A unanimous Supreme Court turned back a challenge to the FDA’s approval and rules for the abortion pill mifepristone, finding that the anti-abortion doctor group that sued lacked standing to do so. But abortion foes have other ways they intend to curtail availability of the pill, which is commonly used in medication abortions, which now make up nearly two-thirds of abortions in the U.S.

Meanwhile, the Biden administration is proposing regulations that would bar credit agencies from including medical debt on individual credit reports. And former President Donald Trump, signaling that drug prices remain a potent campaign issue, attempts to take credit for the $35-a-month cap on insulin for Medicare beneficiaries 鈥� which was backed and signed into law by Biden.

This week’s panelists are Julie Rovner of 蘑菇影院 Health News, Anna Edney of Bloomberg News, Rachana Pradhan of 蘑菇影院 Health News, and Emmarie Huetteman of 蘑菇影院 Health News.

Panelists

Among the takeaways from this week’s episode:

• All nine Supreme Court justices on June 13 rejected a challenge to the abortion pill mifepristone, ruling the plaintiffs did not have standing to sue. But that may not be the last word: The decision leaves open the possibility that different plaintiffs 鈥� including three states already part of the case 鈥� could raise a similar challenge in the future, and that the court could then vote to block access to the pill.
• As the presidential race heats up, President Joe Biden and former President Donald Trump are angling for health care voters. The Biden administration this week proposed eliminating all medical debt from Americans’ credit scores, which would expand on the previous, voluntary move by the major credit agencies to erase from credit reports medical bills under $500. Meanwhile, Trump continues to court vaccine skeptics and wrongly claimed credit for Medicare’s $35 monthly cap on insulin 鈥� enacted under a law backed and signed by Biden.
• Problems are compounding at the pharmacy counter. Pharmacists and drugmakers are reporting the highest numbers of drug shortages in more than 20 years. And independent pharmacists in particular say they are struggling to keep drugs on the shelves, pointing to a recent Biden administration policy change that reduces costs for seniors 鈥� but also cash flow for pharmacies.
• And the Southern Baptist Convention, the nation’s largest branch of Protestantism, voted this week to restrict the use of in vitro fertilization. As evidenced by recent flip-flopping stances on abortion, Republican candidates are feeling pressed to satisfy a wide range of perspectives within even their own party.

Also this week, Rovner interviews 蘑菇影院 president and CEO Drew Altman about 蘑菇影院’s new “Health Policy 101” primer. You can learn .

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

Julie Rovner: HuffPost’s “,” by Jonathan Cohn.

Anna Edney: Stat News’ “,” by Tara Bannow.

Rachana Pradhan: The New York Times’ “,” by Emily Schmall and Sapna Maheshwari.

Emmarie Huetteman: CBS News’ “,” by Alexander Tin.

Also mentioned on this week’s podcast:

• Bloomberg News’ “,” by Anna Edney and Peter Robison.
• 蘑菇影院 Health News’ “Biden Plan To Save Medicare Patients Money on Drugs Risks Empty Shelves, Pharmacists Say,” by Susan Jaffe.
• 蘑菇影院 Health News’ “More States Legalize Sales of Unpasteurized Milk, Despite Public Health Warnings,” by Tony Leys.

蘑菇影院 Health News’ 鈥榃hat the Health?’听Episode Title: 鈥楽COTUS Rejects Abortion Pill Challenge 鈥� For Now’Episode Number: 351Published: June 13, 2024

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]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 13, at 10:30 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 Anna Edney of Bloomberg News.

Anna Edney: Hi there.

Rovner: Rachana Pradhan of 蘑菇影院 Health News.

Rachana Pradhan: Hello.

Rovner: And Emmarie Huetteman, also of 蘑菇影院 Health News.

Emmarie Huetteman: Good morning.

Rovner: Later in this episode we’ll have my interview with 蘑菇影院 President and CEO Drew Altman, who I honestly can’t believe hasn’t been on the podcast before. He is here to talk about “Health Policy 101,” which is 蘑菇影院’s all-new, all-in-one introductory guide to health policy. But first, this week’s news.

So, as we tape, we have breaking news from the Supreme Court about that case challenging the abortion pill mifepristone. And you know how we always say you can’t predict what the court is going to do by listening to the oral arguments? Well, occasionally you can, and this was one of those times the court watchers were correct. The justices ruled unanimously that the anti-abortion doctors who brought the suit against the pill lack standing to sue. So the suit has been dismissed, wrote Justice [Brett] Kavanaugh, who wrote the unanimous opinion for the court: “A plaintiff’s desire to make a drug less available for others does not establish standing to sue.” So, might anybody have standing? Have we not maybe heard the end of this case?

Edney: Yeah, I think certainly there could be someone else who could decide to do that. I mean, just quickly looking around when this came out, it seems like maybe state AGs [attorneys general] could take this up, so it doesn’t seem like it’s the last of it. I also quickly saw a statement from Sen. [Bill] Cassidy, a Republican, who mentioned this wasn’t a ruling on the merits exactly of the case, but just that these doctors don’t have standing. So it does seem like there would be efforts to bring it back.

Rovner: This is not going to be the last challenge to the abortion pill.

Edney: Yeah.

Pradhan: Just looking in my inbox this morning after the decision, I mean it’s clear the anti-abortion groups are really not done yet. So I think there’s going to be a lot of pressure, of course, from them. It is an election year, so they’re trying to get, notch wins as far as races go, but also to get various AGs to keep going on this.

Rovner: And if you listen to last week’s podcast, there are three AGs who are already part of this case, so they may take it back with the district court judge in Texas. We shall see. Anyway, more Supreme Court decisions to come.

But moving on to campaign 2024 because, and this seems impossible, the first presidential debate is just two weeks away.President [Joe] Biden is still struggling to convince the public that he’s doing things that they support. Along those lines, this week the administration proposed rules that would ban medical debt from being included in calculating people’s credit scores. I thought that had happened already. What would this do that hasn’t already been done?

Huetteman: Well, last year the big credit agencies volunteered to cut medical debt that’s below $500 from people’s credit reports. Of course, there’s a lot of evidence that shows that that’s not really the way that people get hurt with their credit scores, they get hurt when they have big medical bills. So this addresses a major concern that a lot of Americans have with paying for health care in the United States.

I oversee our “Bill of the Month” project with NPR and I can say that a lot of Americans will pay their medical bills without question, even for fear of harm to their credit score, even if they think that their bill might be wrong. Also, it’s worth noting also that researchers have found that medical debt does not accurately predict whether an individual is credit-worthy, actually, which is unlike other kinds of debt that you’d find on credit scores.

Rovner: So yeah, not paying your car payment suggests what you might or might not be able to do with a mortgage or a credit card. But not paying your surprise medical bill, maybe not so much?

Huetteman: Yes, exactly. Really, we can all end up in the emergency room with a big bill. You don’t get a big bill just because you have trouble meeting your credit card bills or you have trouble meeting your car payments, for example.

