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

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

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

Panelists

Among the takeaways from this week’s episode:

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

Also this week, Rovner interviews 蘑菇影院 Health News’ Bram Sable-Smith, who reported and wrote the latest 蘑菇影院 Health News-NPR “Bill of the Month” feature about a free cruise that turned out to be anything but. If you have an outrageous or baffling bill you’d like to send us, you can do that here.

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

• Julie Rovner: Abortion, Every Day’s “,” by Jessica Valenti.
• Alice Miranda Ollstein: The Washington Post’s “,” by Lauren Weber.
• Rachel Cohrs Zhang: ProPublica’s “,” by Isabelle Taft, Mississippi Today.
• Sandhya Raman: Air Mail’s “,” by Clara Molot.

[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.]听

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for 蘑菇影院 Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, June 6, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Sandhya Raman of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: And Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Right.

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

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

Rovner: Right, which they have done all along.

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

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

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

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

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

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

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

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

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

Ollstein: In many states.

Rovner: 鈥� right? 鈥�

Ollstein: Exactly.

Rovner: 鈥� when they can intervene.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bram Sable-Smith: Thanks for having me.

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

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

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

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

Rovner: Wild pigs, right?

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

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

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

Rovner: And how much was it?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sable-Smith: Always a pleasure.

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

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

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

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

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

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

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

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

Raman: .

Rovner: Alice?

Ollstein: .

Rovner: Rachel?

Cohrs Zhang: .

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

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In April, in a 3-2 vote, the FTC prohibiting contracts that prevent an employee from taking a job with a competitor. Calling the noncompete agreements “a widespread and often exploitative practice,” an agency announcement described them as an unfair method of competition that depresses wages and hinders new business formation.

The rule bars employers in most industries, including health care, from using contract clauses that block employees from leaving for other jobs or starting a competing business in the same geographic area for a fixed period of time.

But that doesn’t help many health professionals, because the FTC Act gives the agency authority over companies organized to operate for profit but not over nonprofit, charitable organizations, which are also tax-exempt.

Still, the agency noted some nonprofits could be bound by the rule if they do not operate as true charities. The rule establishes a two-part test to determine if the FTC has jurisdiction over a nonprofit 鈥� whether the organization is carrying on business for only charitable purposes, and whether its income goes to public rather than private interests.

“Our rulemaking record includes powerful stories from health care workers who are employed by nonprofits about how noncompetes hurt patients and providers,” said FTC Commissioner Rebecca Kelly Slaughter, one of three Democratic commissioners, before the April 23 vote. “I do not think there is a good justification for them to be excluded from this rule.”

Noncompete contract terms for physicians, nurse practitioners, and other medical professionals in hospitals and various health care facilities. Some providers say these agreements have forced them to leave their communities and patients behind if they wanted to exit unethical or unsafe workplace conditions.

of U.S. community hospitals are nonprofits or government-owned, and they employ many of the nation’s medical professionals. As of 2022, nearly three-quarters of U.S. physicians were employed by , both nonprofit and for-profit.

Based on their designation as charities that don’t have to pay income or property taxes, U.S. nonprofit hospitals received a total estimated tax exemption of , according to 蘑菇影院, a nonpartisan research organization.

That exceeded the estimated $16 billion they spent on charity care for patients unable to afford their medical bills, 蘑菇影院 said.

Physician and nursing groups say it makes no sense to treat nonprofit hospitals differently because they are just as money-driven as for-profit hospitals. Patients, they say, will benefit if providers are free to call out unsafe conditions and change jobs. “Giving physicians freedom of movement will force hospitals to compete to improve working conditions,” said Jonathan Jones, immediate past president of the American Academy of Emergency Medicine.

Chad Golder, general counsel and secretary of the American Hospital Association, which represents mostly nonprofit hospitals, said the rule would increase health care costs and reduce patient access by triggering hospital bidding wars for physicians. He predicted the FTC would try to apply the rule to both nonprofit and for-profit hospitals.

“They aren’t saying exactly what they’ll do, but it’s a pretty significant move for them to say we’ll apply our own test to determine if we can regulate a nonprofit,” Golder said. “Nonprofit entities now will need to be extra careful.”

In addition, some nonprofit hospitals have joint ventures with for-profit hospitals and medical groups. That could create complicated questions about whether their employee contracts come under the rule, said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents for-profits.

