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<title>Lawsuit Alleges Obamacare Plan-Switching Scheme Targeted Low-Income Consumers</title>
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<dc:creator><![CDATA[Julie Appleby, KFF Health News]]></dc:creator>
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<description><![CDATA[The lawsuit filed in federal court alleges that large call centers were used to enroll people into Affordable Care Act plans or to switch their coverage, all without their permission.]]></description>
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A wide-ranging lawsuit filed Friday outlines a moneymaking scheme by which large insurance sales agency call centers enrolled people into Affordable Care Act plans or switched their coverage, all without their permission.
According to the lawsuit, filed in U.S. District Court for the Southern District of Florida, two such call centers <a href="https://kffhealthnews.org/wp-content/uploads/sites/2/2024/04/2024-04-12-Complaint.pdf">paid tens of thousands</a> of dollars a day to buy names of people who responded to misleading advertisements touting free government “subsidies” and other rewards. In turn, sales agents used the information to either enroll them in ACA plans or switch their existing policies without their consent.
As a result, the lawsuit alleges, consumers lost access to their doctors or medications and faced financial costs, such as owing money toward medical care or having to repay tax credits that were paid toward the unauthorized coverage.
Some consumers were switched multiple times or had duplicative policies.
“We allege there was a plan that targeted the poorest of Americans into enrolling in health insurance through deceptive ads and unauthorized switching,” to gain compensation for the sign-ups or capture the commissions that would have been paid to legitimate insurance agents, said Jason Doss, one of two lawyers who filed the case following a four-month investigation.
Doss and Jason Kellogg, the other lawyer on the case, which was filed on behalf of several affected policyholders and agents, are seeking class action status.
KFF Health News has <a href="https://kffhealthnews.org/news/article/aca-obamacare-plans-switched-without-enrollee-permission-investigation/">in recent weeks</a> reported on <a href="https://kffhealthnews.org/news/article/aca-unauthorized-obamacare-plan-switching-concern/">similar concerns</a> raised by consumers and insurance agents.
Named as defendants are TrueCoverage and Enhance Health, which operate insurance call centers in Florida and other states; Speridian Technologies, a New Mexico-based limited liability company that owns and controls TrueCoverage; and Number One Prospecting, doing business as Minerva Marketing, which is also a lead-generating company. The lawsuit also names two people: Brandon Bowsky, founder and CEO of Minerva; and Matthew Herman, CEO of Enhance Health. Attempts to reach the companies for comment were unsuccessful.
According to the lawsuit, the call centers had access to policyholder accounts through “enhanced direct enrollment” platforms, including one called Benefitalign, owned by Speridian.
Such private sector platforms, which <a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/EDE-Approved-Partners.pdf">must be approved</a> by the Centers for Medicare & Medicaid Services, streamline enrollment by integrating with the federal ACA marketplace, called healthcare.gov. The ones included in this case were not open to the public, but only to those call center agencies granted permission by the platforms.
One of the plaintiffs, Texas resident Conswallo Turner, signed up for ACA coverage in December through an agent she knew, and expected it to go into effect on Jan. 1, according to the lawsuit. Not long after, Turner saw an ad on Facebook promising a monthly cash card to help with household expenses.
She called the number on the ad and provided her name, date of birth, and state, the lawsuit says. Armed with that information, sales agents then changed her ACA coverage and the agent listed on it five times in just a few weeks, dropping coverage of her son along with way, all without her consent.
She ended up with a higher-deductible plan along with medical bills for her now-uninsured son, the lawsuit alleges. Her actual agent also lost the commission.
The lawsuit contains similar stories from other plaintiffs.
The routine worked, it alleges, by collecting names of people responding to online and social media ads claiming to offer monthly subsidies to help with rent or groceries. Those calls were recorded, the suit alleges, and the callers’ information obtained by TrueCoverage and Enhance Health.
The companies knew people were calling on the promise “of cash benefits that do not exist,” the lawsuit said. Instead, call center agents were encouraged to be “vague” about the money mentioned in the ads, which was actually the subsidies paid by the government to insurers toward the ACA plans.
The effort targeted people with low enough incomes to qualify for large subsidies that fully offset the monthly cost of their premium, the lawsuit alleges. The push began after March 2022, when a special enrollment period for low-income people became available, opening up a year-round opportunity to enroll in an ACA plan.
The suit asserts that those involved did not meet the privacy and security rules required for participation in the ACA marketplace. The lawsuit also alleges violations of the federal Racketeer Influenced and Corrupt Organizations Act, <a href="https://www.justia.com/criminal/docs/rico/#:~:text=Criminal%20RICO,are%20included%20on%20the%20list.">known as RICO</a>.
“Health insurance is important for people to have, but it’s also important to be sold properly,” said Doss, who said both consumers and legitimate agents can suffer when it’s not.
“It’s not a victimless crime to get zero-dollar health insurance if you don’t qualify for it and it ends up causing you tax or other problems down the road,” he said. “Unfortunately, there’s so much fraud that legitimate agents who are really trying to help people are also being pushed out.”
<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/article/toxic-ethylene-oxide-gas-southwest-memphis/view/republish/">details</a>).]]></content:encoded>
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<title>KFF Health News' 'What the Health?': Florida Limits Abortion — For Now</title>
<link>https://kffhealthnews.org/news/podcast/what-the-health-341-florida-abortion-court-rulings-april-4-2024/</link>
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<pubDate>Thu, 04 Apr 2024 18:50:00 +0000</pubDate>
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<category><![CDATA[Multimedia]]></category>
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<category><![CDATA[The Health Law]]></category>
<category><![CDATA[Abortion]]></category>
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<description><![CDATA[The Florida Supreme Court handed down dual abortion rulings this week. One said voters will be allowed to decide in November whether to create a state right to abortion. The other ruling, though, allows a 15-week ban to take effect immediately — before an even more sweeping, six-week ban replaces it in May. Meanwhile, President Joe Biden is doubling down on his administration’s health care accomplishments as he kicks off his general election campaign. Lauren Weber of The Washington Post, Joanne Kenen of the Johns Hopkins University schools of nursing and public health, and Tami Luhby of CNN join KFF Health News’ Julie Rovner to discuss these stories and more. Also this week, Rovner interviews health care analyst Jeff Goldsmith about the growing size and influence of UnitedHealth Group in the wake of the Change Healthcare hack.]]></description>
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<h3>
The Host </h3>
<img />
Julie Rovner
KFF Health News
<a href="https://twitter.com/jrovner">
@jrovner </a>
<a href="https://kffhealthnews.org/news/author/julie-rovner/">
Read Julie's stories. </a>
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Florida this week became a major focus for advocates on both main sides of the abortion debate. The Florida Supreme Court simultaneously ruled that the state’s 15-week ban, passed in 2022, can take effect immediately before a more sweeping, six-week ban replaces it in May and that voters can decide in November whether to create a state right to abortion.
Meanwhile, President Joe Biden, gearing up for the general election campaign, is highlighting his administration’s health accomplishments, including drug price negotiations for Medicare.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins University schools of nursing and public health, Tami Luhby of CNN, and Lauren Weber of The Washington Post.
<h3>
Panelists </h3>
<img />
Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico
<a href="https://twitter.com/JoanneKenen">
@JoanneKenen </a>
<a href="https://publichealth.jhu.edu/faculty/4294/joanne-l-kenen">
Read Joanne's articles. </a>
<img />
Tami Luhby
CNN
<a href="https://twitter.com/Luhby">
@Luhby </a>
<a href="https://www.cnn.com/profiles/tami-luhby">
Read Tami's stories. </a>
<img />
Lauren Weber
The Washington Post
<a href="https://twitter.com/LaurenWeberHP">
@LaurenWeberHP </a>
<a href="https://www.washingtonpost.com/people/lauren-weber/">
Read Lauren's stories. </a>
Among the takeaways from this week’s episode:
<ul>
<li>The Florida Supreme Court’s decisions this week will affect abortion access not only in the state, but also throughout the region. Florida’s six-week ban, which takes effect on May 1, would leave North Carolina and Virginia as the only remaining Southern states offering the procedure beyond that point in pregnancy — and, in North Carolina, abortion is banned at 12 weeks after a woman’s last menstrual period.</li>
<li>Since the U.S. Supreme Court overturned the constitutional right to an abortion in 2022, six states have voted on their own constitutional amendments related to abortion access. In every case, the side favoring abortion rights has won. But Florida’s measure this fall will appear on the ballot with the presidential race. Could the two contests, waged side by side, boost turnout and influence the results?</li>
<li>Former President Donald Trump made many attempts during his term to undermine the Affordable Care Act, and this week the Biden administration reversed another one of those lingering attempts. Under a new regulation, the use of short-term insurance plans will be limited to four months — down from 36 months under Trump. The plans, which Biden officials call “junk plans” due to their limited benefits, will also be required to provide clearer explanations of coverage to consumers.</li>
<li>In other Biden administration news, March has come and gone without the release of an anticipated ban on menthol flavoring in tobacco, and anti-tobacco groups are suing to force administration officials to finish the job. Menthol cigarettes are particularly popular in the Black community, and — like Trump’s decision as president to punt a ban on vaping to avoid alienating voters in 2020 — the Biden administration may be loath to raise the issue this year. Activists say, however, that it may be at the expense of Black lives.</li>
<li>“This Week in Medical Misinformation” looks at an <a href="https://kffhealthnews.org/news/article/fact-check-covid-19-misinformation-persists-vaccines-deaths/">article from PolitiFact</a> about the health misinformation that persists even with the pandemic mostly in the rearview mirror.</li>
</ul>
Also this week, Rovner interviews health care analyst Jeff Goldsmith about the growing size and influence of UnitedHealth Group in the wake of the Change Healthcare hack.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 
Julie Rovner: Politico’s “<a href="https://www.politico.com/news/2024/04/01/anti-abortion-movement-ivf-war-00149766">Republicans Are Rushing to Defend IVF. The Anti-Abortion Movement Hopes to Change Their Minds</a>,” by Megan Messerly and Alice Miranda Ollstein.
Tami Luhby: The Washington Post’s “<a href="https://www.washingtonpost.com/health/2024/04/03/biden-sanders-drug-prices/">Biden Summons Bernie Sanders to Help Boost Drug-Price Campaign</a>,” by Dan Diamond.
Lauren Weber: The Washington Post’s “<a href="https://www.washingtonpost.com/health/2024/04/01/bird-flu-human-case-cow-texas/">Bird Flu Detected in Dairy Worker Who Had Contact With Infected Cattle in Texas</a>,” by Lena H. Sun and Rachel Roubein. 
Joanne Kenen: The 19th’s “<a href="https://19thnews.org/2024/04/illinois-sexual-assault-survivor-law-hospitals/">Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care</a>,” by Kate Martin, APM Reports.
Also mentioned on this week’s podcast:
<ul>
<li>KFF Health News’ “<a href="https://kffhealthnews.org/news/article/aca-obamacare-plans-switched-without-enrollee-permission-investigation/">ACA Plans Are Being Switched Without Enrollees’ OK</a>,” by Julie Appleby.</li>
<li>KFF Health News’ “<a href="https://kffhealthnews.org/news/article/medicare-advantage-breakups-contracts-hospitals-doctors-patients-choice/">Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage</a>,” by Susan Jaffe.</li>
<li>Health Affairs’ “<a href="https://www.healthaffairs.org/content/forefront/change-healthcare-incident-change-health-care">Will the Change Healthcare Incident Change Health Care?</a>” by Jeff C. Goldsmith.</li>
<li>The Health Care Blog’s “<a href="https://thehealthcareblog.com/blog/2024/04/02/optum-testing-time-for-an-invisible-empire/">Optum: Testing Time for an Invisible Empire</a>,” by Jeff Goldsmith.</li>
</ul>
click to open the transcript
Transcript: Florida Limits Abortion — For Now
KFF Health News’ ‘What the Health?’Episode Title: Florida Limits Abortion — For NowEpisode Number: 341Published: April 4, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 4, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this, so here we go.
We are joined today via video conference by Tami Luhby of CNN.
Tami Luhby: Good morning.
Rovner: Joanne Kenen of the Johns Hopkins University Schools of Nursing and Public Health and Politico magazine.
Joanne Kenen: Hi, everybody.
Rovner: And Lauren Weber, the Washington Post.
Lauren Weber: Hello.
Rovner: Later in this episode, we’ll have an interview with Health Policy Analyst and Consultant Jeff Goldsmith about the continuing fallout from the Change Healthcare hack. But first, this week’s news. One of these weeks, we won’t have to lead with abortion news, but this is not that week. On Monday, the Florida Supreme Court ruled separately, but at the same time, that state voters could decide this November whether to make a right to abortion part of the state’s constitution and that the state’s constitution currently does not guarantee that right.
