to the state’s abortion ban, while in Ohio, a woman who miscarried after being sent home from the hospital is facing criminal charges.
• Meanwhile, the Supreme Court soon could rule on whether EMTALA, or the Emergency Medical Treatment and Active Labor Act, requires doctors to perform abortions in emergencies. And justices are also considering whether to allow a settlement deal to move forward that does not hold the Sacker family accountable for the harm caused by opioids.
• “This Week in Medical Misinformation” highlights a lawsuit filed by Texas Attorney General Ken Paxton accusing Pfizer of failing to end the covid-19 pandemic with its vaccine.

Also this week, Rovner interviews Dan Weissmann, host of KFF Health News’ sister podcast, “An Arm and a Leg,” about his investigation into hospitals suing their patients for unpaid medical bills.

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

Julie Rovner: The Wisconsin State Journal’s “Dane, Milwaukee Counties Stop Making Unwed Fathers Pay for Medicaid Birth Costs,” by David Wahlberg.  

Anna Edney: Bloomberg News’ “Tallying the Best Stats on US Gun Violence Is Trauma of Its Own,” by Madison Muller.  

Alice Miranda Ollstein: Stat’s “New Abortion Restrictions Pose a Serious Threat to Fetal Surgery,” by Francois I. Luks, Tippi Mackenzie, and Thomas F. Tracy Jr. 

Rachana Pradhan: KFF Health News’ “Patients Expected Profemur Artificial Hips to Last. Then They Snapped in Half,” by Brett Kelman and Anna Werner, CBS News.

Also mentioned in this week’s episode:

• Bloomberg News’ “The Pentagon Wants to Root Out Shoddy Drugs. The FDA Is in Its Way,” by Anna Edney and Riley Griffin.
• Ars Technica’s “Texas Sues Pfizer With COVID Anti-Fax Argument That Is Pure Stupid,” by Beth Mole.

KFF Health News’ ‘What the Health?’Episode Title: Democrats See Opportunity in GOP Threats to Repeal Health LawEpisode Number: 325Published: Dec. 7, 2023

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest reporters in Washington. We’re taping this week on Thursday, Dec. 7, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Anna Edney of Bloomberg News.

Anna Edney: Hello.

Rovner: And my KFF Health News colleague Rachana Pradhan.

Rachana Pradhan: Good morning, Julie.

Rovner: Later in this episode we’ll have my interview with Dan Weissmann, host of our sister podcast, “An Arm and a Leg.” Dan’s been working on a very cool two-part episode about hospitals suing their patients that he will explain. But first, this week’s news. So now that former President [Donald] Trump has raised the possibility of revisiting a repeal of the Affordable Care Act, all of the other Republican presidential wannabes are adding their two cents.

Florida Gov. Ron DeSantis says that rather than repeal and replace the health law, he would “repeal and supersede,” whatever that means. Nikki Haley has been talking up her anti-ACA bona fides in New Hampshire, and the leading Republican candidate for Senate in Montana is calling for a return to full health care privatization, which would mean getting rid of not only the Affordable Care Act, but also Medicare and Medicaid.

But the Affordable Care Act is more popular than ever, at least judging from this year’s still very brisk open enrollment signups. Alice, you wrote an entire story about how the ACA of 2023 is not the ACA of 2017, the last time Republicans took a serious run at it. How much harder would it be to repeal now?

Ollstein: It would be a lot harder. So, not only have a bunch of red and purple states expanded Medicaid since Republicans took their last swing at the law — meaning that a bunch more constituents in those states are getting coverage they weren’t getting before and might be upset if it was threatened by a repeal — but also just non-Medicaid enrollment is up as well, fueled in large part by all the new subsidies that were implemented over the last few years. And that’s true even in states that resisted expansions.

DeSantis’ Florida, for instance, has the highest exchange enrollment in the country. There’s just a lot more people with a lot more invested in maintaining the program. You have that higher enrollment, you have the higher popularity, and we still haven’t seen a real replacement or “supersede” plan, or whatever they want to call it. And folks I talk to on Capitol Hill, Republican lawmakers, even those that were pretty involved last time, do not think such a plan is coming.

Rovner: It did get asked about at the “last” Republican presidential primary debate last night, and there was an awful lot of hemming and hawing about greedy drug companies and greedy insurance companies, and I heard exactly nothing about any kind of plan. Has anybody else seen any sign of something that Republicans would actually do if they got rid of the Affordable Care Act?

Pradhan: No. There was a time, immediately after the ACA’s passage, that health care was a winning political issue for Republicans, right? It was multiple election cycles that they capitalized on Obamacare and used it to regain House majorities, Senate majorities, and the presidency eventually. But that has not been true for multiple years now. And I think they know that. I think establishment Republicans know that health care is not a winning issue for the party, which is why Democrats are so eager to capitalize on this reopening of ACA repeal, if you will.

Rovner: What a perfect segue, because I was going to say the Biden administration is wasting no time jumping back into health care with both feet, trying to capitalize on what it sees as a gigantic Republican misstep. Just this morning, they are rolling out new proposals aimed at further lowering prescription drug prices, and to highlight the fact that they’ve actually gotten somewhere in some lowering of prescription drug prices.

Now they would like to make it easier to use government “march-in rights,” which would let the government basically tell prescription drug companies, “You’re going to lower your price because we’re going to let other people compete against you, despite your patent.” They’re also doing, and I will use their words, a cross-government public inquiry into corporate greed in health care. Now, some of these things are super controversial. I mean, the march-in rights even before this was unveiled, we saw the drug industry complaining against. But they could also have a real impact if they did some of this, right? Anna, you’ve watched the drug price issue.

Edney: Yeah, I think they definitely could have an impact. This is one of those situations with the march-in rights where we don’t have any clue on where or how exactly, because we haven’t been told that this drug or this class of drugs are kind of what we’re aiming at at this point. It sounds like maybe there’s a little bit more of the plan to be baked, but I am sure there are a lot of progressives, particularly, who had pushed for this that, over the years, who are very excited to even see it mentioned and moving in some sort of way, which hasn’t really happened before.

And, clearly, the Biden administration wants to, like you said, capitalize on health care being part of the campaign. And they’ve done a lot on drug prices, at least a lot in the sense of what can be done. There’s negotiation in Medicare now for some drugs. They kept insulin for Medicare as well. So this is just another step they can say, “We’re doing something else,” and we’d have to see down the line exactly where they’d even plan to use it.

And, of course, as pharma always does, they said that this will hurt innovation and we won’t get any drugs. Not that things have been in place that long, but, clearly, we haven’t seen that so far.

Rovner: Yes, that is always their excuse. I feel like this is one of those times where it doesn’t even matter if any of these things get done, they’re putting them out there just to keep the debate going. This is obviously ground that the Biden campaign would love to campaign on — rather than talking about the economy that makes people mostly unhappy. I assume we’ll be seeing more of this.

Edney: Yeah. Your food prices and other things are very high right now. But if they can talk about getting drug prices lower, that’s a totally different thing that they can point to.

Ollstein: And it’s an easy way to draw the contrast. For people who might be apathetic and think, “Oh, it doesn’t matter who wins the presidential election,” this is an area where the Biden administration can credibly claim, based on what Trump recently said, “This is what’s at stake. This is the difference between my opponent and me. The health care of millions is on the line,” which has been a winning message in past elections.

And what’s been really striking to me is that even talking to a bunch of conservatives now, even though they don’t like the Affordable Care Act, they even are starting to argue that full-scale repeal and replace — now that it’s the status quo — that’s not even a conservative proposal.

They’re saying that it’s more conservative to propose smaller changes that chip around the edges and create some alternatives, but mainly leave it in place, which I think is really interesting, because for so long the litmus test was: Are you for full repeal, root and branch? And we’re just not really hearing that much anymore — except from Trump!

Rovner: The difficulty from the beginning is that the basis of the ACA was a Republican proposal. I mean, they were defanged from the start. It’s been very hard for them to come up with a replacement. What it already is is what Mitt Romney did in Massachusetts. Well, let us turn to the other big issue that Democrats hope will be this coming election year, and that’s abortion, where there was lots of news this week.

We will start with the fact that the 10-month blockade of military promotions by Alabama Republican Sen. Tommy Tuberville is over. Well, mostly over. On Tuesday, the Senate approved by voice vote more than 400 promotions that Tuberville had held up, with only a few four-star nominees still in question. Tuberville’s protests had angered not just Senate Democrats and the Biden administration, who said it was threatening national security, but increasingly his own Senate Republican colleagues.

Tuberville said he was holding up the nominations to protest the Biden administration’s policy of allowing active-duty military members and their dependents to travel out of state for an abortion if they’re stationed where it’s illegal, like in, you know, Alabama. So Alice, what did Tuberville get in exchange for dropping his 10-month blockade?

Ollstein: So, not much. I mean, his aim was to force the Biden administration to change the policy, and that didn’t happen — the policy supporting folks in the military traveling if they’re based in a state where abortion is banned and they need an abortion, supporting the travel to another state, still not paying for the abortion itself, which is still banned. And so that was the policy Tuberville was trying to get overturned, and he did not get that. So he’s claiming that what he got was drawing attention to it, basically. So we’ll see if he tries to use this little bit of remaining leverage to do anything. It does not seem like much was accomplished through this means, although there is a lot of anxiety that this sets a precedent for the future, not just on abortion issues, but, really, could inspire any senator to try to do this and hold a bunch of nominees hostage for whatever policy purpose they want.

Rovner: I know. I mean, senators traditionally sit on nominees for Cabinet posts. And the FDA and the CMS [Centers for Medicare & Medicaid Services] didn’t have a director for, like, three administrations because members were angry at the administration for something about Medicare and Medicaid. But I had never seen anybody hold up military promotions before. This was definitely something new. Rachana, you were going to add something?

Pradhan: Oh, I mean, I was just thinking on Alabama specifically. I mean, I don’t claim to know, even though there was rising anger in Sen. Tuberville’s own party about this move. I mean, I’m not saying I know that this is a factor or not, but in Alabama, regardless of what he tried to do, I think that the attorney general in Alabama has made it clear that he might try to prosecute organizations that help people travel out of state to get abortions.

And so, it’s not like this is only the last word when you’re even talking about military officers or people in the military. Even in his home state, you might see some greater activity on that anyway, which might make it easier for him to honestly, in a way, give it up because it’s not the only way that you could presumably prosecute organizations or people who tried to help others go out of state to access abortion.

Rovner: Yeah, it’s important to say that while he irritated a lot of people in Washington, he probably had a lot of support from people back home in Alabama, which he kept pointing out.

Ollstein: Right. And I saw national anti-abortion groups really cheering him on and urging their members to send him thank-you letters and such. And so definitely not just in his home state. There are conservatives who were backing this.

Rovner: Well, moving on to Texas, because there is always abortion news out of Texas, we have talked quite a bit about the lawsuit filed by women who experienced pregnancy complications and couldn’t get abortions. Well, now we have a separate emergency lawsuit from a woman named Kate Cox, who is currently seeking an abortion because of the threat to her health and life.

Both of these lawsuits aren’t trying to strike the Texas ban, just to clarify when a doctor can perform a medically needed abortion without possibly facing jail time or loss of their medical license. Alice, I know the hearing for Kate Cox is happening even now as we are taping. What’s the status of the other case? We’re waiting to hear from the Texas Supreme Court. Is that where it is?

Ollstein: Yeah. So oral arguments were the other day and a bunch of new plaintiffs have joined the lawsuit. So it’s expanded to a few dozen people now, mostly patients, but some doctors as well who are directly impacted by the law. There was some interesting back and forth in the oral arguments over standing.

And one of the things the state was hammering was that they don’t have standing to sue because they aren’t in this situation that this other woman is in today, where they’re actively pregnant, actively in crisis, and being actively prevented from accessing the health care that they need that their doctor recommends, which in some circumstances is an abortion. And so I think this is an interesting test of the state’s argument on that front.

Rovner: Also, the idea, I mean, that a woman who literally is in the throes of this crisis would step forward and have her name in public and it’s going to court in an emergency hearing today.

Ollstein: Right, as opposed to the other women who were harmed previously. By the time they are seeking relief in court, their pregnancy is already over and the damage has already been done, but they’re saying it’s a threat of a future pregnancy. It’s impacting their willingness to become pregnant again, knowing what could happen, what already happened. But the state was saying like, “Oh, but because you’re not actively in the moment, you shouldn’t have the right to sue.” And so now we’ll see what they say when someone is really in the throes of it.

Rovner: In the moment. Well, another troubling story this week comes from Warren, Ohio, where a woman who experienced a miscarriage is being charged with “abuse of a corpse” because she was sent home from the hospital after her water broke early and miscarried into her toilet, which is gross, but that’s how most miscarriages happen.

The medical examiner has since determined that the fetus was, in fact, born dead and was too premature to survive anyway. Yet the case seems to be going forward. Is this what we can expect to see in places like Ohio where abortion remains legal, but prosecutors want to find other ways to punish women?

Ollstein: I mean, I also think it’s an important reminder that people were criminalized for pregnancy loss while Roe [v. Wade] was still in place. I mean, it was rare, but it did happen. And there are groups tracking it. And so I think that it’s not a huge surprise that it could happen even more now, in this post-Roe era, even in states like Ohio that just voted overwhelmingly to maintain access to abortion.

Pradhan: Julie, do we know what hospital? Because when I was looking at the story, do we know what kind of hospital it was that sent this person away?

Rovner: No. The information is still pretty sketchy about this case, although we do know the prosecutor is sending it to a grand jury. We know that much. I mean, the case is going forward. And we do know that her water broke early and that she did visit, I believe, it was two hospitals, although I have not seen them named. I mean, there’s clearly more information to come about this case.

But yeah, Alice is right. I mean, I wrote about a case in Indiana that was in 2012 or 2013, it was a long time ago, about a woman who tried to kill herself and ended up only killing her fetus and ended up in jail for a year. I mean, was eventually released, but … it’s unusual but not unprecedented for women to be prosecuted, basically, for pregnancy loss.

Ollstein: Yeah, especially people who are struggling with substance abuse. That’s been a major area where that’s happened.

Pradhan: I would personally be very interested in knowing the hospitals that are a part of this and whether they are religiously affiliated, because there’s a standard of care in medicine for what happens if you have your water break before the fetus is viable and what’s supposed to happen versus what can happen.

Rovner: There was a case in Michigan a few years ago where it was a Catholic hospital. The woman, her water broke early. She was in a Catholic hospital, and they also sent her home. I’m trying to remember where she finally got care. But yeah, that has been an issue also over the years. Well, meanwhile, back here in Washington, the Supreme Court is likely to tell us shortly, I believe, whether the 1986 Emergency Medical Treatment and Active Labor Act, known as EMTALA, requires doctors to perform abortions in life-threatening situations, as the Biden administration maintains.

Alice, this case is on what’s known as the “shadow docket” of the Supreme Court, meaning it has not been fully briefed and argued. It’s only asking if the court will overturn a lower court’s ruling that the federal law trumps the state’s ban. When are we expecting to hear something?

Ollstein: It could be after justices meet on Friday. Really, it could be whenever after that. As we’ve seen in the last few years, the shadow docket can be very unpredictable, and we could just get, at very odd times, major decisions that impact the whole country or just one state. And so, yes, I mean, this issue of abortion care and emergency circumstances is playing out in court in a couple different states, and the federal government is getting involved in some of those states.

And so I think this could be a big test. Unlike a lot of lawsuits going on right now, this is not seeking to strike down the state’s abortion ban entirely. It’s just trying to expand and clarify that people who are in the middle of a medical emergency shouldn’t be subject to the ban.

Rovner: It’s similar to what they’re fighting about in Texas, actually.

Ollstein: Yeah, exactly. And this is still playing out at the 9th Circuit, but they’re trying to leapfrog that and get the Supreme Court to weigh in the meantime.

Rovner: Yeah, and we shall see. All right, well, while we’re on the subject of “This Week in Court,” let us move on to the case that was argued in public at the Supreme Court this week about whether the Sackler family can keep much of its wealth while declaring bankruptcy for its drug company, Purdue Pharma, that’s been found liable for exacerbating, if not causing much of the nation’s opioid epidemic.

The case involves basically two bad choices: Let the Sacklers manipulate the federal bankruptcy code to shield billions of dollars from future lawsuits or further delay justice for millions of people injured by the company’s behavior. And the justices themselves seem pretty divided over which way to go. Anna, what’s at stake here? This is a lot, isn’t it?

Edney: Yeah. I mean, it’s interesting how it doesn’t exactly break down on ideological lines. The justices were — I don’t want to say all over the place, because that sounds disrespectful — but they had concerns on many different levels. And one is that the victims and their lawyers negotiated the settlement because for them it was the best way they felt that they could get compensation, and they didn’t feel that they could get it without letting the Sacklers off the hook, that the Sacklers basically would not sign the settlement agreement, and they were willing to go that route.

And the government is worried about using that and letting the Sacklers off the hook in this way and using this bankruptcy deal to be able to shield a lot of their money that they took out of the company, essentially, and have in their personal wealth now. And so that’s something that a lot of companies are, not a lot, but companies are looking to hope to use the sign of bankruptcy protection when it comes to big class-action lawsuits and harm to consumers.

And so I think that what the worry is is that that then becomes the precedent, that the ones at the very top will always get off because it’s easier to negotiate the settlement that way.

Rovner: We’ll obviously have to wait until — as this goes a few months — to see the decisions in this case, but it’s going to be interesting. I think everybody, including the justices, are unhappy with the set of facts here, but that’s why it was in front of the Supreme Court. So our final entry in “This Week in Court” is a twofer. It is also “This Week in Health Misinformation.”

Texas Attorney General Ken Paxton has filed suit against Pfizer for allegedly violating Texas’ Deceptive Trade Practices Act because its covid vaccine did not, in fact, end the covid epidemic. Quoting from the attorney general’s press release, “We are pursuing justice for the people of Texas, many of whom were coerced by tyrannical vaccine mandates to take a defective product sold by lies.” It’s hard to even know where to start with this, except that, I guess, anyone can sue anyone for anything in Texas, right?

Edney: Yeah, that’s a very good point. The entire concept of it feels so weird. I mean, a vaccine doesn’t cure anything, right? That’s not the point of a vaccine. It’s not a drug. It is a vaccine that is supposed to prevent you from getting something, and not everybody took it. So that feels like the end of the story, but, clearly, the attorney general would prefer attention, I think, on this, and to continue to sow doubt in vaccines and the government and the Food and Drug Administration seems to be maybe more of the point here.

Rovner: I noticed he’s only suing for, I think, it’s $10 million, which is frankly not a ton of money to a company as big as Pfizer. So one would assume that he’s doing this more for the publicity than for the actual possibility of getting something.

Pradhan: Yeah, I think Pfizer’s CEO’s annual salary is more than the damages that are being sought in this case. So it’s really not very much money at all. I mean, more broadly speaking, I mean, Texas, Florida, I think you see especially post-public-health-emergency-covid times, the medical freedom movement has really taken root in a lot of these places.

And I think that it just seems like this is adding onto that, where doctors say they should be able to give ivermectin to covid patients and it helped them and not be at risk of losing their license. And that’s really kind of an anti-vaccine sentiment. Obviously, it’s very alive and well.

Rovner: We are post-belief-in-scientific-expertise.

Edney: Well, I was going to say, I appreciated The Texas Tribune’s story on this because they called out every time in this lawsuit that he was twisting the truth or just completely not telling the truth at all in the sense that he said that more people who took the vaccine died, and that’s clearly not the case. And so I appreciated that they were trying to call him out every time that he said something that wasn’t true, but was just completely willing to put that out in the public sphere as if it was.

Rovner: There was also a great story on Ars Technica, which is a scientific website, about how the lawsuit completely misrepresents the use of statistics, just got it completely backwards. We’ll post a link to that one too. Well, while we are talking about drug companies, let’s talk about some drugs that really may not be what companies say they are.

Anna, you have a new story up this week about the Pentagon’s effort to ensure that generic drugs are actually copies of the drugs they’re supposed to be. That effort’s running into a roadblock. Tell us a little about that.

Edney: Yeah, thanks for letting me talk about this one. It’s “The Pentagon Wants to Root Out Shoddy Drugs. The FDA Is in Its Way.” So the FDA is the roadblock to trying to figure out whether the drugs, particularly that the military and their family members are taking, work well and don’t have side effects that could be extremely harmful. So what’s going on here is that the Defense Department and others, the White House even, has grown skeptical of the FDA’s ability to police generic drugs, largely that are made overseas.

We did some analysis and we found that it was actually 2019 was the first time that generic drug-making facilities in India surpassed the number of those in the U.S. So we are making more, not just active ingredients, but finished products over in India. And the FDA just doesn’t have a good line into India. They don’t do many unannounced inspections. They usually have to tell the company they’re coming weeks in advance. And what we found is when the Defense Department started looking into this, they partnered with a lab to test some of these drugs.

They got some early results. Those results were concerning, as far as the drug might not work, and also could cause kidney failure, seizures. And even despite this, they’ve been facing the FDA around every corner trying to stop them and trying to get them not to test drugs. They say it’s a waste of money, when, in fact, Kaiser Permanente has been doing this for its 12.7 million members for several years.

And it just seems like something is going on at the FDA and that they don’t want people to have any questions about generic drugs. They really just want everyone to accept that they’re always exactly the same, and they even derail the White House effort to try to look into this more as well. But the Pentagon said, “Thank you very much, FDA, but we’re going forward with this.”

Rovner: Yeah. I mean, I could see that the FDA would be concerned about … they’re supposed to be the last word on these things. But, as you point out and as much of your reporting has pointed out over the last couple of years, the FDA has not been able to keep up with really making sure that these drugs are what they say they are.

Edney: One thing I learned that was interesting, and this is that in Europe, actually, there’s a network of 70 labs that do this kind of testing before drugs reach patients and after they reach patients. So it’s not a totally unusual thing. And for some reason, the FDA does not want that to happen.

Rovner: Well, finally on the drug beat this week, CVS announced earlier that it would overhaul its drug pricing to better reflect how much it pays for the drugs, all of which sounds great, but the fact is that how much CVS pays for the drugs doesn’t have all that much effect on how much we end up paying CVS for those same drugs, right? They’re just changing how they get the drugs from the manufacturers, not necessarily how they price it for the customers.

Pradhan: I think my main question would be, what does that mean for a patient’s out-of-pocket cost for prescriptions? I don’t know how much of this has to do with … for CVS as the pharmacy, but we have CVS Caremark, which is a major PBM, and how this affects the pricing models there. And PBMs, of course, have been under scrutiny in Congress. And there’s outside pressure too, right? The story that you highlighted, Julie, talks about Mark Cuban’s affordable-drug effort. And so, yeah, I don’t know. I mean, I think it sounds good until maybe we see some more details, right?

Rovner: I saw one story that said, “This could really help lower drug prices for consumers,” and one that said, “This could actually raise drug prices for consumers.” So I’m assuming that this is another one where we’re going to have to wait and see the details of. All right, well, that is this week’s news.

Now we will play my interview with Dan Weissmann of the “Arm and a Leg” podcast, and then we will come back with our extra credits. I am pleased to welcome back to the podcast Dan Weissmann, host of KFF Health News’s sister podcast, “An Arm and a Leg.” Dan has a cool two-part story on hospitals suing patients for overdue bills that he’s here to tell us about. Dan, welcome back.

Dan Weissmann: Julie, thanks so much for having me.

Rovner: So over the past few years, there have been a lot of stories about hospitals suing former patients, including a big investigation by KFF Health News. But you came at this from kind of a different perspective. Tell us what you were trying to find out.

Weissmann: We were trying to figure out why hospitals file lawsuits in bulk. Investigative reporters like Jay Hancock at KFF [Health News] have documented this practice, and one of the things that they note frequently is how little money hospitals get from these lawsuits. Jay Hancock compared the amount that VCU [Health] was seeking from patients and compared it to that hospital system’s annual surplus, their profit margin, and it looked tiny. And other studies document essentially the same thing. So why do they do it?

And we got a clue from a big report done by National Nurses United in Maryland, which, in addition to documenting how little money hospitals were getting compared to the million-dollar salaries they were paying executives in this case, also noted that a relatively small number of attorneys were filing most of these lawsuits. Just five attorneys filed two-thirds of the 145,000 lawsuits they documented across 10 years, and just one attorney filed more than 40,000 cases. So we were like, huh, maybe that’s a clue. Maybe we found somebody who is getting something out of this. We should find out more.

Rovner: So you keep saying “we” — you had some help working on this. Tell us about your partners.

Weissmann: Oh my God, we were so, so lucky. We work with The Baltimore Banner, which is a new daily news outlet in Baltimore, new nonprofit news outlet in Baltimore, that specializes in data reporting. Their data editor, Ryan Little, pulled untold numbers of cases, hundreds of thousands of cases, from the Maryland courts’ website and analyzed them to an inch of their life and taught us more than I could ever have imagined.

And Scripps News also came in as a partner and one of their data journalists, Rosie Cima, pulled untold numbers of records from the Wisconsin court system and worked to analyze data that we also got from a commercial firm that has a cache of data that has more detail than what we could pull off the website. It was a heroic effort by those folks.

Rovner: So what did you find? Not what you were expecting, right?

Weissmann: No. While Rosie and Ryan were especially gathering all this data and figuring out what to do with it, I was out talking to a lot of people. And what I found out is that in the main, it appears that frequently when these lawsuits happen and when hospitals file lawsuits in general, they’re not being approached by attorneys. They’re working with collection agencies. And most hospitals do work with a collection agency, and it’s essentially like, I put it like, you get a menu, oh, I’m having a hamburger, I’m going to pursue people for bills.