The new rule arose from President Joe Biden’s 2021 executive order to curb the unfair use of noncompete agreements, part of his broader mandate to boost U.S. economic competition and worker mobility.

The FTC argued that banning noncompetes, which it said cover 1 in 5 American workers, would lower health care costs by up to $194 billion over the next decade. It will ensure Americans “freedom to pursue a new job, start a new business, or bring a new idea to market,” FTC Chair Lina Khan said.

The rule also prohibits contract terms that function like noncompetes to stop employees from leaving to work for competing companies or start their own businesses. These might include overbroad nondisclosure agreements, training repayment provisions, and nonsolicitation clauses.

“No one should be trapped in an unsafe job by onerous contracts that prevent them from taking another job,” said Brynne O’Neal, a regulatory policy specialist at National Nurses United, the profession’s largest dedicated labor union in the U.S. Hospitals, she said, use that require nurses to pay as much as $30,000 in training costs if they leave, essentially locking them in their jobs.

California, Minnesota, North Dakota, and Oklahoma already ban enforcement of noncompete clauses for all employees of both nonprofits and for-profits, while prohibit noncompetes for physicians. Even in states without bans, when they have found them to be overbroad or unreasonable.

Hospital executives argue that the noncompete rule will force them to compete against each other to hire physicians and other providers and ultimately cost them more, and that it advantages nonprofits over for-profits. “All it would do is increase the price of labor in a field that already has labor shortages and thin margins,” Golder said.

“The nonprofit hospital across the street could pursue our employees, while their employees would be protected, and that’s a basic fairness issue,” Kahn said.

But Clifford Atlas, an employment attorney with Jackson Lewis in New York, said that argument against the noncompete rule “won’t fly” in court because preventing competition for the services of physicians or other workers is not a business interest that’s protected by law or public policy.

The rule is set to take effect in September, though business groups against it in Texas and . Many legal experts predict that conservative judges will strike down the rule on the grounds that it .

Physician and nurses’ groups hope the FTC rule, whatever its fate in the courts, helps persuade hospitals and other health care employers to stop using noncompetes and to prohibit them.

“We’re telling our members it could be struck down, but we’re asking them to renegotiate their contracts,” said Jones of the American Academy of Emergency Medicine. “They should be asking their employers, 鈥榃ouldn’t you like to be on the right side and not to be seen as fighting against physicians and patients?’”

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In the emails, David Morens, a career federal scientist now on administrative leave, described deleting messages and using a personal email account to evade disclosure of correspondence under the Freedom of Information Act.

“i learned from our foia lady here how to make emails disappear after i am foia’d but before the search starts, so i think we are all safe,” Morens wrote in a Feb. 24, 2021, email. “Plus i deleted most of those earlier emails after sending them to gmail.”

The pressure is on as Fauci himself prepares to appear June 3 before a House subcommittee exploring the origins of covid-19. The NIH, a $49 billion agency that is the foremost source of funding in the world for biomedical research, finds itself under unusual bipartisan scrutiny. The subcommittee has demanded more outside oversight of NIH and its 50,000 grants and raised the idea of term limits for officials like Fauci, who led the National Institute of Allergy and Infectious Diseases, an NIH component, from 1984 to 2022.

Lawmakers are likely to put Fauci on the spot about Morens’ emails at a time when Republicans are questioning NIH’s credibility and integrity. Even Democrats have cautioned the agency’s leaders.

“When people don’t trust scientists, they don’t trust the science,” Rep. Deborah Ross (D-N.C.) told Morens.

The subcommittee has yet to turn up evidence implicating the NIH or U.S. scientists in the pandemic’s beginnings in Wuhan, China. Nor has its work shed light on the origin of the virus.

But in , the subcommittee’s chairman, Rep. Brad Wenstrup (R-Ohio), said the evidence “suggests a conspiracy at the highest levels of NIH and NIAID to avoid public transparency regarding the COVID-19 pandemic.”

Rep. Jill Tokuda, a subcommittee Democrat from Hawaii, said the evidence shows no such conspiracy. She predicted the bipartisan criticism of Morens, 76, will give way to “a clash of intentions” at the hearing as Republicans try to pin covid on Fauci.

“For them, I think this is their moment to, again, bring a lot of these baseless, false allegations to the front,” Tokuda said.

On May 29, Wenstrup asked Fauci to turn over personal e-mails ahead of his testimony.