So the state’s 15-week abortion ban signed by Gov. Ron DeSantis in April of 2022 can take immediate effect. But wait, there’s more. First, the decision on the 15-week ban overruled years of precedent that Florida’s Constitution did, in fact, protect the right to abortion. And second, allowing the 15-week ban to take effect automatically triggers an even more sweeping six-week ban that Gov. DeSantis signed in 2023. That will take effect May 1. That’s the one he signed in the middle of the night without an audience people may remember. And this is going to affect far more people than just the population of Florida, right?
Kenen: The whole South. This is it. If you count the South as North Carolina and what we think of as the South, North Carolina is the only state that still has legal abortion, and that is only up to 12 weeks. And there are some conditions and hurdles, but you can still get an abortion in North Carolina.
But to get from a place, people were going to Florida, it’s easier to get from Alabama to Florida than it is from Alabama to even Charlotte. I think I read it’s a 17-hour drive from Florida or something like that. I don’t remember. It’s long. So it’s not just people who live within Florida, but people who live in 11 or 12 states in the American South have far fewer options.
Rovner: And even though the Florida ban feels less than a complete ban because it allows abortions up to six weeks, the fine print actually makes this one of the most restrictive bans in the country. It looks, in effect, like most people won’t be able to get abortions in Florida at all.
Weber: I would say that’s right, Julie. And just to reiterate what Joanne said, 80,000 women get abortions in Florida every year. That’s about one in 12 women in America that get abortions per year, and they will no longer have that kind of access because, at six weeks, a lot of women don’t know they’re pregnant. So, I mean, that’s a very restrictive abortion ban.
Rovner: Remember that six weeks isn’t really six weeks of having been pregnant. Six weeks is six weeks since your last menstrual period, which can be as little as two weeks in some cases.
Kenen: And I also think that even if you do know within six weeks, getting an appointment, given how few places there are in the entire South, even if you know and you get on the phone right away, can you get an appointment before your six weeks is an additional challenge because access is really limited …
Rovner: Right.
Kenen: … intentionally.
Rovner: Yes, and we’ve seen this with other six-week bans. We should point out that some people consider Virginia the South still, and you can go to Virginia, but that’s basically the last place that a good chunk of the country, geographically, if not population-wise, would need to turn to in order to get an abortion.
Well, if that’s not all confusing enough, even if voters do approve the ballot measure in November, the Florida Supreme Court suggested it could still strike down a right to abortion based on a majority of justices findings that the state’s constitution could include personhood rights for fetuses.
I’m having trouble wrapping my head around why the justices would allow a vote whose results they might then overturn. But I guess this is part of the continuing evolution, if you will, to use that word, of this concept of personhood for fetuses and embryos, and what has us talking about IVF, right?
Weber: Yeah, absolutely. I think, as many conservative Christian groups will say, this is the natural line that pro-life is. I mean, they argue, and while they’re pushing this view is not necessarily held by the majority of constituents, but this is their argument that a fetus, an embryo, such as one that could be used in IVF, is a person.
And so, I mean, I think that’s kind of the natural conclusion of pro-life ideology as we’re seeing it right now. And I think it will have a lot of political effects going forward because that IVF is obviously much more popular than abortion. I think we’ll see a lot of voting firepower potentially used on that.
Rovner: Well, I’m so glad you said that because I want to turn to politics. Some Democrats are suggesting that this could boost turnout for Democrats and help, if not put Florida in play for president, maybe the Democrat running to unseat Senator Rick Scott, the Republican.
On the other hand, while abortion ballot questions have done very well around the country, as we know, even in states redder than Florida, there is evidence that some Republicans vote for abortion rights measures and then turn around and vote at the same time for Republicans who would then vote to overturn them.
There are in fact Florida abortion rights advocates who don’t want Democrats to make this issue partisan because they want Republicans to come and vote for the ballot measure, which needs a 60% majority to pass, even if those Republicans then go on to vote for other Republicans. So, who really is helped by this entire mess, or is it impossible to tell at this point?
Weber: I think it’s impossible to tell, but I do think what is complicating is we haven’t seen the presidential race thrown into these abortion ballots. I mean, what we’re looking at is two candidates who potentially are facing a lot of low turnout due to lack of enthusiasm in their bases for both of them. And I am curious if the abortion ballot measures could have much more of an impact on the presidential race than maybe some of these other lower-office races that we’ve seen. I think that’s the main question that I guess we’ll see in November.
Rovner: As we have spoken about many times, President Biden is not super comfortable talking about this issue. He’s an 81-year-old Catholic. It does not come naturally to him to be in favor of abortion rights, which he now is. But Vice President Harris has been sent out. She’s sort of become the standard-bearer for this administration on reproductive health issues, and she’s been very active. And Joanne, you wanted to say something?
Kenen: There are a couple of points. In addition to the abortion ballot initiative. There’s also a marijuana legalization. I think we will see higher turnout and particularly among younger people who have been pretty disaffected this election. So that’s one, whether it affects the presidential race, whether it affects the Senate race. I mean, just as Democrats feel really strong about abortion, Republicans feel really strong about immigration. We don’t know what’s going to happen in November, but I do think this boosts turnout. The second thing to remember, though, is in terms of abortion ballot initiatives have passed every time they’ve come up since the fall of Roe [v. Wade].
This is a 60% threshold, and I do not believe that any state has reached that. I think the highest was about 57%. So even though it may get well over 50, it could get 59.9, the Florida ballot initiative needs 60%. That is a tall order. So you might end up seeing a big turnout, a big pro-abortion rights vote, maybe a big legal weed vote, and the abortion measure could still fail. But I do think it definitely changes the dynamics of Florida from the presidential race on down the ballot. I do think it is a different race than we would’ve seen beforehand.
Rovner: And I will point out, since she didn’t, that Joanne has spent time covering Florida and covering the politics in Florida. So you know where of you speak on this.
Kenen: Well, I lived there for a while, though it was a while ago. The state has, in fact, changed like everything else, including me, right? But I’m somewhat familiar with Florida. I was just there a few weeks ago in fact.
Rovner: And I want to underscore something that Lauren said, which is that we’ve seen all of these ballot measures since Roe was overturned, but we have not seen these ballot measures stacked on top of the presidential race. So I think that will be interesting to watch as we go forward this year.
Well, back here in D.C., the Biden administration issued a long-awaited rule reigning in the use of those short-term health plans that Democrats like to call junk insurance and that President Trump had expanded when he was in office. Tami, what is the new rule, and what will it do?
Luhby: Well, it’s actually curtailing the short-term plans and pretty much reversing the Trump administration rule. So it’s the latest move by the president to contrast his approach to health care with that of former President Donald Trump. Trump extended the duration of the short-term health insurance plans to just under a year and allowed them to be renewed for a total of 36 months. And it was seen as an effort to weaken the Affordable Care Act, draw out younger people, make it more difficult for the marketplace, probably send the older, sicker people there, which would raise premiums, basically cause more chaos in the marketplace.
Rovner: Yeah. And remind us why these plans can be problematic.
Luhby: I will tell you that the short-term plans do not have to adhere to Obamacare’s consumer protections, which is the big difference. For instance, they’re not required to provide comprehensive coverage, and they can discriminate against people with pre-existing conditions, charge them more, deny them, et cetera. As I’d said, the Trump administration heralded them as a cheaper alternative because since they can underwrite, they have typically cheaper premiums. But they also have very limited benefits, or they can have limited benefits depending on the patient or the consumer.
So the Biden rule, which was proposed last month as a series of actions aimed at lowering health care costs, limits the duration of new sales of these controversial plans to three months, with the option of renewal for a maximum of four months. So it’s going on these new plans from 36 months potentially to four months, which was the original idea of these plans because originally they were thought to be for people who might be switching jobs or have a temporary lapse in coverage. They were not intended to be a substitute for full insurance. And it also requires, notably, that the plans provide consumers with a clear explanation of their benefits and inform them of how to find more comprehensive coverage.
Rovner: And obviously this will continue to be controversial, but I think the Democrats, in general, who support the Affordable Care Act feel pretty strongly that this is something that’s going to help them. And as we talked about, we’re not sure yet how the administration is going to play the abortion issue in the campaign, but it is pretty clear that they are doubling down on health care.
One problem for the administration, as we have talked about, is that particularly on really popular things like Medicare drug price negotiations, lots of the public has no idea that that’s happened or if it’s happened that it’s because the Democrats did it. So, in part of an effort to overcome that, Biden invited Bernie Sanders to the White House this week. What was that about?
Luhby: Well, that’s my extra credit. Would you like me to discuss that now?
Rovner: Sure, let’s do that now.
Luhby: OK. So my extra credit is a Washington Post story titled “<a href="https://www.washingtonpost.com/health/2024/04/03/biden-sanders-drug-prices/">Biden Summons Bernie Sanders to Help Boost Drug-Price Campaign</a>,” by Dan Diamond. And I have to admit, I hope I can do that here, that I am a fangirl of Dan Diamond’s stories, and even more so now because apparently, the Biden administration gave Dan a heads-up in advance, that since he published a pretty in-depth story an hour before the embargo lifted for the rest of us who were only given a few tidbits of information about what this meeting or what this speech was going to be about at the uncharacteristically late hour of 8:30 at night.
So Dan’s story looked at how the two former rivals, Joe Biden and [Sen.] Bernie Sanders, who were rivals in the 2020 Democratic presidential nomination, how they had very different views on how the nation’s health care system should operate and Dan’s story looked at how they were uniting to improve awareness of Biden’s efforts to lower drug prices and improve his chances in November. Biden invited Sanders to the White House to discuss the administration’s actions on drug prices, including the latest effort to reduce the out-of-pocket cost of inhalers, which really hasn’t gotten a lot of press.
Sanders brings his progressive credentials and his two-decade-plus track record of fighting for lower drug prices and, “naming and shaming individual pharmaceutical companies and executives.” He’s known to be pretty outspoken and fiery. So the story’s a good example of policy meets politics in an election year. It relays that most Americans still don’t know about the administration’s efforts despite the numerous speeches, news releases, and officials’ trips around the country, hence the need to tap Sanders, and it also provides a nice walk down memory lane, revisiting the duo’s battles in the 2020 primary as well as some of former President Trump’s drug price efforts.
Rovner: Yeah. And a little peek behind the journalistic curtain. I think we all got this sort of mysterious note from Sanders’ press people the night before saying, “If you’ll agree to our embargo, we’ll tell you about this secret thing that’s going to happen,” followed by an advisory from the White House saying that Bernie Sanders was coming to the White House to talk about drugs. [inaudible 00:13:30] …
Luhby: Right. And also, uncharacteristically, when I asked for a comment from Sanders directly, they said tomorrow, which is not like Sanders at all.
Kenen: Sanders and Biden were obviously opponents in the primary, but Sanders has really been very supportive of Biden. I think he’s really sort of highlighted the progressive things that Biden has done and stayed quiet about the more centrist things that Biden has done. He’s been a real ally, and he still has a lot of credibility, and I think they sort of like each other in a funny way. You can sort of see it, but that’s their issue.
Luhby: Biden has also been able to do things that other people have not been able to do with the congressional Democrats. Biden has been able to do things that congressional Democrats have tried to for years and have not been able to, and they may not be the extent to which the Democrats would like. If you remember the 2019 Medicare Drug Negotiation bill, I think, was 250 drugs a year. What ended up passing in the IRA [Inflation Reduction Act] was 10 drugs and ramping up, but at least it’s something.
Kenen: And it’s more than 20 years in the making. I mean, this goes way, way back.
Luhby: Mm-hmm.
Rovner: And I was going to underscore something that Joanne said earlier about Florida, which is that both sides are trying to gin up their base, and young people are really fond of Bernie Sanders in a lot of the things that he says, and this may be a way that Biden can ironically use the Medicare drug price negotiation issue to stir up his young person base to get them out to vote. So I was interested in the combination.
Kenen: So it’s Bernie Sanders and legal weed.
Rovner: That’s right. It’s Bernie Sanders and legal weed, at least in Florida.
Kenen: I’m not implying anything about Bernie Sanders’ use of it. It’s just the dynamic for the young voters.
Rovner: Yes. Things to draw young people out to the polls in November. Well, while the Biden administration is doing lots of things using its regulatory power, one thing it is not doing, at least not yet, is banning menthol flavoring in tobacco.