Like, OK, do you want onions? Do you want mustard? Do you want relish? What do you want on it? And in this case, it’s like, how hard do you want us to go after people? Do you want us to hit their credit reports — if you still can do that, because the CFPB [Consumer Financial Protection Bureau] has been making regulations about that — but do you want us to do that? How often can we call them? And do you want us to file lawsuits if we don’t get results? And so that is essentially in consultation with the hospital’s revenue department and the collection agency, and it’s a strategic decision between them.

That was what we found out through talking to people. What Rosie and Ryan turned up, and the data we had from the folks in New York backed up, is that, surprisingly, in the three states that we looked at, there’s just so much less of this activity than we had expected to find. In Maryland, Ryan sent me a series of emails, the first saying, like, “I’m not actually seeing any this year. That’s got to be wrong. They must be hiding them somewhere. I’m going to go investigate.” And a week later he was like, “I think I found them, and then we’ll go run some more numbers.”

And then a week later, after going to the courthouse and looking at everything you could find, he was like, “No, actually Maryland hospitals just do not seem to be suing anybody this year.” And we had expected there to be fewer lawsuits, but zero was a surprise to everybody. In New York, we appear to have found that two of those three law firms handling all those cases are no longer handling medical bill cases. And in Wisconsin, final numbers are still being crunched. Our second part will have all those numbers.

The Banner is coming out with their numbers this week. But Scripps News and us are still crunching numbers in Wisconsin. But what was the biggest shocker was, I can just tell you, there were so many fewer lawsuits than we had expected, and many of the most active plaintiffs had either cut the practice entirely, like filing zero lawsuits or filing hardly any. One of the things that a lot of these reports that look at across a state, like in New York and the Maryland report, note, and that we found in Wisconsin too, is that most hospitals don’t do this.

Noam Levey at KFF [Health News] found that many hospitals have policies that say, “We might file a lawsuit,” and some larger number of hospitals file some lawsuits. But in all these cases where you’re seeing tons of lawsuits filed, the phenomenon of suing people in bulk is actually not business as usual for most hospitals. That is driven by a relatively small group of players. There was a study in North Carolina by the state treasurers, obviously and Duke University, that found 95% of all the lawsuits were filed by just a few institutions.

The New York people found this. We’ve seen it in Wisconsin. So I mean, it’s another very interesting question when you’re looking at why does this happen. It’s like it’s not something that most institutions do. And again, in Wisconsin, we found that most of the players that had been the most active had basically stopped.

Rovner: Do we know why? Is it just all of the attention that we’ve seen to this issue?

Weissmann: Probably the answer is we don’t know why. Our colleagues at The Banner called every hospital in Maryland and were not told very much. We emailed all the hospitals in Wisconsin that we could that we had seen dramatically decrease, and nobody came to the phone. So we don’t really know.

But it does seem like, certainly in Maryland and New York, there were these huge campaigns that got tons of publicity and got laws changed, got laws passed. And there has been attention. The reports that Bobby Peterson put out in Wisconsin got attention locally. Sarah Kliff of The New York Times, who’s been writing about these kinds of lawsuits, has written multiple times about hospitals in Wisconsin. So it seems like a good first guess, but it’s a guess. Yeah.

Rovner: Well, one thing that I was interested that you did turn up, as you pointed out at the top, hospitals don’t get very much money from doing this. You’re basically suing people for money that they don’t have. So you did find other ways that hospitals could get reimbursed. I mean, they are losing a lot of money from people who can’t pay, even people with insurance, who can’t pay their multi-thousand-dollar deductible. So what could they be doing instead?

Weissmann: They could be doing a better job of evaluating people’s ability to pay upfront. The majority of hospitals in the United States are obligated by the Affordable Care Act to have charity care policies, financial assistance policies, in which they spell out, if you make less than a certain amount of money, it’s a multiple of the federal poverty level that they choose, we’ll forgive some or all of your bill. And, frequently, that number is as much as four times the federal poverty level. They might knock 75% off your bill, which is a huge help.

And as a guy that I met noted, using data from KFF, 58% of Americans make less than 75% of the federal poverty level. That is a lot of people. And so if you’re chasing someone for a medical bill, they might very well have been someone you could have extended financial assistance to. This guy, his name is Nick McLaughlin, he worked for 10 years for a medical bill collections agency. Someone in his family had a medical bill they were having a hard time paying, and he figured out that they qualified for charity care, but the application process, he noted, was really cumbersome, and even just figuring out how to apply was a big process. And so he thought, I know that chasing people for money they don’t have isn’t really the best business model and that we’re often chasing people for money they don’t have. What if we encourage hospitals to be more proactive about figuring out if someone should be getting charity care from them in the first place?

Because, as he said, every time you send someone a bill, you’re spending two bucks. And you’re not just sending one bill, you’re sending like three bills and a final notice. That all adds up, and you’re manning a call center. You’re spending money and you’re missing opportunities by not evaluating people. Because while you’re asking about their income, you might find out they’re eligible for Medicaid, and you can get paid by Medicaid rather than chasing them for money they don’t have.

And two, they might update their insurance information from you and you can get money from their insurance. You can extend financial assistance to somebody, as you said, who has a deductible they can’t pay, and they might actually come to you for care that you can unlock money from their insurance if they’re going to come to you because they’re not afraid of the bill.

I should absolutely say, while Nick McLaughlin is selling hospitals on the idea of adopting new software, which is a great idea, they should do that, they should be more proactive, an entity called Dollar For, a nonprofit organization out of the Pacific Northwest that’s been doing work all over the country, has been beating the drum about this and has a tool that anybody can use.

Essentially, go to their website, dollarfor.org, and type in where you were seen and an estimate of your income, and they will tell you, you’re likely to qualify for charity care at this hospital, because they have a database of every hospital’s policy. And if you need help applying, because some of these applications are burdensome, we’ll help you. So this exists, and everybody should know about it and everybody should tell everybody they know about it. I think the work they’re doing is absolutely heroic.

Rovner: Well, Dan Weissmann, thank you so much for joining us. We will post a link to Dan’s story in our show notes and on our podcast page.

Weissmann: Julie, thanks so much for having me.

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

Edney: Sure. This is from my colleague Madison Muller, “Tallying the Best Stats on US Gun Violence Is Trauma of Its Own.” And I thought she just did such an amazing job with this story, talking to Mark Bryant, who helped start an organization, Gun Violence Archive, which is essentially the only place that is trying to tally every instance of gun violence.

And because of a lot of the restrictions that the NRA has helped get into government regulations and things, some of them which are more recently loosening, but because of those in the past, this is really the only way you could try to look up these statistics. And he’s just given the last decade of his life, with no breaks, trying to do this and his health is failing. And I thought it was just a really poignant look at somebody who has no skin in the game, but just wanted the right information out there.

Rovner: Yeah, obviously this is a big deal. Alice.

Ollstein: I did an op-ed that was published in Stat by a group of fetal medicine specialists who are writing about how their work is being compromised by state abortion bans right now. They were saying these are very risky, high-stakes procedures where they perform operations in utero, latent pregnancy usually, and it’s an attempt to save the pregnancy where there is a big risk. But with all of these, there are risks that it could end the pregnancy, and now they’re afraid of being prosecuted for that.

And they describe a bunch of challenging situations that, even without these bans are challenging, things where there’s twins and something to help one could harm the other twin, and this could all affect the health and life of the parent as well. And so they’re saying that they’re really in this whole new era and have to think about the legal risks, as well as the medical and bioethical ones that they already have to deal with.

Rovner: I’ve reported about this over the years, and I can tell you that these are always really wrenching family decisions about trying to desperately save a pregnancy by doing this extraordinarily difficult and delicate kind of procedure. Rachana.

Pradhan: My extra credit is a story from our colleague Brett Kelman, who worked on this investigation with CBS News. It is about a type of artificial hip known as Profemur that literally were snapping in half in patients’ bodies. I told Brett earlier this week that I was cringing at every line that I read. So if folks want to get a really, frankly, pretty gruesome, awful story about how people around the country have received these artificial hips, and the fact that they broke inside their bodies has really caused a lot of damage.

And, frankly, I know we talked about the FDA, but also this story really sheds light on how the FDA has dropped the ball in not acting with more urgency. And had they done that, many of these injuries likely would’ve been avoided. So, I urge everyone to read it. It’s a great story.

Rovner: It is. I also flinched when I was reading a lot of it. Well, my story is from the Wisconsin State Journal by David Wahlberg, and it’s called “Dane, Milwaukee Counties Stop Making Unwed Fathers Pay for Medicaid Birth Costs.” And while I have been covering Medicaid since the 1980s, and I never knew this even existed, it seems that a handful of states, Wisconsin among them, allows counties to go after the fathers of babies born on Medicaid, which is about half of all births — Medicaid’s about half of all births.

Not surprisingly, making moms choose between disclosing the father to whom she is not married to the state or losing Medicaid for her infant is not a great choice. And there’s lots of research to suggest that it can lead to bad birth outcomes, particularly in African American and Native American communities. I have long known that states can come after the estates of seniors who died after receiving Medicaid-paid nursing home or home care, but this one, at the other end of life, was a new one to me.

Now, I want to know how many other states are still doing this. And when I find out, I’ll report back.

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. Thanks, as always, to our tireless tech guru, Francis Ying, who’s back from vacation. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky and Threads. Anna?

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

Rovner: Rachana.

Pradhan: I’m @rachanadpradhan on X.

Rovner: Alice.

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

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

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This story can be republished for free (details).

Former president and current 2024 Republican front-runner Donald Trump is aiming to put a repeal of the Affordable Care Act back on the political agenda, much to the delight of Democrats, who point to the health law’s growing popularity.

Meanwhile, in Texas, the all-Republican state Supreme Court this week took up a lawsuit filed by more than two dozen women who said their lives were endangered when they experienced pregnancy complications due to the vague wording of the state’s near-total abortion ban.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Johns Hopkins University and Politico Magazine, Victoria Knight of Axios, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Among the takeaways from this week’s episode:

• The FDA recently approved another promising weight loss drug, offering another option to meet the huge demand for such drugs that promise notable health benefits. But Medicare and private insurers remain wary of paying the tab for these very expensive drugs.
• Speaking of expensive drugs, the courts are weighing in on the use of so-called copay accumulators offered by drug companies and others to reduce the cost of pricey pharmaceuticals for patients. The latest ruling called the federal government’s rules on the subject inconsistent and tied the use of copay accumulators to the availability of cheaper, generic alternatives.
• Congress will revisit government spending in January, but that isn’t soon enough to address the end-of-the-year policy changes for some health programs, such as pending cuts to Medicare payments for doctors.
• “This Week in Medical Misinformation” highlights a guide by the staff of Stat to help lay people decipher whether clinical study results truly represent a “breakthrough” or not.

Also this week, Rovner interviews KFF Health News’ Rachana Pradhan, who reported and wrote the latest “Bill of the Month” feature, about a woman who visited a hospital lab for basic prenatal tests and ended up owing almost $2,400. If you have an outrageous or baffling medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: KFF Health News’ “Medicaid ‘Unwinding’ Makes Other Public Assistance Harder to Get,” by Katheryn Houghton, Rachana Pradhan, and Samantha Liss.

Joanne Kenen: KFF Health News’ “She Once Advised the President on Aging Issues. Now, She’s Battling Serious Disability and Depression,” by Judith Graham.  

Victoria Knight: Business Insider’s “Washington’s Secret Weapon Is a Beloved Gen Z Energy Drink With More Caffeine Than God,” by Lauren Vespoli.

Sarah Karlin-Smith: ProPublica’s “Insurance Executives Refused to Pay for the Cancer Treatment That Could Have Saved Him. This Is How They Did It,” by Maya Miller and Robin Fields.

Also mentioned in this week’s episode:

• KFF Health News’ “Progressive and Anti-Abortion? New Group Plays Fast and Loose to Make Points,” by Darius Tahir.
• ProPublica’s “Some Republicans Were Willing to Compromise on Abortion Ban Exceptions. Activists Made Sure They Didn’t,” by Kavitha Surana.

KFF Health News’ ‘What the Health?’Episode Title: Trump Puts Obamacare Repeal Back on AgendaEpisode Number: 324Published: Nov. 30, 2023

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go.

We are joined today via video conference by Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

Rovner: Victoria Knight of Axios News.

Victoria Knight: Hello, everyone.

Rovner: And Joanne Kenen of the Johns Hopkins University and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: Later in this episode we’ll have my interview with my colleague Rachana Pradhan about the latest KFF Health News-NPR “Bill of the Month.” This month’s patient fell into an all-too-common trap of using a lab suggested by her doctor’s office for routine bloodwork without realizing she might be left on the hook for thousands of dollars. But first, this week’s news — and last week’s, too, because we were off.

Because nothing is ever gone for good, the effort to repeal and replace Obamacare is back in the news, and it’s coming primarily from the likely Republican presidential nominee, Donald Trump. Just to remind you, in case you’ve forgotten, Trump, during his presidency, even in the two years that Republicans controlled the House and the Senate, was unable to engineer a repeal of the Affordable Care Act, nor did his administration even manage to unveil an alternative. So what possible reason could he have for thinking that this is going to help him politically now?

Knight: My takeaway is that I think it’s a personal grudge that former President Trump still has, that he failed at this. And I think, when you talk to people, he’s still mad that Sen. John McCain did his famous thumbs-down when the rest of the Republican Party was on board. So I’m not sure that there is much political strategy besides wanting to just make it happen finally, because upset it didn’t happen.

Rovner: Is this part of his revenge tour?

Knight: I mean, I think somewhat. Because if you ask House Freedom Caucus people, they will say, “Yeah, we should repeal it.” But if you ask some more moderate Republican members, they’re like, “We’ve already been through that. We don’t want to do it again.” So I don’t think the Republican Party on the Hill has an appetite to do that, even if Congress goes to Republicans in both chambers.

Kenen: Trump never came up with a health plan and repeal died in the Senate, but remember, it was a struggle to even get anything through the House, and what the House Republicans finally voted for, they didn’t even like. So I don’t know if you call this a revenge tour, but it’s checking a box. But I think it’s important to remember that if you look closely at what Republican policies are, they don’t call it repeal, they don’t say, “We are going to repeal it.” That didn’t go so well for them, and it probably cost them an election.

But they still do have a lot of policy ideas that would water down or de facto repeal many key provisions of Obamacare. So they haven’t tried to go that route, and I’m not sure they would ever try a full-out repeal, but there are lots of other things they could do, some of which would have technical names: community rating and things like that, that voters might not quite understand what they were doing, that could really undermine the protections of Obamacare.

Rovner: Yeah, I mean, I was going to say the Republican Party, in general, this has been the running joke since they started “repeal and replace” in 2010, is that they haven’t had the “replace” part of “repeal and replace” at all. Trump kept saying he was going to have a great plan, it’s coming in two weeks, and, of course, now he’s saying he’s going to have a great plan. We’ve never seen this great plan because the Republicans have never been able to agree on what should come next. Aside from, as Joanne says, tinkering around with the Affordable Care Act.

Kenen: Some of that tinkering would be significant.

Rovner: It could be.

Kenen: I mean there are things that they could tinker that wouldn’t be called repeal, but would actually really make the ACA not work very well.

Rovner: But most of the things that the Republicans wanted to do to the ACA have already been done, like repealing the individual mandate, getting rid of a lot of the industry-specific taxes that they didn’t like.

Kenen: Right. So they ended up getting rid of the spinach and they end up with the stuff that even Republicans, they might not say they like the ACA, but they’re being protected by it. And the individual mandate was the single-most unpopular, contentious part of the law and even a lot of Democrats didn’t like it. And so that target of the animus is gone. So by killing part of it, they also made it harder to do things in the future. They could do damage, though.

Rovner: Yeah. Or they could take on entitlements which, of course, is where the real money is. But we’ll get to that in a minute. Sarah, we have not seen you in a while, so we need to catch up on a bunch of things that are FDA-related. First, a couple of payment items since you were last here. The FDA has, as expected, approved a weight loss version of the diabetes drug Mounjaro that appears to be even more effective than the weight loss version of Ozempic. But insurers are still very reluctant to pay for these drugs, which are not only very expensive, they appear to need to be consumed very long-term, if not forever. Medicare has so far resisted calls to cover the drugs, despite some pressure from members of Congress, but that might be about to change.

Karlin-Smith: I think Medicare is getting a lot of pressure. They’re going to have to probably re-look at it at some point. What I found interesting is recently CMS [the Centers for Medicare and Medicaid Services] regulates other types of health plans as well, and in the ACA space they seem to be pushing for coverage of these obesity drugs. And I think they’re thinking around that. They note that the non-coverage allowance for these ACA plans was based on … they were following what Medicare was doing and there’s some acknowledgment that maybe the non-Medicare population is different from the Medicare population. But I think it’s also worth thinking about some of their other reasoning for coverage there, including that these drugs are different than some of the older weight loss drugs that provided more minimal weight loss, had worse side effects, and it came at a time when weight loss was seen as more of a cosmetic issue. So if that ACA provision rule goes through, I think that does help the case for people pushing for coverage in Medicare Part D of these drugs.

Rovner: Yeah, I mean this seems to be one of these “between a rock and a hard place” … that the demand for these drugs is huge. The evidence suggests that they work very well and that they work not just to help people lose weight, but perhaps when they lose weight to be less likely to have heart attacks and strokes and all that other stuff that you don’t want people to have. On the other hand, at the moment, they are super expensive and would bankrupt insurance companies and Medicare.

Karlin-Smith: Right. I mean, we’ve seen this before where people worry there’s a new class of expensive drugs that a lot of people seem like they will need and it’s going to bankrupt the country, and oftentimes that doesn’t happen even whether it is, in theory, more coverage to some extent. We saw that with hep C. There was a new class of cholesterol drugs that came out a few years ago that just haven’t taken off in the way people worried they would. Some of these obesity drugs, they do work really well, not everybody really tolerates them as well as you would think. So there’s questions about whether that demand is really there. Sen. [Bill] Cassidy [R-La.] has made some interesting points about “Is there a way to use these drugs initially for people and then come up with something more for weight maintenance that wouldn’t be as expensive?”

Rovner: We should point out that Sen. Cassidy is a medical doctor.

Karlin-Smith: But I think the pressure is coming on the government. Recently, I got to hear the head of OPM [Office of Personnel Management], who deals with the insurance coverage for federal government employees, and they have a really permissible coverage of obesity drugs. Basically, they require all their health insurance plans to cover one of these GLP-1 drugs, and they have some really interesting language I’ve seen used by pharmaceutical companies to say, “Look, this part of the federal government has said obesity is a disease. It needs to be treated,” and so forth. So I don’t think the federal government is going to be able to use this argument of, “This is not a medical condition, and these are expensive, we’re not going to cover it.” But there’s definitely going to be tensions there in terms of costs.

Rovner: Well, definitely more to come here. Meanwhile, CMS is also looking at changing the rules, again, for some pharmacy copay assistance programs, which claim to assist patients but more often seem to enrich drug companies and payers. What is this one about? And can you explain it in English? Because I’m not sure I understand it.

Karlin-Smith: So most people, when you get a prescription for a drug, have some amount of copay, so your insurance company pays the bulk of the cost and you pay maybe $10, $20, $30 when you pick up your prescription. For really high-cost drugs, pharmaceutical companies and sometimes third-party charities often offer copay support, where they will actually pay your copay for you.

The criticism of these charities and pharma support is that it lets the companies keep the prices higher. Because once you take away the patient feeling the burden of the price, they can still keep that higher percentage that goes to your health plan and into your premiums that you don’t think about. And so health insurance companies have said, “OK, well we’re not going to actually count this coupon money towards your copay, your out-of-pocket max for the year, because you’re not actually paying it.”

So that doesn’t end up doing the patient much good in the end because, while you might get the drug for free the first part of the year, eventually you end up having to pay the money. The courts have weighed in, and the latest ruling was that the effect of it was essentially telling CMS, “You need to re-look at your rules. We don’t think your logic is consistent,” and they seem to potentially suggest that CMS should only allow copay accumulators if there’s a cheaper drug a patient could take.

So, basically, they’re saying it’s unfair to put this burden on patients and not let them benefit from the coupons if this is the only drug they can take. But if there’s a generic drug they should be taking, that’s the equivalent then, OK, insurance company, you can penalize them there. But interestingly, CMS has basically pushed back on the court ruling. They’re asking them for basically more information about what they’re exactly directing them to do and signaling that they want to keep their broader interpretation of the law.

It’s a tricky situation, I think, policy-wise, because there’s this tension of, yes, the drug prices are really high. The insurance companies have a point of how these coupons create these perverse incentives in the system, and, on the other hand, the person that gets stuck in the middle, the patient is not really the fair pawn in this game. And when talking about a similar topic with somebody recently, they brought up what happened with surprise billing and they made this parallel of we need to think about it as, OK, you big corporate entities need to figure out how to duke out this problem, but stop putting the patient in the middle because they’re the one that gets hurt. And that’s what happened in surprise billing. I’m not sure if there’s quite that solution of how you could do that in this pharmaceutical space though.

Rovner: I was just going to say that this sounds exactly like surprise billing, but for prescription drugs. Well, while we are talking about Capitol Hill, let’s turn to Capitol Hill, where the big news of the week is that House Republican conservatives, the so-called Freedom Caucus, have apparently agreed to abide by the deal they agreed to abide by earlier this year. At least that’s when it comes to the overall total for the annual spending bills. Then-Speaker [Kevin] McCarthy’s attempt to adhere to that deal is one of the things that led to his ouster. The conservatives had wanted to cut spending much more deeply than the deal that was cut, I think it was in May. Although I feel compelled to add: Cutting the appropriations bills, which is what we’re talking about here, doesn’t really do very much to help the federal budget deficit. Most of the money that the federal government spends doesn’t go through the appropriations process. It’s automatic, like Social Security and Medicare.

But I digress. Victoria, what prompted the Freedom Caucus to change their minds and what does that portend for actually getting some of these spending bills done before the next cutoff deadline, which is mid-January?

Knight: I mean, I think it’s the Freedom Caucus just facing reality and that it’s really hard to do budget cuts, and a lot of these bills, the cuts are very deep. For the Labor-HHS bill, which is the bill that funds the Department of Health and Human Services, the cut is 18%. To the CDC [Centers for Disease Control and Prevention], 12% to the department itself. Those are really big cuts. And all the bills, you look at them, they all have really deep cuts.

The agriculture bill has deep cuts to the Department of Agriculture that some moderate Republicans don’t like. So all of the bills have these issues, and so I think they’re realizing it is just not possible to get what they want. Some of them didn’t vote for the Fiscal Responsibility Act, which was the deal that former Speaker McCarthy did with the debt limit that set funding levels. So they’re not necessarily going back on something that they voted for.

Rovner: They’re going back on something that the House voted for.

Knight: Yeah. So yeah, I think they’re just realizing the appropriations process, it’s difficult to make these deep spending cuts. I’ve also heard rumors that there might still be a big omnibus spending bill in January. Despite all this talk of doing the individual appropriations bills, I’ve heard that it may end up, despite all the efforts of the Republican Caucus, it may end where they have to just do a big bill because this is the easiest thing to do and then move on to the rest of the business of Congress for the next year. So we’ll see if that happens. But I have heard some rumors already swirling around that.

Rovner: I mean the idea they have now “agreed” to a spending limit that should have been done in the budget in April, which would’ve given them several months to work on the appropriations bills coming in under that level. And, of course, now we’re almost three months into the new fiscal year, so I mean they’re going to be late starting next year unless they resolve this pretty soon. But in the meantime, one thing that won’t happen is that we won’t get a big omnibus bill before Christmas because the deadline is now not until January, and that’s important for a bunch of health issues because we have a lot of policies that are going to end at the end of the year. Things like putting off cuts in Medicare payments to doctors, which a lot of people care about, including, obviously, all the doctors. Is there a chance that some of these “extender provisions” will find their way onto something else, maybe the defense authorization bill that I think they do want to finish before Christmas?

Knight: Yeah, I think that’s definitely possible. I’ve also heard they can retroactively do that, so even if they miss the deadline, it will probably be fixed. So it doesn’t seem like too big a worry,

Rovner: Although those doctor cuts, I mean, what happens is that CMS pens the claims, they don’t pay the claims until it’s been fixed retroactively. They have done it before, it’s a mess.

Kenen: And it’s bad for the doctors because they don’t get paid. It takes even longer to get paid because they’re put in a hold pile, which gets rather large.

Rovner: It does. Not that the defense bill doesn’t have its own issues around defense, but while we’re on the subject of defense, it looks like Alabama Republican Sen. Tommy Tuberville might be ready to throw in the towel now on the more than 400 military promotions he’s been blocking to protest the Biden administration’s policy allowing members of active-duty military and their dependents to travel to other states for an abortion if it’s banned where they are stationed. This has been going on since February. My impression is that it’s his fellow Republicans who are getting worried about this.

Kenen: Yeah. They’re as fed up as the Democrats are now. Not 100% of them are, but there’s a number who’ve come out in public and basically told him to cut it out. And then there are others who aren’t saying it in public, but there are clearly signs that they’re not crazy about this either. But we keep hearing it’s about to break. We’ve been hearing for several weeks it’s about to be resolved, and until it’s resolved, it’s not resolved. So I think clearly there’s movement because the pressure has ramped up from his fellow Republicans.

Rovner: Well, to get really technical, I think that the Senate Rules Committee passed a resolution that could get around this whole thing-

Kenen: But they don’t really want to, I mean the Republicans would rather not confront him through a vote. They’d rather just stare him down and get him to pretend that he won and move on. And that’s what we’re waiting to see. Is it a formal action by the Senate or is there some negotiated way to move forward with at least a large number of these held-up nominations.