Rovner: We’ll see if this one resonates with the public because a lot of the things that the administration has done have not. Meanwhile, President [Donald] Trump, who presided over one of the most rapid and successful vaccine development projects ever, for the covid vaccine, now seems to be moving more firmly into the anti-vax camp, and it’s not just apparently anti-covid vaccine. Trump said at a rally last month that he would strip federal funding from schools with vaccine mandates 鈥� any vaccines apparently, like measles and mumps and polio 鈥� and he says he would do it by executive order. No legislation required. This feels like it could have some pretty major consequences if he followed through on this. Anna, I see you nodding. You have a toddler.

Edney: Right, right. I was just thinking about that going into kindergarten, what that could mean, and there’s just so many 鈥� I mean, even kids don’t have to get chickenpox nowadays. That seems like a really great thing. I don’t know. I mean, I had chickenpox. I think that it could take us backwards, obviously, into a time that we’re seeing pockets of as measles crops up in certain places and things like that. I’d be curious. What I don’t know is how much federal funding supports a lot of these schools. I know there’s state funding, county funding, how much that’s actually taking away if it would change the minds of certain ones. But I guess if you’re in maybe a state that doesn’t like vaccines in the first place, it’s a free-for-all to go ahead and do that.

Pradhan: One of the questions I have, too, is through the CDC [Centers for Disease Control and Prevention] we have the Vaccines for Children Program, which provides free immunizations to children for a lot of these infectious diseases, for children who are either uninsured or underinsured or low-income. And so that’s been a really long-standing program and I’m very curious as to whether they would try to maybe reduce or eliminate a bunch of the vaccines that are provided through that, which obviously could affect a significant number of children nationwide.

Rovner: Yeah, it’s funny, the anti-vax movement has been around for, I don’t know, 20, 25 years; whenever that Lancet piece that later got rescinded came out that connected vaccines to autism. It seems it’s getting a boost and, yes, that’s an intended pun right now. I guess covid, and the doubts about covid, is pushing onto these other vaccines, too.

Edney: I think that we’ve certainly seen that. Before covid, at least my understanding of a lot of the concerns around the behavioral issues and autism linked to vaccines or things like that was more of the left-wing, maybe crunchier people who were seeing it as not wanting to put, in their words, poison in their bodies. But now we’re seeing this also right-wing opposition to it, and I think that’s certainly linked to covid. Any mandate at this point from the government is pushed back against more so than before.

Rovner: Well, we have lots of news this week on drugs and drug prices. Anna, you have quite the story about how trying to save money by ? As I describe it: the scary story of the week. Tell us about it.

Edney: Yes. Yeah, thank you. Yeah, I did this data dive looking into store-brand medication. So when you go into CVS or Walgreens, for example, you can see the Tylenol brand name there, but next to it you’ve got one that looks a lot like it, but it’s got CVS Health or Walgreens on the name and it costs usually a few dollars less. What I found is that of those store brands, CVS has a lot more recalls than the rest, even though they’re selling these same store-brand drugs. So they have two to three times more recalls than Walgreens and Walmart. And what’s happening is they are more often going to shady contract manufacturers to make their generic products that they’re selling over the counter. I found one that was making kids’ medication with contaminated water. And then the really disturbing one that was nasal sprays for babies on the same machines that this company was using to make pesticides. And just wrote about a whole litany of these kinds of companies that CVS is hiring at a higher rate than the other two 鈥� Walgreens and Walmart 鈥� that I was able to do the data dive on.

And interestingly, these store brands have a loophole, so they’re not responsible for the quality of those medications, even though their name’s on it. They can just walk away and say, “Well, we put it on the shelves. We agree with that, but it’s up to these companies that are making it to verify the quality.” And so, that’s usually not how this works. Even if there’s contract manufacturers, which a lot of drugmakers use, they usually have to also verify the quality. But store brands are considered just distributors, and so there’s this separation of who even owns the responsibility for this drug.

Pradhan: Yeah, I think a collective reaction reading this. I know, how many people did I text your story to Anna, saying, “Yikes! 鈥� FYI.”

Rovner: So on the one hand, you get what you pay for. On the other hand, price is not the only problem that we find with drugs. A new study from the University of Utah Drug Information Service just found that pharmacists are reporting the largest number of drugs in shortage since the turn of the century. And my colleague Susan Jaffe has a story on how some shortages are being exacerbated at the pharmacy level by a new Medicare rule that was intended to lower prices for patients at the counter.

Anna, how close are we to the point where the drug distribution system is just going to collapse in on itself? It does not seem to be working very well.

Edney: Yeah, it does feel that way because I always think of that example of the long balloon and when you squeeze it at one end the other end gets bigger. Because when you’re trying to help patients at the counter, somebody’s taking that hit, that money isn’t just appearing out of thin air in their pockets. So the pharmacists are saying 鈥� and particularly smaller pharmacies, but also some of the bigger ones 鈥� are saying the way that these drugs are now being reimbursed, how that’s working under this new effort, is they don’t have as much cash on hand, so they’re having trouble getting these big brand-name drugs. It was a really interesting story that Susan wrote. Just shows that you can’t fix one end of it, you need to fix the whole thing somehow. I don’t know how you do that.

And shortages are another issue just of other kinds, whether it’s quality issues or whether it’s the demand is growing for a lot of these drugs, and depending even on the time of year. So I think we’re all seeing it just appear to be disintegrating and hoping that there’s just no tragedy or big disaster where we really need to rely on it.

Rovner: Yeah, like, you know, another pandemic.

Edney: Exactly.

Rovner: There’s also some good news on the drug front. An FDA [Food and Drug Administration] advisory committee this week recommended approval for yet another potential Alzheimer’s drug, donanemab, I think I’m pronouncing that right. I guess we’ll learn more as we go on. The drug appears to have better evidence that it actually slows the progression of the disease without the risks of Aduhelm, the controversial drug approved by the FDA that’s been discontinued by its manufacturer. This would be the second promising drug to be approved following Leqembi last year. When we first started talking about Aduhelm 鈥� what was that, two years ago 鈥� we talked about how it could break Medicare financially because so many people would be eligible for such an expensive drug. So now we’re looking at maybe having two drugs like this and I don’t hear people talking about the potential costs anymore.

Is there a reason why or are we just worried about other things?

Edney: Well, I think there’s a benefit that they seem to have proven more than Aduhelm. But there’s also still a risk of brain swelling and bleeding, and that I’m sure would factor into someone’s decision of whether they want to try this. So maybe people aren’t exactly flocking in the same way to want to get these drugs. As they’re used more, maybe that changes and we see more of “Can you spot the swelling? Can you stop it?” And things like that. But I think that there just seems to be a lot of questions around them. Also, Aduhelm was the biggest one, which obviously Medicare didn’t cover, and then they’re not even trying to sell anymore. But I think that there’s just always questions about how they’re tested, how much benefit really there is. Is a few months worth that risk that you could have a major brain issue?