This is a regulation that’s now been sitting around for nearly two years and that officials had promised to finalize by the end of March, which of course was last week and which didn’t happen. So now three anti-tobacco groups have sued to try to force the regulation over the finish line. Somebody remind us why banning menthol is so very controversial.
Weber: It’s controversial in part because a lot of industry will say that banning menthol will lead to over-policing in Black communities. The jury is very much out on if that is an accurate representation or part of the cigarette playbook to keep cigarettes on the market. Look, a presidential election year and things to do with smoking is not new.
When I was at KFF Health News with Rachel Bluth back in the day, we wrote a story about how Trump postponed a vape ban to some extent because he was worried about vaping voters. So I mean, I think what you’re seeing is a pretty clear political calculus by the Biden folks to push this off into the new year, but as activists and public health advocates will say, it’s at the expense of, potentially, Black lives.
Rovner: That’s right.
Weber: So banning menthol cigarettes would really… what it would do is statistically save Black Americans who die from, predominantly from smoking these types of cigarettes. So it’s a pretty weighty decision to put off with a political calculus.
Rovner: He’s taking incoming from both sides. I mean, obviously, there are members of the Black community who say, as you point out, this could lead to an unnecessary crackdown on African American smokers who use menthol more statistically than anybody else does. Although, there’s some young people who use it too. On the other hand, you have people representing public health for the Black community saying, “We want you to ban this” because, as you point out, people are dying from smoking-related illnesses by using this product. So it’s a win-win, lose-lose here that is continuing on. We’ll be interested to see what, if the lawsuit can produce anything.
Well, speaking of things that are controversial, we also have Medicare Advantage. The private plan alternative to traditional Medicare now enrolls more than half of those in the program, many who like the extra benefits that often come with the plans and others who feel that they can’t afford traditional Medicare’s premiums and other cost-sharing. Except one reason those extra benefits exist is because the government is overpaying those Medicare Advantage plans. That’s a vestige of Republican plans to discourage enrollment in original Medicare that date back to the early part of this century.
So now taxpayers are footing more of the Medicare bill than they should. This week’s news is that the federal government is effectively trimming back some of those overpayments. And investors in the insurance companies, who make money from the overpayments, are going crazy. This is the subhead on a story from the Wall Street Journal, “Managed care stocks are set to fall due to disappointment with the government’s decision not to revise the 2025 Medicare payment proposal.” How is this ever going to get sorted out? Somebody always is going to be a loser in this game, either the patients or the insurance companies or the taxpayers. Everybody cannot win here.
Luhby: Right. And Humana got hit really hard when the rule came out because it is really focused on Medicare Advantage. So yeah, the insurers were hit, but as everything with the market, it’s not forever.
Rovner: I’m continually puzzled by … if the payments were equivalent, which was what they were originally supposed to be. Originally, originally back in the 1980s, insurance companies came to Congress and said, “We can provide managed care and Medicare cheaper, so you can pay us 95% of the average that you pay for a fee for service patient. We can make a profit on that.”
Well, that is long since gone. The question is how much more they will make. And as I point out, when they get overpaid, they do have to rebate those back effectively to the patients in terms of higher benefits. And that’s why many of them offer dental coverage and eyeglasses coverage and other types of, quote-unquote, extra benefits that Medicare doesn’t offer.
But also you get this lack of choice, and so we see when people try to leave these plans and go back to traditional Medicare, they can’t, which is only one of the sort of things that I think a lot of <a href="https://kffhealthnews.org/news/article/medicare-advantage-breakups-contracts-hospitals-doctors-patients-choice/">people don’t know about how Medicare Advantage</a> works. Another place with an awful lot of small print.
Weber: It’s a lot of small print under a very good marketing name. The name itself implies that you’re making a better choice, but that isn’t necessarily what the small print would say.
Kenen: And there are people who are very satisfied with it and who get great care. I mean, it’s not monolithic. I mean, it is popular. It is growing and growing and growing. It’s partly economic, and there’s some plans that patients like, and there’s word of mouth or that were negotiated as part of union agreements and are actually pretty strong benefits. But they’re also people who are really encountering a lot of trouble with prior authorization, and limited networks, and your doctor’s no longer in it, et cetera, et cetera.
I think that those things, I actually checked with somebody about the provider networks, what we know about who’s dropping out, and I don’t think there’s really up-to-date data, but there is a perception, and you’re hearing it and seeing it online. But they do an incredible amount of marketing, an incredible amount of marketing. And if you’re in it and you like it and you save money and you’re getting great health care, terrific. You’re going to stay in it.
If you’re in it and you don’t like it and you’re not getting great health care and a lot of hassles or you can’t see the right doctors, it’s hard to get out and get back into it depending on what state you’re living … It’s not monolithic. But I think we might be between the financial pressures from the government and some of the debates about some of these things they’re doing there may be some reconsideration. But they have strong backers in Congress and not just Republicans.
Rovner: Oh, yeah. I mean, and as you point out, more than half of the people in Medicare are now on Medicare Advantage. I did want to sort of highlight my colleague Susan Jaffe, who has a story this week about the fact that patients can’t change plans in the middle of the year, but plans can drop providers in the middle of the year, so people may sign up for a health plan because their doctor or their hospital is in it and then suddenly find out mid-year that their doctor and their hospital is no longer in it.
There are occasionally, if you’re in the middle of treatment, there are opportunities sometimes to change, but often there aren’t. People do end up in these plans, and they can be happy for, basically, until they’re not, that there are trade-offs when you do it. And I think, as we point out, there’s so much marketing, and the marketing somehow doesn’t ever talk about the trade-offs that you make when you go into Medicare Advantage.
Luhby: Well, one also thing is that this is the peak 65 year, where the most baby boomers, and where are they coming from? They’re coming from private commercial insurance, so they’re familiar with it, and they were like, “Oh, OK, that’s seemingly very much like my employer plan. Sure, that sounds great. I know how to deal with that.” So that’s one of the things. And one cudgel that the insurers have is they say, “Oh, government, you’re going reduce our payments. We’re going to reduce the benefits and increase the premiums because we’re not going to have all of that extra government funding.” And that can scare the government because they don’t want the insurers to tell their patients, who are older patients who vote, “Oh, because of the government, we can no longer offer you all of these benefits, or we’ve had to raise your premium because of that.” So we’ll see if they actually do that.
Kenen: Joe Biden took away your gym, right?
Luhby: Exactly.
Rovner: [inaudible 00:22:11].
Luhby: And your dental benefits. So that’s always the threat that the insurers roll out. That’s the first thing that they say often, but we’ll see what happens. We don’t know yet until the fall, when enrollment starts, what will actually happen?
Rovner: We saw exactly that in the late ’90s after Congress balanced the budget. They took a big whack out of the payments for what was then, I think, called Medicare Plus Choice. It was the previous version of Medicare Advantage, and a lot of the companies just completely dropped out of the program. And a lot of the people, who as Joanne said, had been in those plants had been very happy, threw a fit and came to Congress to complain, and lo and behold, a lot of those payments got increased again. In fact, that was what led to the big increase in payments in 2003 was the huge cut that they made to payments, which drove a lot of the insurers out of the program. So we do know that the insurers will pack up and leave if they’re not paid what they consider to be enough to stay in the program.
Moving on. One of the things that Jeff Goldsmith talks about in this week’s interview is that our health system has become one of deep distrust between patients, providers, and insurers. Speaking of Medicare Advantage. That is sad and dysfunctional, except that sometimes there are good reasons for that distrust. One example comes this week from my KFF Health News colleague Julie Appleby. It seems that <a href="https://kffhealthnews.org/news/article/aca-obamacare-plans-switched-without-enrollee-permission-investigation/">unscrupulous insurance brokers are disenrolling people</a> in Obamacare plans from their health plans and putting them in different plans, which is unbeknownst to them until they find their doctor is no longer in their network or their drug isn’t covered.
The brokers who are doing this can earn bigger commissions. But patients can end up not just having to pay for their own medical care but owing the government money because suddenly they’re in plans getting subsidies that don’t match their incomes. It is a big mess. And it seems that the obvious solution, which would be making it harder for agents to access people’s enrollment information so they can switch them, would delay legitimate enrollment. It has to be easy for agents to basically manipulate people’s applications. So how do you guard against bad actors without inconveniencing everyone? This seems to be the question here and the question for Medicare Advantage, Lauren.
Weber: I was going to say, I mean, I think that’s the question Medicare itself has been dealing with for years. I mean, there’s a reason that many federal prosecutors call this a pay-and-chase situation in which there is rampant Medicare fraud. They prioritize the ease of patients accessing care to the disadvantage of some folks, or in this case, the American taxpayer, in this case, actual patients, being swindled.
But I don’t have an answer. I don’t think anyone really has an answer, considering we’re seeing things like the $2 billion catheter fraud that we’ve talked about here. So I think again, this is one of these things where the government’s been left a little flat-footed in trying to protect against bad actors.
Rovner: Yeah, well, the health sector is what a fifth of the economy now, so I guess it shouldn’t come as much of a surprise that you have not just bad actors, people who are making a lot of money from doing illegal things and find it to be worth their while and that some of them get caught, but presumably most of them don’t. I guess that’s what happens when you have that much money in one place, you need sort of better watchdogs. All right. Well, finally, this week in medical misinformation comes from PolitiFact in a story called “Four Years After Shelter-in-Place, Covid-19 Misinformation Persists.” That’s an understatement.
That last part was mine. At the top of the list says, “We have discussed before is growing resistance to vaccines in general, not just the covid vaccine,” which is not all that surprising considering how many people now believe fictitious stories about celebrities dropping dead immediately after receiving vaccines. There’s even a movie called “Died Suddenly.” Or that government leaders and the superrich orchestrated the pandemic. That’s another popular story that goes around. Or that Dr. Tony Fauci brought the virus to the United States a year before the pandemic. Lauren, health misinformation is your beat. Is it getting any better now that the pandemic is largely behind us, or is it just continuing unabated?
Weber: No, I would argue it’s possibly getting worse because the trust in institutions is at an all-time low. Social media has allowed for fire hose. I mean, it’s made everything … it’s made the public square that used to be more limited, all corners of the country.
I would say that misinformation has led to mistrust about basic medical things, including childhood vaccinations, but also other medical treatment and care. And I think you’re really seeing this kind of post-truth world post-covid, this distrust, this misinfo is going to continue for some time. And there’s too much to cover on my beat. There’s constantly stories around the bend, and I don’t expect that improving anytime soon.
Kenen: Every single time a celebrity, not just dies, because it’s always no matter what happens, it’s blamed on the covid vaccine, but also gets sick. I mean, Princess Kate. We don’t know everything about her health, but I mean, all of us know it wasn’t. Whatever it is, it’s not because the covid vaccine. But if you go online, you hear that that’s whatever she has it’s because she’s vaccinated.
And the other thing is it’s fed into this general vaccine mistrust. So when I wrote about the RSV vaccine, which we talked about a few weeks ago, it wasn’t so much that there’s a campaign against the RSV vaccine. There is somewhat of that. But it’s just this massive, “vaccines are bad.” So it’s spilling over into anything with a needle attached is part of this horrible plot to kill us all. So it’s just sort of this miasma of anti-vaccination that’s hovering over a lot of health care.
Rovner: Well, at the risk of getting a little too bleak, that will be the news for this week. Now, we will play my interview with Jeff Goldsmith, and then we’ll come back and do our extra credits. I am pleased to welcome back to the podcast Jeff Goldsmith, one of my favorite big-picture health system analysts. Jeff has been writing of late about the <a href="https://www.healthaffairs.org/content/forefront/change-healthcare-incident-change-health-care">Change Healthcare</a> hack and the growing size and influence of its owner, UnitedHealth Group, and what that means for the country’s entire health enterprise. Jeff, thanks for joining us again.
Jeff Goldsmith: You bet.
Rovner: So the lead of your latest piece gives a pretty vivid description of just how big United has become, and I just want to read it. “Years ago, the largest living thing in the world was thought to be the blue whale. Then someone discovered that the largest living thing in the world was actually the 106-acre, 47,000-tree Pando aspen grove in central Utah, which genetic testing revealed to be a single organism.
With its enormous network of underground roots and symbiotic relationship with a vast ecosystem of fungi, that aspen grove is a great metaphor for UnitedHealth Group. United, whose revenues amount to more than 8% of the U.S. health system, is the largest health care enterprise in the world.” Let’s pick up from there for people like me who haven’t been paying as much attention as maybe they should have, and still think that United is mainly a health insurance company. That is not true and hasn’t been for some time, has it?