Rovner: It’s the George Santos-Bob Menendez health issue. In other words, they would like him to step down himself rather than have to vote to take it down, but they would definitely like him to back off.

Kenen: I mean, not confusing anybody but they’re not talking about expelling her from the Senate. They’re [inaudible] talking about “Cut this out and let these people get their promotions,” because some of them are very serious. These are major positions that are unfilled.

Rovner: Yes, I mean it’s backing up the entire military system because people can’t move on to where they’re supposed to go and the people who are going to take their place can’t move on to where they’re supposed to go, and it’s not great for the Department of Defense. All right, well, while we are on the subject of abortion, at least tangentially, the Texas Supreme Court this week heard that case filed by women who had serious pregnancy complications for which they were unable to get medical care because their doctors were afraid that Texas’ abortion ban would be used to take their medical licenses and/or put them in jail.

Kenen: For 99 years!

Rovner: Yeah, the Texas officials defending against the lawsuit say the women shouldn’t be suing the state. They should be suing their doctors. So what do we expect to happen here? This hearing isn’t even really on the merits. It’s just on whether the exceptions the lower court came up with will be allowed to take effect, which at the moment they’re not.

Kenen: The exception-by-exception policy, where things get written in, is problematic because it’s hard to write a law allowing every possible medical situation that could arise and then that would open it to all other litigation because people would disagree about is this close to death or not? So the plaintiffs want a broader, clearer exception where it’s up to the doctors to do what they think is correct for their patients’ health, all sorts of things can go wrong with people’s bodies.

It’s hard to legislate, which is OK and which isn’t. So the idea of suing your doctor, I mean, that’s just not going to go anywhere. I mean, the court is either going to clarify it or not clarify it. Either way, it’ll get appealed. These issues are not going away. There’s many, many, many documented cases of people not being able to get standard of care. Pregnancy complications are rare, but they’re serious and the state legislatures have been really resistant so far to broadening these exemptions.

Rovner: It’s not just Texas. ProPublica published an investigation this week that found that none of the dozen states with the strictest abortion bans broadened exceptions even after women and their doctors complained that they were being put at grave risk, as Joanne just pointed out. When we look at elections and polls, it feels like the abortion rights side very much has the upper hand, but the reverse seems to be the case in actual state legislatures. I mean, it looks like the anti-abortion forces who want as few exceptions as possible are still getting their way. At least that’s what ProPublica found.

Kenen: Right. One of the other points that the ProPublica piece made was many of these laws were trigger laws. They were written before Roe was toppled. They were written as just in case, if the Supreme Court lets us do this, we’ll do it. So they were symbolic and they were not necessarily written with a lot of medical input. And they were written by activists, not physicians or obstetricians.

And the resistance to changing them is coming from the same interest groups that want no abortions, who say it’s just not ever medically necessary or so rarely medically necessary, and it is medically necessary at times. I mean, there are people who, and this line saying, “Well, if you’re in trouble, you can’t have an abortion. But if you’re close to death you can,” that can happen in split seconds. You can be in trouble and then really be in real trouble. You can’t predict the course of an individual, and it’s tying the hands for physicians to do what needs to be done until it might be too late.

Knight: I think a lot of them don’t realize, until it starts happening, how many times it is sometimes medically necessary. It’s not even that a woman necessarily wants to get an abortion, it’s just something happens, and it’s safer for her to do that in order to save her life.

Karlin-Smith: And you’ve seen in some of these states, sometimes Republican women prominently coming out and pushing for this and trying to explain why it’s necessary. In some cases, they also have made the argument, too, that sometimes to preserve a woman’s fertility, these procedures are necessary given the current situations they face.

Kenen: There was a quote in that ProPublica story, and it’s not necessarily everybody on the anti-abortion rights side, but this individual was quoted as saying that the baby’s life is more important than the mother’s life. So that’s a judgment that a politician or activist is making. Plus, if the mother dies, the fetus can die too. So it doesn’t even make sense. It’s not even choosing one. I mean, in many cases if the pregnant person dies, the fetus will die.

Rovner: Well, finally this week, I want to give a shout-out to a story by my KFF Health News colleague Darius Tahir, who, by the way, became a father this week. Congratulations, Darius. The story’s about a group called the Progressive Anti-Abortion Uprising that purports to be both anti-abortion and progressively leftist and feminist. One of its goals appears to be to get courts to overturn the federal law that restricts protests in front of abortion clinics. The Freedom of Access to Clinic Entrances Act, known as FACE, is I think the only explicitly abortion rights legislation that became law in the entire 1990s, which makes you wonder if this group is really as leftist and feminist as it says it is, or if it’s just a front to try and go after this particular law.

Kenen: It sets limits of where people can be and tries to police it somewhat. But in Darius’ story, his reporting showed that they did, at least some of them, had ties to right-wing groups. So that they’re calling themselves leftist and progressive … it’s not so clear how accurate that is for everybody involved.

Rovner: Yeah, it was an interesting story that we will link to in the show notes. All right, now it is time for “This Week in Health Misinformation,” and it’s good news for a change. I chose a story from Stat News called “How to Spot When Drug Companies Spin Clinical Trial Results.” It’s actually an update of a 2020 guide that STAT did to interpret clinical trial results, and it’s basically a glossary to help understand company jargon and red flags, particularly in press releases, to help determine if that new medical “breakthrough” really is or not. It is really super helpful if you’re a layperson trying to make sense of this.

OK that is this week’s news, and I now will play my “Bill of the Month” interview with Rachana Pradhan, and then we will come back with our extra credits.

I am pleased to welcome back to the podcast my colleague Rachana Pradhan, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment. Always great to see you, Rachana.

Rachana Pradhan: Thanks for having me, Julie.

Rovner: So this month’s patient fell into what’s an all-too-common trap. She went to a lab for routine bloodwork suggested by her doctor without realizing she could be subjected to thousands of dollars in bills she’s expected to pay. Tell us who she is and how she managed to rack up such a big bill for things that should not have cost that much.

Pradhan: So our patient is Reesha Ahmed. She lives in Texas, just in a suburb of the Dallas-Fort Worth area, and what happened to Reesha is she found out she was pregnant and she went to a doctor’s office that she had never gone to before for a standard prenatal checkup, and she also had health insurance. I want to underscore that that is an important detail in this story. So the nurse recommended that Reesha get routine blood tests just down the hall in a lab that was in the adjoining hospital. And it was routine. There was nothing unusual about the blood tests that Reesha received. So what she was advised to do is after her checkup, she was told, “Well, here’s the bloodwork you need, and just go down the hallway here, into the hospital,” to get her blood drawn.

Rovner: How convenient, they have their own lab.

Pradhan: Exactly. And Reesha did what she was told. She got bloodwork done. And then, soon after that, she started getting bills. And they first were small amounts, like there was a bill for $17, and she thought, “OK, well that’s not so bad.” Then she got a bill for over $300 and thought, “That’s unusual. Why would I get billed this?” Then came the huge one. It was over $2,000. In total, Reesha’s overall lab work bills were close to $2,400 for, again, standard bloodwork that every pregnant woman gets when they find out that they’re pregnant. And so she, needless to say, was shocked and immediately actually started trying to investigate herself as to how it was possible for her to get billed such astronomical amounts.

Rovner: And so what did she manage to find out?

Pradhan: She tried taking it up with the hospital and her insurance company. And she just got passed around over and over again. She appealed to her insurance. They denied her appeal saying that, “Well, this bloodwork was diagnostic and not preventive, so it was coded correctly based on the claim that was submitted to us,” and the hospital even sent her to collections for this bloodwork. Unfortunately for Reesha, this pregnancy ended in a miscarriage, and so it was particularly difficult. She was dealing with all the emotional, physical ramifications of that, and then on top of that, having to deal with this billing nightmare is just a lot for any one person to handle. It’s too much, honestly.

Rovner: So we, the experts in this, what did we discover about why she got billed so much?

Pradhan: You can get bloodwork at multiple places in our health system. You could get it maybe within a lab just in your doctor’s office. You can go to an outside lab, like an independent commercial one, to get bloodwork done and you can sometimes get labs within a hospital building. They may not look any different when you’re actually in there, but there’s a huge difference as to how much they will charge you.

Research has shown that if a patient is getting blood tests done, things that are relatively routine and just as a standalone service, hospital outpatient department labs charge much, much more. There’s research that we cite in the story about Reesha that … she lives in Texas … bloodwork in Texas, if it’s done in a hospital outpatient department is at least six times as expensive compared to if you get those same tests in a doctor’s office or in an independent commercial lab.

Rovner: To be clear, I would say it’s not just bloodwork. It’s any routine tests that you get in a hospital outpatient department.

Pradhan: That research, in particular, was looking at blood tests actually, in particular, just any lab work that you might get done. So the conclusion of that is really that there’s no meaningful quality difference. There’s really no difference at all when you get them in a doctor’s office versus a hospital or a lab, and yet the prices you pay will vary dramatically.

Rovner: Yeah, there should be a big sign on the door that says: “This may be more convenient, but if you go somewhere else, you might pay a lot less and so will your insurance.” What eventually happened with Reesha’s bill?

Pradhan: Well, eventually, the charges were waived and zeroed out and she was told that she would not have to pay anything and all the accounts would be zeroed out to nothing.

Rovner: Eventually, after we started asking questions?

Pradhan: Yes. It was a day after I had sent a litany of questions about her billing that they gave her a call and said, “You now won’t have to pay anything.” So it’s a big relief for her.

Rovner: Obviously this was not her fault. She did what was recommended by the nurse in her doctor’s office, but there are efforts to make this more transparent.

Pradhan: Yeah. I think in health care policy world, the issue that she experienced is a reflection of something called site-neutral payment, which essentially means if payment is site-neutral for a health care provider, it means that you get a service and regardless of where you get that service, there is no difference in the amount that you are paying. There are efforts in Congress and even in state legislatures to institute site-neutral pay for certain services.

Bloodwork is one that is not necessarily being targeted, at least in Congress. But I will say, I think one of the big takeaways about what patients can do is if they do get paperwork from your doctor’s office saying, “OK, you need to get some blood tests done,” you can always take that bloodwork request and get it done at an independent lab where the charges will be far, far less than in a hospital-based lab, to avoid these charges.

Rovner: Think of it like a prescription.

Pradhan: Exactly. It might not be as convenient in that moment. You might have to drive somewhere, you can’t just walk down a hallway and get your blood tests and labs done, but I think you will potentially avoid exorbitant costs, especially for bloodwork that is very standard and is not costly.

Rovner: Yet another cautionary tale. Rachana Pradhan, thank you very much.

Pradhan: Thanks for having me, Julie.

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

Karlin-Smith: Sure. I took a look at a ProPublica piece by Maya Miller and Robin Fields, “Insurance Executives Refused to Pay for the Cancer Treatment That Could Have Saved Him. This Is How They Did It.” And it tells the story of a Michigan man who had cancer, and the last resort treatment for him was CAR-T, which is a cellular therapy where they basically take some of your cells, reengineer them, and put them back into your body, and it is quite expensive and it can come with a lot of expensive side effects as well.

FDA considers it a drug, and Michigan state law requires cancer drugs be covered. The insurance company of this man, basically on a technicality, denied it, describing it as a gene therapy, and he did die before he was able to fully push this battle with the insurance company and get access to the treatment and so forth. But I think the piece raises these broader issues about [how] few states are able to proactively monitor whether insurance plans are properly implementing the laws around what is supposed to be covered and not covered.

Few people really have the knowledge or skill set, particularly when you’re dealing with devastating diseases like cancer, which are just taking all of your energy just to go through the treatment, to figure out how to fight the system. And it really demonstrates the huge power imbalances people face in getting health care, even if there are laws that, in theory, seem like they’re supposed to be protected.

I also thought there’s some really interesting statistics in the story about, yes, even though the price tag for these products are really expensive, that the health insurance company actually crunched the numbers and found that if they shifted the cost to premiums in their policyholders, it would lead to, like, 17 cents a month per premium. So I thought that was interesting, as well, because it gives you a sense of, again, where their motivation is coming from when you boil it down to how the costs actually add up.

Rovner: And we will, I promise, talk about the growing backlash against insurance company behavior next week. Victoria.

Knight: So my extra-credit article is a Business Insider story in which I’m quoted, but the title is “Washington’s Secret Weapon Is a Beloved Gen Z Energy Drink With More Caffeine Than God.” And it basically talks about the phenomenon of Celsius popping up around the Hill. So it’s an energy drink that contains 200 milligrams of caffeine. It tastes like sparkling water, it’s fruity, but it’s not like Monster or Red Bull. It tastes way better than them, which I think is partly why it’s become so popular.

But anyways, I’ve only been on the Hill reporting for about a year and in the past couple months it has really popped up everywhere. It’s all around in the different little stores within the Capitol complex, there’s machines devoted to it. So it talks about how that happened. And I personally drink almost one Celsius a day. I’m trying to be better about it, but the Hill is a hard place to work, and you’re running around all the time, and it just gets you as much caffeine as you need in a quick hit. But the FDA does recommend about 400 milligrams a day. So if you drink two, then you’re not going over the recommendation.

Rovner: Well, you can’t drink anything else with caffeine if you drink two.

Knight: That’s true. And I do drink coffee in the morning, but it has some funny quotes to our members of Congress and chiefs of staff and reporters about how we all rely on this energy drink to get through working on the Hill.

Rovner: I just loved this story because, forever, people wonder how these things happen in the middle of the night. It’s not the members, it’s the staff who are going 16 and 20 hours a day, and they’ve always had to rely on something. So, at least now, it’s something that tastes better.

Knight: It does taste better.

Rovner: That’s why it amused me, because it’s been ever thus that you cannot work the way Capitol Hill works without some artificial help, shall we say. Joanne.

Kenen: We used to just count how many pizza boxes were being delivered to know how long a night it was going to be. I guess now you count how many empty cans of Celsius.

Knight: Exactly.

Rovner: I personally ran more on sugar than caffeine.

Kenen: OK. This is a piece by Judy Graham of KFF Health News, and the headline is “A Life-Changing Injury Transformed an Expert’s View on Disability Services.” And it’s about a woman many of us know, actually Julie and I both know: Nora Super. I’ve known her for a long time. She’s an expert on aging. She ran one of the White House aging conferences. She worked at Milken for a long time. She worked at AARP for a while.

She’s in her late 50s now, and in midlife, she started having really severe episodes of depression, and she became very open about it, she became an advocate. Last summer, she had another episode and she couldn’t get an appointment for the treatment she needed quickly enough. And while she was waiting, which is the story of American health care right now, and while she was waiting for it, she did try to take her own life. She survived, but she now has no sensation from the waist down.

And her husband is a health economist, and I should disclose, my former boss at one point, I worked for and with Len for two years, Len Nichols. So this is a story about how she has now become an advocate for disability. And this is a couple with a lot of resources. I mean both knowledge, connections, and they’re not gazillionaires, but they have resources, and how hard it has been for them even with their resources and connections. And so now Nora who, when she’s well, she’s this effervescent force of nature, and this is how she is turning — her prognosis, it could get better, they don’t know yet — but clearly an extraordinarily difficult time. And she has now taken this opportunity to become not just an advocate for the aging and not just an advocate for people with severe depression, but now an advocate for people with severe disability.

Rovner: Yeah, I mean, it’s everything that’s wrong with the American health care system, and I will say that a lot of what I’ve learned about health policy over very many years came from both Len Nichols and Nora, his wife. So they do know a lot. And I think what shocked me about the story is just how expensive some of the things are that they need. And, again, this is a couple who should be well enough off to support themselves, but these are costs that basically nobody could or should have to bear.

Kenen: Even … it was just a lift to get her into their car, just that alone was $6,500. And there are many, many, many things like that. And then another thing that they pointed out in the article is that most physicians don’t have a way of getting somebody from a wheelchair onto the examining table other than having her 70-year-old husband hoist her. So that was one of the many small revelations in this story. Obviously, it’s heartbreaking because I know and like her, but it’s also another indictment of why we just don’t do things right.

Rovner: Yes. Where we are. Well, my story is yet another indictment of not doing things right. It’s by my colleagues Katheryn Houghton, Rachana Pradhan, who you just heard, and Samantha Liss, and it’s called “Medicaid ‘Unwinding’ Makes Other Public Assistance Harder to Get.” And it’s just an infuriating story pointing out that everything we’ve talked about all year with state reviews of Medicaid eligibility, the endless waits on hold with call centers, lost applications, and other bureaucratic holdups, goes for more than just health insurance. The same overworked and under-resourced people who determine Medicaid eligibility are also the gatekeepers for other programs like food stamps and cash welfare assistance, and people who are eligible for those programs are also getting wrongly denied benefits.

Among the people quoted in the story was DeAnna Marchand of Missoula, Montana, who is trying to recertify herself and her grandson for both Medicaid and SNAP (food stamps), but wasn’t sure what she needed to present to prove that eligibility. So she waited to speak to someone and picking up from the story, “After half an hour, she followed prompts to schedule a callback, but an automated voice announced slots were full and instructed her to wait on hold again. An hour later, the call was dropped.” It’s not really the fault of these workers. They cannot possibly do what needs to be done, and, once again, it’s the patients who are paying the price.

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 this week to Zach Dyer for filling in as our technical guru while Francis [Ying] takes some much-deserved time off. Also, as always, you can email us your questions or comments. We are at whatthehealth@kff.org. Or you can still find me at X, for now, @jrovner, or @julierovner at Bluesky and Threads. Joanne.

Kenen: I’m mostly at Threads, @joannekenen1. Occasionally I’m still on X, but not very often, that’s @JoanneKenen.

Rovner: Sarah.

Karlin-Smith: I am @SarahKarlin, or @sarahkarlin-smith, depending on the platform.

Rovner: Victoria.

Knight: I am @victoriaregisk [on X and Threads]. Still mostly on X, but also on Threads at the same name.

Rovner: We’re all trying to branch out. We will be back in your feed next week. Until then, be healthy.

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And Haun was about $800 short.

When she couldn’t book the gigs she needed, Haun, with husband Johnston’s help, came up with a plan: to crowdfund enough money to make their own movie starring Haun, called “Ellen Needs Insurance.”

In this episode of “An Arm and a Leg,” host Dan Weissmann speaks with Haun and Johnston about their short film, how they were affected by the 2023 SAG-AFTRA strike, and their ongoing quest to stay insured.

Credits

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. OK, here’s something I never expected to say — I’ve got a funny, kind of sweet story about health insurance. OK, maybe sweet and sour. Here it is …

As we record this, it’s November, which means it’s open enrollment for lots of people — time to get next year’s health insurance figured out, both on the Obamacare exchanges and at lots of workplaces. A year ago, Ellen Haun and her husband Dru Johnston were HUSTLING to get their health insurance set up for 2023. In the most creative possible way … by crowdfunding a creative project. They posted a video of course.

Ellen: Hi, I’m Ellen, and I need health insurance. 

Dru: And I’m Dru, and I also need health insurance.

Dan: Ellen and Dru work in Hollywood — acting and writing — and folks in that industry get their insurance through the unions. But only if they’ve racked up enough wages for union work over a 12-month period. They’d been on Ellen’s insurance through the actors’ union, SAG. But last fall, as they explained in their crowdfunding video, that union insurance wasn’t looking like a sure thing for the coming year.

Dru: Right now, Ellen is $804 short. So we’re making a short film. 

Ellen: And that short film is called “Ellen Needs Insurance.”

Dan: The video outlined their plan: to employ not just Ellen but other actors who also needed a little help getting over the finish line to qualify.

Dru: Also, which brings up the next point, are you an actor that’s close to hitting your health insurance? Then please get in touch.

Ellen: Yes, we want to cast you. We want you to have insurance.

Dru: And if we raise more money than our goal, we will use all of that only

towards casting more actors and getting them insurance. 

Ellen: We’ll add parts. We don’t care.

Dru: Yeah, this isn’t Shakespeare. This is a script we wrote. We’ll add parts.

Ellen: We can … We’ll make them up.

Dan: That was a year ago. And spoiler: They did make the film. Of course now they need insurance for 2024. And Ellen’s union spent a lot of 2023 on strike, which has narrowed down the opportunities to earn that insurance again. So… I wanted to talk with them!

[“An Arm and a Leg” theme music plays.]

This is “An Arm and a Leg” — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge.

So the job we’ve picked here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering and useful.

[“An Arm and a Leg” theme music ends.]

Ellen and Dru met at a wedding.

Ellen: I was friends with the bride and Drew was friends with the groom. And at the bachelorette party, Emily had been, like, talking about all the single guys that were going to be at the wedding, but she had forgot to include Dru on that list. So I was like, just, I was like, why is this guy talking to me so much? He’s probably got a girlfriend somewhere.

Dru: Turns out I didn’t. And then, uh, we ended up, uh, starting to date almost immediately after that wedding.

Dan: By then, Ellen was earning enough as an actor to qualify for health insurance, starting with an ad for Xfinity Internet and a recurring role as a law student on “How to Get Away with Murder.”

Viola Davis: Ms. Chapin, can you tell us what the Fifth Amendment is?

Ellen: The Fifth Amendment? Um, right.

It, um, assures your right to protection from self incrimination.

Viola Davis: Are you asking me?

Ellen: No, that’s my answer.

Viola Davis: And it’s a correct one.

Dan: Getting that insurance was a big professional milestone. More than 85 percent of SAG members do not book enough union work to qualify– it takes about 26 thousand dollars across a one-year period. (And, you know, of course most actors, Ellen included, pick up other work on the side, or even hold down a day job.) For most of the last few years, Ellen had no worries about making enough money to qualify for insurance. She’d been getting paid for a commercial that ran and ran, because it was so terrific. You may have seen it. Even I have seen it … and I kinda never watch TV. Ellen plays BOTH parts in it. She’s call center employee

Claire in Phoenix: This is Claire in Phoenix, can I help you? 

Dan: And she’s a woman who’s dialed in for customer support. 

Ellen as customer: Yes.

Claire in Phoenix: Great.

Ellen as customer: Correct.

Claire in Phoenix: Ma’am. This isn’t an automated computer.

Ellen as customer: Operator?

Claire in Phoenix: Ma’am? I’m here. I’m live.

Ellen as customer: Wait, you’re real?

Claire in Phoenix: Yeah! With Discover Card, you can talk to a real person.

Dan: Ellen had been getting a “holding fee” — to keep her from auditioning for commercials for competitors.

Ellen: And I kind of knew in the back of my mind that like, okay, eventually this holding fee is going to go away because this commercial isn’t running anymore.

Dan: And then last June, she got the call.

Ellen: My agent was like, Hey, they’re releasing you from the holds. Uh, you’re not getting that payment. You, um, you’re free to audition for other commercials.

And I was like, okay, but what about that health insurance?

Dan: This was in June. She needed to make another 6 thousand dollars, by the end of December, to keep her insurance.

Ellen: And I thought, okay, I’ve got half the year. Like that’s just booking like one other commercial.

Dan: But that wasn’t a sure thing. She’d done it for years and years, but she wanted to hedge her bets. She experimented with working as an extra.

Ellen: And I was getting like, pretty consistent work, but also background work does not pay very well.

Dan: $187 a day. More if there’s overtime, but still. It’s not that it’s not that much, especially if you’re trying to chip away at like a 6,000 balance.

I was like, I don’t know if I’m going to make this, um, I knew that it was definitely going to be down to the wire. So that’s when I was like, you know what, maybe we should think about making a movie about this.

Dan: Actually, this was an idea that had kind of been on Dru’s shelf for a few years. As a comedy writer for a TV talk show, Dru had gotten his insurance from the screenwriter’s union, the WGA. And then in 2018 the show got canceled. Lucky for Drew, he was married to Ellen by then, so they put him on her SAG insurance. And then after that saga had ended, he had a fun idea.

Dru: I was like, oh, you know what I should have done is I should have just made a web series called, “Dru Needs Insurance.” And then I was like, well, it’s too late. I guess that’s an idea that I’m never going to have to do. And then flash forward.

Dan: They’re in the same boat! all over again.

Except now, it’s Ellen who’s short, and nothing to fall back on. I asked if they remembered the day when they decided to try making the film. Dru was like, …

Dru: It was in the OBGYN’s office.

Dan: Yeah. They were pregnant! This was the first doctor visit.

Dru: We had gone to the ultrasound. We saw the baby. We heard the heartbeat. We were like, well, that we were having the baby. It’s coming.

Dan: Now they were gonna see the doctor, talk about next steps.

Dru: And we had about 20 minutes in that waiting room, just sitting there kind of going like, okay, our life’s gonna change.

We got to make some, some choices, or we got to, like, figure out, like, what room are we going to use? All that stuff. But also in the middle of that, we were like, oh, also our health insurance is going … is set to run out.

Dan: Actually, it was going to run out exactly one month before the baby’s due date.

Dru: And I was like, well, shit, we need that health insurance. Um, and, and that’s when Ellen said, I think I need to make a movie and we need to do that.

Dan: So they did! They banged out a script — and brought a friend’s production company on board. (The union doesn’t let you just pay yourself directly.) Which brings us to the point in the story when they made that crowdfunding video

[Bouncy music plays in the background.]

Dru: It’s a comedy about an actress named Ellen, and the things she does to get insurance.

Ellen: Things like begging my agent for a job, praying to the gods for a surprise residual check, and even background work.

Also, the movie’s just about how hard it is to navigate insurance in this country.

[Bouncy music ends.

Dan: How’d it come out? That’s next.

This episode of “An Arm and a Leg” is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health care in America. Their journalism is terrific– wins all kinds of awards every year– and I’m honored to work with them.