Rovner: While we are on the subject of drugs and drug prices, we have “This Week in Misinformation” from former President Trump, who as we all know, likes to take credit for things that are not his and deflect blame from things that are. Now in a post on his Truth Social platform, he says that he is the one who lowered insulin copayments to $35 a month, and that President Biden “had nothing to do with it.” Yes, the Trump administration did offer a voluntary $35 copayment program for Medicare Part D plans, but it was limited. It was time-limited and not all the plans adopted it. President Biden actually didn’t do the $35 copay either, but he did propose and sign the law that Congress passed that did it. It was part of the Inflation Reduction Act. Ironically, President Biden didn’t get all he wanted either. The intent was to limit insulin copayments for all patients, but so far, it’s only for those on Medicare. I would guess that Trump is saying this to try to neutralize one of the few issues that maybe is getting through to the public about something that President Biden did.

Pradhan: Well, I mean, I think even during President Trump’s first term, I mean lowering drug prices, he made it very clear that that was something that was important to him. He certainly wasn’t following the traditional or older Republican Party’s friendliness to the pharmaceutical industry. I mean, he was openly antagonizing them a lot, and so it’s certainly something that I think he understands resonates with people. And it’s a pocketbook issue similar to what’s going on on medical debt that we talked about earlier, right? These new regulations that are being proposed 鈥� they may not be finalized, we’ll have to see about that because of the timing 鈥� but these are things that are, I think at the end of the day, of course, are very relatable to people. Unlike, perhaps, abortion is a big campaign issue, but it’s not necessarily going to resonate with people in the same way and certainly not potentially men and women in the same way. But I think that there’s much more broad-based understanding of having to pay a lot for medications and potentially not being able to afford it. Obviously, insulin is probably the best poster child for a lot of reasons for that. So no surprise he wants to take credit for it, and also perhaps that it’s not really what happened, so 鈥�

Rovner: If nothing else, I think it signals that drug prices are still going to be a big issue in this campaign.

Pradhan: For sure. And I mean Joe Biden has made it very clear. I mean the Inflation Reduction Act of course included other measures to lower people’s out-of-pocket costs for drugs, which he’s very eagerly touting on the trail right now to shore up support.

Rovner: Let’s move on from drugs to abortion via the FDA spending bill on Capitol Hill this week. The annual appropriations bills are starting to move in House committees, which is notable itself because this is when they are supposed to start moving if they’re going to get done by Oct. 1, the start of the next fiscal year. We haven’t seen that in a long time. So last year Republicans got hung up because they wanted their leaders to attach all manner of policy riders to the spending bills, most of them aimed at abortion, which can’t get through the Senate. Well in a big shift, Republicans appear to be backing off of that, and the current version of the bill that funds the Department of Agriculture, as well as the FDA, does not include language trying to ban or further restrict the abortion pill mifepristone. Of course, that could still change, but my impression is that the new [House] Appropriations chairman, [Rep.] Tom Cole, who’s very much a pragmatist, wants to get his bills signed into law.

Pradhan: I do wonder, though, if because of the Supreme Court decision that just came out today, whether that will change the calculation, or at the very least, the pressure that he is under to include something in the FDA bill. But as you know, there’s plenty of time for abortion riders to make it in or out. I feel like this is, it’s like Groundhog Day. Usually something related to abortion policy will upend various pieces of legislation. So I’ll be curious to be on the lookout for that, whether it changes anything.

Rovner: Anna, were you surprised that they left it out, at least at the start?

Edney: Yeah, I think you’re just what we’ve seen with all of the rancor around abortion and abortion-related issues, I guess a little surprised. But also maybe it makes sense in just the sense that there are Republicans who are struggling with that issue and don’t want to have to keep talking about it or voting on it in the same way.

Rovner: Well, that leads right to my next subject, which is that the Senate is voting this afternoon, after we tape, on a bill that would guarantee access to IVF. Republicans are expected to block it as they did last week on the bill to guarantee access to contraception. But as of Wednesday, it’s going to be harder for Republicans to say they’re voting against the bill because no one is threatening to block IVF. That’s because the influential Southern Baptist Convention, one of the nation’s largest evangelical groups, voted, if not to ban IVF, at least to restrict the number of embryos that can be created and ban their destruction, which doctors say would make the treatments more expensive and less successful. It sounds like the rift among conservatives over contraception and IVF is a long way from getting settled here.

Huetteman: That certainly seems to be true. It’s also worth noting that there are a lot of influential members of Congress who are Baptist, of course, including House Speaker Mike Johnson. And I was refreshing my memory of the religious background of the current Congress with a Pew report: They say 67 members of this Congress are Baptist. Of course, Southern Baptist is the largest piece of that. And 148 are Catholic, which of course is another denomination that opposes IVF as well. So that’s a pretty big constituency that has their churches telling them that they oppose IVF and should, too.

Rovner: Yeah, everybody says they’re not coming for contraception, they’re not coming for IVF. I think we’re going to see a very spirited and continued debate over both of those things.

Well, speaking of the rift over reproductive health, former President Trump is struggling to please both sides and not really succeeding at it. He made a video address last week to the evangelical group, The Danbury Institute, which is a conservative subset of the aforementioned Southern Baptist Convention, in which former President Trump didn’t use the word abortion and skirted the issue. That prompted some grumbling from some of the attendees, reported Politico. Even as Democrats called him an anti-abortion radical for even speaking to the group, which has labeled abortion “child sacrifice.”

So far, Trump has gotten away with telling audiences what they want to hear, even if he contradicts himself regularly. But I feel like abortion is maybe the one issue where that’s not going to work.

Pradhan: Well, I think the struggle really is even if people are more forgiving of him saying different things, it puts a lot of down-ballot candidates in a really difficult position. And I know, Julie, you’d wanted to talk about this, but Republican candidates for U.S. Senate, I mean just how they have to thread the needle, and I don’t know that voters will be as forgiving about changes in their position. So I think they say it’s like, it’s not just about you. It’s like when two people get married, they’re like, “It’s not just about the two of you. It’s like your whole family.” This is like the family is your party and everyone down-ballot who has to now figure out what the best message is, and as we’ve seen, they’ve really struggled with “We’ve shifted now from being many candidates and Republican officeholders supporting basically near-total abortion bans, if not very early gestational limits, to the 15-week ban being a consensus position.” And now saying, well, Trump’s saying he’s not going to sign a national abortion ban, so let’s leave it to the states. I mean, it keeps changing, and I think obviously underscores the difficulty that they’re all having with this. So I don’t think it helps for him to be saying inconsistent things all the time because then these other candidates for office really struggle, I think, with explaining their positions also.

Rovner: So as I say every week, I’ve been covering abortion for a very long time, and before Roe [v. Wade] was overturned the general political rule is you could change positions on abortion once. If you were anti-abortion you could become pro-choice, and we’ve seen that among a lot of Democrats, Sen. [Bob] Casey in Pennsylvania, sort of a notable example. And if you supported abortion rights, you could become anti-abortion, which Trump kind of did when he was running the first time. Others have also as, there are 鈥� and again we’re seeing this more among Republicans, but not exclusively.