Goldsmith: The difference between United and a health insurance company is that it also has $226 billion worth of care system revenues in it, some of which are services rendered to United and other, believe it or not, services rendered to United competitors. So, there isn’t anything remotely that size in the health insurance world. That $226 billion is more than double the size of Kaiser. Just to give you an idea of the scale.
Rovner: Which, of course, is the other companies that are both insurers and providers. That’s pretty much the only other really big one, right?
Goldsmith: Yes. I have a graphic in the piece that shows the <a href="https://thehealthcareblog.com/blog/2024/04/02/optum-testing-time-for-an-invisible-empire/">Optum Health</a> part, which is the care delivery part of Optum, is just about the same size as Kaiser, but it generates six and a half billion dollars in profit versus Kaiser’s $323 million. So it dwarfs Kaiser in terms of profitability even though it’s about the same size top line.
Rovner: So split it up for people who don’t know. What are sort of the main components that make up UnitedHealth Group?
Goldsmith: Well, there’s a very large health insurance business, $280 billion health insurance business. Then, there is a care system called Optum Health, which is about $95 billion. It has 90,000 affiliated or employed docs, a huge chain of MedExpress urgent care centers, surgery centers, a couple of very large home health care agencies. So that’s the care delivery part of United.
There’s Optum Insight, which is about $19 billion. That’s the part that Change Healthcare was inside of. It’s a business intelligence and corporate services business, and consulting business, that also manages care systems financials. And then, finally, there’s Optum Rx, which is about $116 billion, so a little bit more than half of Optum’s total, and that is a pharmacy benefit management company. Believe it or not, the third-largest one. So there are bigger pharmacy benefits management companies than Optum, but those are the three big pieces.
Rovner: I feel like this is almost as big as a lot of the government health programs, isn’t it?
Goldsmith: Yeah. I mean, I can’t remember top line how big the VA [Department of Veterans Affairs] is these days, but it’s VA scale, but it’s in a bunch of little pieces scattered all over the United States. I mean, that’s the big part of all of this. The care system is in at least 30 states. I have a map showing where some of the locations are. That map took me months to find. There isn’t a real registry of what the company owns, but it is a vast enterprise. And they’re great assets, if you’ll pardon a financial term for them.
Some of the finest risk-bearing multispecialty group practices in the United States are a part of Optum: Healthcare Partners based in Los Angeles; The Everett Clinic; the former Fallon Clinic, and Atrius in New England, which are the two finest risk-bearing, multispecialty physician groups in the Northeast. They weren’t dredging the bottom here at all. They got a tremendous number of high-quality groups that they’ve pulled together in the organization. The issue is it really an organization or is it a collection of assets that have been acquired at a very rapid pace over a period of the last 15 years.
Rovner: One of the things that I think the Change Healthcare hack proved for a lot of people is that nobody realized what a significant percentage of claims processing could go through one company. You have to wonder, have regulators, either at the state or federal level, kind of fallen down on this and sort of let this happen so that when somebody hacks into it, half the system seems to go down?
Goldsmith: The federal government challenged the Change acquisition and basically lost in court. They were unable to make the case. They were arguing that Change controlling all of these transactions of not only United but a lot of other insurers gave them access to information that enabled United to have some type of unfair competitive advantage. It was a difficult argument to make that didn’t make it. But the result of the Change acquisition was that about a third of the U.S. health system’s money flowed through one company’s leaky pipes.
And what we’re sort of learning as we learn more about Change is that there were something like a hundred separate programs inside Change, all of which somehow were vulnerable to this hack. And I think that’s one of the things that I think when [Sen.] Ron Wyden and [Sen.] Mark Warner get around to getting some facts about this, they’re going to wonder how did that happen. How could you have that many applications, that loosely tied together, that they were vulnerable to something like this?
And what my spies tell me is that a hacker, and it could have been a single hacker, not a country, but one guy was able to drop down into all of those data silos, vacuum out the data, and then delete the backups, so that United was basically left with no claims trail, no provider directories, nothing, and has had to reconstruct them; panicky reconstruction here in the last six weeks.
Rovner: Which I imagine is what’s taking so long for some of these providers to get back online.
Goldsmith: Julie, the part I don’t understand, is if it is true that that Change was processing a trillion and a half dollars worth of claims a year, a month interruption is $125 billion. That’s $125 billion that didn’t get paid to providers of care after the fact of them rendering the care. So the extent of the damage done by this is difficult to comprehend.
I mean, I have a lot of provider contacts and friends. Some of them, believe it or not, had no Change exposure at all because their main payers didn’t use Change. Some of them, it was all their payers used, and cash flow just ceased, and they had to go to the bank and borrow money to make their payrolls. None of this, for some reason, has made it in its full glory out into the press, and it isn’t that there aren’t incredibly high-quality business reporters in this field. There are.
Rovner: I know. I live in Maryland. I’ve driven over the Francis Scott Key Bridge in Baltimore. I know what it means. I mean, basically took apart the Baltimore Beltway. I mean, no longer goes in a circle. And I know how big the Port of Baltimore is, and I feel like everybody can understand that because it’s visceral. You can see it. There’s video of the bridge falling down. There isn’t video of somebody hacking into Change Healthcare and stopping a lot of the health system in its tracks.
Goldsmith: The metaphor that occurred to me, as you know, I’m a metaphor junkie, was actually Deepwater Horizon, and of course, we had a camera on that gushing well the whole time. This is like a gusher of red ink, a Deepwater Horizon-sized gusher of red ink that went on for a month. From what I’m able to understand, people are able to file the claims now. How many people have actually been paid for the month or six weeks’ worth of work they’ve done is elusive. And I still don’t have access to really good facts on how much of what they owed people they’ve actually paid.
I do know a lot of my investor analyst friends are waiting for United’s first-quarter financials to drop, which will probably show a four- or five-day drop in their medical loss ratio because of all the claims they were not able to pay, and therefore money was sitting in their coffers earning, what, 5% interest. That’s going to be kind of a festival when the first-quarter financials drop. And, of course, it isn’t just United, Humana, the Elevance, Cigna, all the rest of them. A lot of these folks use Change to process their claims. So there’s going to be a swollen offer here on the health insurance side from a month of not paying their bills.
Rovner: Well, is it the next Standard Oil? Is it going to have to be taken apart at some point?
Goldsmith: Yeah, but I mean, the question is, on what basis? Our health care system is so vast and fragmented, even a generous interpretation of antitrust laws, you’d have trouble finding a case. The Justice Department or FTC [Federal Trade Commission] is going to try again. But I’ll tell you, I think they’ve got their work cut out for them. I think the real issue isn’t anti-competitiveness, it’s a national security issue. If you have a third of the health systems dollars flowing through one company’s leaky pipes, that’s not an antitrust problem. It’s a national security problem, and I think there are some folks in the U.S. Senate that are righteously pissed about this.
There’s a lot of fact-finding that needs to happen here and a lot of work that needs to be done to make this system more secure. And I’ve also argued to make it simpler. Change was processing 15 billion transactions a year. That’s 44 transactions for every man, woman, and child in the country, and that was only a third of them. What are we doing with 100 billion transactions? What’s up with that? It beggars the imagination to believe that we to minutely manage every single one of those transactions. That is just an astonishing waste of money. It’s also an incredible insult to our care system. The assumption that there at any moment, every one of those folks could potentially be ripping us off, and we can’t have that.
Rovner: So we’re spending all of this money to try and not be ripped off for presumably less money.
Goldsmith: Hundreds of billions of dollars, but who’s counting?
Rovner: It’s kind of a depressing picture of what our health system is becoming, but I feel like it is kind of an apt picture for what our health system has become.
Goldsmith: It’s the level of mistrust. The idea that every one of his patients is trying to get a free lunch, and every doctor is trying to pad his income. We’ve built a system based on those twin assumptions. And when you think about them for a minute, they really are appalling assumptions. Most of what motivated me when I had cancer was fear.
I wasn’t trying to get stuff I wasn’t entitled to or didn’t need. I wanted to figure out a way to not be killed by the thing in my throat. And my doctors were motivated by a fear that if they let me go, maybe my heirs would sue them. I guess this idea that we are just helpless pawns of a behaviorist model of incentives, I think the economists ran wild with this thesis. And I think it’s given us a system that doesn’t work for anybody.
Rovner: Is there a way to fix it?
Goldsmith: I think we ought to cut the number of transactions in half. We ought to go and look at how many prior authorizations are really needed. Is this a model we really want to continue with, effectively universal surveillance of every clinical decision? We ought to be paying in bundles. We ought to pay our primary care physicians monthly for every patient that they see that’s a continuing patient and not chisel them over every single thing they do. We ought to pay for complex care in bundles where a cancer treatment is basically one transaction instead of hundreds.
I think we could get a long way to simplifying and reducing the absurd administrative overburden by doing those things. I also think that the idea that we have 1,100 health insurers. United’s the biggest, but it’s not by any means the only health insurer. There’s 1,100 rule sets that determine what data you need in order to pay a claim and whether a claim is justified or not. I think that’s a crazy level of variation. So I think we need to attack the variation. We’ve had health policy conversations about this for years and not done anything, and I think it’s really time to do it.
Rovner: Maybe this will give some incentive to some people to actually do something. Jeff Goldsmith, thank you so much.
Goldsmith: Julie. It’s good talking to you.
Rovner: OK. We are back, and 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 <a href="https://kffhealthnews.org/news/tag/podcast/">podcast page</a> at <a href="https://kffhealthnews.org/">kffhealthnews.org</a> and in our show notes on your phone or other mobile device. Tami, you’ve already done yours this week. Lauren, why don’t you go next?
Weber: Yeah. I think we’re all keeping an eye on this in this podcast, but the title of this story is “<a href="https://www.washingtonpost.com/health/2024/04/01/bird-flu-human-case-cow-texas/">Bird Flu Detected in Dairy Worker Who Had Contact With Infected Cattle in Texas</a>,” which was written by my colleagues, Lena Sun and Rachel Roubein. Also, great pieces by Helen Branswell in the Texas Tribune on this as well.
But, essentially, just so listeners know, there has been a case of human bird flu detected, which is very concerning. As all of us on this podcast know, avian human flu is one of the worst-case scenarios in terms of a pathogen and infectiousness. As of right now, this is only one person. It seems to be isolated. We don’t know. We’ll see how this continues to mutate, but definitely something to keep an eye on for potential threat risk. TBD.
Rovner: Yeah. It is something I think that every health reporter is watching with some concern. Although, as you point out, we really don’t know very much yet. And so far, we have not seen. I think what the experts are watching for is human-to-human transmission, and we haven’t seen that yet.
Kenen: And this person seems to have a mild case, from the limited information we have, which is also a good sign for both that individual and everybody else in terms of spreadability.
Rovner: But we will continue to watch that space. Joanne.
Kenen: Well, you said enough bleak, but I’m afraid this is somewhat bleak. This is a piece by Kate Martin from APM Reports, which is part of American Public Media, and it was published in cooperation with The 19th, and the headline is “<a href="https://19thnews.org/2024/04/illinois-sexual-assault-survivor-law-hospitals/">Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care</a>.” So there’s a very, very strong sort of everybody points to it as great law in Illinois saying that what kind of care hospitals have to provide to sexual assault victims and what kind of testing and counseling and everything. This whole series of services that legally they must do, and they’re not doing it. Even in cases of children being assaulted, they’re sending people 40 miles away, 80 miles away, 40 miles away. They’re not doing rape kits. They’re not connecting them to the counselors, et cetera. It is a pretty horrifying story. It begins with a story of a 4-year-old because they didn’t do what they were supposed to do. The father was the suspected perpetrator, and because the hospital didn’t do what they should have done he still has joint custody of this little girl.
Rovner: My story this week is from our podcast colleague, Alice [Miranda] Ollstein, and her Politico colleague, Megan Messerly, and it’s called “<a href="https://www.politico.com/news/2024/04/01/anti-abortion-movement-ivf-war-00149766">Republicans Are Rushing to Defend IVF. The Anti-Abortion Movement Hopes to Change Their Minds</a>.” And it’s about the fact that while maybe not trying to outlaw IVF entirely, the anti-abortion movement does want to dramatically change how it’s practiced in the U.S.
For example, they would like to decrease the number of embryos that can be created and transplanted, both of which would likely make the already expensive treatment even more expensive still. Anti-abortion activists also would like to ban pre-implantation genetic testing so that, “Defective embryos can’t be discarded.” Except that couples with genes for deadly diseases often turn to IVF exactly because they don’t want to pass those diseases on to their children, and they would like to test them before they are implanted.