Here are things to know as the subcommittee gears up for Fauci’s appearance.

What Is the Subcommittee Looking For?

The Select Subcommittee on the Coronavirus Pandemic is supposed to be investigating how the pandemic started and the federal government’s response. That includes such hot-button issues as vaccination policies and school closures.

A central question is whether the covid virus leaped from animals to humans at a market in Wuhan, China, or spread from a leak at the nearby Wuhan Institute of Virology. The Wuhan lab received funding from an NIH grant recipient called EcoHealth Alliance.

The congressional probe is in some ways an extension of the nation’s political, cultural, and scientific battles arising from the pandemic.

The Republican-led subcommittee has been examining NIH’s performance and that of Fauci, who advised both former President Donald Trump and President Joe Biden, becoming the face of many of the government’s most polarizing pandemic policies.

The panel called for the government to , a process the Department of Health and Human Services .

EcoHealth’s president, Peter Daszak, was Morens’ friend and the recipient of many of the emails under scrutiny. A wildlife biologist credited with helping to develop the first covid antiviral drug, remdesivir, Daszak said he and his organization did nothing wrong.

“We were so accurate in our predictions that a bat coronavirus would emerge from China and cause a pandemic, that when it did, we’re dragged in front of the crowd with their pitchforks and blamed for it,” Daszak said in an interview.

What’s at Stake for NIH?

The Republican-led subcommittee is challenging NIH’s credibility. The agency performs and funds a wide variety of medical and scientific research, work that is often the foundation of new medicines and other treatments, and has long enjoyed bipartisan support from Congress. The agency is home to the “,” a Biden priority.

As head of NIAID and a presidential adviser, Fauci helped guide the public during the pandemic on measures to avoid infection, such as mask-wearing and maintaining physical distance.

But at a May 22 hearing, Wenstrup said Fauci’s NIAID “was, unfortunately, less pristine than so many, including the media, would have had us all believe.”

In his letter to Bertagnolli, Wenstrup said there was evidence that a former chief of staff of Fauci’s might have used intentional misspellings 鈥� such as a variant of “EcoHealth” 鈥� to prevent emails from being captured in keyword searches by FOIA officials.

Wenstrup’s office did not respond to questions or an interview request.

An aide to the top Democrat on the subcommittee, Rep. Raul Ruiz of California, said he was unavailable for an interview.

Why Were Morens’ Emails Alarming?

The emails show a pattern of trying to shield communications from public disclosure.

“We are all smart enough to know to never have smoking guns, and if we did we wouldn’t put them in emails, and if we found them we’d delete them,” Morens wrote on June 16, 2020.

“The best way to avoid FOIA hassles is to delete all emails when you learn a subject is getting sensitive,” he wrote on June 28, 2021.

Some of Morens’ emails included sexual or sexist remarks, including one from December 2020: “Beverage is always good, and best delivered by a blonde nymphomaniac.” In , discussing how former Centers for Disease Control and Prevention Director Rochelle Walensky got her job, he remarked, “Well, she does wear a skirt.”

Morens apologized at the May 22 hearing and called some of what he wrote “misogynistic.”

“Some of the emails I’ve seen that you all have provided look pretty incriminating,” he testified.

Asked if he ever sent information related to covid to Fauci’s personal email, he said he didn’t remember but might have.

Morens said some of his comments were “snarky jokes” intended to cheer up his friend Daszak, the EcoHealth president, who was receiving death threats over media coverage of his organization’s relationship with the Wuhan lab.

Morens testified that he didn’t knowingly delete official records.

Ross, the North Carolina representative, said the emails “inflict serious damage on public trust for the entire scientific enterprise.” She said the dangers can be seen in eroding public confidence in vaccines, contributing to recent outbreaks of measles.

Rep. Debbie Dingell (D-Mich.) said Morens showed disdain for the Freedom of Information Act. The subcommittee’s investigation has been an unfounded effort to pin the blame for the pandemic on NIH and NIAID, and Morens’ emails have helped blur the issues, she said.

Do the Emails Reveal the Origins of Covid?

No, as Democrats have emphasized.

In a way, Morens’ correspondence undercuts allegations that people at the top of NIAID covered up a lab leak in Wuhan.