But people who try to change back usually get hammered. And as I say, Trump has violated every political rule about everything. So not counting him, I’m wondering about, as you say, Rachana, some of these Senate candidates, some of these down-ballot candidates who are struggling to really rationalize their current positions with maybe what they’d said before is something I think that bears watching over the next couple of months.

Huetteman: Absolutely. And we’re seeing candidates who will change their tone within weeks of saying something or practically days at this point. They’re really banking on our attention being pretty low as a public.

Rovner: Yeah. Although they may be right about that part.

Pradhan: Yeah, that’s true. And there’s a lot of time between now and November, but I think even the 鈥� just all the things, even this week of course, between now and November is an eternity. But we just talked about the Southern Baptist Convention stance on IVF. Of course, usually when these things happen, it prompts a lot of questions to lawmakers about whether they support that decision or not, whether they agree with it. And I think these court decisions 鈥� the Supreme Court, of course, will be out by the end of June, and so right now it might be fresh on people’s minds. But it’s hard to know whether September or October is the dominant or very prominent campaign issue in the same way.

Rovner: At the same time, we have a long way to go and a short way to go, so we will actually all be watching.

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

I am pleased to welcome to the podcast Drew Altman, president and CEO of 蘑菇影院, and of course my boss. But lest you think that this is going to be a suck-up interview, you will see in a moment it’s also a shameless self-promotion interview. Drew, thank you so much for joining us.

Drew Altman: It’s great to be on “What the Health?” Thank you.

Rovner: I asked you here to talk about 蘑菇影院’s new “Health Policy 101” project which launched last month, as a resource to help teach the basics of health policy. I know this is something you’ve been thinking about for a while. Tell us what the idea was and who’s the target audience here.

Altman: Well, since the Bronze Era, when I started 蘑菇影院, faculty and students found their way to our stuff and they found it useful. It might’ve been a fact sheet about Medicaid or a policy brief about Medicare or a bunch of charts that we produced. But they’ve had to hunt and peck to find what they wanted and someone would find something on Medicaid or Medicare or the ACA [Affordable Care Act] or health care costs or women’s health policy or international comparisons or whatever it was. And for a very long time, I have wanted to organize our material about health policy for their world so that it was easy to find. It was one stop, and you could find all the basic materials that you wanted on the core stuff about health policy as a service to faculty and students interested in health policy because we don’t just analyze it and poll about it and report on it. We have a deep commitment. We really care about health policy and health policy education.

Rovner: You said those are the main topics covered. I assume that other topics could be added in the future? I mean, I could see a chapter on AI and health care.

Altman: Yes, and we’re starting with an introduction for me. There’s a chapter by Larry Levitt about challenges ahead. There’s a chapter by somebody named Julie Rovner on Congress and the agencies, who also wrote a book about all of that stuff, which is still available, folks.

Rovner: It desperately needs updating. So I’m pleased to be contributing to this.

Altman: But this is just the first year. And there were 13 chapters on the issues that I ticked off a moment ago and many more issues. And we’re starting the process of adding chapters. So the next chapter will probably be on LGBTQ issues, and then, though it’s not exactly the same thing as health policy, by popular demand, we will have a chapter on the basics of public health and what is the public health system, and spending on public health.

And I will admit, some of this also has origins in my own personal experience because before I was in government or in the nonprofit world or started and ran 蘑菇影院, I was an academic at MIT [Massachusetts Institute of Technology] and I was fine when it came to big thoughts. And there I was and I’d written a book about health cost regulation. But what I didn’t know much about was how stuff really worked and the basics. And if I really needed to understand what was happening with regulation of private health insurance or the Medicaid program or the Medicare program, I didn’t really have any place to go to get basic information about the history of the program, or the details of the program, or a few charts that would give me the facts that I needed, or what are the current challenges. And when it really sunk in was when I left MIT and I went to work in what is now CMS [Centers for Medicare & Medicaid Services] and then was called the HCFA [Health Care Financing Administration], and boy on the first day did I realize what I did not know. It was only when I entered the real world of health policy that I understood how much I had to learn. So I wanted to bridge the two worlds a little bit by making available this basic “Health Policy 101.”

Rovner: I confess, I’m a little bit jealous that this hadn’t existed when I started to learn health policy because, like you, I had to ferret it all out, although thankfully 蘑菇影院 was there through most of it and I was able to find most of it along the way.

Altman: Exactly, and I think there’ll be other audiences for this because if you’re working on the Hill 鈥� but you don’t work full time on health 鈥� if you’re working in an association, if you’re working anywhere in the health care system, there’s lots of times when you really just need to understand. I just read about an 1115 waiver. What is that? Or what really is the difference between traditional Medicare and the Medicare Advantage plan? How is it that you get your drugs covered in the Medicare program? It seems to be lots of different ways. And just I’m confused. How does this actually work?

I’ll admit to you, also, I personally have an ulterior motive in all of this. And my ulterior motive is that it is my feeling now, and this has been a slowly creeping problem, that there isn’t enough what I would call health policy in health policy education. So that over time it has become more about what is fashionable now, which is delivery and quality and value.

And I won’t name names, but I spent a couple of days advising a health policy center at a renowned medical school about their curriculum in what they called health policy. And the draft of it had nothing in it that I recognized as health policy. Some of this is understandable. It’s because if you’re faculty with a disciplinary base 鈥� economics, political science, sociology, whatever 鈥� there’s no reason you would know a lot about what we recognize as the core of health policy. There has been a serious decline in faith in government, in young people taking jobs in certainly the federal government, but a little bit in state government as well. So the jobs now are all in the health care industry, they’re in tech, they’re in consulting firms. And so I think there’s just less of an incentive to learn a lot about Medicare, Medicaid, the ACA, the federal agencies, because you’re not going to go work in the federal agencies, at least as frequently as students did in my time. And so just to be blunt about it, I am, in my mind, trying to get more health policy back into health policy education.

Rovner: Well, as you know, I endorse that fully because that’s what we’re trying to do, too. One more question since I have you. I’ve been thinking about this a lot. When I started covering health policy shortly after you left HCFA, the big issue was people without insurance. And then throughout the early 2000s the big issue was spiraling costs. I feel like now the big issue is people who simply cannot navigate the system. The system has become so byzantine and complicated that, well, now there’s a “South Park” about it. I mean, it’s really to get even minor things dealt with is a major undertaking. I mean, what do you see as the biggest issue in policy for the next five or 10 years?

Altman: Well, I think the big issue for health care people used to be access to care. Now only about 8% of the population is uninsured. The big issue now is affordability, in my mind, and the struggles Americans are having paying their health care bills. It is an especially acute problem, virtually a crisis, for people with severe illnesses or people who are chronically ill. Fifty[%], 60% of those people really struggle to pay their medical bills. The crisis or the problem that isn’t discussed enough 鈥� because it isn’t a single problem it rears its head in so many ways 鈥� is the one you’re talking about: that is the complexity of the health care system. Just the sheer complexity of it; how difficult it is to navigate and to use for people who have insurance or don’t have insurance. Larry Levitt and I wrote a piece in JAMA about this, and we, all of us at 蘑菇影院, are trying to focus more attention on that problem. Need to do more work on that problem and the many parts of it. It’s partly why we set up an entire program a couple of years ago on consumer and patient protection, where we intend to focus more on just this issue of the complexity of the system makes it hard to make it work for people. But especially for patients who are people who encounter the system because they need it.