Dan: So, Ellen and Dru did raise the money: more than 33 thousand dollars. They actually did beat their goal. The movie is delightfully meta. It starts with Ellen-the-character in her kitchen in the middle of a conversation with her best friend …

Best Friend: Why can’t you just pay the difference?

Ellen: Oh yeah, I tried. But I called and they told me that’s not allowed.

Best Friend: I thought that was the whole thing about health insurance in this country. You have to pay for it.

Ellen: Apparently, not when you want to. If I want to keep my health insurance, I have to book another SAG job by the end of the year.

Best Friend: Couldn’t you cast yourself in something?

Ellen: Like in what, my own movie? Yeah. I mean, I’d have to get funding,

write a script, hire a production team, get a payroll company, …

Dan: So just like the real Ellen did, movie-Ellen decides to go all out to book another commercial. And if you ever thought it might be fun to take a crack at a career in acting, the audition scene — with Ellen and a casting director — that might dissuade you.

Casting director: Alright, we’ll start on action and, uh, remember, this determines whether or not you can see a doctor in the next year.

Dan: Soon, we see Ellen looking up COBRA — which you may have looked up yourself, like if you ever left a job without your next gig — and your next insurance — lined up.

COBRA pitch: Losing your health insurance?

Don’t worry. It happens all the time. Cobra is here for you. …

Dan: And if you’ve looked at it, you know: COBRA is EXPENSIVE. Like, average employer coverage for a family costs more than 20 thousand dollars a year. So that’s the price range for COBRA.

COBRA pitch: The fact that it’s named after a deadly and venomous snake is just part of the fun, and has nothing to do with the fact that it feels like death. You made less money, and now you have to pay more.

Dan: On her agent’s advice, Ellen tries background work, another case of art imitating life. And, in a scene that really highlights some of the peculiarities about how all of this works,  she debriefs with her friend, over drinks at a bar.

Best Friend: How is it?

Ellen: It’s not as bad as I thought, but it does not pay very well. You get a

lot more if you have a line.

Dan: And suddenly, another patron in the bar leans into the conversation… Bar patron: Excuse me, did you say you get more money if you have a line?

Ellen: Yeah.

Bar patron: Got it.

Dan: And another patron. Bar patron: Just one line?

Ellen: Yeah.

You get more if you have more than five lines, too.

Bar patron: Wow. Wow.

Dan:Now it’s everybody in the bar.

Bar patrons: Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow.

Dan: The bit about a pay bump is real, of course. Including the bump for more-than-five-lines. And just to expand on that for a minute here – Dru experienced the downside of that rule — ridiculously, painfully — when he did a one-shot appearance on Orange Is the New Black. It was a big meaty scene, but somehow wasn’t more than five lines.

Dru: I was a lawyer and every line was about a half of a page of just legalese

Dru as Lawyer: based on copious witness testimony, the U. S. attorney has charged you and four others

[DUCKS UNDER: with inciting the riot. They allege that you created and maintained a secret riot bunker, and there’s also evidence that directly implicates you in the kidnapping and false imprisonment of Officer Desmond Piscatella…]

Dan: But that’s how a “line” gets defined in this situation: As long as nobody interrupts you, a monologue is just one line. A role with five lines or less gets called an “under-five”

Dru: And I was like, this is an under five? I was like, okay, well, there we go. I’ll just lecture for two pages.

Dru as Lawyer: I’ve negotiated a plea deal for you. If you admit to the riot charges, they’re willing to drop everything else. This is very good.

Dan: We have still not gotten to the end of Dru’s first line in this scene Dru as Lawyer: It’ll garner you the shortest possible sentence.

Dru as Lawyer: Do you understand?

Dan: Back in the film, the Ellen character is still freaking out when she shows up for a doctor’s appointment.

Dr Receptionist: Has your insurance changed?

Ellen: No, but it might soon, so I wanted to make sure that you all would still take it.

Dr. Receptionist: Well, we take most insurances, so I’m sure we’ll be fine.

Ellen: Great. Um, I was looking on the California Insurance Exchange. Dr Receptionist: Uh, no.

Ellen: Excuse me?

Dr. Receptionist: No, we, we don’t take that.

Dan: And in the doctor’s office– in another echo of Ellen and Dru’s story– Ellen-the-character gets an ultrasound.

Ellen: Congratulations.

Dan: And she flashes back to the first scene, with her friend…

Best Friend: Couldn’t you cast yourself in something?

Ellen: Like in what? My own movie? (echos) My own movie?

Dan: And of course, that’s where she decides. She’s gonna do this. On her way out, she tells the receptionist…

Ellen: My insurance is not going to change. You can count on it. 

Dr. Receptionist: Um, okay.

Dan: When I saw the movie, I did not know that Ellen Haun had been pregnant when they made it.

Dru: We never brought it up in crowdfunding. But then when we were making the movie, we were like, let’s just use real life. Not only was it real, it felt like the easiest way to explain it.

Dan: They shot the movie over three days in December 2022. Making this film on $33,000 and change was a feat on its own. They paid 15 actors, and a crew. There was a location to rent, and equipment…

Ellen: You’ve got to pay for food to feed your cast and crew. And especially, you know, everyone is kind of working a little bit under their rate so you want to buy them good food.

Dan: You’ve heard some of the results. I won’t spoil the rest. It’s a very-enjoyable 13 minutes. We’ll have a link wherever you’re listening to this. With the movie wrapped by New Years, Ellen qualified for her insurance, so she was on it when their baby Bruce was born a few weeks early.

Ellen: We spent three weeks in the NICU and the entire time that we were in the hospital with him, we just kept saying, I’m so glad we have insurance. I’m so glad we have insurance. I’m so glad we have insurance.

Dan: Just a few weeks after Bruce was born, Dru’s union– the Writer’s Guild– went on strike. Then Ellen’s union went on strike too.

Ellen: We took Bruce to his very first picket when he was like two months old. And I’ve been going, like, about, once a week to, to picket with him. So everybody knows him at 

the Disney Picket location. He’s a little union baby.

Dru: We say the joke, he went straight from labor to labor action.

Dan: No joke, though: the SAG strike meant there was less work for actors in 2023– fewer chances to earn money and qualify for insurance. The health plan extended a grace period to keep folks from getting cut off, and a new law in California lets workers who are on strike get subsidized insurance from the state’s Obamacare exchange. Meanwhile, Ellen managed to book another commercial — only TV shows and movies were targeted by the strike, not ads — so their family is set for next year too. 

It’s a happy ending … for now. 

But this seems like an exhausting merry-go-round to stay on for the rest of your life. I asked Ellen and Dru how they felt about it.

Ellen: So something that has been nice about the strike has been talking to a bunch of our friends about how hard it’s gotten over the last several years to make a living doing this.

I was like in my late twenties when I got the SAG health insurance for the first time. I thought, like, “Great.” Like, “this is it.”

Dan: That was almost ten years ago. But somehow getting consistent work actually got harder over time. And that felt personal.

Ellen: It was like feeling, like, emotionally, like there’s something wrong with me that I am not making the amount of money that I made earlier in my career. And so, honestly, that has been a nice part of the strike has been realizing that, hey, this is happening to all of us. It’s not just happening to me. It’s really hard.

Dan: But it’s not just hard for actors and writers.

Dru: My brother works in tech. Right. And like, I think the nature of employment, across many industries has changed. And like, there isn’t really that same job security that there used to be when, like, my parents were coming up.

Dan: Dru thinks back to the time, years ago, when he first quit his day job, to write and perform full-time. It was touch and go at first. Like, week to week, it could feel precarious.

Dru: I had a kind of a down week and I was like, maybe it’s time to get a real day job like my brother. And right that week, he got laid off. He’s found another job, he’s figured it out, but it was that moment where I was like, oh, there’s no job that you can just get and be like, now I’m set with health insurance. So that’s a long answer to say, I don’t think we’re leaving the entertainment industry anytime soon.

Ellen: Yeah, we’ve kind of put all of our chips on the table.

Dan: And like Dru said: Fewer of us these days have jobs where we don’t have to worry about where our health insurance is coming from, or if it’s gonna be any good. I mean, if more of us had that kind of security, I would literally never have started making this show. There would be no reason to make it. But of course, five years in, I do not expect to run out of material.

As we publish this episode, we’ve also just put out an installment of our First Aid Kit newsletter, this one sums up and updates all our best advice about how to pick the least-crappy health insurance for you.

I’ve learned a lot in five years. And we’re able to share what we’ve learned because you’ve been supporting us. And if you can, this is the absolute best moment to pitch in, because right now, every dollar you give — up to a thousand dollars per person! — get matched. Thanks to NewsMatch from the Institute for Nonprofit News, every dollar you give us counts for double. The place to go is arm and a leg show, dot com, slash support. That’s https://armandalegshow.com/support/.

We’ll be back in three weeks with part one of a big investigative story we’ve been working on … pretty much all year. Talk about learning a ton. It’s been a wild ride. We’ve been able to do that — and we’ll be able to share the results with you– because of your support, and I am super-thankful. I’ll leave you with that address one more time: arm and a leg show dot com, slash, support. Thanks! I’ll catch you in three weeks. Till then, take care of yourself.

This episode of “An Arm and a Leg” was produced by Emily Pisacreta and me, Dan Weissman and edited by Ellen Weiss.

Daisy Rosario is our consulting managing producer. 

Adam Raymonda is our audio wizard. 

Our music is by Dave Winer and Blue Dot Sessions.

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.

Bea Bosco is our consulting director of operations. 

Sarah Ballema is our operations manager.

“An Arm and a Leg” is produced in partnership with KFF Health News — formerly known as Kaiser Health News. That’s a national newsroom producing in-depth journalism about healthcare in America, and a core program at KFF — an independent source of health policy research, polling, and journalism. You can learn more about KFF Health News at: https://armandalegshow.com/about-x/partners-and-supporters/kaiserhealthnews/

Zach Dyer is senior audio producer at KFF Health News. He is editorial liaison to this show.

Big thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about INN at INN.org

And now for one of my favorite parts of the gig … giving a shout out to some of the people who’ve come aboard to support this show in the last few weeks. Thanks at this time to our supporters (Dan lists donors.) Thank you so much! 

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and X, formerly known as Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Congress narrowly avoided a federal government shutdown for the second time in as many months, as House Democrats provided the needed votes for new House Republican Speaker Mike Johnson to avoid his first legislative catastrophe of his brief tenure. But funding the federal government won’t get any easier when the latest temporary patches expire in early 2024. It seems House Republicans have not yet accepted that they cannot accomplish the steep spending cuts they want as long as the Senate and the White House are controlled by Democrats.

Meanwhile, a pair of investigations unveiled this week underscored the difficulty of obtaining needed long-term care for seniors. One, from KFF Health News and The New York Times, chronicles the financial toll on families for people who need help for activities of daily living. The other, from Stat, details how some insurance companies are using artificial intelligence algorithms to deny needed rehabilitation care for Medicare patients.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• Congress passed a two-part continuing resolution this week that will prevent the federal government from shutting down when the current CR expires Nov. 18 at 12:01 a.m. The new measure extends some current spending levels, including funding for the FDA, through Jan. 19. The rest of federal agencies, including most of the Department of Health and Human Services, are extended to Feb. 2.
• House Speaker Mike Johnson (R-La.) has said he wants to use the next two months to finish work on individual appropriations bills, none of which have passed both the House and Senate so far. The problem: They would deeply cut many popular federal programs. They also are full of changes to abortion restrictions and transgender policies, highlighting the split between the GOP caucus’ far-right wing and its more moderate members.
• In the wake of abortion rights successes in passing abortion rights ballot initiatives, new efforts are taking shape in Ohio and Michigan among state lawmakers who are arguing that when Dobbs turned this decision back to states, it meant to the state legislatures — not to the courts or voters. Most experts agree the approach is unlikely to prevail. Still, it highlights continuing efforts to change the rules surrounding this polarized issue.
• Sen. Tim Scott (R-S.C.) — who was the only remaining Republican presidential candidate pushing for a national, 15-week abortion ban — suspended his campaign last week. He, along with former Vice President Mike Pence, who bowed out of the race at the end of October, were the field’s strongest anti-abortion candidates. This seems to suggest that the 15-week ban is not drawing voter support, even among Republicans. Meanwhile, former President Donald Trump, the GOP’s front-runner by miles, continues to be willing to play both sides of the abortion debate.
• Amid increasing concern about the use of artificial intelligence in health care, a California class-action lawsuit charges that UnitedHealth Group is using algorithms to deny rehabilitation care to enrollees in its Medicare Advantage program. The suit comes in the wake of an investigation by Stat into insurer requirements that case managers hew to the AI estimates of how long the company would pay for rehabilitation care, regardless of the patient’s actual medical situation.
• More than 10 million people have lost Medicaid coverage since states began reviewing eligibility earlier in the year. Advocates for Medicaid patients worry that the Biden administration has not done enough to ensure that people who are still eligible for the program — particularly children — are not mistakenly terminated.

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

Julie Rovner: KFF Health News’ “How Lawmakers in Texas and Florida Undermine Covid Vaccination Efforts,” by Amy Maxmen.

Alice Miranda Ollstein: The New York Times’ “They Wanted to Get Sober. They Got a Nightmare Instead,” by Jack Healy.

Rachel Cohrs: Stat’s “UnitedHealth Pushed Employees to Follow an Algorithm to Cut Off Medicare Patients’ Rehab Care,” by Casey Ross and Bob Herman.

Joanne Kenen: ProPublica’s “Mississippi Jailed More Than 800 People Awaiting Psychiatric Treatment in a Year. Just One Jail Meets State Standards,” by Isabelle Taft, Mississippi Today.

Also mentioned in this week’s episode:

• KFF Health News’ “Facing Financial Ruin as Costs Soar for Elder Care,” by Reed Abelson, The New York Times, and Jordan Rau.
• JAMA Internal Medicine’s “Excess Death Rates for Republican and Democratic Registered Voters in Florida and Ohio During the COVID-19 Pandemic,” by Jacob Wallace, et al.

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 16, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go.

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

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs of Stat News.

Rachel Cohrs: Hi, everybody.

Rovner: And Joanne Kenen of the Johns Hopkins University and Politico Magazine.

Joanne Kenen: Hi everyone.

Rovner: No interview this week, but more than enough news, so we will get right to it. So the federal government is not going to shut down when the current continuing spending resolution expires at 12:01 a.m. Saturday. In basically a rerun of what happened at the end of September, new House Speaker Mike Johnson ended up having to turn to Democrats to pass another CR. This one extends a bunch of federal programs until Jan.19 and the rest of them until Feb. 2. Most of HHS [the Department of Health and Human Services] is in the latter category, but the FDA, because it’s funded through the Department of Agriculture, its spending bill would be in the group that’s funded only through Jan. 19. Don’t worry if you don’t remember that.

The stated goal here is to use the next two months, minus what’s likely to be a sizable Christmas break, to finish work on the individual appropriation bills, of which exactly zero of 12 have passed both the House and Senate and been sent to the president. Meanwhile, in just the last week, House Republicans have been unable to pass any of the individual appropriations they have brought to the floor and a few haven’t been able to even get to the floor. Yesterday, Republican leaders pulled the plug on the rest of the week’s floor schedule, literally in the middle of a series of votes on the HHS spending bill. So Democrats are not going to bail them out on these individual bills the way they have on the relatively clean continuing resolutions because the individual bills include very deep spending cuts and lots of abortion and transgender and other culture wars riders. So what exactly do they think is going to change between now and the next deadline?

Ollstein: Well, there’s been a lot of chatter about how cranky members of Congress have gotten because they worked 10 weeks in a row. Most of us work 10 weeks in a row without destroying each other, but there it is. And so there’s the hope that when they come back …

Rovner: Yes, there were threats of physical violence this week.

Ollstein: And allegedly some actual physical violence. Most of us work 10 weeks in a row without assaulting our colleagues, but we are not members of Congress. So the idea is they could take some time to cool off and come back and be more collaborative, but really this is a problem the Republican Caucus has not been able to solve. You have dissent on the right of the caucus and the sort of more moderate left or more left side of the caucus. You have moderate members who are worried about getting reelected in districts that voted for [President Joe] Biden who are not wanting to vote for these spending bills that are full of anti-trans and anti-abortion provisions, which you could easily picture that being used against them in campaign ads. And then you have folks on the far right in the Freedom Caucus who are sort of tanking these individual bills to protest the overall trajectory of spending and the overall process. So this is not going away anytime soon. And, like you said, Democrats are not bailing them out here.

Cohrs: One other point I wanted to make, sorry, Julie, on the deadlines is that for people who are interested in health policy and PBM [pharmacy benefit manager] reform and DSH [Medicaid’s Disproportionate Share Hospital] cuts, all of those. Those all have a Jan. 19 deadline. So those will come with the first round. So I think for the people out there who are worried about those policies, community health centers, extenders, that will happen with the first deadline even though the full Labor, HHS preparations aren’t until the second one.

Rovner: Yeah, these continuing resolutions do carry some of these extraneous, what we like to call “extender,” provisions that would otherwise have expired. And so they’ll keep them going for another couple of months and keep lobbyists busy wringing their hands and keep all of our inboxes full of emails of people warning of terrible things that will happen if these programs aren’t continued. But I want to go back to the underlying problem here, though, is that first of all, the conservative Republicans say they want to put the budget on a different trajectory. Well, discretionary spending, which is what we’re talking about here with the 12 spending bills, is a tiny portion of what makes up the budget and the budget deficit. So even if they were to cut all of these programs as dramatically as they like, they wouldn’t have much of an impact on the overall budget. I’m sort of mystified that people don’t keep pointing that out.

Ollstein: Well, and they’re also cutting things that won’t save money. I mean, they wanted to cut things like IRS enforcement, which would lose money because then the IRS wouldn’t be going after wealthy tax cheats and recouping that government spending. And so some of this is ideological. They’re going after health care programs that support LGBT people, for instance, and that doesn’t save that much money. But there’s been a lot of speeches from Republicans railing against the substance of the programs and calling them “woke” and inappropriate and such. And so, yes, some of this is fiscal, but a lot of it is also ideological.

Kenen: Yeah, it’s a relatively small portion of federal dollars, but a relatively large portion of culture war.

Rovner: Yes, I think that is a very good way to put it because, of course, it’s a place where they can put culture war things because they have to come up every year. But yeah, I think that’s why we end up fighting over this. All right, well this fight has been put off until 2024, although it’ll be the first thing when we get back.

Kenen: Yeah. And nothing’s really going to change except maybe cooler heads prevail. Anyone see any cooler heads around there? They may come back a little bit more personally tolerant when they’ve had some time off over the holidays. But the basic ideological and political alignment and the loggerheads, it’s like the only thing that changes between November, December, and January is it’s colder here then.

Rovner: Yeah, that’s exactly correct. Yeah. The far right of the House Republican Caucus is going to have to realize that there is a Senate and there is a president and they all get a say in what these final bills look like too. So they can’t just dictate we’re going to make all these cuts and, if not, we’re going to close down the government, unless that’s what they decide to do.

Kenen: But I think they skipped that session in their orientation.

Rovner: Yeah. Apparently.

Kenen: They’re not finding, “OK, where’s the compromise? What do we really, really, really want? And what are we willing to trade that for?” They’re not doing that. If you give and take, everybody gets some victory, and you have to identify what victory you can get that satisfies you. But there’s no sign of any kind of realistic grasp that this is divided government.

Rovner: Right. And they yet to figure that out. All right, well let us turn to abortion, where there is always news. We are going to start in Ohio, where last week voters, by a pretty healthy margin, approved a ballot measure to enshrine abortion rights in the state constitution. Now, though, some anti-abortion lawmakers in Ohio say, “Never mind, we can overrule that.” Really, Alice?

Ollstein: So there are efforts going on in both Ohio and Michigan to block, undo, undermine what voters voted for in these referenda and, based on talking to sources, it seems like neither of these really have legs. They’re sort of seen as just messaging. But I think that even the attempt to try to undermine or undo what voters overwhelmingly approved is telling and interesting. And, of course, it builds on all of the attempts leading up to the votes that we saw from these same forces to try to change the rules, make it more difficult. So I think when state legislatures around the country come back into session in January, we’re going to be watching closely to see if they pass things that aim to block these votes. So definitely something to keep an eye on.

Rovner: I did see that this speaker of the Ohio House has poured at least some cold water on this effort. The argument had been from some of these lawmakers that because the Supreme Court gave this decision back to the states, that means only state legislatures and not the courts and not the voters directly. Am I interpreting that right?

Kenen: Yeah, the speaker was pretty firm. He said … what did he say? It was “Schoolhouse Rock”? He basically said that the voters, they matter.

Rovner: Yeah.

Ollstein: And what’s interesting is that the court that they want to cut out of this in Ohio is very conservative. And so this isn’t like, “Oh, we want to block these liberal activist judges from weighing in here.” This is “We want to keep this solely in the hands of the legislature and not have, really, courts have a role in it at all,” although the courts are very conservative and tilt in the anti-abortion direction anyway, which I think is notable.

Rovner: We’ll definitely watch that space in the upper Midwest/Great Lakes. Well, elsewhere, in Alabama, in a story that I didn’t think got the coverage it deserved, the Justice Department is joining a case brought by an abortion fund and some former abortion providers about whether the state might be able to prosecute them for helping women travel to obtain an abortion in another state. Department of Justice says, “Of course, states can’t prevent people from traveling to other states for things that are legal in another state, but not in their state. Otherwise, very few people would be able to go to Las Vegas.” But the state attorney general has yet threatened to try to prosecute, has he not?

Ollstein: Yeah, so this is happening in a few states, but it’s sort of come to a head in Alabama in terms of treating groups that either provide material support for people to travel across state lines for an abortion or even just information, even just “Here’s a clinic that you can call in this other state.” Not even a formal referral, medical referral, but just information about where to go. The attorney general has threatened to consider that kind of a criminal conspiracy to violate Alabama’s abortion ban.

So this is an interesting test, and I think it may — like the travel bans we’ve been seeing proposed and even implemented in some cities, states, et cetera. They’re sort of trying a bunch of different things. But these are basically impossible to enforce. And so, really, what’s happening here is an attempt to undo some of the chilling effect of these laws. Right now, people are so afraid of being charged with criminal conspiracy that they’re holding off on, even providing publicly available information that’s likely protected by the First Amendment. And so they’re hoping that a court ruling saying “You do have the right to at least discuss this and even give people support to travel” will undo some of that chilling effect. And yeah, I think that’s sort of the key here.

Rovner: Yeah. Well, moving on to Texas, where a lot of these other travel bans have been tried, at least in some cities and counties, we want to go back to that case where a half a dozen women who couldn’t get care for pregnancy complications, because of the state’s abortion ban, sued. Well, now there are 22 plaintiffs in that case, including two doctors and a then-medical student who discovered her fetus’s lethal abnormalities at an 18-week scan. The Texas Supreme Court is supposed to hear this case later this month, but, Alice, this could really end up before the U.S. Supreme Court, couldn’t it? This is the concern of women who are not trying to have abortions. They were basically trying to complete pregnancies and have had things go terribly wrong. And, as you just said, doctors are afraid to treat them for fear that they’re going to be prosecuted.

Ollstein: Yeah. And so this is where state abortion bans are running up against federal protections for … you have to treat a patient who comes in who’s experiencing a medical emergency. This is the EMTALA, a federal law, and these things are in conflict. Anti-abortion groups and advocates say that they are not, and that medical care in these situations is already protected. But as we’ve seen with this chilling effect, doctors are afraid to act in these situations and they’re telling patients to go away and come back when things are more dire. And that, in some cases, in these plaintiff’s cases, has led to pretty permanent damage, damage to their future fertility, threats to their lives. And so these cases are not seeking to get rid of the abortion bans entirely, as some other lawsuits are, but they are seeking to really make clear, because it’s not clear to medical providers right now, make clear what is allowed in these really sensitive and precarious medical situations.

Rovner: Yeah, I keep hearing a lot of the anti-abortion forces saying, “Well, it’s not technically an abortion in these cases. If it’s an ectopic pregnancy or something or the woman’s water has broken early and she’s going to get septic.” And it’s like, “Except that medically, yes, they are. A termination of pregnancy is termination of pregnancy.” And that’s why the doctors are saying, “You can call this anything you want. We’re the ones who are going to get thrown in jail and lose our medical licenses.” All right. Well, before we move on, I want to talk some abortion politics. Sen. Tim Scott of South Carolina, who had been the only Republican presidential candidate strongly pushing for a federal 15-week abortion ban, suspended his campaign this week after what happened in Virginia last week, which we talked about at some length. When Republican Gov. Glenn Youngkin tried to win back the state legislature for Republicans by promising to sign his own 15-week ban and lost spectacularly. Where does that leave Republicans on abortion going into 2024? Obviously, the 15-week ban as a compromise doesn’t seem to be flying.

Ollstein: No, it’s certainly not. And Tim Scott and Mike Pence were some of anti-abortion groups’ favorite candidates who were saying what they wanted to hear, and both of their campaigns have now ended. And so, meanwhile, you have the people who have been a little more squishy, from anti-abortion advocates’ perspective anyways, like Nikki Haley and [former President Donald] Trump himself, doing the best. DeSantis also sort of middling right now on the downward trajectory, seemingly.

Rovner: DeSantis, who signed a six-week ban in Florida.