In other words, the anti-abortion movement may or may not be coming for contraception, but it definitely is coming for IVF. OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our technical guru, Francis Ying, and our editor Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, <a href="https://twitter.com/jrovner">@jrovner</a>, or <a href="https://bsky.app/profile/julierovner.bsky.social">@julierovner</a> at Bluesky and <a href="https://www.threads.net/@julie.rovner">@julie.rovner</a> at Threads. Tami, where can we find you?
Luhby: I’m at <a href="https://www.cnn.com/">cnn.com</a>.
Rovner: There you go. Joanne.
Kenen: <a href="https://twitter.com/JoanneKenen">@JoanneKenen</a> on X, and <a href="https://www.threads.net/@joannekenen1">@joannekenen1</a> on Threads. 
Rovner: Lauren.
Weber: <a href="https://twitter.com/laurenweberhp">@LaurenWeberHP</a> on X
Rovner: We will be back in your feed next week. Until then, be healthy.
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<title>KFF Health News' 'What the Health?': The Supreme Court and the Abortion Pill</title>
<link>https://kffhealthnews.org/news/podcast/what-the-health-340-supreme-court-mifepristone-march-28-2024/</link>
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<pubDate>Thu, 28 Mar 2024 19:45:14 +0000</pubDate>
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<description><![CDATA[The Supreme Court this week heard its first abortion case since overturning Roe v. Wade in 2022, about an appeals court ruling that would dramatically restrict the availability of the abortion pill mifepristone. But while it seems likely that this case could be dismissed on a technicality, abortion opponents have more challenges in the pipeline. Meanwhile, health issues are heating up on the campaign trail, as Republicans continue to take aim at Medicare, Medicaid, and the Affordable Care Act — all things Democrats are delighted to defend. Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post join KFF Health News chief Washington correspondent Julie Rovner to discuss these issues and more. Also this week, Rovner interviews KFF Health News’ Tony Leys, who wrote a KFF Health News-NPR “Bill of the Month” feature about Medicare and a very expensive air-ambulance ride. Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too.]]></description>
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The Host </h3>
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Julie Rovner
KFF Health News
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Read Julie's stories. </a>
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
In its first abortion case since the overturning of Roe v. Wade in 2022, the Supreme Court this week looked unlikely to uphold an appeals court ruling that would dramatically restrict the availability of the abortion pill mifepristone. But the court already has another abortion-related case teed up for April, and abortion opponents have several more challenges in mind to limit the procedure in states where it remains legal.
Meanwhile, Republicans, including former President Donald Trump, continue to take aim at popular health programs like Medicare, Medicaid, and the Affordable Care Act on the campaign trail — much to the delight of Democrats, who feel they have an advantage on the issue.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.
<h3>
Panelists </h3>
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Sarah Karlin-Smith
Pink Sheet
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@SarahKarlin </a>
<a href="https://pink.pharmaintelligence.informa.com/authors/sarah-karlin">
Read Sarah's stories. </a>
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Alice Miranda Ollstein
Politico
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@AliceOllstein </a>
<a href="https://www.politico.com/staff/alice-miranda-ollstein">
Read Alice's stories. </a>
<img />
Lauren Weber
The Washington Post
<a href="https://twitter.com/LaurenWeberHP">
@LaurenWeberHP </a>
<a href="https://www.washingtonpost.com/people/lauren-weber/">
Read Lauren's stories. </a>
Among the takeaways from this week’s episode:
<ul>
<li>At least two conservative Supreme Court justices joined the three more progressive members of the bench during Tuesday’s oral arguments in expressing skepticism about the challenge to the abortion drug mifepristone. Their questions focused primarily on whether the doctors challenging the drug had proven they were harmed by its availability — as well as whether the best remedy was to broadly restrict access to the drug for everyone else.</li>
<li>A ruling in favor of the doctors challenging mifepristone would have the potential to reduce the drug’s safety and efficacy: In particular, one FDA decision subject to reversal adjusted dosing, and switching to using only the second drug in the current two-drug abortion pill regimen would also slightly increase the risk of complications.</li>
<li>Two conservative justices also raised the applicability of the Comstock Act, a long-dormant, 19th-century law that restricts mail distribution of abortion-related items. Their questions are notable as advisers to Trump explore reviving the unenforced law should he win this November.</li>
<li>Meanwhile, a Democrat in Alabama flipped a state House seat campaigning on abortion-related issues, as Trump again discusses implementing a national abortion ban. The issue is continuing to prove thorny for Republicans.</li>
<li>Even as Republicans try to avoid running on health care issues, the Heritage Foundation and a group of House Republicans have proposed plans that include changes to the health care system. Will the plans do more to rev up their base — or Democrats?</li>
<li>This Week in Medical Misinformation: TikTok’s algorithm is boosting misleading information about hormonal birth control — and in some cases resulting in more unintended pregnancies.</li>
</ul>
Also this week, Rovner interviews KFF Health News’ Tony Leys, who wrote a KFF Health News-NPR <a href="https://kffhealthnews.org/news/article/air-ambulance-flight-surprise-bill-medicare-part-b/">“Bill of the Month” feature</a> about Medicare and a very expensive air-ambulance ride. If you have a baffling or outrageous medical bill you’d like to share with us, <a href="https://kffhealthnews.org/send-us-your-medical-bills/">you can do that here</a>.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: KFF Health News’ “<a href="https://kffhealthnews.org/news/article/chemotherapy-drug-overdose-fluorouracil-common-gene-test-lifesaving/">Overdosing on Chemo: A Common Gene Test Could Save Hundreds of Lives Each Year</a>,” by Arthur Allen.
Alice Miranda Ollstein: Stat’s “<a href="https://www.statnews.com/2024/03/20/fetal-tissue-research-scientists-roadblocks/">Fetal Tissue Research Gains in Importance as Roadblocks Multiply</a>,” by Olivia Goldhill.
Sarah Karlin-Smith: The Washington Post’s “<a href="https://www.washingtonpost.com/travel/2024/03/21/breast-pump-airlines-carryon-rule-dot/">The Confusing, Stressful Ordeal of Flying With a Breast Pump</a>,” by Hannah Sampson and Ben Brasch.
Lauren Weber: Stateline’s “<a href="https://stateline.org/2024/03/27/deadly-fires-from-phone-scooter-batteries-leave-lawmakers-playing-catch-up-on-safety/">Deadly Fires From Phone, Scooter Batteries Leave Lawmakers Playing Catch-Up on Safety</a>,” by Robbie Sequeira.
Also mentioned on this week’s podcast:
<ul>
<li>The Washington Post’s “<a href="https://www.washingtonpost.com/politics/2024/02/22/nikki-haley-wants-consensus-contraception-its-not-that-easy/">Nikki Haley Wants ‘Consensus’ on Contraception. It’s Not That Easy</a>,” by Julie Rovner.</li>
<li>Politico’s “<a href="https://www.politico.com/news/2024/03/27/conservative-abortion-pill-restriction-efforts-00149199">Justices Were Skeptical of Abortion Pills Arguments. Anti-Abortion Groups Have Backup Plans</a>,” by Alice Miranda Ollstein.</li>
<li>Politico’s “<a href="https://www.politico.com/news/2024/03/28/oregon-drug-criminalization-portugal-00148872">Why Portland Failed Where Portugal Succeeded in Decriminalizing Drugs</a>,” by Carmen Paun and Aitor Hernández-Morales.</li>
</ul>
click to open the transcript
Transcript: The Supreme Court and the Abortion Pill
KFF Health News’ ‘What the Health?’Episode Title: ‘The Supreme Court and the Abortion Pill’Episode Number: 340Published: March 28, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 28, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this, so here we go.
We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Morning, everybody.
Rovner: And Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: Later in this episode, we’ll have my Bill of the Month interview with my KFF Health News colleague Tony Leys, about Medicare confusion and a really expensive air ambulance ride. But first, this week’s news.
So the big news of the week here in Washington were the oral arguments at the Supreme Court on a case that could seriously restrict the availability of the abortion pill mifepristone. This was the first major abortion case to come before the justices since they overturned Roe v. Wade in 2022, and the buildup to this case was enormous. But judging from the oral arguments, it seems like this huge case might kind of fizzle away? Alice, you were there. What happened?
Ollstein: Yeah, Sarah and I were both there. We got to hang out in the obstructed-view section of the press section. Luckily, most of the justices’ voices are easily recognizable. So even from behind the curtain, we could tell what was going on. What was obviously expected was that the court’s three more-progressive justices would take a really skeptical and hard look at this case brought by anti-abortion doctors.
But what was somewhat more surprising is that several, at least two, arguably <a href="https://www.politico.com/news/2024/03/27/conservative-abortion-pill-restriction-efforts-00149199">three, of the conservatives joined them in their skepticism</a>. And they really went after two core pieces of this challenge to the FDA. One on “standing,” whether these doctors can prove that they have been harmed by the availability of these pills in the past and are likely to be in the future. There was a lot of talk about how the FDA doesn’t require these doctors to do or not do anything, and the case relies on this speculative chain of events, from the FDA approving these pills to someone seeking out one of these doctors, in particular, to treat them after taking one, and that being way too loose a connection to establish standing.
The other piece that the conservative justices were maybe not in favor of was the demand for this sweeping universal ruling, restricting access to the pills for everyone. They were saying, “Wouldn’t something more tailored to just these doctors make more sense instead of imposing this policy on everyone in the nation?” So that really undermines their case a lot. Although, caveat, you cannot tell how the court’s going to rule based on oral arguments. This is just us reading the tea leaves. Maybe they’re playing devil’s advocate, but it is telling.
Rovner: Yeah, somebody remind us what could happen if the justices do reach the merits of this case. Obviously from the oral argument, it looks like they’re going to say that these particular doctors don’t have standing and throw the case out on that basis. But if in case, as Alice says, they decide to do something else, what could happen here? Sarah, this is a big deal for drug companies, right?
Karlin-Smith: Right. So in terms of the actual abortion pill mifepristone itself, the approval of the drug is not on the line at this point. That was taken off the table, though a lower court did try and restrict the drug entirely. What’s on the table are changes FDA made to its safety programs for the drug since 2016 that have had the impact of making the drug more available to people later in pregnancy. It’s just easier to access. You no longer have to go to a health provider and take the drug there. You can pick it up at a pharmacy, it can be sent via mail-order pharmacy. It’s just a lot easier to take and has made it more accessible. So those restrictions could basically go back in time to 2016.
Rovner: And I know. I remember at some point, one of the people arguing the case was there for Danco, the company that makes the pill, or the brand-name company that makes the pill. And at some point, they were saying if they rolled back the restrictions to 2016, they’d have to go through the labeling process all over again because the current label would be no longer allowed. And that would delay things, right?
Karlin-Smith: Right. All of the drug that is currently out there would be then deemed misbranded and it’s not superfast to have to update it. The other thing, I don’t think this came up that much on arguments but it’s been raised before is that actually, you can make a strong case that going back to [the] 2016 state might be actually potentially more dangerous for people because they actually also adjusted the dosing of mifepristone a bit. So there’s actually been changes that people might actually say actually would create more potential. … If you believe these doctors might actually be injured in the sense of they would see more women in the ER because of adverse events from these drugs, there’s a case you can make that actually says it would be more unsafe if you go back to 2016 than if you operate under the current way the drug is administered today.
Ollstein: This also didn’t come up, but Sarah is exactly right. And, if this case did end up in the future going after the original FDA approval of mifepristone, providers around the country have said they would switch to a misoprostol-only regimen where people just take the second of the two pills that are usually taken together. And that brings up a very similar issue to what Sarah just mentioned because if that happens, there is a, not hugely, but slightly greater risk of complications if that happens. And so, exactly, the relief that these doctors are seeking could, in fact, lead to more people coming for treatment in the future.
Rovner: Well, it seemed like the one … the merits of this case that the justices did ask about was the idea of judges substituting their medical judgment for that of the FDA. That’s obviously a big piece of this. I was surprised to see even some of the conservative justices, particularly Amy Coney Barrett, wondering maybe if that was a great idea.
Ollstein: It was also just so notable how much talk there was of just the particulars of reproduction and abortion and women’s bodies. You just don’t hear that a lot in the Supreme Court, and I don’t know if that is a function of there being more women than before sitting on the Supreme Court. You heard about how to diagnose ectopic pregnancies without an ultrasound. You heard about pregnancies being dated by the person’s last menstrual period. I don’t know when I’ve heard the words “menstrual period” said in the Supreme Court before, but we heard them this week.