Rovner: Well, we will both continue to try to keep explaining it as it keeps getting more byzantine. Drew Altman, thank you so much for joining us.

Altman: Thank you, Julie, very much.

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

Huetteman: Sure. My story comes from CBS [News]. The headline is “.” So the story says that there are three more states that have had their first reported cases of bird flu in the last month. And two of them don’t really have a way to conduct increased oversight of dairy cows and the industry that seems to be particularly having problems here. Wyoming and Iowa are those two states. Basically, these are states where raw milk is unregulated, so there’s no way for them to implement surveillance and restrictions on raw milk that might protect people from the fact that pasteurization appears to kill bird flu. But you don’t have pasteurization with raw milk, of course, that’s the definition.

Actually, this leads me to an extra, extra credit. 蘑菇影院 Health News’ Tony Leys wrote about the raw milk change in Iowa last year, and he was reporting on how Iowa only just changed their law, allowing legal sales of raw milk. And his story, among other things, pointed out that pasteurization helped rein in many serious illnesses in the past, including tuberculosis, typhoid, and scarlet fever. So unfortunately, this is a public health issue that’s been going on for a century or more, and we’ve got a method to deal with this, but not if you’re drinking raw milk. So that’s my story this week.

Rovner: Now people are going to drink raw milk and not get childhood vaccines. We’ll see how that goes. Sorry. Anna, you go next.

Edney: Yeah, mine is from Stat and it’s “.” It’s really scary, and maybe not totally surprising, unfortunately, that this is how an older Black man was treated when he went to the hospital. But this is Alexander Morris, a member of the Motown group The Four Tops. These are in the Rock & Roll Hall of Fame, The Four Tops, and he had chest pain and problems breathing and went to the hospital in Detroit and was immediately just assumed he was mentally ill, and he ended up quickly in a straitjacket. So he is suing this hospital. And I think he brought up in this article he’d seen people talk about driving while Black or walking while Black, and he essentially had become sick while Black. And he was able to prove he was a famous person and they took him out of the straitjacket. But how many other people haven’t had that ability, and just been assumed, because of the color of their skin, to not be having a serious health issue? So I think it’s worth a read.

Rovner: Yeah, it was quite a story. Rachana.

Pradhan: This week, I will take a story from The New York Times that is headlined “.” It is basically an examination of how TikTok, Instagram, and others, how they moderate/remove content about abortion. What’s interesting about this is, so this is being told from the perspective of individuals who support access to abortion services. And it recounts some examples of Instagram suspending one group, it was called Mayday Health, which provides information about abortion pill access. There’s a telemedicine abortion service called Hey Jane, where TikTok briefly suspended them. What I thought was really interesting about this is anti-abortion groups have said for longer, actually, that technology companies have suppressed or censored information about crisis pregnancy centers, for example, that designed to dissuade women from having abortions. But I think it’s concerns about, broadly speaking, just what the policies are of some of these social media companies and how they decide what information is acceptable or not. And it details these examples of, again, women who support abortion access or posting TikToks that maybe spell abortion phonetically. Like “tion” is, instead of T-I-O-N, it’s S-H-U-N. Or they’ll put a zero instead of an O, and so it doesn’t get flagged in the same way. So yeah, definitely an interesting read.

Rovner: The fraughtness of social media moderation on this issue and many others. Well, my extra credit this week is from my fellow Michigan fan and sometime podcast guest Jonathan Cohn of HuffPost, and it’s called “.” And it’s basically the story of the entire mental health system in the United States over the last century, as told through the eyes of one middle-class American family, about one patient whose trip through the system came to a tragic end. Even if you think you know about this country’s failure to adequately treat people with mental illness, even if you do know about this country’s failures on mental health, you really do need to read this story. It is that good.

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 doing-double-duty editor this week, Emmarie Huetteman. As always, you can email us your comments or questions. We’re whatthehealth, all one word, @kff.org. Or you can still find me at X, I’m . Anna?

Edney: .

Rovner: Rachana?

Pradhan: I’m on X.

Rovner: Emmarie?

Huetteman: I’m lurking on X .

Rovner: We will be back in your feed next week. Actually, we’ll be coming to you from Aspen next week. But until then, be healthy.

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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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One of them was the son of Ashley Eades. Her family lost their Medicaid coverage in the “unwinding” of protections that had barred states from dropping people for years during the covid pandemic.

Many families, including Ashley’s, still qualify for Medicaid but lost it for “procedural reasons.” Basically, missing paperwork.

The unwinding process has been messy.

In this episode, host Dan Weissmann talks with Ashley about the months she spent fighting to get her son reenrolled in 2023 to get an on-the-ground look at how the unwinding is affecting families.

Then, Dan hears from staff at the , of Georgetown University’s Center for Children and Families, and 蘑菇影院 Health News correspondent Brett Kelman, who has been covering Medicaid in Tennessee for years.

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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. You know what we have NEVER talked about on this show? Medicaid. The big, federally-funded health insurance program for folks with lower incomes. And I did not realize: That’s been a huge omission. Because it turns out, Medicaid covers a TON of people. Like about a quarter of all Americans. And about forty percent of all children. That’s four out of every ten kids in this country who are insured by Medicaid.听

And this is the perfect time to look at Medicaid because– well: tens of millions of people are losing their Medicaid coverage right now. It seems like a lot of these people? Well, a lot of them may actually still qualify for Medicaid.听

This is all kind of a “Back to the Future” moment, which started when COVID hit: The feds essentially hit pause on a thing that used to happen every year– requiring people on Medicaid to re-enroll, to re-establish whether they were eligible. And back then, tons of people got dropped every year, even though a lot of them probably still qualified.听

The pause lasted through the COVID “public health emergency,” which ended in spring 2023. Since then, states have been un-pausing: Doing years and years of re-enrollments– and un-enrollments– all at once. People call it the “unwinding.” And it’s been messy. And, another thing I’ve been learning: Medicaid operates really differently from one state to another. It even has different names. In California, it’s called Medi-Cal. In Wisconsin, it’s BadgerCare. And this unwinding can look completely different from one state to the next.