Ollstein: Exactly, but was also kind of unclear about what he would do as president, which the anti-abortion groups did not like. It’s interesting, maybe telling, that the people who were sort of the staunchest anti-abortion voices have not seemed to do well in this moment, but let’s be real. Trump is the far-and-away front-runner here. It’s most important to examine Trump. And he’s sort of trying to have it both ways. He’s both touting his anti-abortion bona fides by talking about appointing the justices to the Supreme Court that overturned Roe v. Wade, taking credit for that. And at the same time sort of pushing this line of, “Oh, we’ll strike some sort of compromise.” He really talks up exemptions for rape and incest, which, by the way, a lot of anti-abortion groups don’t want those. And so he’s sort of speaking out of both sides of his mouth, but, at least according to the polls, it seems to be working.

Rovner: Yeah, maybe that’s the answer for Republicans is tell everybody what you think they want them to know. I guess we will see going forward. Well, I want to move on. I’m calling this next segment, “Getting Old Sucks: Ask Me How I Know.” I want to start with a joint project that KFF Health News has out this week with The New York Times called “Dying Broke.” It’s about, and stop me if you’ve heard me say this before, the fact that the U.S. has no policy to help pay for long-term care, save for Medicaid, which only pays if you basically bankrupt yourself and your family.

There is a lot in this series, and I highly recommend it, but one of the things that jumped out to me is that the cost of long-term care has risen so much faster than incomes that even if you started saving for retirement in your 20s — I started saving for retirement in my 20s — you’d still be unlikely to have enough to self-insure for long-term care when you’re 75 or 80. Joanne, you’ve spent as much time as I have, probably more, writing about our lack of a long-term care policy. Anything jump out at you from this project?

Kenen: It was a terrific, terrific story, and it brought to life that even people who are definitely what you would think of as economically comfortable, it’s not enough. It’s just the luck of the draw, right? I mean, if you die fast, you can at least leave money to your kids. If you die slow, you can’t. It was a really good story. But what I always am left with when I read these stories is it doesn’t make a difference. Congress does not want to deal with this. Julie and I actually did a panel for a health group a few weeks ago, and one of the state … someone from California came up to talk about us and asked, “Why doesn’t the United States have a long-term care policy? I’m going to change that.” And we were trying to be polite, but it was like, “OK, good luck with that.” And this is not a partisan issue. Republicans and Democrats both get old and Republicans and Democrats both end up needing long-term care, whether it’s in the nursing home or assistance in your own home. Republicans and Democrats both get Alzheimer’s and other forms of dementia. They both get disabled. And we have a government that just plugs up its ears because it costs so much money and it’s an entitlement and they just don’t even want to deal with it. And generation after generation, it’s a disaster. It’s inhumane.

Rovner: And, of course, there was this brief effort in the Affordable Care Act with the CLASS Act that everybody was very excited …

Kenen: To nibble around the edges of it. The CLASS Act was good, but it wasn’t even solving the problem.

Rovner: And it went away because they discovered that even that was going to be too expensive. It could not be self-sustaining. And that’s been the problem with the private long-term care insurance market too, that you basically can’t get private long-term care insurance anymore because insurers cannot afford to sell it. They lose too much money on it, and therefore it would be too expensive if they actually charged what they needed to to even break even.

Kenen: Right. And there is an idea circulating, but it’s not getting any traction. It’s circulated in the past too, a joint approach, a reinsurance approach, that you’d try to strengthen the private long-term care insurance market, which is very broken. You’d try to fix that, but you wouldn’t expect the private insurance market to do the whole problem, so that there’d be reinsurance from the government. So for people who had maybe, I don’t know exactly how it works, say a year or two of expenses that private insurance would kick in and we would make that market work better and be there when you needed it. But then if you were somebody who had multiple years and you exhausted that benefit, there would be a backup entitlement.

Rovner: But I’ve heard this talked about for at least 10 years, and it’s never gone anywhere.

Kenen: It’s revived and it’s not getting … I don’t think it has a sponsor in this Congress. It did in the last Congress. There’s no discussion. There’s no … a lot of people think that Medicare actually pays for nursing homes, and then that’s a pretty big surprise because it only pays for very limited … it pays, like if you have surgery and you need some rehab at a nursing home for, what is it? Is it 12 weeks? I forget what it is, but it’s short-term. It’s a couple of months. It’s not dementia care. And even the other thing is when you read about the cost of long-term care, that’s just the room and board, that doesn’t include your doctors’ bills, your medication, clothing, personal aide, because people who are complicated and need a lot of care often need a personal aide in addition to the staff. It’s just a phenomenal amount of money. My kids don’t understand when I say we need to save money, they say, “Don’t you have enough?” And no, nobody has enough. Bill Gates has enough.

Rovner: Yeah, Warren Buffett has enough. Well, so, as I mentioned, one of the big problems with long-term care is that there’s essentially no private insurance for it anymore because it’s so expensive and because so many people end up needing it. That’s very different from Medicare Advantage, where insurers are and have been making lots of money providing benefits that would otherwise be paid for by the federal government. But Rachel, some of your colleagues have discovered that, and in at least some cases, those insurers are making all that money because they’re denying care to patients who need it. This is your extra credit this week, but I want you to talk about it now.

Cohrs: I’ll talk about it early. Yes. So my colleagues, Casey Ross and Bob Herman have been digging into the role of algorithms in insurance decisions for the past year. And they just released a new story this week about — with internal documents of a subsidiary called naviHealth of UnitedHealth — showing that the company was instructing managers to keep care timelines for a really expensive rehab that older people, I think, need after having injuries or something like that within 1% of the time that this algorithm was predicting, regardless of what their actual human doctors were saying. And truly, the stories behind these care denials are just really horrifying … of somebody who had a knee surgery and was expected to slide on their butt down the stairs because they weren’t paying for rehab. Families who’ve had to pay tens of thousands of dollars out of their own pocket after this care was denied because they saw that their loved one clearly needed money, and there was a class-action lawsuit filed, then after the story was published, by people who had deceased relatives who had UnitedHealthcare MA plans, and were denied rehab and later died. And so I think it’s just really eye-opening as to the actual instructions by managers inside the company saying that this is your expectation, and if you’re not keeping coverage care rehab timelines within this 1% margin, then you aren’t performing up to our standards.

Rovner: So this is basically AI being used to deny care. We keep talking about AI and health care. This is it, right? This is an algorithm that says, “Person who goes into rehab with these kinds of problems should only need 19 days.” And if you need more than that, tough. That’s essentially what’s going on here, right?

Cohrs: And the lawsuit did highlight as well that when people did appeal, they won most of the time, but most people didn’t appeal, and the company knew that. And so I think that was also part of the lawsuit that came up. It’s hard to prove intent with these things or what is a denial based on an algorithm? But I think this lays out the case in as explicit terms as we’ve ever seen from the internal side.

Rovner: It does. All right, well let us move on from Medicare to Medicaid, the unwinding — involving reviewing everyone on the program to make sure they’re still eligible now that the pandemic emergency has expired — continues with more than 10 million people now having lost their coverage, according to the tracker being updated by my KFF colleagues. And state Medicaid directors are predicting a year-over-year decrease in enrollment of 8.6%, which is pretty dramatically large. We also know that more than 70% of those being disenrolled may in fact still be eligible, but the state was unable to locate them or they didn’t file the right paperwork. Ironically, even with a much smaller caseload, state Medicaid spending is likely to rise because the additional payments that were provided by the federal government also expired at the end of the public health emergency. So states are basically having to pay more per enrollee than they were paying even when they were leaving everybody on the rolls. Advocates have been complaining all year that the Biden administration isn’t doing enough to ensure that states aren’t tossing people off who should still be covered. Has anything changed on that front? I know that the administration is sort of caught between this rock and a hard place. They don’t want to come out guns blazing and have states saying that they’re making this politicized. On the other hand, the numbers are getting pretty big and there’s increasing evidence that a lot of the people who are being relieved of their coverage should still have it.

Ollstein: Including a lot of children who absolutely did not do anything wrong in this situation. And so it kind of reminds me of some stuff during covid, where the Biden administration did not want to get into a public fight with GOP-controlled states and was trying to negotiate behind the scenes to get the policies they wanted to protect people. But at the same time, not wanting that open confrontation means that a lot of this is continuing to go on unchecked. And so the data is coming out showing that a lot of people who are losing coverage are not reenrolling in other coverage. Some are, but a lot are not. And so I think now that we’re getting, going to get into Obamacare open enrollment, I think that’ll be really key to see — can we scoop up a lot of these newly uninsured people?

Rovner: And we did, we saw the administration put out a press release saying that the early part of open enrollment has seemed very large, much larger-than-expected enrollment. And you kind of wonder, I’m kind of wondering, how many of those people were people who got kicked off of Medicaid. And, of course, we know that when people got kicked off of Medicaid, they were supposed to be steered to the Affordable Care Act, for which they would’ve obviously been eligible. But I’m wondering whether some of those people didn’t get steered and now that they’re seeing that enrollment is open, it’s like, “Oh, maybe I can get this.” I have not seen anybody answer that question, but it’s certainly a question in my mind.

Cohrs: Right. And coverage is more affordable as well because subsidies from the covid-era spending bills do extend through 2025. But again, people might see increases in costs once those end, if Congress doesn’t extend them. So even if we do see some people moving from Medicaid to ACA enrollment, then there’s a chance that they could see spikes in a pretty short amount of time.

Rovner: Yeah, I’ll be curious to see as open enrollment continues, whether they can break down where some of those people are coming from. All right, now it is time for “This Week in Health Misinformation.” I have chosen a KFF Health News story, which is also my extra credit this week, from science journalist Amy Maxmen, called “How Lawmakers in Texas and Florida Undermine Covid Vaccination Efforts.” It seems that in Texas health departments and other organizations funded by the states are now prohibited from advertising or recommending covid vaccines or even saying that they are available, unless that’s in conjunction with telling them about other vaccines that are available, too. In Florida, as we have talked about here before, the health department has issued specific guidance recommending against the new covid vaccine for children and teens and now men under the age of 40. Unless you think this hasn’t had any impact before the vaccines were available, Democrats and Republicans were dying of covid in roughly equal proportions in Florida and Ohio, according to a study published earlier this summer in the journal JAMA Internal Medicine.

But by the end of 2021, which was the first full year that covid vaccines were widely available, Republicans had an excess death rate of 43% higher than Democrats. So medical misinformation has consequences. All right, now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Rachel, you’ve done yours already. Alice, why don’t you go next?

Ollstein: Sure. So I have a very depressing one out of The New York Times by Jack Healy and it’s called “They Wanted to Get Sober. They Got a Nightmare Instead.” And it is about these fraudulent, scammy addiction treatment facilities in Arizona, but it notes that they do exist in other states as well, that have been bilking the state Medicaid program for just millions and millions and millions of dollars and providing inadequate or nonexistent treatment to really vulnerable people in need, with very deadly consequences. And the places profiled in this piece really went after Native American folks specifically. So very sad report, but it sounds like more attention on this is leading to the state cracking down on places like this. So, hopefully, we’ll make some progress there.

Rovner: Yeah, quite a story, Joanne.

Kenen: This is a story, part of an ongoing series from Mississippi Today, in conjunction with ProPublica’s local reporting network: “Mississippi Jailed More Than 800 People Awaiting Psychiatric Treatment in a Year. Just One Jail Meets State Standards.” It’s by Isabella Taft. In Mississippi, if you’re unfortunate enough to have such serious mental illness that a court orders you to have treatment and there’s no room in a state hospital, they put you in jail while you wait for a room in state hospitals. And sometimes they’re housed in these facilities or rooms that are meant for people with severe mental illness, but they’re awful. And sometimes they’re just housed with a regular prison population. And the sheriffs say, “Wait a minute, it’s not really our problem to be housing … state hospitals have to fix this.” And they have a point! But in the meantime, that’s who they have. That’s where they end up. They end up in these jails, these local jails, and the sheriffs are responsible. And only one hospital meets the state certification for what these people need.

And some of these stays. They’re not like two days, they can be prolonged. There’ve been a lot of deaths, there’ve been a lot of suicides. It’s a really pretty disturbing situation. It’s sort of the mental health crisis and the mental health provider shortage and countrywide really writ large among some of the most vulnerable people.

Rovner: All right, well, we’ve had four grim extra credits this week, but they’re all good stories. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks this week to Zach Dyer for filling in as our technical guru while Francis [Ying] takes some much-deserved time off. We’re going to take next week off, too, for the Thanksgiving holiday. As always, you can email us your comments or questions or your suggestions for our medical misinformation segment. We are at whatthehealth@kff.org. Or you can still find me at X, @jrovner, or @julierovner at Bluesky and Threads. Alice?

Ollstein: @AliceOllstein on X, and at AliceMiranda on Bluesky.

Rovner: Rachel.

Cohrs: I’m @rachelcohrs on X and rchohrsreporter on Threads.

Rovner: Joanne.

Kenen: @JoanneKenen on X, and I’m increasingly switched to Threads at @joannekenen1.

Rovner: We will be back in your feed in two weeks. Until then, be healthy.

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Supporters of abortion rights again scored big at the polls in several states’ off-year elections Nov. 7, including in some Republican-dominated states like Ohio and Kentucky. The biggest prize came in Ohio, where voters approved a ballot measure writing the right to an abortion into the state constitution, despite strong opposition from the governor and other top elected state officials.

Meanwhile, the Senate approved the nomination of Monica Bertagnolli to become the new director of the National Institutes of Health by a bipartisan 62-36 vote. Bertagnolli — previously director of the National Cancer Institute, a large NIH component — had seen her nomination held up for weeks by Sen. Bernie Sanders (I-Vt.) over a mostly unrelated fight with the Biden administration about prescription drug prices.

This week’s panelists are Julie Rovner of KFF Health News, Tami Luhby of CNN, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll.

Panelists

Among the takeaways from this week’s episode:

• Election night 2023 was a very good night for abortion rights supporters generally and, specifically, in Ohio, Kentucky, Virginia, Pennsylvania, and New Jersey. Republican governors and state leaders invested significant political capital to defeat abortion rights ballot questions and candidates, and lost. Some anti-abortion leaders’ embrace of a 15-week abortion ban as a potential compromise didn’t seem to help their cause.
• Abortion rights supporters’ winning streak raises a broader point about ballot initiatives. State legislatures in some red-leaning states have not only enacted abortion restrictions but also fought off Democratic-backed issues like Medicaid expansion only to have the state’s voters reverse them through ballot questions. As a result, conservative leaders are pushing states to make it harder to get referendums on state ballots.
• On Capitol Hill, lawmakers are once again facing a potential government shutdown Nov. 17, with the expiration of the last “continuing resolution” to keep government spending going. But House Republicans are not making much progress on passing individual spending bills, as several measures have been pulled from the House floor because they lacked the votes to pass.
• The Federal Trade Commission this week announced it is challenging more than 100 patents on brand-name medicines. Although mind-numbingly complex, the action, which could open the door to more generic options for some commonly used medicines such as asthma inhalers, could lead to lowering drug costs.
• “This Week in Medical Misinformation” highlights a study from the Ohio State University that found much of the information available to gynecologic cancer patients on TikTok is inaccurate or of little value.

Also this week, Rovner interviews KFF Health News’s Julie Appleby, who reported and wrote the latest “Bill of the Month” feature, about a woman who got billed for what should have been a no-cost physical exam. If you have an outrageous or baffling medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: ProPublica’s “Find Out Why Your Health Insurer Denied Your Claim.”

Alice Miranda Ollstein: Politico’s “Congenital Syphilis Jumped Tenfold Over the Last Decade,” by Alice Miranda Ollstein.

Sandhya Raman: The Texas Tribune’s “Sex Trafficking, Drugs and Assault: Texas Foster Kids and Caseworkers Face Chaos in Rental Houses and Hotels,” by Karen Brooks Harper.

Tami Luhby: ProPublica’s “Big Insurance Met Its Match When It Turned Down a Top Trial Lawyer’s Request for Cancer Treatment,” by T. Christian Miller.

Also mentioned in this week’s episode:

The Journal of Gynecologic Oncology’s “‘More Than a Song and Dance’: Exploration of Patient Perspectives and Educational Quality of Gynecologic Cancer Content on TikTok,” by Molly Morton et al.

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 9, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Tami Luhby of CNN.

Tami Luhby: Hello.

Rovner: And Sandhya Raman of CQ Roll Call.

Sandhya Raman: Hello, everyone.

Rovner: Later in this episode, we’ll have my interview with my colleague Julie Appleby, who wrote the latest KFF Health News-NPR “Bill of the Month.” This month’s patient had a very small bill, but it violated an important principle. But first, this week’s news, and there is more than enough.

Election night 2023 has come and gone, and it was a very good night for abortion rights supporters in Ohio, Kentucky, Virginia, Pennsylvania, and New Jersey. Alice, catch us up here.

Ollstein: Yeah, so this was a really striking example that I think undermined some of the talking points from the anti-abortion side after the 2022 midterms, where they also did worse than they expected. The narrative after that was that they lose when Republican candidates shy away from the abortion issue and don’t forcefully campaign on it. And the results this week sort of undermined that because, in Ohio, the Republican state officials went all in. I was at rallies where they were speaking, they cut ads saying, “Vote no on this abortion rights amendment.” They really put political capital into it.

An even stronger example is in Virginia, where Gov. Glenn Youngkin went all in on promoting his 15-week ban, wanting to flip the state legislature in order to advance that. He put a lot of his own money into this, et cetera. And it just …

Rovner: And the state legislature did flip, just not his way.

Ollstein: Exactly. It flipped the other way. So it really flopped in both places. And so now you have another round of finger-pointing on the right and disagreements over why they lost and what they need to do better. And so you have some people staying on that same narrative from last year saying, “Oh, they need to campaign even harder on restricting abortion.” And then you have other people saying, “Look, this is clearly a loser for us. We need to talk about other topics.”

But what was really striking, you mentioned New Jersey, and that’s sort of a counter-example because there, the Republican candidates tried to sidestep the abortion issue and say, “Look, this is settled. Abortion is legal in our state. This is not something we’re going to touch.” And they still lost. So it’s like, they lose on abortion when they campaign hard on it, they lose on abortion when they don’t campaign hard on it. And you have people arguing over what sort of magic words to use to connect with voters, but it really seems that it’s not really about the words; it’s about the policy itself.

Rovner: I want to dig a little harder into the whole 15-week-ban thing, and in Ohio it was just a straight up or down, are we going to enshrine abortion rights in the state constitution? And voters said yes, which did surprise a lot of people in a red state, although it’s, what, the fifth red state to do this?

But in Virginia, it was a little more subtle. The governor was trying to push a 15-week and they were calling it a limit, not a ban. And that’s apparently been the talking point for national Republicans, too, on federal, that this could be a compromise to have only a 15-week limit. Not working so well, right?

Ollstein: That’s right. I mean, that goes to what I was saying about you can sort of rebrand all you want. There’s been talk about rebranding “ban” to “limit.” There’s been talking about rebranding the term “pro-life,” but, ultimately, because of the events of the last several years, people associate Republicans with wanting to ban abortion. And that’s true whether it’s a total ban or a 15-week ban. It’s true whether you call it a ban or a limit or a restriction or whatever. And, like I said, it’s true when Republicans talk about it and when they don’t talk about it.

Most people, the country is still quite divided on this, but most people, a majority, enough to sway these elections, are saying that they would rather not have these kinds of imposed restrictions. And that’s really been galvanized by the overturning of Roe [v. Wade]. A lot of people were bringing up what Justice [Samuel] Alito wrote in his opinion overturning Roe saying, “Women are not without political power.” And people are saying, “Hey, look, that’s quite true. Thank you, Justice Alito.”

Rovner: So the other big political event obviously this week was the third Republican presidential candidate debate, this time with only five candidates on the stage, none of them named Trump.

As popular as abortion is turning out to be as a voting issue, President [Joe] Biden is not popular. In fact, I’ve seen many, many of these charts that showed that support for abortion rights is running 10 or 15 points better than President Biden. So these Republicans, who are hoping that something happens to Donald Trump, did finally talk about abortion, and most of them still seem to be in the “I’m proudly pro-life” stage. I mean, is there any way to walk this tightrope for them?

Ollstein: I think what was fascinating about the debate was you’re not really seeing a shift in reaction to this electoral shellacking that they got. The candidates who were for national bans and restrictions are still for national bans and restrictions. The candidates who want the states to decide say, “I want the states to decide.”

And it’s interesting that Nikki Haley is getting a lot of praise for her position, which she came out and said, “Yes, I’ll sign whatever Congress is able to pass that restricts abortion, but we should be upfront with voters and say that it is highly unlikely that anything will be able to pass the Senate.” It’s interesting that that seems to be appealing to people because …

Rovner: It’s true.

Ollstein: It is true, but it pisses off multiple groups. Democrats are zeroing in and hammering her on saying, “I will sign whatever ban Congress is able to pass” as evidence that she is still a threat to abortion access. Meanwhile, folks on the right, conservatives, anti-abortion people, they want her to champion a ban. They don’t want her to sort of downplay its likelihood. They want her to say, “Look, this might be very hard to get done, but I will be your champion for it.” And so she’s sort of not appealing to the left or the right with that stance, but it seems like there are some she is appealing to.

Rovner: Yeah. If anybody has ever succeeded in straddling the middle, she’s certainly making the effort.

I want to go back to the states for a minute. I think it was in your story that I read that one of the anti-abortion groups was talking about “the tyranny of the majority,” which took me a minute to think about, trying to get some of these states that could still put abortion constitutional amendments on their ballots, trying to get that stopped. Is that basically the next battleground we’re going to see?

Ollstein: Oh, yes. And it’s already started, but what really struck me is how open they’re being about it. So over the past year, a lot of states have quietly moved with legislation and through other means to try to make it harder or impossible to put an up-or-down question about abortion before voters, raising the threshold, raising the signature limit, mandating that people get signatures from this many counties and this and that and the other thing, making it more difficult. Mississippi is trying to make a carve-out so you can do a ballot measure on anything but abortion. We’ll see where that goes.

And so this has been going on, but the statements after Tuesday’s election from anti-abortion groups openly saying, “This is the tyranny of the majority and the human rights of babies should not be subject to a popular vote,” just completely going down this anti-Democratic road and being explicit about it. So I think it’s definitely something to keep an eye on.

Luhby: And this started with expanding Medicaid also because there’ve been multiple states now that have expanded Medicaid through ballot measures, multiple red states, and several states, including states that eventually passed that, have been trying to limit the ability of voters to pass it.

Rovner: Yes, we’ve got all these sort of Republican-dominated legislatures, but when the voters actually go to these single topics, they don’t necessarily agree with the legislators that they have elected.

Raman: Last year, one of the ones that abortion rights supporters had really championed was Michigan as the first citizen-led constitutional amendment to codify abortion rights. And then this week, we had a lawsuit brought against to invalidate that passing last year, and it’s unclear how that’ll go and play out in the courts, but it really seems like they’ve been slowly ramping up the strategies to see what sticks to be able to claw back some of this stuff.

Rovner: They, the anti-abortion force.

Raman: Yes, yes. And I was also going to say that when we’re talking about Mississippi, that is probably one of the one places where I think abortion opponents really had their win in that we had Lynn Fitch, their attorney general, who was the one that litigated the Dobbs decision that is making this such a big topic now, who pretty handily won reelection. And her opponent was pretty vocally an abortion rights supporter, Greta Kemp Martin. So that is one …

Rovner: The Republican governor also won in Mississippi.

Raman: Yes, yeah.

Rovner: It kind of prevented it from being a clean sweep for Democrats.

All right, well, I want to go back to the debate for a minute because they also talked mostly about foreign policy, but they did talk about entitlement reform, which had not come up, I don’t think, before. Talk about trying to straddle the middle. Here, Donald Trump has come out and vowed not to cut Social Security and Medicare, and yet we know that both programs need to have some kind of change or else they’re going to run out of money.

So how are these candidates trying to separate themselves on this thorny problem, Tami? They all seemed to say as much as they could without really saying anything.

Luhby: Exactly. I’m not sure there’s a lot of separation there, other than just saying, “We’ll look at it and we’ll see it.” But I mean, to some extent they’re right. The moderators were really trying to press them on what’s the age? What are you going to raise the age to? It’s now, the full retirement age is being ramped up to 67. The early retirement age has stayed at 62, and the moderators were like … they wanted a number.

And the candidates were sort of right in saying that they can’t just give a number because there are multiple things that can be done. I mean, a little bit more than I think what Nikki Haley said, or one of them had said it was three things that can be done. There’s more levers than that, but the age will ultimately depend on what they do with the formula, what they do with COLA, what they do with taxes. So there’s multiple things that can be done.

But what is definitely true is you can’t say that discussions are off the table because, according to the latest Trustees Report, Social Security will not be able to pay full benefits after 2034. At that time, it’ll only be able to pay about 80%. Medicare Part A can only pay full-schedule benefits till 2031. After that, it’ll only be able to cover 89%. And the new [House] speaker, Mike Johnson, has called for a debt commission and he says he wants to address Medicare and Social Security’s insolvency as part of the debt commission, which has really scared a lot of Social Security and Medicare advocates because of his Republican Study Committee background.

Rovner: Of actually wanting to cut Social Security and Medicare.

Luhby: Right. And do a lot of the things, although not raise taxes, but do a lot of things that the advocates don’t like. But yeah, there wasn’t really a lot to take away from the debate on Social Security and Medicare, other than them saying they wanted to do something, which they need to do.

Rovner: I was amused, though, that Nikki Haley said she wanted to expand Medicare Advantage without pointing out that Medicare … as if that was a way to save money because, as we’ve talked about many, many, many times, Medicare Advantage actually costs more than traditional Medicare at the moment. That’s one of the things that’s hastening the demise of Medicare’s trust fund in other places.

While we are on the subject of Washington and spending, we have yet another funding deadline coming up, this one Nov. 17, which is a week from Friday. We’ll obviously talk more about this next week, but Sandhya, how is it looking to keep the lights on?