None of Morens’ emails describe any effort to suppress evidence of a lab leak and, in an email sent from a private account, he ridiculed the idea, calling it “false to the point of being crazy.” But the subcommittee’s senior Democrat, Ruiz, criticized Morens for dismissing the lab leak theory.

“Unless and until we see specific evidence on the origins” of the virus that causes covid, “the scientific process requires that we examine all possible hypotheses with objectivity,” Ruiz said.

蘑菇影院 Health News senior correspondent Arthur Allen contributed to this report.

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Customers often don’t discover the changes until they’re denied medical coverage or get stuck with a bill for ACA tax credits they have to repay.

Senate Finance Committee Chair Ron Wyden (D-Ore.) said he’ll propose legislation to allow the Centers for Medicare and Medicaid Services to hold fraudulent brokers “criminally responsible” for their actions. The agency, which oversees the ACA exchanges, can fine individuals up to $250,000 for submitting false information in an application for a health plan, but it hasn’t done so, Wyden said.

“I am disappointed these penalties have not yet been used to hold bad actors accountable,” Wyden wrote last week in a sharply worded letter to CMS Chief Chiquita Brooks-LaSure.

Jimmy Patronis, who oversees agencies including insurance regulators as Florida’s chief financial officer, called on Congress to push CMS to require two-factor authentication on and related platforms that agents use to sign people up for coverage. According to Patronis, the state has into problem enrollments.

“It’s far easier to prevent fraud from occurring in the first place than it is to ask state regulators to chase down these bad actors after the fact,” Patronis wrote.

The problem appears concentrated among the 32 states using the federal marketplace 鈥� 鈥� because, brokers say, it’s too easy for rogue agents to access policyholder information. All they need is a name, date of birth and state.

States that run their own insurance markets generally have additional security requirements.

CMS tallied 90,000 complaints about unauthorized sign-ups or plan switching in just the first quarter of 2024, out of more than 16 million enrollments.

Jeff Wu, acting director of the Center for Consumer Information and Insurance Oversight at CMS, has said his agency is preparing regulatory and technological fixes, investigating brokers and working to restore consumers to chosen plans.

But even with Wyden’s legislation on the way, Congress looks unlikely to act. Lawmakers are in the middle of an election year in which President Biden is trying to win votes for bolstering enrollment in ACA plans while knocking his opponent, former president Donald Trump, for his unsuccessful attempt to repeal the law.

Sabrina Corlette, who follows the ACA market as co-director of the Center on Health Insurance Reforms at Georgetown University, said the feds can do more, including coordinating better with state investigations.

But states like Florida should also regulate the marketplaces, she said.

“If there’s a lot of bad brokers in Florida, then Florida needs to look inward and maybe do a better job of policing brokers,” she said.

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In Anamosa, Iowa 鈥� a town of fewer than 6,000 residents located more than 900 miles from the nation’s capital 鈥� rural hospital leader Eric Briesemeister is watching for Congress’ next move. The 22-bed hospital Briesemeister runs averages about seven inpatients each night, and its most recent federal filings show it earned just $95,445 in annual net income from serving patients.

Yet Briesemeister isn’t interested in converting the facility into a rural emergency hospital, which would mean getting millions of extra dollars each year from federal payments. In exchange for that financial support, hospitals that join the program keep their emergency departments open and give up inpatient beds.

“It wasn’t for us,” said Briesemeister, chief executive of UnityPoint Health-Jones Regional Medical Center. “I think that program is a little bit more designed for hospitals that might not be around without it.”

Nationwide, only of the more than 1,500 eligible hospitals have become rural emergency hospitals since the program launched last year. At the same time, rural hospitals continue to close 鈥� 10 since the fix became available.

Federal lawmakers have introduced a handful of legislative solutions since March. In , senators from Kansas and Minnesota list a myriad of tactics, including allowing older closed facilities to reopen.

Another in the House by two Michigan lawmakers is the Rural 340B Access Act. It would allow rural emergency hospitals to use the 340B federal drug discount program, which Congress created in 1992.

The 340B program, named after its federal statute, lets eligible hospitals and clinics buy drugs at a discount and then bill insurance companies, Medicare, or Medicaid at market rates. Hospitals get to keep the money they make from the difference.

Congress approved 340B as an indirect aid package to help struggling hospitals stay afloat. Many larger hospitals say the cash is used for community benefits and charity care, while many small hospitals depend on the drug discounts to help cover staffing and operational shortfalls.