We’re gonna look mostly at one state– Tennessee, where the program is called TennCare. And in some ways, according to the numbers on the unwinding, TennCare is鈥� kinda average.听

But the problems some people have had, trying to keep from getting kicked off TennCare? Before this unwinding and during it? They sound pretty bad. We’re gonna hear from one of those people– a mom named Ashley Eades.听

Ashley Eades: Yeah. TennCare. Put me through the wringer, I tell you what.听

Dan: We’ll hear how Ashley spent months fighting to keep her son Lucas from getting kicked off TennCare. And we’ll hear from some folks who can help us put her story in perspective. Including folks who helped Ashley ultimately win her fight. Folks who are fighting– in Tennessee and around the country– to keep programs like TennCare from putting people like Ashley through the wringer.听

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 chosen around here is to take one of the most enraging, terrifying, depressing parts of American life, and to bring you a show that’s entertaining, empowering, and useful. Ashley Eades is a single mom in Nashville. She works in the kitchen at Red’s Hot Chicken, near Vanderbilt University.听

Ashley Eades: We’re just like every other person in Nashville trying to say they got the best hot chicken.听

Dan: Ashley buys her insurance from the Obamacare marketplace, but her son Lucas– he’s 12 鈥� is on TennCare. In April 2023, Ashley got a notice from TennCare saying, “It’s time to renew your coverage!” Meaning Lucas’s coverage. Meaning, welcome to the unwinding! When I talk with Ashley, she uses one word about a half-dozen times:听

Ashley Eades: it just was a nightmare. It was a nightmare. So that was the nightmare. A terrible nightmare you can’t wake up from. Oh my god, that was a nightmare.听

Dan: So: After Ashley filled out the renewal packet, she got another notice, saying “We need more information from you.” TennCare wanted proof of “unearned income”– like bank statements, or a letter saying she was entitled to something like workers compensation– or a court-ordered payment. But Ashley didn’t have any unearned income. Lucas’s dad was supposed to pay child support, but– as Ashley later wrote to state officials– he didn’t have regular employment so couldn’t pay.听

Ashley says she called TennCare for advice and got told, “Never mind. There’s nothing to send, so you don’t have to send us anything.” Which turned out to be wrong. A few weeks later, in May, TennCare sent Ashley a letter saying “Why your coverage is ending.”听

It gave two reasons: First, it said “We sent you a letter asking for more facts鈥� but you did not send us what we needed.” It also said “We’ve learned that you have other insurance” for Lucas. But she didn’t. And not having insurance for Lucas was going to be an immediate problem. He got diagnosed with epilepsy a few years ago, and he needed ongoing treatment.听

Ashley Eades: he was on three different medications. I mean, that alone would cost me about $1,500 a month with no health insurance. And this is anti-seizure medication. Like we can’t just stop it听

Dan: Yeah. Ashley says she did everything she could think of: mailed in paper forms, submitted information online, and made a lot of phone calls.

Ashley Eades: like back and forth on the phone with people I don’t even know who Italked to, just dozens and dozens of people I talked to. And every single time it was go through the same story over and over and over and over and over again and just get transferred Put on holds, you know disconnected yelled at, told I’m wrong like听

Dan: It went on for months. She reapplied. She was approved. Then she was un-approved. She appealed. The appeal was denied. Then, in July, the full nightmare: Lucas ended up in the emergency room after a seizure. While he was officially uninsured.听

Ashley Eades: I just didn’t know what to do. Like, I was shutting down mentally.听

Dan: And then, out of nowhere, a relative mentioned that a nonprofit called the Tennessee Justice Center had helped *her* out with a TennCare application. Ashley called the group right away.听

Ashley Eades: and I’m not a spiritual person, but they were like a fudging godsend. You know what I mean? Like, it was amazing

听Dan: A client advocate named Luke Mukundan looked at all of TennCare’s letters to Ashley and confirmed one thing right away: Ashley wasn’t wrong to be confused.听

Ashley Eades: He’s like going through all of these letters and he’s like, it doesn’t even make sense听

Dan: Later I talked with Luke, on kind of a lousy Zoom connection. But he said to me: This was confusing, even to him.听

Luke Mukundan: she was providing the information that they asked for, um,听

Dan: But they kept asking the same questions. And they kept saying that her son had some other insurance.听

Luke Mukundan: when I knew and she knew that wasn’t the case

Dan: Luke’s boss at the Tennessee Justice Center, Diana Gallaher, told me she wasn’t surprised that Ashley got confused by that early question about un-earned income. She says the process can be really confusing.听

Diana Gallaher: Heck, I get confused. I still, I’ll look at a question and say, you know, wait, what are they asking? How do I answer this one?听

Dan: And you’ve been doing this for a while, right?听

Diana Gallaher: Oh, yeah. Yeah.听

Dan: How long have you been doing this?听

Diana Gallaher: Since 2003, 2004.听

Dan: More than twenty years. Of course, Ashley’s been going through this process at an especially rough time: The unwinding. When so many people were going through this process at once.听

For instance, Luke and Diana say the help lines at TennCare were super-jammed– like, it wasn’t unusual to spend 45 minutes or an hour on hold.听

By the time Ashley found the Tennessee Justice Center, it was August. She’d been fighting alone for months. Luke helped Ashley with a new appeal. And on September 22, TennCare sent Ashley an update. Her son is approved. “You qualify for the same coverage you had before,” it says. “And you’ll have no break in coverage.”听

So Ashley’s “nightmare” was one person’s experience of the unwinding. But it’s not a one-off: According to reports from 蘑菇影院 and Georgetown University, more than two-thirds of the people who lost Medicaid in the last year were disenrolled, like Ashley, for what are called “procedural reasons.” Missing paperwork.

Now, some of those people who got dropped for “procedural reasons” probably didn’t even try to renew Medicaid because they didn’t need it anymore. They had new jobs that came with insurance.

But we know those folks are in a minority. Researchers at 蘑菇影院– the parent group of our journalist pals at 蘑菇影院 Health News– did a survey of folks who got dropped from Medicaid. Most of them– seventy percent– ended up either uninsured or, the biggest group, back on Medicaid. And again, more than two-thirds of the folks who got dropped were cut for “procedural reasons”– paperwork. Like Ashley’s son Lucas.听

So, when a lot of people can’t renew their Medicaid for “procedural” reasons, it seems worth looking at that procedure. And what’s happening in the unwinding isn’t actually a new phenomenon. It’s just un-pausing an old procedure– a system that always had these problems. And that’s really clear in Tennessee, because people in Tennessee have been documenting– and fighting– these problems for a long time.听

Next up: Taking TennCare to court.听

This episode of An Arm and a Leg is a co-production of Public Road Productions and 蘑菇影院 Health News. The folks at 蘑菇影院 health news are amazing journalists– and in fact, we’re about to hear from one of them, right now.听

Brett Kelman: My name is Brett Kelman.听

Dan: Brett’s an enterprise correspondent with 蘑菇影院 Health News听

Brett Kelman: And I report from the city of Nashville, where I have lived for about seven years.听

Dan: Brett came to Nashville initially to cover health care for the local daily, the Tennessean. Which meant he heard about Medicaid– about people losing medicaid– a lot.听

Brett Kelman: You hear two versions of the same story. You hear patients who get to the doctor’s office and suddenly discover they don’t have Medicaid when they used to, and they thought they still did. And then you hear the other side of that coin. You hear doctors, particularly a lot of pediatricians, where their patients get to their office and then discover in their waiting rooms they don’t have Medicaid.听