Raman: I think we could just put a big question mark and that would be evergreen, but we’re still not close to a consensus, either short-term or long-term. So ideally, in the next several days, we’re going to get some sort of short-term selection, solution, and that it would get the votes. And those are big maybes.

Speaker Mike Johnson has said that he would come up with kind of a stopgap plan by the weekend, but this is all allegedly, and if that is something that would also be appeasable to the senators. And so a lot of that is still a question mark, but the House is still going ahead on trying to get HHS funding. So they recently released a revised version of their Labor, HHS, and Education bill. It’s still all the same topline spending, but it has additional …

Rovner: Which is lower than was agreed to. Right?

Raman: Yes, yeah.

Rovner: I mean, this bill’s having trouble … because of the magnitude of the cuts that it would make.

Raman: Yeah. They didn’t do any additional cuts to that, but they did add several more social policy riders. So the revised version would prevent funding from going to a hospital that requires abortion training or funding from athletic programs in schools that allow trans children to participate, which is something the House has passed legislation on earlier this year, calls for barring … calling for a public health emergency related to guns, a lot of just social issues that they’ve been messaging on.

So if this were to pass, this is also going to make it even more difficult to come to an agreement with the Senate. So the next thing to watch is that Monday, the House Rules Committee is going to meet and see the path to get it to the floor. And then even there, if it gets past the Rules Committee, it’s a will-or-will-not pass there. Because if you look at some of the other spending bills that have been going through, a lot of them have been getting pulled or not getting votes or getting pulled and repulled and all sorts of things.

Rovner: Pulled from the House floor?

Raman: Yes.

Rovner: Pulled like … they put them on the House floor and they don’t have the votes and they say, “Oops,” so they pull them back.

Raman: Yeah. So it’s all very tenuous. And I think one other interesting thing is that we didn’t have a full committee markup of this bill, which is something that the House has traditionally done and the Senate has not done in a few years. But the Senate did have their full markup. They did have a bipartisan consensus on it. And so we’ve kind of flipped roles, at least for now, in terms of how the regular order of Congress is going.

Rovner: Yeah, that’s right. Again, because the cuts were so big that the HHS bill couldn’t get through the Appropriations Committee.

Raman: Yeah. A lot of this is to be determined in the next few days.

Rovner: And this whole “laddered CR” that the speaker was talking about that nobody seems to quite understand except it would create different deadlines for different programs, that doesn’t seem to be on the table anymore or is it?

Raman: It also further complicates something that when they all have the same deadline, we’re still already struggling to get that done. So changing the dates is going to make it even more complicated to get to that point, but so much has really been in flux that I don’t think that that’s really on the table right now.

Rovner: Maybe he was hoping that having a partial shutdown would not be as disruptive or look as bad as having a full shutdown. I mean, I kept trying to figure out why he would try to do this because it just seemed, as you say, way more complicated.

Raman: If you look at the letter that he sent to other members of the House before he was elected as speaker, he did have a plan of outlining when he intends to get various bills done. And if you look at Labor, HHS, and Education, that one was one of the later ones kind of pegged to getting a deal for fiscal 2024 in April or so as the deadline, versus we’re still in November and the deadline was technically the end of September. There’s so many loose-hanging threads that hopefully they will come together with some sort of short-term solution over the next few days.

Rovner: They will, obviously, we shall see. Well, the House, as we say, is not getting a lot done, but the Senate is sort of.

The National Institutes of Health has a new director, former Cancer Institute director Monica Bertagnolli, whose nomination was approved on a bipartisan vote of 62 to 36 after being held up for months by Democrats who were upset that she wouldn’t, in the words of Senate Health, Education, Labor, and Pensions Committee Chairman Bernie Sanders, “take on Big Pharma enough.”

So when did controlling drug prices become part of the NIH portfolio? That’s not something that I was aware necessarily went together.

Ollstein: I think it was just that her nomination was the one that was up, so you got to sort of dance with the partner you can find. Obviously, other agencies and other official positions would have made more sense and had more direct power over drug prices. But this was the open seat, and so this was the leverage they thought they could use, and whether what they got out of it made it worth it, that’s up for debate. But yeah, it is very unusual to see somebody going against a president with whom they are largely aligned.

So this was eventually cleared, but Bernie Sanders wasn’t the only one. There were some other Democratic senators who were asking for ethics pledges and other things around this nomination, but it did ultimately go through.

Rovner: Yeah, there was a statement from John Fetterman. He said, “I’m not going to vote for her because she’s not going to be tough enough on the drug industry.” It’s like, I’m pretty sure that’s not her job as the head of NIH.

I mean, before people start to complain, I know that there are some levers that NIH can pull in deciding how to do some of their clinical trials. They can have sort of a secondary effect on drug prices, but it’s certainly not …

Ollstein: Not as direct.

Rovner: … their main role in the federal bureaucracy.

Well, meanwhile, there was some actual real stuff on drug prices this week. The Federal Trade Commission, which the last time I checked was in charge of unfair pricing practices, is officially challenging 100 drug industry patent listings charging that the listings are inaccurate. And because those listings help prevent cheaper generics from entering the market, that’s not fair. This is one of those things that’s kind of mind-numbingly complex, but it can have a real impact, right? If some of these patents get disallowed or delisted, I guess, from the Orange Book, the official listing of patents for drugs?

Luhby: If that happens, it does clear the pathway for us to get generics and cheaper drugs that way. So there definitely is that that could lower the prices of some of these, and some of the ones listed are pretty commonly used things that people use on a regular basis like inhalers, that kind of stuff.

Rovner: So if there was a generic, it could have a big impact because a lot of people would end up using it.

Finally, this week the Biden administration — remember the Biden administration? — issued a rule that would crack down on some marketing tactics by Medicare Advantage plans. Meanwhile, the Senate Finance Committee approved a health “extenders” bill that extends programs that would otherwise expire, and it includes, among lots of Medicare and Medicaid odds and ends, a requirement that Medicare Advantage plans keep a more timely list of the providers that are in and out of network, which I think might be the most frustrating thing about most managed-care plans, not just Medicare Advantage.

Both the administration’s proposed rule and the finance bill are smallish, but they represent stuff that keeps these programs up to date. I mean, Tami, there’s some significant stuff here, isn’t there?

Luhby: Yeah. Medicare Advantage is getting more attention because it’s getting larger. I think this is the first year that it’s crossed the 50% threshold and it’s expected to just continue growing as younger baby boomers coming in who are used to employer health insurance want to keep that. And there are a lot of pros and cons about Medicare Advantage for the consumer, and the administration is making sure … or is trying incrementally to make sure that people understand what they’re getting into.

I’ve seen a couple, now that it’s open enrollment time, I’ve seen a couple of the ads, which interestingly do seem to be targeted towards older women, not necessarily baby boomers coming in, but they’re kind of crazy and they can be very misleading. And the administration, in this latest effort, is trying to limit commissions of brokers because there are additional incentives that companies and insurers can provide to brokers beyond just the fees. So they’re trying to rein that in. Previously, they were working on Medicare Advantage marketing, so there’s a lot that they’re trying to do to just make sure that people are aware of what they can do.

This proposed rule would require that these supplemental benefits, which are one of the attractive features of Medicare Advantage, because Medicare doesn’t cover vision, dental, hearing, et cetera, but the administration wants to make sure that people actually know about these benefits and are using them and it’s not just a sweetener that the insurers are dangling at open enrollment time.

Rovner: To get people to sign up.

Luhby: They’re incremental, but they’re trying to make it a little more transparent.

Rovner: Yeah, I think it’s just important to remember that the incessant marketing, and boy, it is incessant, suggests that these companies are making a lot of money on Medicare Advantage.

Luhby: Oh, yeah.

Rovner: They would not be spending all of this money to advertise if this were not a very profitable line of business for them.

Luhby: And a growing line, of course, because more and more people are going to be eligible.

Rovner: Yeah. So we will watch that space too.

Well, before we get to our “Bill of the Month” interview, it’s time for “This Week in Medical Misinformation.” I chose this week a study from the Ohio State University of health advice related to gynecologic cancers that was most popular on TikTok. The study found at least 73% of content was inaccurate and of poor educational quality and that it furthered already existing racial disparities in cancer care. We will link to the study in the notes, but at least we know that there are people trying to quantify the amount of misinformation that’s out there, if not figure out what to do about it.

OK. That is this week’s news. Now we will play my interview with my colleague Julie Appleby, then we will come back with our extra credits.

I am pleased to welcome back to the podcast my colleague Julie Appleby, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment. Julie, thanks for joining us again.

Julie Appleby: Thanks for having me.

Rovner: So this month’s patient had a very small bill compared to most of them, but likely the kind that affects millions of patients. Tell us who she is and what brought her to our attention.

Appleby: Yes, exactly. Her name is Christine Rogers and she lives in Wake Forest, North Carolina. And like a lot of us, she went in for an exam with her doctor, sort of an annual-type exam. And while she was in the waiting room, they handed her a screening form for depression and for other mental health concerns, and she filled it out, and then went and saw her doctor.

During the discussion with her doctor, her doctor asked her about depression and her general mood, and Rogers had lost her mother that year, and so she told her doctor, “Yeah, it’s been a horrible year. I lost my mom.” So they had some discussion about that, and Rogers estimates it was about a five-minute discussion about depression, and then the visit wrapped up. Her doctor didn’t recommend any treatment or refer her for counseling or anything like that. It was just a discussion.

So Rogers was a little surprised when, later, she got a bill for that visit because, as you’ll remember, under the Affordable Care Act, preventive services, including depression screening, is supposed to be covered without a copay or a deductible. So she was a little surprised, and yeah, it wasn’t much. It was $67. That was her share of the visit. So she was just curious, why is this happening and what’s going on?

Rovner: So she calls the doctor’s office and said, “This is supposed to be free.” And what did they say?

Appleby: Right. She said that, and they explained to her that she had a discussion above and beyond just preventive, and so she was billed for a separate visit, basically, a 20- to 29-minute visit, specifically for the discussion treatment and that’s why she owed the money. So really, it wasn’t part of the wellness exam. It was part of a separate exam even though she was in the same office at the same time.

Rovner: But when I go for an annual physical, they give you a questionnaire. It’s not just about mental health. It’s about a lot of things, and it includes mental health. If you had a discussion about any of them, would that be billed separately? Could it be billed separately?

Appleby: Well, here’s where the nuance kicks in. So, as I said, under the Affordable Care Act, there’s a lot of preventive services that are covered without a copay. Things like certain cancer tests, certain vaccines, and yes, depression screening, but if you bring up something else during your wellness visit, they can indeed bill you for that.

So let’s say, for example, you mentioned to your doctor, “My shoulder’s really been killing me ever since I started playing pickleball,” and so then the doctor did some more exam of your shoulder. That could potentially be billed separately because it’s not part of the wellness visit. And in this case, initially, the doctor’s office coded it as two separate visits because it went above and beyond just a quick discussion of the questionnaire or just filling out the questionnaire.

Rovner: She goes to the doctor, the doctor says, “No, this is correct.” Then what happens?

Appleby: So then after we started calling around, we did talk to the insurer, Cigna, and the doctor’s practice, which is owned by WakeMed Physician Practices. And initially, they said the bill was coded correctly from the doctor’s office because it was a separate discussion. But after Cigna got involved, eventually after we talked to them, Rogers got a new explanation of benefits that zeroed out the visit. And a Cigna spokesperson said that the wellness visit was initially billed incorrectly with these two separate visit codes, basically, and that they had fixed that.

And so Christine Rogers did get her $67 back. But I think this does illustrate the issue of not all preventive services are covered without a copay if it goes beyond what they consider preventive. And that can be challenging. And many people that I spoke with for this article said Rogers did the exact right thing. She talked to her doctor honestly, and everybody emphasized that people should not avoid discussing health concerns with their doctors at a wellness visit for fear of getting a bill because, really, you’re there to get health care.

So what they do suggest is if after one of these wellness visits, if you do get a bill, you should ask about it, ask for an explanation of benefits, ask for an itemized billing statement. And if something seems off, question that. But keep in mind that some things, if they go beyond the preventive care guidelines, that you might get a separate bill even during what you might otherwise think would be a no-cost wellness visit.

Rovner: And if your shoulder’s bothering you after you take up pickleball, you probably should let a doctor look at it.

Appleby: You probably should.

Rovner: And I know that this was a fairly small bill, certainly in the scope of the bills that we usually look at, but this happened a lot with colonoscopies, that people would go in for the preventive colonoscopy that was paid for, but then if they found a polyp and took it off, suddenly they’d be charged for the surgery having the polyp removed. And that’s a lot more than $67.

Appleby: Right. And that has since been fixed. There’s been some clarification issued by CMS and others that that is not supposed to happen. So again, you go in for a screening colonoscopy, and that is supposed to be covered whether they find a polyp or not.

Now, if you go in because you have symptoms and there’s some other kind of problem, that’s where it can get more complicated. And we’ve seen that with other screenings too, such as mammograms. A screening mammogram is covered under the preventive services guidelines, but if you find a lump, there may be some questions to whether it’s gone from a screening mammogram to a diagnostic mammogram, which is covered under different guidelines.

Rovner: Bottom line, you should always look at your bill even if it’s for something small.

Appleby: Yes, that’s always a good rule of thumb. And if you have any questions, certainly contact your physician’s office and start there and ask about that. And you may also want to ask your insurer.

Rovner: Great. Julie Appleby, thanks for joining us.

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

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

Raman: So my extra credit is called “Sex Trafficking, Drugs and Assault: Texas Foster Kids and Caseworkers Face Chaos in Rental Houses and Hotels,” and it’s by Karen Brooks Harper at the Texas Tribune.

Her story examines a report that looks at the Texas Department of Family and Protective Services that was done by some court-appointed watchdogs to report about some of the efforts to improve the foster care system. And they found a lot of overworked case workers that didn’t have training and no round-the-clock security. And it’s just a really important story about what’s trying to be done and what needs to be done for caring for some very vulnerable kids. Many of them, as the title suggests, are sex trafficking victims or from psychiatric facilities, and it’s just an unsafe environment for both the workers and the kids. So check that out.

Rovner: Alice?

Ollstein: So I picked a piece I did this week that sort of fell through the cracks in the news, but people should really be paying attention to this. It was a pretty scary report out of the Centers for Disease Control [and Prevention] about congenital syphilis. This is syphilis in pregnant people that is passed to infants in birth. And when not treated, it can be really deadly. It can cause stillbirths, it can cause birth defects, it can cause all kinds of issues, infertility in the parent, et cetera. And this has jumped tenfold over the last decade. It is killing hundreds of infants.

This is really scary. They sound that … so many people are just getting no prenatal care at all. And even when they are, they’re not getting tested for syphilis. And even when they’re getting tested and even when it’s detected, they’re not getting the treatment. And so people are really falling through the cracks. And, hopefully, this gets some more attention on this, but it’s also coming at a time when Congress is debating cutting these kinds of sexual health programs and services even more, not expanding them, which is what the report says is needed.

Rovner: That’s right. These are some of the things that would be cut in the proposed HHS spending bill that’s still kicking around in the House. Tami?

Luhby: So I looked at a ProPublica story. ProPublica has done several excellent deep dives into health insurers’ rejections of policyholders’ claims. These are very hard stories to do. They really are good at pulling back the curtain on these decisions that most people know very little about. So the latest story is by T. Christian Miller. It’s titled, “Big Insurance Met Its Match When It Turned Down a Top Trial Lawyer’s Request for Cancer Treatment.” It’s a long story, but it’s a piece about Robert Salim, I think, a litigator who was diagnosed with stage 4 throat cancer in 2018. His doctor recommended proton therapy, which specifically would minimize the damage to the surrounding tissues. Some of the side effects could be loss of hearing, damage to the sense of taste and smell, brain issues, memory loss. But the insurer, Blue Cross Blue Shield of Louisiana, refused to pay for it, saying it was not medically necessary. So Salim was able to pay the nearly $100,000 cost of treatment because he didn’t want to do these additional therapies first, which could leave him with hearing loss and all these other problems.

Rovner: Yeah, because he’s a rich trial lawyer, so he could afford it.

Luhby: Right, so he could afford it and he didn’t want to waste the time. But he also decided to battle Blue Cross and Blue Shield because, as he put it, he’s paid them $100,000 in premiums for him and for his employees at his law firm. And he’s just like, “Now that I need it, they’re not there.” So the story goes into the lengths that Salim had to go to, including his doctor sending in a 225-page request to Blue Cross to do an independent medical review. But what was interesting was that multiple doctors that were hired by the insurer to battle Salim’s appeal kept referring to guidelines that are created by this company called AIM Specialty Health, which is actually part of Anthem. So Salim, who has now been cancer-free for nearly five years, the appeal didn’t work, so he ended up taking Blue Cross to court and he actually won, but he’s still waiting to get his reimbursement. So read the story. It has a lot of twists and turns and shows that even someone with means and expertise, the battle is still so difficult. How can people who don’t have the resources, both financially and legally to do this … he had to hire a friend of his to take them to court, like a childhood friend or a college friend, because it was such a difficult case to put before the courts. It’s a good story.

Rovner: Yeah, it’s the juicy story of the week.

Luhby: It’s a scary story.

Rovner: Scary and juicy. Well, my story actually builds on Tami’s story. It’s also from ProPublica. It also builds on our “Bill of the Month” project. It is a new tool that can help patients file the paperwork to find out why their insurer denied a claim. As we have pointed out so many times, most people simply don’t bother to argue with their health care providers or insurers because they don’t know how, and it is not easy. They make it difficult on purpose. This tool actually walks you through a key part of the process: how to ask for the information that the insurance company used to deny the claim. It’s super helpful and it’s a good place to go rather than doing the sort of one at a time, “I have this bill, will you look at it, journalist?” Here’s a way where people can at least start to do their own digging. As Tami says, it gets harder, but many people are being denied care that they are, in fact, eligible to. So here’s a way to at least start to try and get that care.

OK. That is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our tireless engineer, Francis Ying.

Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner or @julierovner at Bluesky and Threads. Sandhya?

Raman: @SandhyaWrites.

Rovner: Tami?

Luhby: Well, I’m at @Luhby, but it’s not really worth looking at it.

Rovner: Alice?

Ollstein: @AliceOllstein.

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

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It turns out they were.

“The care I was delivering to patients was resulting in them showing up in court, or having their wages garnished, or signing up for a payment plan that they would be paying for the better part of a decade,” said Messac.

In this episode of “An Arm and a Leg,” host Dan Weissmann speaks with Messac about his book, “Your Money or Your Life: Debt Collection in American Medicine,” and how people working in health care can try to reform these practices.

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Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. A couple years ago, I got in touch with a guy who’d been posting about this show on Twitter.

Luke Messac: Hi, yeah, my name is Luke Messac.

Dan: Luke is a doctor. He’s an instructor of emergency medicine at Harvard. And he’s a Ph.D. historian.

He told me he was writing a history of something we cover a lot on this show. Medical debt.

Luke Messac: It’s a problem I couldn’t avoid and therefore couldn’t avoid writing about.

Dan: And now that book is out. It’s called Your Money or Your Life. It tells the story of how the collection of medical debt in the US became so aggressive, the real impact it has on patients and – especially important for us – a different way to do things.

This is An Arm and a Leg, a show about why healthcare costs so freaking much and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So, our job on this show, it’s to take one of the most enraging, terrifying, depressing parts of American life and bring you something entertaining, empowering, and useful.

Dan: Luke Messac says his journey begins with this guy.

Paul Farmer: It’s not intellectually shallow to have hope. That’s a profound thing, you know…

Dan: That’s Paul Farmer – and YES, you may have heard me mention him recently, like when we talked about the writer John Green. Paul Farmer was a doctor who founded an amazing global health organization called Partners in Health.

He’s the subject of a book called Mountains Beyond Mountains, which focuses a lot on his work in Haiti, and which, I’m gonna say again here: When we start a book club on this show, that’s my vote for our first read.

Anyway, Luke started watching Paul Farmer’s videos as a kid. And ended up as

his student.

Luke Messac: I knew I wanted to be in medicine. I knew I wanted to be a doctor. When I first got into Harvard as a 17 year old kid, I, I think YouTube was just starting at that point. I’m going to date myself. And I saw some of his lectures and this was right around the time when Mountains Beyond Mountains came out. And I started to learn more about his work. My father was born in Haiti and I’ve always had a special affinity for the country. And, and so I, I heard about him. I really lucked out. In that one year, he was teaching a freshman seminar, uh, for 12 kids and I, ended up taking this class with him as freshmen and then kind of clung for dear life to, to work with the organization, uh, after that, because we were hooked.

Dan: Yeah, I mean, what an incredible opportunity. And, you know, I’ve only, I only know him right through his kind of public persona and mostly through reading that book, which is now like 20 years old, I think, um but you know, he seems like such an incredibly inspiring person who doesn’t accept half measures.

Luke Messac: Yeah, he, he insisted on a few things, and one of them was that the poor patient shouldn’t get care any less, uh, decent than the care that anyone else would expect, that the care that we deliver at Brigham and Women’s Hospital, where he also worked, should be the standard of care that should be delivered everywhere, including rural Haiti, including rural Rwanda. And he would call that an aspirational goal sometimes, but it’s one that he was extremely serious about and devoted. This guy did not stop working. Uh, you couldn’t keep up with him, but he also made space for students, especially younger students, people who weren’t even in their medical training yet. He made so much time for me. So much time for us. He’d always respond to our emails and text messages.

Dan: So did you, like, apply to MD PhD programs, like, at the same time, like you’re, like, finishing undergrad and you’re like, okay, uh, all right, here’s the, here’s the plan for the next 15 years. Or did, things evolve? Like, how did that work?

Luke Messac: Yeah, essentially. I mean, I’m somewhat loathe to give up a little secret, which is that the MD PhD programs in the United States are paid for by the federal government. At least that still remains the case. And so if you want to get a medical degree in the United States, most of the time you’re going to come out unless you’re independently wealthy with six figures in debt. And I’m not talking low six figures. If you want to get an MD-PhD in the United States, that is still funded by the federal government. So you’re going to graduate with 0 in debt from medical school or graduate school, and you’ll get a stipend on top of that. So it is a long road, but it is one that comes with some benefits and doesn’t leave you tremendously in the hole when you come out feeling like you can’t do anything but try to pay back that debt.

Dan: That is really, really wild. It’s really interesting that it’s, I mean, There’s something very poetic about you entering this program that allows you to, uh, emerge from it without debt, and then using that resource to build an understanding of and campaign against debt.

So, it’s fall 2019 and this is your story. This is how you arrived here. You are yourself basically debt free, and you’ve been following a path. And you note that you had been reading about, medical debt lawsuits.

Luke Messac: Yeah, I’d seen it in ProPublica, Kaiser Family Foundation, um, and in various newspapers across the country. And I had friends in training at Johns Hopkins hospitals, in Baltimore, and I saw them post pictures of their protests against their own hospitals, practice of suing patients, oftentimes their own low paid employees for medical debts they couldn’t afford to pay. Their work was really an inspiration to me to find out if this kind of thing was going on elsewhere. I thought it didn’t. I thought it was very anomalous practice. I didn’t think I’d find too much, uh, in the way of it happening in my neck of the woods, but I was, I was wrong about that.

Dan: So in the book, you tell the story that you went to the courthouse in Providence, Rhode Island, where you were working as a medical resident to look up medical debt lawsuits, And you’re still imagining this as like, well, this is some kind of outlier thing. I’m not going to find it. But you’re like, you’re just a little curious?

Luke Messac: Being a historian is a very solitary and quiet existence. And that is something that you cannot say of the emergency department, neither solitary nor quiet ever. And so I was I had a day off. I wanted to relive my days in the archive. And I wanted to answer this question, and I went to the courthouse. And I asked to be led into the court records. And so basically they let you into this back room, uh, looks like, uh, an office from office space, like the movie, uh, a lot of UV light and white walls. And a very old computer that looks like it came out of the late 1990s, early 2000s, and you pull up the database, also a very clunky looking old database, and you can type in your hospital or type in your business or type in an individual and see if they’ve ever been involved in the court system. And so I did that, I looked up, uh, my hospital system, other hospital systems in the state, and some of the lawsuits were what you’d expect.

Dan: Like medical malpractice suits. And run of the mill employment disputes. But he also saw lawsuits against the hospital’s patients. A lot of lawsuits.

Luke: And when they were filed, oftentimes they would get a response from the defendant, and these responses would show me that some of the defendants were single mothers. Some of the defendants were living on social security disability. Some of the defendants were recent immigrants who had trouble responding in English and so wrote back in their native languages, pleading for leniency. And when they asked for such, they would get some in the form of usually a payment plan. Maybe they would be asked to pay some amount every month for the next five years, six years, seven years to cover the cost of a single visit. And if they signed up for those payment plans, then they would be told that if they missed any payments, that they would be charged double digit interest rates. And if they didn’t respond, as many didn’t, then they would lose the case by default. And oftentimes have their wages garnished, have 25% of their wages taken from them every month. And so these were really punitive measures being taken against really vulnerable patients. The vast majority of lawsuits in the state were filed by the hospitals in which I worked,. And this was really disturbing to me. I always comforted my patients who worried about the cost of their care when they came in and said, oh boy, am I going to be able to afford this? Um, you know, should I have come in at all? And I always tried to comfort them and say, oh, don’t worry about it. Even if you’re uninsured, we have financial assistance. You’ll, you know, we don’t, we don’t go after people. And I was wrong. I was dead wrong about that. And that made me feel, uh, pretty awful.

Dan: In the book, you say you felt shame.