Currently, emergency hospitals are not eligible for 340B discounts. According from U.S. Rep. Jack Bergman (R-Mich.), the House proposal would “correct this oversight.” Backers of the House bill include the American Hospital Association and the National Rural Health Association.

In Iowa, Briesemeister said the 340B federal drug discount program “can be used for tremendous good.” The small-town hospital uses money it makes from 340B to subsidize emergency services and uninsured and underinsured patients who frequent the emergency department, he said.

Chuck Grassley, Iowa’s longtime Republican senator, shepherded the Rural Emergency Hospital program into law. His spokesperson, Gillie Maddox, did not respond directly to questions about why the federal law creating rural emergency hospitals omitted the 340B program. Instead, Maddox said the designation was a “product of bipartisan negotiations.”

A survey conducted by the health analytics and consulting firm Chartis, along with the National Rural Health Association, found that nearly 80% of rural hospitals had participated in 340B and nearly 40% said they reaped $750,000 or more annually from the program.

Sanford Health, a largely rural health system headquartered in Sioux Falls, South Dakota, considered converting a handful of smaller critical access hospitals into rural emergency hospitals.

Martha Leclerc, vice president of corporate contracting for Sanford, said the system analyzed how much revenue would be lost by closing inpatient beds, which is also a requirement of the emergency hospital program, and by being unable to file for drug discounts.

In the end, she said, switching did not “make a lot of sense.”

While many rural hospitals are clamoring for the 340B provision to be added to the rural emergency hospital program, opponents have said 340B can be a cash cow for hospitals that don’t serve enough vulnerable patients.

Nicole Longo is deputy vice president of public affairs for the Pharmaceutical Research and Manufacturers of America, the nation’s largest, most influential pharmaceutical lobbying group. She wrote in a recent blog post that hospital systems and chain pharmacies are “exploiting the program” and said patients have not benefited from the growth in the program.

In an interview, Longo said PhRMA supports rural emergency hospitals being able to access 340B because they are treating “vulnerable patients in underserved communities” and are “true safety net providers.”

PhRMA, she said, wants to encourage a thoughtful conversation about “which types of hospitals should be in the program.” Last year, PhRMA formed an unlikely pact with community health centers to create the Alliance to Save America’s 340B Program, or ASAP 340B.

Vacheria Keys, associate vice president of policy and regulatory affairs at the National Association of Community Health Centers, said, “There is a new day of openness, from all parties.”

Use of the drug discount program skyrocketed after provisions in the Patient Protection and Affordable Care Act,听, increased the number of hospitals and clinics allowed to contract with an unlimited number of retail pharmacies, such as Walgreens and CVS, which are paid a fee to dispense the discounted drugs.

Adam J. Fein, president of the industry research organization Drug Channels Institute, reports that the 340B program is the second-largest federal drug program, trailing Medicare Part D. The flow of drugs purchased under the 340B program , about $9.8 billion more .

In response to the exploding use of contract pharmacies, pharmaceutical manufacturers have restricted the drugs they offer at a discount through the pharmacies. That throttling is affecting rural hospitals like Labette Health, a Kansas hospital whose president asked President Joe Biden for help in dealing with the pharmaceutical companies.

Rena Conti, an associate professor of markets, public policy, and law at Boston University’s Questrom School of Business, has studied the drug discounts for years and said she has “significant worries about expanding” the 340B program.

“There is a lot of money being generated in this program that we really can’t understand exactly how much that really is and exactly who it is benefiting,” Conti said.

At the same time, said Conti, a health care economist, giving rural hospitals access to the federal drug discounts “makes sense because they are hospitals that are serving particularly vulnerable patient populations.”

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“We want the Centers for Medicare & Medicaid Services to hold these brokers criminally responsible for ripping people off this way,” he told 蘑菇影院 Health News.

In a sharply worded letter sent to CMS Administrator Chiquita Brooks-LaSure, the Oregon Democrat expressed “outrage” over the practice, which nets unscrupulous agents commission payments while leaving consumers with a potential host of problems, from losing access to their regular doctors or treatments to higher deductibles and even owing taxes.

Noting that tens of thousands of Americans have been victimized, Wyden called on regulators to step up enforcement and be more proactive in notifying potentially affected consumers. He vowed to introduce legislation that would make participating in such schemes subject to criminal penalties.