Dan: And by the way– you noticed how Brett said he heard especially from pediatricians about this issue in Tennessee. That’s because Tennessee is one of the states that never expanded Medicaid after the Affordable Care Act took effect. In those states, Medicaid still covers a lot of kids but a lot fewer adults than other states. Docs treating patients with Medicaid– a lot of them are gonna be pediatricians.听

So, Brett’s hearing all of this seven years ago– the before-time. Before the unwinding. Before COVID. People kept losing Medicaid and not knowing about it until they got to the doctor’s office. And Brett wanted to know: how did that happen? He and a colleague ended up doing a huge investigation. And came back with a clear finding:听

Brett Kelman: Most of the time, when people lose their Medicaid in Tennessee, it is not because the state looked at their finances and determined they aren’t qualified. Paperwork problems are the primary reason that people lose Medicaid coverage in Tennessee.听

Dan: Brett and his reporting partner used a public-records request to get a database with the form letters sent to about three hundred thousand people who needed to renew their Medicaid coverage.听

Brett Kelman: And what we determined was that, you know, 200,000 plus children, had been sent a form letter saying that they were going to lose their Medicaid in Tennessee, again, not because the state determined they were ineligible, but because they couldn’t tell.听

Dan: About two thirds of people in that database got kicked off Medicaid for “procedural reasons”– paperwork issues. This is years before the current “unwinding” but that two-thirds number, it’s pretty similar to what we’re seeing today.

Brett Kelman: And, you know, that raises a lot of questions about if we’re doing the system correctly, because do we really want to take health care away from a family who is low income? Because somebody messed up a form or a form got lost in the mail.听

Dan: Around the time Brett published that story in 2019, the Lester family found out that they had lost their Medicaid– because a form had gotten lost in the mail. It took them three years to get it back. Brett met them at the end of that adventure听

Brett Kelman: they were a rural Tennessee family, a couple of rambunctious boys who seemed to injure themselves constantly. And honestly, I saw him almost get hurt while I was there doing the interview. One of the young boys had. Climbed up to the top of a cat tower. And I believe jumped off as I was interviewing his parents and I could see the insurance, I could see the medical claims racking up before my eyes.听

Dan: In 2019, one of the boys had broken his wrist jumping off the front porch. And when the Lesters took him to the doctor, that’s when they learned they’d been cut from Medicaid. Over the next three years, they racked up more than a hundred thousand dollars in medical debt– dealing with COVID, with more injuries, with the birth of another child. Finally, the Tennessee Justice Center helped them get Medicaid back– and figure out what had gone wrong.听

Brett Kelman: And when it all came down to it, we eventually determined that this paperwork that their health insurance hinged on, the health insurance that they were entitled to, they had lost it because the state had mailed that paperwork to the wrong place.听

Dan: Oh, and where had the state been mailing that paperwork to? A horse pasture.听

Brett Kelman: It wasn’t far from their house, but there was certainly no one receiving mail there听

Dan: Was there like a mailbox for the horses? Like where did they, where did it even go? Get left.听

Brett Kelman: I don’t remember if there was a mailbox for the horses. I don’t think so. I mean, if you think about this chain of events, they were sent paperwork they were supposed to fill out and return to keep their health insurance, but it went to the horse pasture, so they didn’t fill it out. Then they were sent a letter saying, Hey, you never filled out that paperwork. We’re gonna take your health insurance away. But it went to the horse pasture, so they didn’t fix it, and then they were sent paperwork saying, we’ve cut off your health insurance. You won’t have health insurance as of this date But it was sent to the horse pasture, so they didn’t know about it.听

Dan: And their three-year fight to get Medicaid back took place AFTER Brett published his initial story. So, some things, it seemed, hadn’t changed a whole lot. But one thing had happened: In 2020, the Tennessee Justice Center had filed a class-action lawsuit, demanding that TennCare re-enroll about a hundred thousand people who had gotten cut off– the lawsuit alleges, without due process. Here’s Brett’s take:听

Brett Kelman: And yes, I recognize that there could just have a Medicaid recipient who is not on top of this and ignores the paperwork and lets it rot in a pile of mail on their kitchen counter. I have some mail like that. I’m not going to pretend like I have never done this, but how do you tell the difference between that person and somebody who never got this paperwork that their child’s health care hinges upon?听

Dan: This exact question comes up in the lawsuit. In a filing, the state’s lawyers say TennCare does not owe a hearing to anybody who says they just didn’t get paperwork. “The simple reason for this policy is that it is well known that mail is ordinarily delivered as addressed, TennCare enrollees have a responsibility to keep the program apprised of address changes (as explained to them in TennCare’s notices), and it is exceedingly common for individuals who have missed a deadline to claim they did not receive notice.”听

Class action lawsuits move slowly. This one, filed more than four years ago, only went to trial recently. A judge’s decision is 鈥� pending. In a post-trial filing, the Tennessee Justice Center tells the stories of 17 people cut off from Medicaid allegedly due to errors by TennCare.听

In TennCare’s filings, the state’s lawyers say, in effect: None of this proves there’s a systemic problem. And as a couple people have said to me: You don’t have to set out to build a bad system. If you don’t take care to build a good one, your system will definitely have problems.

听We sent TennCare a long note about what we’ve been learning: About Brett Kelman’s reporting, about the class-action lawsuit, and about what happened to Ashley Eades. We asked them for any comment– or to let us know if they thought we’d gotten anything wrong. We haven’t heard back from them.听

So, let’s zoom out a little bit to look at how these systems are working across 50 states. The person to talk to here is Joan Alker. She’s a professor at Georgetown, and she runs the university’s Center for Children and Families.听

Joan Alker: Yeah, Medicaid really is my jam. I have been working on Medicaid issues for about 25 years now, which is a little frightening.听

Dan: So of course she and her colleagues have been tracking how all 50 states have been dealing with the unwinding, compiling all kinds of data. When we talked, they’d just updated a ticker showing how many kids have been dropped in each state.听

Joan Alker: We just hit 5 million net child Medicaid decline just today. Um, so that’s very troubling.听

Dan: And according to Joan Alker’s report, kids were even more likely to be dropped for “procedural reasons”– paperwork issues– than adults.听

Joan Alker: Most of these children are probably still eligible for Medicaid and many of them won’t have another source of coverage. And that’s what I worry a lot about.听

Dan: But it varies a TON. A couple states– Maine and Rhode Island– actually have MORE kids enrolled than when the unwinding started. A half-dozen others have dropped very few kids.听

Joan Alker: But then we had some states that went out really assertively and aggressively to, um, to To have fewer people enrolled in Medicaid听

Dan: Her numbers show that Texas is a standout. They’ve got one point three million fewer kids enrolled in Medicaid than they did before the unwinding鈥� Tennessee– with all the problems documented by Brett Kelman and the Tennessee Justice Center– is kind of around the middle of the pack.听

Joan Alker: Unfortunately, this is the norm. Right? When you look at the number of disenrollments nationwide, the average for procedural red tape reasons is 70%. Only 30 percent of those people losing Medicaid nationwide have lost it because they’ve clearly been determined to be ineligible.听

Dan: Obviously, Joan Alker is not happy about this. But she is also not hopeless! The unwinding has been an example of what happens– what can happen– when you require people to renew their enrollment every year. But now some states are experimenting with 鈥� not requiring that anymore, at least not for young kids.听

Joan Alker: 鈥ecause we know so many of them are going to remain eligible. They’re cheap to insure. They’re not where the money is being spent in our healthcare system. But they need regular care.听

Dan: Oregon, Washington, and New Mexico now keep kids enrolled through age six. Another seven states are aiming to do the same.听

Joan Alker: This is an idea that we’ve been promoting for like 15 years and we were kind of crying out in the wilderness for a long time, but it’s breaking through now听

Dan: I’m not gonna lie. There’s a ton that’s not gonna get fixed with Medicaid anytime soon. We don’t know yet how the judge in the Tennessee Justice Center’s class-action lawsuit is gonna rule. But seeing these fights, it reminds me of something I’ve said before on this show: We are not gonna win them all. But we don’t have to lose them all either.