Luke Messac: Yeah, it was a mixture of anger and surprise and shame, because I always knew that our healthcare system was full of injustice, that so many people can’t afford insurance, even those who do, aren’t always able to afford their care, that the distribution of resources runs along steep gradients of inequality. But I didn’t realize that I was such a direct participant in that injustice, that the care I was delivering to patients was resulting in them showing up in court or having their wages garnished or signing up for a payment plan that they would be paying for the better part of a decade. So that was really the source of my shame.

Dan: And what did you do? Like, I know eventually you took lots of actions, but like, what did you do immediately?

Luke Messac: Yeah, I talked to my friends. I talked to some mentors. I talked to my wife, who is also in medicine, but was working elsewhere. And all of us shared the same sense of shock and anger and shame, because none of us wanted to be doing that to our patients. We all kind of shared the same sense of shock but. I didn’t know what to do at first. I didn’t know where to turn.

Dan: At first you tried Twitter, right? Or Facebook or…

Luke Messac: uh, yeah, I did. I just started using Twitter the year before I put out a couple of, you know, impotently angry tweets about it and said, someone’s got to do something about this. This shouldn’t exist. And, uh, didn’t get much of a response. You know, a few friends of mine said, right on. But, you know, it, it wasn’t, it wasn’t making much of a dent.

Dan: So he wrote an op ed. Submitted everywhere he could think of – New York Times, Wall Street Journal, Washington Post, even his hometown paper, the Providence Journal.

Luke Messac: No one was interested. No bites. And then there was a small, uh, lefty blog run by this guy, Steve Alquist, a real muckraking crusader here in Providence. And I sent it to him and he said, this is really interesting. Absolutely., I’ll run it. I didn’t know if it would make any difference whether this blog post on Uprise Rhode Island, uh, uh, you know, would, would cause any waves, but sure enough, the morning it went up, I got a call from my superiors of the hospital saying they definitely wanted to meet. So it had, it had something of its desired effect. Although, uh, I won’t recommend the approach to everybody because it, it, it did imperil my job.

Dan: Because that first meeting was not set up as a friendly chat. The message also said he could face public correction or worse, dot dot dot.

Luke Messac: So I wondered what that or worse could be.

Dan: You met with a top administrator who was like, you’re just wrong buddy, we don’t do that, that never happens, I would know.

Luke Messac: Yeah, they did tell me that they didn’t sue patients, that I was wrong. And to be honest, it raised a couple other questions in my mind, saying… Is this guy just lying to me or does he literally not know? And so when I was able to prove to the folks who I was meeting with that were indeed suing patients, in fact, some of these lawsuits were filed in the last few weeks, they quickly changed course, they severed their relationship with the debt collector who was filing the lawsuits on their behalf and dismissed the remainder of the cases. So that was a, that was a sanguine outcome from that one thing, but it did make me realize a few things. One was that, you know, I’d really only started to understand what on earth was going on and how so many patients were being sued and how it was being done in a way that, uh, most of us who were involved in delivering care and even a lot of the people who were involved in running the hospital didn’t seem to know that this was happening.

Dan: So Luke Messac, the doctor, now knew that hospitals, including his, were suing patients to collect debt. Luke Messac, the historian, wanted to figure out when this practice started and why. That’s after this…

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health care in America. Their work is terrific. Wins all kinds of awards every year. So proud to work with them.

Luke writes: “Medical debts have long spurred people to desperate acts: theft, suicide, plane hijacking,” And yes, the story of the hijacking is in the book. But, he also writes quote: “the modern era of pay-up-or-else health financing and aggressive debt collection began in earnest during the last two decades of the twentieth century, as threats to their own survival made hospitals less financially forgiving toward their patients.” Unquote. He writes about the eighties, how changes to Medicare and Medicaid left hospitals strapped for cash. And how they tried to make up the difference by charging higher prices to private insurers– which meant higher prices for the

uninsured too. And how in the nineties, private insurers started pushing back hard on how much they’d pay, and what they’d pay for. And that hit hospitals in the pocketbook hard.

Luke Messac: And really the question is when those cost pressures start, who’s going to make up the difference? And for a lot of places, it was patients. It was patients paying in the form of higher deductibles, higher copays, or for the uninsured, more aggressive debt collection measures. And so a lot of hospitals would leave debts on the books for years, even decades, until this time when they started saying, we’re done waiting for our money. Literally, we’re done waiting for our money was the line. And so they turned to third party debt collectors to whom they would either assign debts or sell debts, and those debt collectors really introduced a whole new series of tactics that involved the court system that involved, uh, wage garnishment and reporting debt to credit bureaus and placing liens on property and foreclosing on homes and sometimes even seeking the arrest of patients who didn’t show up to hearings. So this was a really brave new world of medical debt collection that we continue to live with today.

Dan: So here’s what I don’t really get, um, this comes up whenever you see stories about hospitals sue patients over debts. It’s like how little money this actually generates for hospitals. And this is evident from like your very, your accounts of the very first sales of debts that hospitals are selling you know, these very large collections of debts for tiny, tiny amounts and like, so, what’s the point?

Luke Messac: That is the persisting mystery of all of this. I think I have a few reasons why this might’ve happened. One is that it is a revenue garnering tactic, even as small as it is, it puts you a little more in the black or a little less in the red. And if you are a hospital financial administrator who’s charged with making sure that you remain as much in the black as possible or less in the red, then you’re going to take every tool in your toolkit until someone tells you not to. And without doctors and nurses and healthcare professionals really being involved in the process or aware that the process is going on, there’s really nothing to stop them. And the only people who you’re hearing from are debt collectors themselves. They are selling their wares at your door. They are at all your conferences. They are promising you that they will help your situation so

why not? I mean, your billing and collections office doesn’t want to deal with these bills. Folks who work in hospital billing offices, they’re used to dealing with insurers. They don’t mind that at all, right? This trench warfare trying to get insurers to pay up and dealing with all of their rigmarole in the reimbursement process is something in which they are well trained. But very few people want to deal with what are called self pay patients. They don’t want to be on the phone with poor folks trying to get them to pay up. And so you’re taking a headache off their hands by handing it to a third party debt collector who’s telling you that they’ll bet they’re better at it anyway. So I think a lot of

that has to do with kind of just the, the headache saved and the promised resources, however small they are from turning to this tactic. It just is too easy to do at this point.

Dan: Luke’s book profiles some of the early trailblazers in this headache saving business.

A guy named Michael Barrist founded NCO Financial Systems. A company that bought so much medical debt that they became known as the Walmart of debt collection.

A salesman for the company named Charles Piola was so good at selling the company’s services to doctors offices and hospitals that Inc magazine dubbed him the king of cold calls.

Luke writes that the company’s tactics included contacting patients up to 50 times in four or five months, and finding them at their workplaces. And these were not folks whose training started with a hippocratic oath: Do no harm. That was not their context.

Luke Messac: Their reference points are really other forms of consumer debt. When people don’t pay for their cars, their cars get impounded. When people don’t pay their credit card bills, they get double digit interest rates too. When people don’t pay for their homes, those homes get foreclosed. So when people don’t pay their medical bills, then use the tools at your disposal, including the legal system. 

There was also some concern that if hospitals were too lenient on patients, that they might be running afoul of some Medicare rules about kickbacks. Um, and this is an interesting concern, one that I saw raised in some legal papers, but it’s one that, at least for the last 20 years, the Department of Health and Human Services has tried to allay. And some hospitals have forsworn the practice. There are hundreds of hospitals out there who just do not sue patients, will not sue patients, and will tell you straight out, we don’t do it, we won’t do it. And they’re not getting sued by the federal government for kickbacks, right? So it’s not necessary. You don’t have to do it. And yet hospitals still do.

Dan: Towards the end of the book, you talk about like, how do we reform this system and that this issue of these kind of aggressive debt collection practices kind of rouse the conscience of most everyone. When individual institutions get the spotlight shown on, they generally stop doing it. But it’s not enough. Like it still leaves people with so, so many people with so much debt, with so many bills they can’t pay.

Luke Messac: Yeah. I have a lot of sympathy for people who feel like this problem is just too big. Or that they have other things that they need to do. For patients, often the patients who face this problems, you know, they’re often dealing with their own illnesses and their own debts and their own problems and to ask them to solve the problem themselves doesn’t seem a reasonable solution. But then I also have sympathy for the people who work in hospitals, the doctors, the nurses, the respiratory technicians, the janitors, the administrators, even who feel like their work is harder than ever and that they have enough trouble trying to make sure their patients get decent care and that they’re able to keep their own heads above water while doing it and not burn out and ask them to really look upon a really ugly feature of the healthcare system. And not only imbibe it and make sense of it, but do something about it. That’s asking a lot. And I’m really cognizant of the fact that we’re already asking so much of healthcare workers around the country. But I do think it’s something we need to take on. The best efforts are really the collective ones. And so I would say any possibility of joining up with other like minded folks who are already doing this work is going to be so much more fun, so much more effective.

Dan: Find your people,

Luke Messac: Amen. And then look around and see what your own place is doing your own hospital system because I regret to inform you that some of them won’t be what you hoped, but they are susceptible to pressure. They are capable of shame. And so there is a lot you can do close to home to make sure that your own institution is doing right by patients. Find out if your institution is suing patients. Look up your own hospital’s financial assistance policy and see what sort of extraordinary collection actions they will take against patients. See how patients qualify for free and discounted care and ask yourself is that as much as the hospital system could be doing given their resources. So there’s a lot you could do. Some of it involves grand systemic change, and some of it involves just making sure that where you go to work every day, where you’re training, where you’re studying is a place that you can believe in.

Dan: Luke Messac’s book is “Your Money or Your Life: Debt Collection in American Medicine.” It is out NOW from Oxford University Press. And speaking of right now: NEWSMATCH– is in effect. This is where we raise the biggest piece of our budget for next year, with your help. And the NewsMatch program matches every dollar you give us. The place to go is arm and a leg show dot com, slash, support. 

Next time on “An Arm and a Leg:” For a lot of us, November is open enrollment for next year’s health insurance.

Last year around this time, Ellen Hahn was absolutely scrambling — super creatively.

Ellen Hahn: When I was a kid, I dreamed about being an actor. I didn’t dream about having health insurance. I just kind of thought I would have it.

Dan: She decided to make a short film and cast herself in it. And she raised the money by crowdsourcing online. The title: Ellen Needs Insurance.

Now, the movie’s out, We’ll hear all about it.

And: of course this year, she needs insurance all over again. Plus her union has

been on strike since May. Whoa. We’ll find out what she’s got planned.

That’s in two weeks. Meanwhile, I am saying please do take a minute to pitch in to help us make this show. Every dollar gets matched.

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Thank you so much. Catch you in a couple weeks, with  “Ellen Needs Insurance.” Till then, take care of yourself.

This episode of “An Arm and a Leg” was produced by Emily Pisacreta and me, Dan Weissman and edited by Ellen Weiss.

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Adam Raymonda is our audio wizard. 

Our music is by Dave Winer and Blue Dot Sessions.

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This story can be republished for free (details).

In 1975, smallpox eradication workers in the capital of Bangladesh, Dhaka, rushed to Kuralia, a village in the country’s south. They were abuzz and the journey was urgent because they thought they just might get to document the very last case of variola major, a deadly strain of the virus.  

When they arrived, they met a toddler, Rahima Banu. 

She did have smallpox, and five years later, in 1980, when the World Health Organization declared smallpox eradicated, Banu became a symbol of one of the greatest accomplishments in public health. 

That’s the lasting public legacy of Rahima Banu, the girl. 

Episode 8, the series finale of “Eradicating Smallpox,” is the story of Rahima Banu, the woman — and her life after smallpox. 

To meet with her, podcast host Céline Gounder traveled to Digholdi, Bangladesh, where Banu, her husband, their three daughters, and a son share a one-room bamboo-and-corrugated-metal home with a mud floor. Their finances are precarious. The family cannot afford good health care or to send their daughter to college.

The public has largely forgotten Banu, while in her personal life she faced prejudice from the local community because she had smallpox. Those negative attitudes followed her for decades after the virus was eradicated.

“I feel ashamed of my scars. People also felt disgusted,” Banu said, crying as she spoke through an interpreter.

Despite the hardship she’s faced, she is proud of her role in history, and that her children never had to live with the virus.

“It did not happen to anyone, and it will not happen,” she said.

The Host:

Voices From the Episode:

Podcast Transcript Epidemic: “Eradicating Smallpox” Season 2, Episode 8: The Scars of Smallpox Air date: Nov. 7, 2023 

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast. 

Céline Gounder:  Just when you thought smallpox was gone someplace, it could roar back. 

Alan Schnur: We were aware that in some other countries there had been celebrations and then later found, uh, there had been ongoing transmission that wasn’t detected. 

Céline Gounder: The virus was persistent and slippery, but smallpox did end, and Alan Schnur was there when it did. 

Alan Schnur: I was one of the team members who was the first international responders to the last case of variola major smallpox. 

[Upbeat music begins playing.] 

Céline Gounder: The beginning of the end was 1975 in Bangladesh. Alan was in the capital city of Dhaka, meeting with other fieldworkers from the World Health Organization. They were gathered in a Quonset hut. If you’ve ever seen a World War II movie, you know what it looks like: Picture a big tin can cut down the middle — resting on its side. 

The meeting was uneventful, which was a change of pace. When Alan first came to Bangladesh, smallpox cases had exploded. The country was reeling from a war for liberation. 

But by that day, the outbreak had fizzled. 

Alan Schnur: Things had gone very quiet. No reports of any active smallpox cases despite searches going on for several weeks. 

Céline Gounder: Alan remembers that the walls of the Quonset hut were covered with maps and manuals documenting their work, and they kept a running tally of suspected cases. 

Alan Schnur: And there was a big zero up there on the wall staring down at us for this whole meeting. So we were feeling pretty good at the time. 

Céline Gounder: Not a single case of smallpox across the entire country. The team was starting to let themselves feel optimistic. Maybe they’d stamped out the disease here. 

[Upbeat music ends.] 

Alan Schnur: And then there was a telegram received saying one smallpox case found in Kuralia village in Bhola. 

[Suspenseful music begins playing.] 

Céline Gounder: The next morning, Alan and the head of the W–H–O mission in Bangladesh took a slow boat through snaking canals to Bhola Island. 

[Ambient sounds of a boat on the water play in the background.] 

Céline Gounder: Day turned into night. Night into day. 

Another boat, then a Land Rover. 

Alan Schnur: And the last half-mile, we had to walk to the house where the case was. 

Céline Gounder: Finally, they made it. 

Alan Schnur: It was a very simple house, certainly poorer than the average Bangladeshi house. 

Céline Gounder: Inside was the patient, a little girl. Rahima Banu. 

Alan Schnur: She was very scared. She was trying to hide behind her mother’s sari. So she was frightened and trying to to run back inside the house, but her mother kept her there. 

Céline Gounder: There’s an iconic photo of Rahima and her mother from that day. Sitting on her mother’s hip, Rahima looks wary. But Alan says all around her there was an air of excitement among the public health workers. 

This could finally be it: the last person with naturally occurring variola major smallpox. 

Alan Schnur: And we didn’t find any more active cases after Rahima Banu. 

[Suspenseful music fades out.] 

Céline Gounder: The WHO continued to monitor Bangladesh for a couple of years, but that’s where the story ends for the deadliest version of smallpox. With Rahima Banu, the girl. 

She became a symbol of — a poster child for — one of public health’s greatest achievements. But she did not share in the prestige or rewards that came after. 

In this final episode of our series “Eradicating Smallpox,” I travel to Bangladesh to meet with Rahima Banu, the woman. We’ll hear how smallpox shaped her life and wrestle with some of the questions that her reality demands of public health. 

I’m Dr. Céline Gounder, and this is “Epidemic.” 

[“Epidemic” theme music plays then fades to silence.] 

[Ambient sounds of chickens squawking in the courtyard outside of Rahima Banu’s home play.] 

Céline Gounder: Many people have tracked down Rahima Banu since 1975. 

I’m just the latest in a line of public health specialists and curious journalists. 

She lives in a village not far from where smallpox workers found her nearly 50 years ago. 

As I enter the courtyard of her home, there are clothes hanging on the line. The house is made from bamboo and corrugated metal. The mud stairs that lead inside are dotted with moss. 

Inside is one giant room with a partition. On the far side are cots where the family sleeps. On the near side is a table, where I sit with Rahima. 

She introduces herself while her husband and two of her daughters sit behind her. 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: I am Rahima Banu from Bangladesh. Rahima Banu of smallpox fame. 

Céline Gounder: Rahima wears a cobalt-blue scarf with white flowers — it’s draped over her head and shoulders and modestly tucked under her chin. A small gold stud sparkles from her nose. 

[Sparse music begins playing softly.] 

Céline Gounder: She has only a few memories of smallpox. She remembers health workers drawing blood from her fingers, for example. But most of the story that’s made her famous, she knows only from what she’s been told. 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: There were lesions like this all over the body. My mother said that if you poked them with a lemon cutter, the water rolled down all over the body. As the juice of the dates rolled down when being cut, my blood also dripped like that. 

Céline Gounder: While Rahima recovered from smallpox, her family was forced to stay at home while the health workers set a mile-and-a-half radius where they monitored every fever and vaccinated every person. 

Two guards monitored the doors of Rahima’s home 24 hours a day. Otherwise, Rahima says, her father would have tried to leave to go find work. He was the lone income earner in the family. 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: If he had run away, the disease would have spread to other places. That’s why they did not allow us to go anywhere. 

Céline Gounder: Alan Schnur says he hired Rahima’s father so the family would have food and an income while they were isolated. And later — a small group of public health workers tried to cobble together some kind of sustainable support for Rahima’s family. 

But, eventually the WHO’s help ended. And, ultimately, attempts to prop up the family’s future fell through. 

[Sparse music swells, then fades to silence.] 

Céline Gounder: Little Rahima grew up. She married and had a family of her own. 

The scars of smallpox are visible on her face, but they are faint. Mostly you notice her eyes. They are warm; her slight smile is welcoming. 

But Rahima says when visitors like me come to visit, they mostly want to know one thing: Is she still alive? 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: But no one wants to know how I am living my life with my husband and children, whether I am in a good condition or not, whether I am settled in my life or not. 

Céline Gounder: The stories about Rahima are not usually about her life today. They’re about her place in history — as an international symbol of one of the crowning achievements of public health. 

But listening to Rahima speak, I’m caught off guard by the pain in her voice. 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: I feel ashamed of my scars. People also felt disgusted. [Rahima cries.] 

Céline Gounder: Rahima is in tears. My reporting partner, Redwan, asks Rahima’s daughter to bring some water. 

Redwan Ahmed [in Bengali]: Will you give her some water? 

[Solemn music begins playing.] 

Céline Gounder: She is around 50 years old when I visit — and the faded pockmarks on her body are perhaps the least of what smallpox left behind. Rahima begins to talk about the emotional scars smallpox left on her family, her life. 

And how living in poverty has made things even harder. As an adult, when she had health problems, there was no outside care. No public health workers bustling around, ready to help. 

She tells me about a time when she had intense vomiting and fevers. 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: I was bedridden for three months, but I still could not go to a good doctor because I could not afford it. 

Céline Gounder: Rahima says the doctor she did see prescribed her cooked fish heads. She also had trouble with her vision for years. 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: I cannot thread a needle because I cannot see clearly. I cannot examine the lice on my son’s head. I cannot read the Quran well because of my vision. 

[Solemn music fades out.] 

Céline Gounder: Rahima and her husband, Rafiqul Islam, have four nearly grown children, three daughters and a son. 

The couple’s marriage was arranged, and Rafiqul didn’t know Rahima had had smallpox. 

After he found out, people would taunt him, saying he’d married a cursed girl. Still, Rafiqul accepted her. 

His family did not. 

[Somber music begins playing.] 

Céline Gounder: Rahima says her in-laws thought her scars — or smallpox itself — would be passed on to her children. 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: My father-in-law and mother-in-law never touched my children with their fingers like one touches other children. 

My father-in-law, mother-in-law,  sister-in-law, and brother-in-law never saw me in a good light. 

Céline Gounder: Rahima says she is still living in that suffering. Rafiqul becomes tearful as we sit around their table listening. And at times he gets up and stands behind the partition, as if he doesn’t want us to see his emotion. 

Rafiqul says he felt powerless watching how his family treated his wife. 

[Rafiqul speaking in Bengali fades under English translation.] 

Rafiqul Islam: Do you get it? As a husband, I couldn’t do anything to stop my parents or my siblings. One of my sisters did most of the abuse. I couldn’t do anything but stand in a corner as she was abused. 

[Somber music ends.] 

Céline Gounder: Their middle daughter is named Nazma Begum. She is tall like her dad — you can tell she’s an eager student. For most of Nazma’s life, people like me have come here to talk with her mother about smallpox. 

I ask Nazma what it’s like to be the child of an international symbol. 

[Nazma speaking in Bengali fades under English translation.] 

Nazma Begum: The good effect is that it is nice to see that you and other people come here. When people come, I like that a lot. The way I feel nice when guests come — it is the same feeling. Apart from that, there was no other effect. It did not help me in any way in my studies or financially. 

Céline Gounder: The family’s only income is the money Rafiqul earns peddling a rickshaw. On a good day, he brings home 500 takas — not quite 5 U.S. dollars. 

Sometimes he brings home  nothing. 

Nazma finished a year of college, but her parents can’t afford to pay for her education anymore. She seems desperate to go back to school, but at the time of my visit, the family had arranged for her to get married instead. 

The cost of a dowry is less than the cost of sending her to school. It’s a common story here in Bangladesh. But, Nazma says, the people who seek out her mother to talk about smallpox are not really curious about Rahima’s children. 

[Nazma speaking in Bengali fades under English translation.] 

Nazma Begum: What are their children doing? Up to what class have they studied? In what condition are they living? What do their children want? I think that’s what they should have asked more about. But in this matter, they have no interest or do not want to know. 

[Reflective music plays softly.] 

Céline Gounder: Nazma is talking to me, but maybe she’s indicting me, too. 

Journalists, public health experts, and government officials — we all return to Rahima again and again. Whenever there’s a big anniversary. Or when we’re looking for smallpox lessons — to get through the latest pandemic. And it is a story worth telling. 

But then we leave. And Rahima is left behind. 

We write up our reports, or publish our podcasts — then raise money around that research and journalism. 

In these sometimes sanitized stories, the reality of Rahima’s life after smallpox is left out. 

She goes back to her family that can’t afford to see a doctor or send their daughter to university. 

It feels extractive — as if we take from Rahima only what we need. And I can’t help but wonder whether I owe her something more. 

[Reflective music fades out.] 

Céline Gounder: There’s this moment from my time with Rahima that I found later, when I was reviewing the tape from the interview. Initially, I missed it because I don’t speak Bengali. While I was adjusting my recording levels, Rahima and the interpreter are talking about how she’ll introduce herself, and she says maybe we could publish that her son is looking for work. 

[Clip of Redwan and Rahima speaking Bengali plays in the background.] 

Céline Gounder: It’s such a simple request, so core to what’s on her mind and what she wants. 

The interpreter is skilled and polite. He tells her he can’t promise anything but maybe it will come up in the interview. 

Of course, it doesn’t — at least not exactly. But at the end of our time together, I ask Rahima what she thinks people should know about her experience. 

[Optimistic music begins playing.] 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: Who wants to know about me? My only dream was to make my son a man. And I wanted to repair the condition of my house, live a better life with my family, and keep my children well. This is my only dream. If I had some financial ability, I would have arranged my daughter’s marriage to a better family. It is the pride of my heart. 

It is my dream. And it is my pride. This is my imagination. 

Céline Gounder: There is one way, though, that Rahima says her role in history has helped her family. 

Her children did not get smallpox. They don’t live with those particular scars. 

[Rahima speaking in Bengali fades under English translation.] 

Rahima Banu: It did not happen to anyone, and it will not happen. 

[Optimistic music fades out.] 

[“Epidemic” theme music plays.] 

Céline Gounder: “Eradicating Smallpox,” our latest season of “Epidemic,” is a co-production of KFF Health News and Just Human Productions. 

Additional support provided by the Sloan Foundation. 

This episode was produced by Zach Dyer, Taylor Cook, and me. 

Bram Sable-Smith was scriptwriter for the episode, with help from Zach Dyer and Taunya English. 

Redwan Ahmed was our translator and local reporting partner in Bangladesh. 

Our managing editor is Taunya English. 

Oona Tempest is our graphics and photo editor. 

The show was engineered by Justin Gerrish. 

We had extra editing help from Simone Popperl. 

Voice acting by Rashmi Sharma, Priyanka Joshi, and Paran Thakur. 

Music in this episode is from the Blue Dot Sessions and Soundstripe. 

We’re powered and distributed by Simplecast. 

If you enjoyed the show, please tell a friend. And leave us a review on Apple Podcasts. It helps more people find the show. 

Follow KFF Health News on X (formerly known as Twitter), Instagram, and TikTok. 

And find me on X @celinegounder. On our socials, there’s more about the ideas we’re exploring on our podcasts. 

And subscribe to our newsletters at kffhealthnews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news. 

I’m Dr. Céline Gounder. Thanks for listening to this season of “Epidemic.” 

[“Epidemic” theme fades to silence.] 

Credits

Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Gabe Brison-Trezise, deputy copy chiefChris Lee, senior communications officer 

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

“Epidemic” is a co-production of KFF Health News and Just Human Productions.

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This story can be republished for free (details).