Rovner: And it was notable, and several people noted it, all three attorneys who argued this case were women. Both the attorney for the plaintiff, the solicitor general, Elizabeth Prelogar, who is a woman, and the attorney for Danco were all women. And the women, the four, now four women on the court, were very active in the questioning and it was. I’ve sat through a lot of reproductive health arguments at the Supreme Court and it was, to me at least, really refreshing to hear actual specifics and not euphemisms, but that were to the point of what we were talking about here, which often these arguments are not.
So one of the things that came up that we did expect was some discussion of the 1873 Comstock Act, mostly brought up by Justices [Samuel] Alito and [Clarence] Thomas. This is the long-dormant anti-vice law that could effectively impose a nationwide ban on abortion if it is resurrected and enforced, right?
Ollstein: Yes. So this was really interesting because this was not part of the core case arguments, but it’s something that the challengers really want to be part of the court arguments. And you had two of the court’s justices, arguably furthest to the right, really grilling the attorneys on whether the FDA should have taken Comstock into account when it approved mail delivery of abortion pills. And the solicitor general said, “Not only would that have been inappropriate, it would arguably have been illegal for the FDA to have done that.” She was saying, “The FDA is by statute only supposed to consider the safety and efficacy of a drug when creating policies.” If it had said, “Oh, we’re not going to do this thing that the science indicates we should do,” which is allow mail delivery because of this long-dormant law that our own administration put out a memo saying it shouldn’t ban delivery of abortion pills, that would’ve been completely wrong.
Now, they asked the same of the attorney for the challengers and she obviously was in favor of taking the Comstock Act into account. And so I think it’s a sign that this is not the last we’re going to hear of this.
Karlin-Smith: I believe the solicitor general also did reference the fact that FDA did to some degree acknowledge the Comstock Act, but deferred to the Biden administration’s Justice Department’s determination that, first of all, not only has this law not really been enforced for years, but that it doesn’t actually ban the mail distribution of a legal, approved drug.
And the other thing, again, they went into this a little bit more in briefs, but FDA has its role and sometimes other agencies have other laws they operate on and you can operate on separate planes. So FDA and DEA [Drug Enforcement Administration] often have to intersect when you’re talking about controlled substances like opioids and so forth. And what happens there is actually, FDA approves the drug and then DEA comes back in later and they do the scheduling of it and then the drug gets on the market. But FDA doesn’t have to take into account and say, “Oh, we can’t approve this drug because it’s not scheduled that they approve it.” Then DEA does the scheduling. So it seems like they’re twisting FDA’s role around Comstock a little bit.
Weber: Just to echo some of that, I think a lot of court watchers and a lot of abortion protectors were alarmed by the mention of the Comstock Act over and over again and are watching to see if there will be a fair amount of road-mapping laid out in the legal opinions that Alito and Thomas are expected to give, likely in dissent to the decision probably to dismiss this case. And I think it’s really interesting that this is coinciding with a lot of reporting that we’ve talked about on this podcast over and over again of Donald Trump talking about a 15- to 16-week abortion ban and his advisers, who are setting a roadmap for his presidency were he to win, talking explicitly about how they would revive the Comstock Act.
So all of these things taken together would seem to indicate that it would certainly play a role if the administration were to be a Trump administration.
Rovner: Perfect segue to my next question, which is that assuming this case goes away, Alice, you wrote a story about backup plans that the anti-abortion groups have. What are some of those backup plans here?
Ollstein: Yeah, I thought it was important for folks to remember that even though this is a huge deal that this case even got this far to the Supreme Court, it is far from the only way anti-abortion advocates and elected officials are working to try to cut off access to these pills. They see these pills as the future of abortion. Obviously, they’ve gained popularity over the recent years and now have jumped from just over half of abortions to more than two-thirds just recently. And so there are bills in Congress and in state legislatures. There are model draft bills that these anti-abortion groups are circulating. There are other lawsuits, and like you said, there are these policy plans trying to lay a groundwork for a future Trump administration to do these things through executive orders, going around Congress. There’s not a lot of confidence of winning a filibuster-proof majority in the Senate, for instance. And so while congressional plans also include attempting to use the appropriations process, as happened unsuccessfully this year, to ban abortion, I think people see the executive branch route as a lot more fruitful.
In addition to all of that, there are also just pressure campaigns and protest campaigns. It’s the same playbook that the anti-abortion movement [used] to topple Roe. They are good at playing the long game, and so there are plans to pressure the pharmacies like Walgreens and CVS that have agreed to dispense abortion pills. I just think that you’re seeing a very throw-everything-against-the-wall-and-see-what-sticks kind of strategy amongst these groups.
Rovner: Meanwhile, as Lauren already intimated, abortion is playing a major role in this year’s campaigns and elections. This week, a Democrat in deep-red Alabama flipped a Statehouse seat running on a reproductive freedom platform. She actually went out and campaigned on trying to reverse the state’s abortion ban. Meanwhile, Donald Trump, who earlier hinted that he might favor some sort of national ban, with exceptions for rape and incest and threats to life, said the quiet part out loud last week, telling a radio show that “people are agreeing on a 15-week ban.” That’s exactly what Republicans running for reelection in the Senate don’t want to hear right now. This has not gone well for Republicans in discussions of abortion as we saw this week in Alabama.
Weber: Yeah. As someone who was born in Alabama — and I’ve talked about this on this podcast, there are a fair amount of influencers that are regular people that I follow that live in Alabama — the IVF ruling was a huge shock to the system for conservative Alabama, especially women, and I think this win by a Democrat in the Deep South like this is a real wake-up call. And probably why all the Republican senators don’t want to talk about abortion or any sort of ban, or really get close to this reproductive issue because it is a real weak spot as this race unfolds with two candidates that are arguably both unpopular with both of their parties.
So this could become a turnout game, and if one side is more activated due to feeling very strongly about IVF, abortion, et cetera, that really could play out in not only the presidential race but the trickle-down races that are involved.
Rovner: I was amused. There’s the story that The Hill had this week about Senate Republicans wincing at Trump actually coming out for a federal ban. And one of them was Josh Hawley, who is not only very avowedly pro-life but whose wife argued the case for the plaintiffs in the Supreme Court, and yet he was saying he doesn’t want to see this on a federal level because he’s up for reelection this year.
Karlin-Smith: It’s interesting because one thing we’ve seen is that when there’s been specific abortion measures that people got to vote for at the state or local level, abortion rights are very popular. But then people have always raised this question of, “Well, would this look the same if you were voting more for a candidate, a person, and you were thinking about their broader political positions, not just abortion?” And this case in Alabama, I think, is a good example when you see that that can carry the day and it’s people who care about abortion rights may be willing to sacrifice potentially other political positions where they might be more aligned with a candidate if that’s an issue that’s a top priority.
Rovner: Yeah. And I think a lot of people took away, the Democrat in Alabama won by 60%, she got 60% of the vote. And she’d run before and lost, I think they said by 7%. It was more than a fluke. She really won overwhelmingly, and I think that raised an awful lot of eyebrows. Speaking of health care and politics and Donald Trump, the presumptive Republican presidential nominee also reiterated his desire to, and again, I quote from his post, this time on Truth Social, “Make the ACA much, much, much better for far less money or cost to our grest,” I presume he meant great, “American citizens who have been decimated by Biden.” This harkens back to all the times when he as president repeatedly promised a replacement for the ACA coming within a few weeks and which never materialized.
Does anybody think he has anything specifically in mind now? I guess as we’ve talked about with abortion, but haven’t really said, there is this Heritage Foundation document that’s supposed to be the guiding force should he get back into office.
Ollstein: But if I’m correct, even that document — which is like a wish list, dreamland, they could do whatever they want, “This is what we would love to do” — even that doesn’t call for repealing Obamacare entirely. It calls for chipping away at it, allowing other alternatives for people to enroll in. But I think it’s telling that even in their wildest dreams, they are not touching that stove again after the experience of 2017.
Weber: Julie, I’m just sad you didn’t read that in all caps. I feel like you really missed an opportunity to accurately represent that tweet.
Rovner: I also didn’t read the whole thing. It’s longer than that. That was just the guts of it. Well, one group that is not afraid to shy away from the specifics is the Republican Study Committee in the U.S. House, which has released its own proposed budget for fiscal 2025. That’s the fiscal year that starts this Oct. 1. The RSC’s membership includes most but not all of Republicans in the U.S. House. And it used to be the most conservative caucus before there was a Freedom Caucus. So it’s now the more moderate of the conservative side of the House.
I should emphasize that this is not the proposed budget from House Republicans. There may or may not be one from the actual House Budget Committee. It’s due April 15, by the way, the budget process — even though the president just signed the last piece of spending legislation for fiscal 2024 — the 2025 budget process is supposed to start as soon as they get back.
In any case, the RSC budget, as usual, includes some pretty sweeping suggestions, including raising the retirement age, block-granting Medicaid, repealing most of the Affordable Care Act and Medicare’s drug price negotiation authority, and making Medicare a “premium support program,” which would give private plans much more say over what kind of benefits people get and how much they pay for them. Basically, it’s a wish list of every Republican health proposal for the last 25 years, none of which have been passed by Congress thus far.
The White House and Democrats, not surprisingly, have been all over it. Both the president and the vice president were on the road this week, talking up their health care accomplishments, part of their marking of the 14th anniversary of the ACA, and blasting the Republicans for all of these proposals that some of them may or may not support or may or may not even know about. Republicans desperately don’t want 2024 to become a health care election, but it seems like they’re doing it to themselves, aren’t they?
Ollstein: So putting out these kinds of policy plans before an election, it’s a real double-edged sword because you want to rev up your own supporters and give your base an idea of “Hey, if you put us in power, this is what we will deliver for you.” But it also can rev up the other side, and we’re seeing that happen for sure. Democrats very eagerly jumped on this to say, “This shows why you can’t elect Republicans and put them in control. They would go after Obamacare, go after Medicare, go after Medicaid, go after Social Security,” all of these very sensitive issues.
And so yeah, we are definitely seeing the backlash and the weaponization of this by Democrats. Are we seeing this inspire and excite the right? I haven’t really seen a ton of chatter on the right about the Republican Study Committee budget, but if you have, let me know.
Rovner: As the campaign goes on, we’ll see more people throwing things against the wall. I think you’re right. I think the Republicans want this election to be about inflation and the border, so, I’m sure we will also hear more about that. Well, moving on, I have a segment this week that I’m calling “This Week in Things That Didn’t Work Out as Planned.” First up was hard-drug decriminalization in Oregon. Longtime listeners will remember when we talked about Oregon voters approving a plan in 2020 to have law enforcement issue $100 citations to people caught using small amounts of hard drugs like cocaine and heroin, along with information on where they can go to get drug treatment. But the drug treatment program basically failed to materialize, overdoses went up, and <a href="https://www.politico.com/news/2024/03/28/oregon-drug-criminalization-portugal-00148872">drug users gathered in public on the streets of Portland</a> and other cities to shoot up.
Now the governor has signed a bill recriminalizing the drugs that had been decriminalized. I feel like this has echoes of the deinstitutionalization movement of the 1960s when people with serious mental illness were supposed to be released from facilities and provided community-based care instead. Except the community-based care also never materialized, which basically created part of the homeless problem that we still have today.
So in fact, we don’t really know if drug decriminalization would work, at least not in the way it was designed. But Alice, you point to a story that one of your colleagues has written about a place where it actually did work, right?
Ollstein: Yeah, so they did a really interesting comparison between Oregon and the country Portugal, and made a pretty convincing case that Oregon did not give this experiment the time or the resources to have any chance of success. Basically, Oregon decriminalized drugs, they barely funded and stood up services to help people access treatment. And then after just a couple of years, politicians panicked at the backlash and are backpedaling instead of giving this, again, the time and resources to actually achieve what Portugal has achieved over decades, which is a huge drop in overdose deaths.
But in addition to more time and resources, you can’t really carve this out of just basic universal health care, which Portugal has, and we definitely do not. And so I think it’s a really interesting discussion of what is needed to actually have an impact on this front.
Rovner: Yeah, obviously it’s still a big problem, and states and the federal government and localities are still trying to figure out how best to grapple with it. Well, next in our things that didn’t work out as planned is arbitration for surprise medical bills. Remember when Congress outlawed passing the cost of insurer-provider billing disputes to patients? Those were these huge bills that suddenly were out-of-network. The solution to this was supposed to be a process to fairly determine what should be paid for those services. Well, researchers from the Brookings Institution have taken a deep dive into the first tranche of data on the program, which is from 2023, and found that at least early on the program is paying nearly four times more than Medicare would reimburse for the disputed services, and that it has the potential to raise both premiums and in-network service prices, which is not what lawmakers intended.