By the way, a little news about Ashley Eades– our mom in Nashville, who fought to keep her son on TennCare.听

Ashley Eades: Last year, I started going back to school, and I’m going to school full time, and I’m working full听

Dan: Oh my gosh!听

Dan: And she’s home-schooling Lucas.听

Ashley Eades: I was like, “we’re going to go to school together, buddy.” Like, we share a desk, you know, and he’s like in class and I’m in class.听

Dan: Wow听

Ashley Eades: I had to get creative. um, so, yeah, I’m like, working this really crappy, stinky job and going to school听

Dan: And it’s working out.听

Ashley Eades: I, um, made Dean’s List this semester, like got straight A’s.听

Dan: Yeah!听

Dan: Ashley wants to go to Medical school. I thought you’d want to know.听

Before we go, I just want to say THANK YOU. In our last episode, we asked you to help us understand sneaky facility fees, by sending your own medical bills, and you have been coming through in a big way. We’ve heard from more than 30 people at this point. Some of you have been annoyed by these fees for years– a couple of you have told us about driving 30 or 40 miles across town, hoping to avoid them. And we’ve been hearing from folks inside the medical billing world, offering us some deeper insight. And I could not be pleased-er. Thank you so much!听

If you’ve got a bill to share, it’s not too late to pitch in, at arm-and-a-leg-show, dot com, slash FEES. I’ll catch you in a few weeks. Till then, take care of yourself.听

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta, and edited by Ellen Weiss. Thanks this time to Phil Galewitz of 蘑菇影院 Health News, Andy Schneider of Georgetown University’s Center for Children and Families, and Gordon Bonnyman of the Tennessee Justice Center for sharing their expertise with us. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and blue dot sessions. Gabrielle Healy is our managing editor for audience. Gabe Bullard is our brand-new engagement editor. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager.听

And Armand a Leg is produced in partnership with 蘑菇影院 Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at 蘑菇影院, an independent source of health policy research, polling and journalism. Zach Dyer is senior audio producer at 蘑菇影院 Health News. He’s editorial liaison to this show.听

And 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. Finally, thanks to everybody who supports this show financially– you can join in any time at arm and a leg show dot com, slash, support– thanks for pitching in if you can, and thanks for listening.

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

To keep in touch with “An Arm and a Leg,”听. You can also听follow the show on听听and听the . And if you’ve got stories to tell about the health care system, the producers听.

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

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

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

The cases highlighted in this episode:

• and , about how much discretion federal agencies should have in interpreting laws passed by Congress.
• , about whether the FDA exceeded its authority in relaxing restrictions on the abortion pill mifepristone.
• and , about whether the federal Emergency Medical Treatment and Labor Act requirement for hospitals participating in Medicare to provide needed medical care overrides Idaho’s near-total abortion ban in emergency cases.

• 蘑菇影院 Health News' 'What the Health?': Abortion 鈥� Again 鈥� At the Supreme Court Apr 24, 2024
• 蘑菇影院 Health News' 'What the Health?': The Supreme Court and the Abortion Pill Mar 28, 2024
• 蘑菇影院 Health News' 'What the Health?': Health Enters the Presidential Race Jan 25, 2024
• 蘑菇影院 Health News' 'What the Health?': The Supreme Court vs. the Bureaucracy Jan 18, 2024

Where to find Supreme Court opinions as they are announced:

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

[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 ato bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at FutureHindsight.com or wherever you listen to podcasts.

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

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

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

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

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

Rovner: And what would an example of that be?

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

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

Sobel: That’s correct.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sobel: Oh, it’s two-thirds.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sobel: Right, right.

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

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

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

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

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

Sobel: Right. Definitely.

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

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

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

Sobel: Thank you for having me, Julie.

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

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

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

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

Panelists

Among the takeaways from this week’s episode:

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

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

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

Julie Rovner: The 19th’s “,” by Shefali Luthra and Chabeli Carrazana.听

Alice Miranda Ollstein: Stat’s “,” by Eric Boodman.听听

Rachel Roubein: The Washington Post’s “,” by Joel Achenbach and Mark Johnson.听听

Joanne Kenen: ProPublica’s “,” by Sharon Lerner; and The Guardian’s “,” by Damian Carrington.听

Also mentioned on this week’s podcast:

• NPR’s “,” by Sarah McCammon.
• 蘑菇影院 Health News’ “Biden Leans Into Health Care, Asking Voters To Trust Him Over Trump,” by Phil Galewitz.
• 蘑菇影院 Health News’ “Exclusive: Senator Urges Biden Administration To Thwart Fraudulent Obamacare Enrollments,” by Julie Appleby.
• 蘑菇影院 Health News’ “KHN’s 鈥榃hat the Health?’: Un-Trumping the ACA,” featuring an interview with journalist Marshall Allen.

[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, May 23, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. We are joined today via a video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, thanks for having me.

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

Joanne Kenen: Hi, everybody.

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

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

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

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

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

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

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

Rovner: Well, let’s talk 鈥�

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kenen: There’s no question that the Maryland 鈥�

Rovner: Yeah.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kenen: There’s a reason they think that.

Rovner: They can.

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

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

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

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

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

Kenen: Right, no, no, no.

Rovner: 鈥� did not involve 鈥�

Kenen: [inaudible 00:21:28].

Rovner: 鈥� electronic medical record.

Kenen: Right. Right.

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

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

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

Kenen: Something or other, right.

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

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

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

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

Luthra: Thank you so much for having me Julie.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kenen: This was a pair of articles, a long one and a shorter, related one. There’s an amazingly wonderful piece in ProPublica by Sharon Lerner, and it’s called “.” I’m going to come back and talk about it briefly in a second, but the related story was in The Guardian by Damian Carrington: “.” Now, that was a small study, but there may be a link to the declining sperm count because of these forever chemicals.

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

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

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

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

Rovner: It is. Rachel.

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

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

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

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

Kenen: We’re at Threads .

Rovner: Alice.

Ollstein: Still on X .

Rovner: Rachel.

Roubein: On X, .

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

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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.]