In most states, open enrollment for plans on the Affordable Care Act exchange — also known as Obamacare — began Nov. 1 and lasts until Dec. 15, though some states go longer. With premiums expected to increase by a median of 6%, consumers who get their health coverage through the federal or state ACA marketplaces are encouraged to shop around. Because of enhanced subsidies and cost-sharing assistance, they might save money by switching plans.

Meanwhile, Ohio is yet again an election-year battleground state. A ballot issue that would provide constitutional protection to reproductive health decisions has become a flashpoint for misinformation and message testing.

This week’s panelists are Mary Agnes Carey of KFF Health News, Jessie Hellmann of CQ Roll Call, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachana Pradhan of KFF Health News.

Panelists

Among the takeaways from this week’s episode:

• Open enrollment for most plans on the Affordable Care Act exchange — also known as Obamacare — began Nov. 1 and lasts until Dec. 15, though enrollment lasts longer in some states. With premiums expected to increase by a median of 6%, consumers are advised to shop around. Enhanced subsidies are still in place post-pandemic, and enhanced cost-sharing assistance is available to those who qualify. Many people who have lost health coverage may be eligible for subsidies.
• In Ohio, voters will consider a ballot issue that would protect abortion rights under the state constitution. This closely watched contest is viewed by anti-abortion advocates as a testing ground for messaging on the issue. Abortion is also key in other races, such as for Pennsylvania’s Supreme Court and Virginia’s state assembly, where the entire legislature is up for election.
• Earlier this week, President Joe Biden issued an executive order that calls on federal agencies, including the Department of Health and Human Services, to step into the artificial intelligence arena. AI is a buzzword at every health care conference or panel these days, and the technologies are already in use in health care, with insurers using AI to help make coverage decisions. There is also the recurring question, after many hearings and much discussion: Why hasn’t Congress acted to regulate AI yet?
• Our health care system — in particular the doctors, nurses, and other medical personnel — hasn’t recovered from the pandemic. Workers are still burned out, and some have participated in work stoppages to make the point that they can’t take much more. Will this be the next area for organized labor, fresh from successful strikes against automakers, to grow union membership? Take pharmacy workers, for instance, who are beginning to stage walkouts to push for improvements.
• And, of course, for the next installment of the new podcast feature, “This Week in Medical Misinformation:” The official government website of the Republican-controlled Ohio Senate is attacking the proposed abortion amendment in what some experts have said is a highly unusual and misleading manner. Headlines on its “On The Record” blog include “Abortion Is Killing the Black Community” and say the ballot measure would cause “unimaginable atrocities.” The Associated Press termed the blog’s language “inflammatory.”

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

Mary Agnes Carey: Stat News’ “The Health Care Issue Democrats Can’t Solve: Hospital Reform,” by Rachel Cohrs.

Jessie Hellmann: The Washington Post’s “Drugstore Closures Are Leaving Millions Without Easy Access to a Pharmacy,” by Aaron Gregg and Jaclyn Peiser.

Joanne Kenen: The Washington Post’s “Older Americans Are Dominating Like Never Before, but What Comes Next?” by Marc Fisher.

Rachana Pradhan: The New York Times’ “How a Lucrative Surgery Took Off Online and Disfigured Patients,” by Sarah Kliff and Katie Thomas.

[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.]

Mary Agnes Carey: Hello, and welcome back to “What the Health?” I’m Mary Agnes Carey, partnerships editor for KFF Health News, filling in this week for Julie Rovner. I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 2, at 10 a.m. ET. As always, news happens fast, and things might’ve changed by the time you hear this.

We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Carey: Jessie Hellmann, of CQ Roll Call.

Jessie Hellmann: Hey there.

Carey: And my KFF Health News colleague Rachana Pradhan.

Rachana Pradhan: Thanks for having me.

Carey: It’s great to have you here. It’s great to have all of you here. Let’s start today with the Affordable Care Act. If you’re interested in enrolling in an ACA plan for coverage that begins Jan. 1, it’s time for you to sign up. The ACA’s open enrollment period began Nov. 1 and lasts through Dec. 15 for plans offered on the federal exchange, but some state-based ACA exchanges have longer enrollment periods. Consumers can go online, call an 800 number, get help from an insurance broker or from other ACA navigators and others who are trained to help you research your coverage options, help you find out if you qualify for a subsidy, or if you should consider changing your ACA plan.

What can consumers expect this year during open enrollment? Are there more or fewer choices? Are premiums increasing?

Hellmann: So, I saw the average premium will increase about 6%. So people are definitely going to want to shop around and might not necessarily just want to stick with the same plan that they had last year. And we’re also going to continue seeing the enhanced premiums, subsidies, that Congress passed last year that they kind of stuck with after the pandemic. So subsidies might be more affordable for people — I’m sorry, premiums might be more affordable for people. There’s also some enhanced cost-sharing assistance.

Carey: So it kind of underscores the idea that if you’re on the ACA exchange, you really should go back and take a look, right? Because there might be a different deal out there waiting.

Kenen: I think the wrinkle — this may be what you were just about to ask — but the wrinkle this year is the Medicaid disenroll, the unwinding. There are approximately 10 million, 10 million people, who’ve been disenrolled from Medicaid. Many of them are eligible for Medicaid, and at some point hopefully they’ll figure out how to get them back on. But some of those who are no longer eligible for Medicaid will probably be eligible for heavily subsidized ACA plans if they understand that and go look for it.

This population has been hard to reach and hard to communicate with for a number of reasons, some caused by the health system, not the people, or the Medicaid system, the states. They do have a fallback; they have some extra options. But a lot of those people should click and see what they’re eligible for.

Pradhan: One thing, kind of piggybacking on what Joanne said, that I’m really interested in: Of course, right now is a time when people can actively sign up for ACA plans. But the people who lost Medicaid, or are losing Medicaid — technically, the state Medicaid agency, if they think that a person might qualify for an ACA plan, they’re supposed to automatically transfer those people’s applications to their marketplace, whether it’s healthcare.gov or a state-based exchange. But the data we have so far shows really low enrollment rates into ACA plans from those batches of people that are being automatically transferred. So I’m really curious about whether that’s going to improve and what does enrollment look like in a few months to see if those rates actually increase.

Carey: I’m also wondering what you’re all picking up on the issue of the provider networks. How many doctors and hospitals and other providers are included in these plans? Are they likely to be smaller for 2024? Are they getting bigger? Is there a particular trend you can point to?

I know that sometimes insurers might reduce the number of providers, narrow that network, for example to lower costs. So I guess that remains to be seen here.

Kenen: I haven’t seen data on the ACA plans, and maybe one of the other podcasters has. I haven’t seen that. But we do know that in certain cities, including the one we all live in [Washington, D.C.], many doctors are stopping, are no longer taking insurance. I mean, it’s not most, but the number of people who are dropping being in-network in some of the major networks that we are used to, I think we have all encountered that in our own lives and our friends’ and families’ lives. There are doctors opting out, or they’re in but their practices are closed; they’re not taking more patients, they’re full.

I don’t want to pretend I know how much worse it is or isn’t in ACA plans, but we do know that this is a trend for multiple years. In some parts of the country, it’s getting worse.

Hellmann: Yeah, the Biden administration has been doing some stuff to try to address some of these problems. Last year there were some rules requiring health plans have enough in-network providers that meet specific driving time and distance requirements. So, they are trying to address this, but I wouldn’t be surprised if some of these plans’ networks are still pretty narrow.

Pradhan: Yeah. I mean, I think the concern for a while now with ACA plans is because insurance companies can’t do the things that they did a decade ago to limit premium increases, etc., one of the ways they can keep their costs down is to curtail the number of available providers for someone who signs up for one of these plans. So, like Jessie, I’m curious about how those new rules from last year will affect whether people see meaningful differences in the availability of in-network providers under specific plans.

Carey: That and many other trends are worth watching as we head into the open enrollment season. But right now, I’d like to turn to another topic in the news, and that’s abortion. “What the Health?” listeners know that last week your host, Julie Rovner, created a new segment that she’s calling “This Week in Health Care Misinformation.” Here’s this week’s entry.

A measure before Ohio voters next Tuesday, that’s Nov. 7, would amend Ohio’s constitution to guarantee the right to reproductive health care decisions, including abortion. Abortion rights opponents say the measure is crafted too broadly and should not be approved. The official government website of the Republican-controlled Ohio Senate is attacking the proposed abortion amendment in what some experts have said is a highly unusual and misleading manner. Headlines on the “On The Record” blog — and that’s what it’s called, “On The Record”; this is on the Ohio state website — it makes several claims about the measure that legal and medical experts have told The Associated Press were false or misleading. Headlines on this site include, and I’m quoting here, “Abortion Is Killing the Black Community” and that the proposal would cause, again, another quote, “unimaginable atrocities.” Isn’t it unusual for an official government website to operate in this manner?

Pradhan: I think yes, as far as we know, and that’s really scary. It’s hard enough these days to sort out what is legitimate and what isn’t. We’ve seen AI [artificial intelligence] used in other political campaign materials in the forms of altered videos, photographs, etc. But now this is a really terrifying prospect, I think, that you could provide misinformation to voters — particularly in close races, I would say, that you could really swing an outcome based on what people are being told.

Kenen: The other thing that’s being said in Ohio by the Republicans is that the measure would allow, quote, “partial-birth abortions,” which is a particular — it’s a phrase used to describe a particular type of late-term abortion that’s illegal. Congress passed legislation, I think it’s 15 to 20 years ago now, and it went through the courts and it’s been upheld by the courts. This measure in Ohio does not undo federal law in the state of Ohio or anywhere else. So that’s not true. And that’s another thing circulating.

Carey: This discussion is very important. And to Rachana’s point, how voters perceive this is very important because Ohio is serving as a testing ground for political messaging headed into the presidential race next year. And abortion groups are trying to qualify initiatives in more states in 2024, potentially including Arizona. So even if you haven’t followed this story closely, I mean, how do you think this tactic may influence voters? Again, you’re talking about something — when you hit a news tab on an official state website, you come to this blog. Do you think voters will reject it? Could it possibly influence them — as you were talking about earlier, tip the results?

Kenen: Well, I don’t think we know how it’s going to tip, because I don’t know how many people actually read the state legislature blog.

Carey: Yeah, that could be an issue.

Kenen: Although, and the coverage of it, one would hope, in the state media would point out that some of these claims are untrue. But I mean, it’s taking — you know, the Republicans have lost every single state ballot initiative on abortion, and it’s been a winning issue for the Democrats and they’re trying to reframe it a little bit, because while polls have shown — not just polls, but voting behavior has shown — many Americans want abortion to remain legal, they aren’t as comfortable with late-term abortions, with abortions in the final weeks or months of pregnancy. So this is trying to shift it from a general debate over banning abortion, which is not popular in the U.S., to an area where there’s softer support for abortions later during pregnancy.

And polls have shown really strong support for abortion rights. But this is an area that is not as strong, or a little bit more open to maybe moving people. And if the Republicans succeed in portraying this as falsely allowing a procedure that the country has decided to ban, I think that’s part of what’s going on, is to shift the definition, shift the terms of debate.

Carey: As we know, Ohio is not the only state where abortion is taking center stage. For example, in Pennsylvania, abortion is a key issue in the state Supreme Court justice election, and it’s a test case of political fallout from the Supreme Court, the United States Supreme Court’s decision last summer to overrule Roe v. Wade. In Texas, the state is accusing Planned Parenthood of defrauding the Republican-led state’s Medicaid health insurance program. And in Kansas, in a victory for abortion rights advocates, a judge put a new state law on medication abortions on hold and blocked other restrictions governing the use and distribution of these medications and imposed waiting periods.

And of course, abortion remains a huge issue on Capitol Hill, with House Republicans inserting language into many spending bills to restrict abortion access, to block funding for HIV prevention, contraception, global health programs, and so on. So, which of these cases, or others maybe that you are watching, do you think will be the strongest indicators of how the abortion battle will shake out for the rest of this year and into 2024?

Pradhan: I’m actually going to make a plug for another one that we didn’t mention, which is for our local, D.C.-area listeners, Virginia next week has a state legislative election. So, Gov. [Glenn] Youngkin of course is still — he’s not up for reelection; he’ll sit one single four-year term, but the entire Virginia General Assembly is up for election. So currently Gov. Youngkin says that he wants to institute a 15-week abortion ban, but Republicans would need to control every branch of government, which they do not currently, but it is possible that they will after next week. So that would be a big change as you see abortion restrictions that have proliferated, especially throughout the South and the Midwest. But now Virginia so far has not, in the wake of last year’s Dobbs [v. Jackson Women’s Health Organization] decision, has not imposed greater restrictions on access to abortion.

But I think the 15-week limit also provides kind of a test case, I think, for whether Republicans might be able to coalesce around that standard as opposed to something more aggressive like, say, a total ban or a six-week ban that’s obviously been instituted in certain states but I think at a national level right now is a nonstarter. I’m pretty interested in seeing what happens even in a lot of our own backyard.

Kenen: Because Virginia’s really tightly divided. I mean, the last few elections. This was a traditional Republican state that has become a purple state. And the last few state legislature elections, didn’t they once decide by drawing lots? It was so close. I mean it’s flipped back. It’s really, really, really tiny margins in both houses. I think Rachana lives there and knows the details better than I do. But it’s razor-thin, and it was Republican-controlled for a long time and Democrats, what, have one-seat-in-the-Senate control? Something like that, a very narrow margin. And they may or may not keep it.

Pradhan: Joanne, your memory’s so good, because they had —

Kenen: Because I edited your stories.

Pradhan: You did. I know. And they had to draw names out of a bowl that was— it was in a museum. It was something that a Virginia potter had made and they had to take it out of a museum exhibit. I mean, it was the most — it’s really fascinating what democracy can look like in this country when it comes down to it. It was such a bizarre situation to decide control of the state House. So you’re very right, so it’s very close.

Kenen: It’s also worth pointing out, as we have in prior weeks, that 15 weeks is now being offered as this sort of moderate position, when 15 weeks — a year ago, that’s what the Supreme Court case was really about, the case we know as Dobbs. It was about a law in Mississippi that was a 15-week ban. And what happened is once the courts gave the states the go-ahead, they went way further than 15 weeks. I don’t know how many states have a 15-week ban, not many. The anti-abortion states now have sort of six weeks-ish or less. North Carolina has 12, with some conditions. So 15 weeks is now Youngkin saying, “Here’s the middle ground.” I mean, even when Congress was trying to do a ban, it was 20, so — when they had those symbolic votes, I think it was always 20. He’s changed the parameters of what we’re talking about politically.

Carey: Jessie, how do you see the abortion riders on these appropriations bills, particularly in the House. House Republicans have put a lot of this abortion language into the approps bills. How do you see that shaking out, resolving itself, as we look forward?

Hellmann: It is hard to see how some of these riders could become law, like the one in the FDA-Ag approps bill that would basically ban mailing of mifepristone, which can be used for abortions. Even some moderate Republicans who are really against that rider — I mean just a handful, but it’s enough where it should just be a nonstarter. So I’m just not sure how I can see a compromise on that right now. And I definitely don’t see how that could pass the Senate. So it’s just everything has become so much more contentious since the Roe decision. And things that weren’t contentious before, like the PEPFAR [The United States President’s Emergency Plan for AIDS Relief] reauthorization, are now being bogged down in abortion politics. It’s hard to see how the two sides can come to an agreement at this point.

Carey: Yes, contentious issues are everywhere. So, let’s switch from abortion to AI. Earlier this week, President Biden issued an executive order that calls on several federal agencies, including the Department of Health and Human Services, to create regulations governing the use of AI, including in health care. What uses of AI now in health care, or even future uses, are causing the greatest concern and might be the greatest focus of this executive order? And I’m thinking of things that work well in AI or are accepted, and things that maybe aren’t accepted at this point or people are concerned about.

Kenen: I think that none of us on the panel are super AI experts.

Carey: Nor am I, nor am I.

Kenen: But we are all following it and learning about it the way everybody else is. I think this is something that Vice President Harris pointed out in a summit in London on AI yesterday. There’s a lot of focus on the existential, cosmic scary stuff, like: Is it going to kill us all? But there’s also practical things right now, particularly in health care, like using algorithms to deny people care. And there’s been some exposés of insurance doing batch denials based on an AI formula. There’s concerns about — since AI is based on the data we have and the data, that’s the foundation, that’s the edifice. So the data we have is flawed, there’s racial bias in the data we have. So how do you make sure the algorithms in the future don’t bake in the inequities we already have? And there’s questions too about AI is already being used clinically, and how well does it really work? How reliable are the studies and the data? What do we know or not know before we start?

I mean, it has huge potential. There are risks, but it also has huge potential. So how do we make sure that we don’t have exaggerated happy-go-lucky mistrust in technology before we actually understand what it can and cannot do and what kind of safeguards the government —and the European governments as well; it’s not just us, and they may do a better job — are going to be in place so that we have the good without … The goal is sort of, to be really simplistic about it, is let’s have the good without the bad, but doing it is challenging.

Carey: Oh, Rachana, please.

Pradhan: Well, all I was going to say was nowadays you cannot go to a health care conference or a panel discussion without there being some session about AI. I guess it demonstrates the level of interest. It kind of reminds me of every few years there’s a new health care unicorn. So there was ACOs [accountable care organizations] for a long time; that’s all people would talk about. Or value-based care, like every conference you went to. And then with covid, and for other reasons, everyone is really big on equity, equity, equity for a long time. And now it’s like AI is everywhere.

So like Joanne said, I mean, we have everything from a chatbot that pops up on your screen to answer even benign questions about insurance. That’s AI. It’s a form of AI. It’s not generative AI, but it is. And yeah, I mean, insurance companies use all sorts of algorithms and data to make decisions about what claims they’re going to pay and not pay. So yeah, I think we all just have to exercise some skepticism when we’re trying to examine how this might be used for good or bad.

Kenen: I just want a robot to clean my kitchen. Why doesn’t anyone just handle the … Silicon Valley does the really important stuff.

Carey: That would be a use for good in your house, in my house, in all our houses.

Kenen: Yeah.

Carey: So, while we’re understandably and admittedly not AI experts, we are experts on Congress here. And the president did say in his announcement earlier this week that Congress still needs to act on this issue. Why haven’t they done it yet? They’ve had all these hearings and all this conversation about crafting rules around privacy, online safety, and emerging technologies. Why no action so far? And any bets on whether it may or may not happen in the near future?

Hellmann: I think they don’t know what to do. We’ve only, as a country, started really talking about AI at kitchen tables, to use a cliche, this year. And so Congress is always behind the eight ball on these issues. And even if they are having these member meetings and talking about it, I think it could take a long time for them to actually pass any meaningful legislation that isn’t just directing an agency to do a study or directing an agency to issue regulations or something that could have a really big impact.

Carey: Excellent. Thank you. So let’s touch briefly — before we wrap, I really do want to get to this point and some of the stuff we continue to see in the news about health care workers under fire. It’s certainly not easy to be a health care worker these days. New findings published by the Centers for Disease Control and Prevention show that, in 2022, 13.4% of health workers said they had been harassed at work. That’s up from 6.4% in 2018. That’s more than double the rate of workplace harassment compared to pre-pandemic times, the CDC found.

We’ve talked about this before. It’s worth revisiting again. What is going on with our health care workforce? And what do these kind of findings mean for keeping talented people in the workforce, attracting new people to join?

Hellmann: Has anyone actually caught a break after the pandemic?

Carey: That’s a good point.

Hellmann: I mean, covid is still out there, but I don’t think that our health care system has really recovered from that. People have left the workforce because they’re burned out. People still feel burned out who stuck around, and I don’t know if they really got any breaks or the support that they needed. There’s just kind of this recognition of people being burned out. But I don’t know how much action there is to address the issue.

I feel like sometimes that leads to more burnout, when you see executives and leaders acknowledging the problem but then not really doing much to address it.

Carey: Well, that’s certainly been the complaint by pharmacy staff and others and pharmacists at some of the large drugstore chains, retail chains, that have gone out on strike. They’ve had these two- and three-day strikes recently. So, I’m assuming that will continue, unfortunately, for all the reasons that Jessie just laid out.

Pradhan: Actually, kind of going back to the strikes from pharmacists, I was thinking about this earlier because we’ve seen recently, I think separately in the news when it comes to labor unions, and maybe this will have some bearing, maybe not, but the United Auto Workers strike — I mean, they extracted some of the largest concessions from automakers as far as pay increases. And people are seeing, they really got a victory after striking for weeks. And I think people, at least the coverage that I’ve seen has talked about how that union win might not just catalyze greater labor union involvement, not just in the auto industry but in other parts of the country and other sectors.

And so, I’m not sure what percentage of pharmacists are part of labor unions, but I think people have sort of said more recently that organized labor is having a moment, or has been, that it has not in a while. And so, I’ll be fascinated to see whether there’s a greater appetite among pharmacists to actually be part of a labor union and sort of whether that results in greater demands of some of these corporate chains. As we know — we can talk about this I think in a little bit — but the corporate chains have really taken over pharmacies in America, and rural pharmacies are really dying off. And so that has a lot of important implications for the country.

Kenen: I think the problems with the health care workforce are not all things that labor unions can address, because some of it is how many hours you work and what kind of shifts you have and how often they change and things that — yeah, I mean, labor is having a moment, Rachana’s right. But they’re also tied to larger demographic trends, with an aging society. It’s tied to, our whole system is geared toward the, like dean of nursing at [Johns] Hopkins Sarah Szanton is always talking about, it’s not so much not having enough nurses; we’ve got them in the wrong places. If we did more preventive care and community care and chronic disease management in the community, you wouldn’t have so many people in the hospital in the first place where the workforce crisis is.

So some of these larger issues of how do we have a better health care system; labor negotiations can address aspects of it. Nursing ratios are controversial, but that’s a labor issue. It’s a regulatory issue as well. But our whole system’s so screwed up now that Jessie’s right, nobody recovered from the strains of the pandemic in many sectors, probably all sectors of society, but obviously particularly brutal on the health care workforce. We didn’t get to hit pause and say, OK, nobody get sick for six months while we all recover. The unmet psychiatric needs. I mean, it’s just tons of stuff is wrong, and it’s manifesting itself in a workforce crisis. So maybe if you don’t have anyone to take care of you, maybe people will pay attention to the larger underlying reasons for that.

Carey: That’s an issue I’m sure we will talk more about in the future because it’s just not going anywhere. But for now, we’re going to turn to our extra credit segment. That’s when we each recommend a story we read this week and 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: Well, speaking of which, after we just talked about, there’s a piece in The Washington Post by Marc Fisher. It has a long headline: “Older Americans Are Dominating Like Never Before, but What Comes Next?” And basically it’s talking about not so much the nursing and physician workforce, although that’s part of it, just the workforce in general. We have more people working longer, and in areas where there’s shortages, there’s nothing wrong with having old people. A lot of communities have shortages of school bus drivers. So if you have a lot of older school bus drivers and they’re safe and like kids and like driving the bus, more power to them. If you’re 55 and you can drive a school bus full of nine-year-olds, middle schoolers, so much more.

Carey: Good luck with that one.

Kenen: But some of the physician specialties — one of the people in the story is a palliative care physician who retired and isn’t happy retired and wants to go back to work. And that’s another area where we need more people. But it’s a cultural shift, like, who’s doing what when, and how does it affect the younger generation? Although there was a reference to Angelina Jolie being on the old side at 48. I guess for an actress that might be old. But that wasn’t the gist of it. But we have this shift toward older people in many places, not just Trump and Biden. It’s sort of the whole workforce.

Carey: Got it. Jessie.

Hellmann: My extra credit is also a story from The Washington Post. It’s called “Drugstore Closures Are Leaving Millions Without Easy Access to a Pharmacy.” Focused specifically on some of the big national chains like CVS and Walgreens and Rite Aid, which have really kind of dominated the drugstore space over the past few decades. But now they are dealing with the repercussions from all these lawsuits that are being filed alleging they had a role in the opioid epidemic. And the story just kind of looks at the consequences of that.

These aren’t just places people get prescriptions. They rely on them for food, for medical advice, especially in rural and underserved areas. So yeah, I just thought it was a really interesting look at that issue.

Carey: Rachana?

Pradhan: So my extra credit is a story in The New York Times called “How a Lucrative Surgery Took Off Online and Disfigured Patients.” It’s horrifying. It’s a story about surgeons who are performing a complex type of hernia surgery and evidently are learning their techniques, or at least a large share of them are learning their techniques, by watching videos on social media. And the techniques that are demonstrated there are not exactly high quality. So the story digs into resulting harm to patients.

Kenen: And it’s unnecessary surgery in the first place — for many, not all. But it’s a more complicated procedure than they even need in a large portion of these patients.

Carey: My extra credit is written by Rachel Cohrs of Stat, and she’s a frequent guest on this program. Her story is called “The Health Care Issue Democrats Can’t Solve: Hospital Reform.” While Democrats have seized on lowering health care costs as a politically winning issue — they’ve taken on insurers and the drug industry, for example — Rachel writes that hospitals may be a health care giant they’re unable to confront alone, and they being the Democrats. As we know, hospitals are major employers in many congressional districts. There’s been a lot of consolidation in the industry in recent years. And hospital industry lobbyists have worked hard to preserve the image that they are the good guys in the health care industry, Rachel writes, while others, like pharma, are not.

Well, that’s 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 others find us too. Special thanks, as always, to our engineer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you could still find me on X. I am @maryagnescarey. Rachana?

Pradhan: I am @rachanadpradhan on X.

Carey: Jessie.

Hellmann: @jessiehellmann.

Carey: And Joanne.

Kenen: I’m occasionally on X, @JoanneKenen, and I’m trying to get more on Threads, @joannekenen1.

Carey: We’ll be back in your feed next week, and until then, be healthy.

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