“CMS must do more and you must do it now,” he wrote in his letter.

Complaints about such unauthorized enrollment schemes have grown in recent months. 蘑菇影院 Health News has reported that unscrupulous brokers or agents can easily access policyholder information to change their coverage through private commercial platforms integrated with the federal Obamacare marketplace, healthcare.gov, which serves 32 states.

The challenge for federal regulators is to thwart the activity without reducing enrollment 鈥� a top priority for President Joe Biden’s administration.

CMS, which oversees the federal website, said it’s working on regulatory and technological fixes and can suspend or terminate problem agents’ access to healthcare.gov.

The agency will respond directly to Wyden, said Jeff Wu, acting director of CMS’ Center for Consumer Information & Insurance Oversight, in a written statement. He further noted that the agency is “consistently evaluating opportunities to identify and resolve issues sooner, including through outreach, technical assistance, and compliance actions.”

Ronnell Nolan, president and CEO of , whose group has been outspoken about the need for regulators to do more, welcomed Wyden’s involvement and the potential for criminal penalties for perpetrators.

“It’s a crime when a person’s insurance is taken from them when they’re in the middle of cancer treatment or on a transplant list and they’re put in a predicament where they might lose their life because of the fraudulent activity,” she said.

After initially declining to quantify the problem, CMS saying it had received more than 90,000 complaints in the first quarter of 2024 about unauthorized enrollments and plan switches. While the number of complaints represents a small percentage of the more than 16 million enrollments processed through healthcare.gov for this year’s coverage, it may understate the breadth of the problem, as complaints likely don’t reflect the magnitude of cases.

Although Wyden lauded CMS’ efforts to fix problems already encountered by consumers, he said in his letter that the agency needs to be more proactive about preventing them.

He urged regulators to contact potentially affected consumers instead of waiting to investigate only after a policyholder files a complaint, which sometimes doesn’t occur until weeks or months after a plan is switched.

It can be difficult for victims to recognize the changes. Rogue agents don’t obtain their consent, and many are signed up for plans that have no monthly premiums, so they don’t get a bill. Other consumers unknowingly enroll when they respond to misleading marketing promising gift cards, “government subsidies,” or other financial help.

Rather than wait for a consumer to complain, regulators could reach out directly when they see a policy submitted or changed by a broker or agency that has been found to be fraudulently enrolling others, Wyden wrote.

Wyden also said CMS should use its authority to impose civil penalties, up to $250,000, against “brokers who submit fraudulent enrollments.”

“I am disappointed these penalties have not yet been used to hold bad actors accountable,” he wrote.

Finally, he wants the agency to review private-sector platforms used by agents and brokers to enroll consumers in ACA plans. Those private companies are not used by 18 states and the District of Columbia, which run their own ACA marketplaces. The state-run marketplaces impose additional layers of identity-proofing and other security measures and have reported far fewer problems with unauthorized enrollment.

Dozens of private “enhanced direct enrollment” to integrate with healthcare.gov. Their involvement was expanded during the Trump administration, which also sharply reduced funding for nonprofits to help with outreach and enrollment.

The platforms were designed to be simpler to use than healthcare.gov. But they have drawn criticism from agents, who say the private websites make it too easy for unscrupulous brokers or others to access policyholder information and make changes. Currently, more than half of federal marketplace enrollments are assisted by agents or brokers, and most act legitimately, regulators and others say.

蘑菇影院 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 蘑菇影院鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

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

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

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

Panelists

Among the takeaways from this week’s episode:

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

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

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

Julie Rovner: NPR’s “,” by Jonathan Lambert.听听

Alice Miranda Ollstein: Time’s “,” by Alana Semuels.听听

Rachel Cohrs Zhang: Stat’s “,” by Nicholas Florko.听听

Sandhya Raman: The Baltimore Banner’s “,” by Ben Conarck.听听

Also mentioned on this week’s podcast:

• Stat’s “,” by Nicholas Florko.
• The Stamford Advocate’s “,” by Dan Haar.
• WKRN’s “,” by Stephanie Langston.
• 蘑菇影院 Health News’ “Medicaid 鈥楿nwinding’ Decried as Biased Against Disabled People,” by Daniel Chang.
• 蘑菇影院 Health News’ “Why Medicaid’s 鈥楿ndercount’ Problem Counts,” by Phil Galewitz.

[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.]