I feel like this was kind of the inevitable result of continuing compromises when they were writing this bill to overcome provider opposition. They were afraid they wouldn’t get paid enough, and so they kept pushing this process and now, surprise, they’re getting paid probably more than was intended. Is there some way to backpedal and fix this? Lauren, you look like you have feelings here.
Weber: I take us back to the name of this podcast, “What the Health?” I feel like this sums up everything in health care. Literally, legislators try to get a fix that it turns out could actually worsen the problem because the premiums and so on could continue to escalate in a never-ending war for patients to share more of the burden of the cost. So it’s good that we have this research and know that this is what’s happening, but yeah, again, this is the name of the podcast. How is this the health care system as we know it?
Karlin-Smith: Also, again, you start to understand why other countries just have these — as much as they’re politically unpopular in the U.S. — these systems where they just set the prices because trying to somehow do it in a more market-based way or these negotiating ways, you end up with these pushes and pulls and you never quite achieve that cost containment you want.
Rovner: Yeah, although we have gotten the patient out of the middle. So in that sense, this has worked, but certainly …
Karlin-Smith: Right, for the people actually getting the surprise bills, they’ve been helped. Again, assuming that down the line, as Lauren mentioned, it doesn’t just raise all of our inpatient bills and our premiums.
Rovner: Yes, we will all be employed forever trying to explain what goes on in the health care system. Finally, diabetes online tools, all those cool apps that are supposed to help people monitor their health more closely and control their disease more effectively. Well, according to a study from the Peterson Health Technology Institute, the apps don’t deliver better clinical benefits than “usual care,” and they increase health spending at the same time — the theme here.
This is the first analysis released by this new institute created to evaluate digital health technology. Although not surprisingly, makers of the apps in question are pushing back very hard on the research. Technology assessment has always been controversial, but it clearly seems necessary if we’re ever going to do something about health spending. So somebody’s going to have to do this, right?
Weber: As we move into this ever more digital health world where billions of dollars are being spent in this space, it’s really important that someone’s actually evaluating the claims of if these things work, because it’s a lot of Medicare money, which is taxpayer dollars, that get spent on some of these tools that are supposedly supposed to help patients. And I believe, in this case, they found a 0.4% improvement, which did not justify, I think it was several hundred dollars worth of investment every year, when other tactics could be used. So quite an interesting report, and I’m very curious, and I’m sure many other digital health creators, too, are curious to see who they’ll be targeting next.
Karlin-Smith: It’s an old story in U.S. health care, right? That the tech people are going to come in and save us all, and then what happens when they come into it and realize that there’s root problems in our system that are not easily solved just by throwing more complicated money and technology at it. So these are certainly not the first people that thought that some innovative technological system would work.
Rovner: So in drug news this week, Medicare has announced it will cover the weight loss drug Wegovy, which is the weight loss version of the drug Ozempic. But not for weight loss, rather for the prevention of heart disease and stroke, which a new clinical trial says it can actually help with. Sarah, is this a distinction without a difference and might it pave the way for broader coverage of these drugs in Medicare?
Karlin-Smith: Distinction does matter. CMS [Centers for Medicare & Medicaid Services] has been pretty clear in guidance. This does not yet open the door for somebody who is just overweight to have the drug in Medicare. And health plans will have a lot of leeway, I think, to determine who gets this drug through prior authorization, and so forth. Some people have speculated they might only be willing to provide it to people that have already had some kind of serious heart event and are overweight. So not just somebody who seems high risk of a heart attack.
So I think at least initially, there’s going to be a lot of tight control over at AHIP. The biggest insurance trade group has indicated that already, so I don’t think it’s going to be as easy to access as people want it to be.
Rovner: Meanwhile, a separate study has both good and bad news about these diabetes/weight loss medications. Medicare is already spending so much money on them because it does cover them for diabetes, that the drugs could soon be eligible for price negotiations. Could that help bring the price down for everyone? Or is it possible that if Medicare cuts a better deal on these drugs everybody else is going to have to pay more?
Karlin-Smith: You mean outside of Medicare or just …?
Rovner: Yeah, I mean outside of Medicare. If Medicare negotiates the price of Ozempic because they’re already covering it so much for diabetes, is that going to make them raise the price for people who are not on Medicare? I guess that’s the big question about Medicare drug price negotiation anyway.
Karlin-Smith: Yeah. Certainly, people have talked about that a little bit. I think the sense that you can raise prices a lot in the private market. People are skeptical of that. There’s also these drugs because they’re actually old enough that they’re getting to the point of Medicare drug price negotiation under the new law. They’re actually more heavily rebated than people realize. The sense is that both private payers and Medicare are actually getting decent rebate levels on them already. Again, they’re still expensive. The rebates are very secretive. They don’t always go to the patients. But there’s some element of these drugs being slightly more affordable than is clearly transparent.
Rovner: There’s a reason that so many people on Ozempic for diabetes can be on Ozempic for diabetes, in other words. Finally, “This Week in Medical Misinformation”: Lauren, you have a wild story about birth control misinformation on TikTok. So we’re going from the Medicare to the younger cohort. Tell us about it.
Weber: Yeah. As everyone on this podcast is aware, we live in a very fractured health care system that does not invest in women’s health care, that is underfunded for years, and a lot of women feel disenfranchised by it. So it’s no surprise that physicians told myself and my reporting [colleague] Sabrina Malhi to some extent that misinformation is festering in that kind of gray area where women feel like they’re sometimes not listened to by their physician or they’re not getting all their information. And instead, they’re turning to their phone, and they’re seeing these videos that loop over and over and over again, which either incorrectly or without context, state misinformation about birth control. And the way that algorithms work on social media is that once you engage with one, you see them repeatedly. And so it’s leaving a lot of younger women in particular, physicians told us, with the impression that hormonal birth control is really terrible for them and looking to get onto natural birth control.
But, what these influencers and conservative commentators often fail to stress, which your physician would stress if you had this conversation with them, is that natural forms of birth control, like timing your sex to menstrual cycles to prevent pregnancy, can be way less effective. They can have an up to 23% failure rate, whereas the pill is 91% effective, the IUD is over 99% effective. And so physicians we talked to said they’re seeing women come in looking for abortions because they believe this misinformation and chose to switch birth controls or do something that impacted how they were monitoring preventing pregnancy. And they’re seeing the end result of this.
Rovner: And obviously there are side effects to various forms of hormonal birth control.
Weber: Yes. Yes.
Rovner: That’s why there are lots of different kinds of them because if you have side effects with one, you might be able to use another. I think the part that stuck out to me was the whole “without context,” because this is a conversation that if you have with a doctor, they’re going to talk about, it’s like, “Well, if you’re having bad side effects with this, you could try this instead. Or you could try that, or this one has a better chance of having these kinds of side effects. And here’s the effectiveness rate of all of these.” Because there actually is scientific evidence about birth control. It’s been used for a very long time.
Ollstein: Oh, yeah. And I think it’s important to remember that this is not just random influencers on TikTok promoting this message. You’re hearing this from pretty high-level folks on the right as well, raising skepticism and even outright opposition to different forms of birth control. The hormonal pills, devices like IUDs that are really effective. They are saying that they are abortifacients in some circumstances when that is not accurate according to medical professionals. And there was just this really interesting backlash recently. I interviewed Kellyanne Conway and she said her polling found that if <a href="https://www.washingtonpost.com/politics/2024/02/22/nikki-haley-wants-consensus-contraception-its-not-that-easy/">Republican politicians came out in favor of access to birth control</a>, that would help them. And then she got this wave of criticism after that, accusing her of promoting promiscuity. And so there’s a big fight over contraception on the right, and it’s, Lauren found in her great story, trickling down to regular folks who are trying to figure out how to use it or not use it.
Rovner: I will link to a story that I wrote a couple of weeks ago about how contraception has always been controversial among Republicans. And it still is. Lauren, you want to say one last thing before we move on?
Weber: No, I think Julie, your point that you mentioned, birth control side effects are real and it is important for patients to speak with their physicians. And what physicians told me is that over the years, their guidance and their training has changed to better involve patients in that decision-making. So women many years ago may not have gotten that same walking-through. And also, birth control is often stigmatized, especially for younger populations. And so all of this feeds into, as Alice has pointed out, and as this piece walks through, how some of these influencers with more holistic paths that they’re possibly selling you, and conservative commentators are getting in these women’s phones and they’re trusting them because they don’t necessarily have a relationship with their physician.
Rovner: They don’t necessarily have a physician to have a relationship with. All right, well, that is the news for this week. Now we will play my Bill of the Month interview with Tony Leys, and then we’ll be back with our extra credits.
I am pleased to welcome to the podcast my colleague Tony Leys, who reported and wrote the latest KFF Health News-NPR Bill of the Month installment. Thank you for joining us, Tony.
Tony Leys: Thanks for having me.
Rovner: So this month’s patient passed away from her ailment, but her daughter is still dealing with the bill. Tell us who this story is about and what kind of medical procedure was involved here.
Leys: Debra Prichard was from rural Tennessee. She was in generally good health until last year when she suffered a stroke and several aneurysms. She twice was rushed to a medical center in Nashville, including once by helicopter ambulance. She later died at age 70 from complications of a brain bleed.
Rovner: Then, as we say, the bill came. I think people by now generally know that air ambulances can be expensive, but how big is this bill?
Leys: It was $81,739 for a 79-mile flight.
Rovner: Wow. A lot of people think that when someone dies, that’s it for their bills. But that’s not necessarily the case here, right?
Leys: No, it’s on the estate then.
Rovner: So they have been pursuing this?
Leys: Right. That would amount to about a third of the estate’s value.
Rovner: Now, Debra Prichard had Medicare, and Medicare caps how much patients can be charged for air ambulance rides. So why didn’t this cap apply to this ride?
Leys: Yeah, if she’d had full Medicare coverage, the air ambulance company would’ve only been able to collect a total of less than $10,000. But unbeknownst to her family, Prichard had only signed up for Medicare Part A, which is free to most seniors and covers inpatient hospital care. She did not sign up for Medicare Part B, which covers many other services including ambulance rides, and it generally costs about $175 a month in premiums.
Rovner: I know. Medicare Part B used to be “de minimis” in premium, so everybody signed up for it, but now, Medicare Part B can be more expensive than an Affordable Care Act plan. So I imagine that there are people who find that $175 a month [is] more than their budget can handle.
Leys: Right. And there is assistance available for people of moderate incomes. It’s not super well publicized, but she may very well have been eligible for that if she’d looked into it.
Rovner: So what eventually happened with this bill?
Leys: Well, her estate faced the full charge. The family’s lawyer is negotiating with the company and they’re making some progress, last we heard.
Rovner: But as of now, the air ambulance company still wants the entire amount from the estate?
Leys: They put in a filing against the estate to that effect, but they apparently are negotiating it.
Rovner: So what’s the takeaway here for people who think they have Medicare or think, no, they don’t have Part B, but think it might cost too much?
Leys: Well, the takeaway is Medicare coverage sure is complicated. There’s free help available for seniors trying to sort it out. Every state has a program called the State Health Insurance Assistance Programs, and they have free expert advice and they can point you to programs that help pay for that premium if you can’t afford it. I don’t know about you, Julie, but I plan to check in with those programs before I sign up for Medicare someday.
Rovner: Even I plan to check in with those programs, and I know a lot about this.
Leys: If Julie Rovner wants assistance, everyone should get it.
Rovner: Everyone should get assistance. Yes, that’s my takeaway, too. Medicare is really complicated. Tony Leys, thank you very much.
Leys: Thanks for having me.
Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the <a href="https://kffhealthnews.org/news/tag/podcast/">podcast page</a> at <a href="https://kffhealthnews.org/">kffhealthnews.org</a> and in our show notes on your phone or other mobile device. Sarah, you were first up this week. Why don’t you go first?
Karlin-Smith: I’ve looked at a Washington Post story, “<a href="https://www.washingtonpost.com/travel/2024/03/21/breast-pump-airlines-carryon-rule-dot/">The Confusing, Stressful Ordeal of Flying With a Breast Pump</a>,” by Hannah Sampson and Ben Broch, and it’s essentially about how there’s no federal rule that protects people flying with a breast pump and being able to bring it on the plane as a carry-on, not a checked bag, and the problems this could cause. If you are pumping breast milk and need to pump it, you often need to pump it as often as every three hours, sometimes even less. And there are medical consequences that can happen if you do not. And the current system in place is just left to each airline to have its own policy. And it seems like flying is the luck of the draw of whether these staff members even understand this policy. And a lot of this seems to date back to basically when the laws that were put in place that protect people with various sorts of medical needs to be able to bring their devices on planes, the kinds of breast pumps people use today really didn’t exist.
But some of this is just an undercurrent of a lack of appreciation for the challenges of being a young parent and trying to feed your kid and what that entails.
Rovner: Maybe we should send it to the Supreme Court. They could have a real discussion about it. People would learn something. Sorry. Alice, why don’t you go next?
Ollstein: Sure. So I have a piece from Stat by Olivia Goldhill called “<a href="https://www.statnews.com/2024/03/20/fetal-tissue-research-scientists-roadblocks/">Fetal Tissue Research Gains in Importance as Roadblocks Multiply</a>.” And it’s about how the people in the U.S. right now doing research that uses fetal tissue — this is tissue that’s donated from people who’ve had abortions, and it’s used in all kinds of things, HIV research, different cancers — it could be really, really important. And the piece is about how that research has not really recovered in the U.S. from the restrictions imposed by the Trump administration.
Not only that, the fear that those restrictions would come back if Trump is reelected is making people hesitant to really invest in this kind of research. And already they’re having to source fetal tissue from other countries at great expense. And so just a fascinating window into what’s going on there.
Rovner: Yeah, it is. People think that these policies that flip and flip back it’s like a switch, and it’s not. It really does affect these policies and what happens. Lauren?
Weber: So I picked a story from Stateline, which by the way, I just want to fan girl about how much I love Stateline all the time. Anyways, the title is “<a href="https://stateline.org/2024/03/27/deadly-fires-from-phone-scooter-batteries-leave-lawmakers-playing-catch-up-on-safety/">Deadly Fires From Phone, Scooter Batteries Leave Lawmakers Playing Catch-Up on Safety</a>,” written by Robbie Sequeira. And I just have anecdotal bias because my sister’s apartment next to her caught on fire due to one of these scooter batteries. But, in general, as the story very clearly lays out, this is a real threat. Lithium batteries, which are proliferating throughout our society, whether they’re scooter batteries or other different types of technology, are harder to fight when they light on fire and they are more likely to light on fire accidentally. And there’s really not a good answer. As lawmakers are trying to get more funding or try to combat this or limit the amount of lithium batteries you can have in a place, people are dying.
There was a 27-year-old journalist, Fazil Khan, who passed away from a fire of this sort. You’re seeing other folks across the country face the consequences. And it’s really quite frightening to see that modern firefighting has made so many strides but this is a different type of blaze, and I think we’ll see this play out for the next couple of years.
Rovner: I think this is a real public health story because this is one of those things where if people knew a lot more about it, there are things you can do, like don’t store your lithium-ion battery in your apartment, or don’t leave it charging overnight. Take it out of the actual object. There are a lot of things that you could do to prevent fires, but the point of this story is that these fires are really dangerous. It’s really scary.
All right, well, my story this week is from my KFF Health News colleague Arthur Allen. It’s called “<a href="https://kffhealthnews.org/news/article/chemotherapy-drug-overdose-fluorouracil-common-gene-test-lifesaving/">Overdosing on Chemo: A Common Gene Test Could Save Hundreds of Lives Each Year</a>,” and it’s about a particular chemotherapy drug that works well for most people, but for a small subset with a certain genetic trait can be deadly. There’s a blood test for it, but in the U.S., it’s not required or even recommended in some cases. It’s a really distressing story about how the FDA, medical specialists, cancer organizations can’t seem to reach an agreement about something that could save some cancer patients from a terrible death.
All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, <a href="https://twitter.com/jrovner">@jrovner</a>, or <a href="https://bsky.app/profile/julierovner.bsky.social">@julierovner</a> at Bluesky or <a href="https://www.threads.net/@julie.rovner">@julie.rovner</a> at Threads. Lauren, where are you these days?
Weber: Just on X, <a href="https://twitter.com/laurenweberhp">@LaurenWeberHP</a>
Rovner: Sarah?
Karlin-Smith: <a href="https://twitter.com/sarahkarlin">@SarahKarlin</a> or <a href="https://bsky.app/profile/sarahkarlin-smith.bsky.social">@sarahkarlin-smith</a>, depending on the various social media platform.
Rovner: Alice?
Ollstein: <a href="https://twitter.com/AliceOllstein">@AliceOllstein</a> on X, and <a href="https://bsky.app/profile/alicemiranda.bsky.social">@alicemiranda</a> on Bluesky
Rovner: We will be back in your feed next week. Until then, be healthy.
<h3>
Credits </h3>
Francis Ying
Audio producer
Emmarie Huetteman
Editor
To hear all our podcasts, <a href="https://kffhealthnews.org/news/tag/podcast/">click here</a>.
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<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/article/cyberattack-fallout-unitedhealth-change-healthcare-medical-providers-financial-instability/view/republish/">details</a>).]]></content:encoded>
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<title>KFF Health News' 'What the Health?': Health Enters the Presidential Race</title>
<link>https://kffhealthnews.org/news/podcast/what-the-health-331-health-presidential-race-january-25-2024/</link>
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<pubDate>Thu, 25 Jan 2024 19:30:00 +0000</pubDate>
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<description><![CDATA[New Hampshire voters have spoken, and it seems increasingly clear that this November’s election will pit President Joe Biden against former President Donald Trump. Both appear to be making health a key part of their campaigns, with Trump vowing (again) to repeal the Affordable Care Act, and Biden stressing his support for contraception and abortion rights. Meanwhile, both candidates will try to highlight efforts to rein in prescription drug prices. Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News, and Jessie Hellmann of CQ Roll Call join KFF Health News chief Washington correspondent Julie Rovner to discuss these issues and more. Also this week, Rovner interviews Sarah Somers of the National Health Law Program about the potential consequences for the health care system if the Supreme Court overturns a key precedent attempting to balance executive vs. judicial power. ]]></description>
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<h3>
The Host </h3>
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Julie Rovner
KFF Health News
<a href="https://twitter.com/jrovner">
@jrovner </a>
<a href="https://kffhealthnews.org/news/author/julie-rovner/">
Read Julie's stories. </a>
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Based on the results of the first-in-the-nation primary in New Hampshire, it appears more likely than ever before that the 2024 presidential election will be a rerun of 2020: Joe Biden versus Donald Trump. And health is shaping up to be a key issue.
Trump is vowing — again — to repeal the Affordable Care Act, which is even more popular than it was when Republicans failed to muster the congressional votes to kill it in 2017. Biden is doubling down on support for contraception and abortion rights.
And both are expected to highlight efforts to rein in the cost of prescription drugs.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News, and Jessie Hellmann of CQ Roll Call.
<h3>
Panelists </h3>
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Alice Miranda Ollstein
Politico
<a href="https://twitter.com/AliceOllstein">
@AliceOllstein </a>
<a href="https://www.politico.com/staff/alice-miranda-ollstein">
Read Alice's stories. </a>
<img />
Anna Edney
Bloomberg
<a href="https://twitter.com/annaedney">
@annaedney </a>
<a href="https://www.bloomberg.com/authors/AP519FMOg7w/anna-edney">
Read Anna's stories. </a>
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Jessie Hellmann
CQ Roll Call
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Among the takeaways from this week’s episode:
<ul>
<li>Trump had a strong showing in the New Hampshire GOP primary. But Biden may be gathering momentum himself from an unexpected source: Drug industry lawsuits challenging his administration’s Medicare price negotiation plan could draw attention to Biden’s efforts to combat rising prescription drug prices, a major pocketbook issue for many voters.</li>
<li>Biden’s drug pricing efforts also include using the government’s so-called march-in rights on pharmaceuticals, which could allow the government to lower prices on certain drugs — it’s unclear which ones. Meanwhile, Sen. Bernie Sanders of Vermont is calling on his committee to subpoena the CEOS of two drugmakers in the latest example of lawmakers summoning Big Pharma executives to the Hill to answer for high prices.</li>
<li>More than a year after the Supreme Court overturned the constitutional right to an abortion, abortion opponents gathered in Washington, D.C., for the March for Life rally, looking now to continue to advance their priorities under a future conservative presidency.</li>
<li>One avenue that abortion opponents are eying is the 19th-century Comstock Act, which could not only prohibit the mailing of abortion pills to patients, but also prevent them from being mailed to clinics and medical facilities. Considering the abortion pill is now used in more than half of abortions nationwide, it would amount to a fairly sweeping ban.</li>
<li>And state legislators continue to push more restrictive abortion laws, targeting care for minors and rape exceptions in particular. The ongoing quest to winnow access to the procedure amid public reservations reflected in polling and ballot initiatives highlights that, for at least some abortion opponents, fetuses are framed as an oppressed minority whose rights should not be subject to a majority vote.</li>
</ul>
Also this week, Rovner interviews Sarah Somers, legal director of the National Health Law Program, about the potential effects on federal health programs if the Supreme Court overturns a 40-year-old precedent established in the case Chevron USA v. Natural Resources Defense Council.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Health Affairs’ “<a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.01041">‘Housing First’ Increased Psychiatric Care Office Visits and Prescriptions While Reducing Emergency Visits</a>,” by Devlin Hanson and Sarah Gillespie.
Alice Miranda Ollstein: Stat’s “<a href="https://www.statnews.com/2024/01/23/white-house-pharmacy/">The White House Has a Pharmacy — And It Was a Mess, a New Investigation Found</a>,” by Brittany Trang.
Anna Edney: The New Yorker’s “<a href="https://www.newyorker.com/news/annals-of-inquiry/what-would-it-mean-for-scientists-to-listen-to-patients">What Would It Mean for Scientists to Listen to Patients?</a>” by Rachael Bedard.
Jessie Hellmann: North Carolina Health News’ “<a href="https://www.northcarolinahealthnews.org/2024/01/24/congenital-syphilis-nc-baby-deaths/">Congenital Syphilis — An Ancient Scourge — Claimed the Lives of Eight NC Babies Last Year</a>,” by Jennifer Fernandez.
Also mentioned on this week’s podcast:
Stat’s “<a href="https://www.statnews.com/2024/01/23/medicare-price-negotiation-lawsuits-may-lift-biden-2024-election/">Pharma’s Attack on Medicare Drug Price Negotiation Might Benefit Biden</a>,” by John Wilkerson.
click to open the transcript
Transcript: Health Enters the Presidential Race
KFF Health News’ ‘What the Health?’Episode Title: Health Enters the Presidential RaceEpisode Number: 331Published: Jan. 25, 2024
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 25, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Good morning.
Rovner: Jessie Hellmann of CQ Roll Call.
Jessie Hellmann: Hi there.
Rovner: And Anna Edney of Bloomberg News.
Anna Edney: Hello.
Rovner: Later in this episode we’ll have my interview with Sarah Somers of the National Health Law Program. She’s going to explain what’s at risk for health care if the Supreme Court overturns the Chevron doctrine, and if you don’t know what that is, you will. But first, this week’s news. We’re going to start this week with politics. To absolutely no one’s surprise, Donald Trump won the first-in-the-nation New Hampshire primary, and even though he wasn’t even on the ballot, because Democrats no longer count New Hampshire as first, President [Joe] Biden handily won a write-in campaign.
Since it seems very likely at this point that the November ballot will pit Trump versus Biden once again, I thought we’d look, briefly at least, at both of their health agendas for now. Trump has once again vowed to try and repeal the Affordable Care Act, which not only didn’t go well in 2017, we learned this week that the federal marketplace enrolled a record 21.3 million people for this year. In 2017, that number was 12.2 million. Not to mention there are now a half a dozen more states that have expanded Medicaid to low-income childless adults.
So with so many more millions of Americans getting coverage via Obamacare, even if Trump wants to repeal and replace it, is there any chance Republicans would go along, even if he wins back majorities in the House and the Senate? They have seemed rather unwilling to reopen this box of worms.
Edney: I mean, certainly, I think that currently they’re unwilling. I don’t want to pretend that I know what the next several months will hold until November, but even before they’re willing or not, what would the plan be? We never saw one, and I don’t anticipate there would be any sort of real plan, particularly if it’s the Trump White House itself having to put the plan together to repeal Obamacare.
Rovner: Yes. How many times did he promise that “we’ll have a plan in two weeks” throughout most of his administration? Alice, you were saying?
Ollstein: Yes. I think what we should be thinking about, too, is this can happen not through Congress. There’s a lot of President Trump could do theoretically through the executive branch, not to repeal Obamacare, but to undermine it and make it work worse. They could slash outreach funding, they could let the enhanced tax credit subsidies expire — they’re set to expire next year. That would also be on Congress. But a president who is opposed to it could have a role in that; they could slash call center assistance. They could do a lot. So I think we should be thinking not only about could a bill get through Congress, but also what could happen at all of the federal agencies.
Rovner: And we should point out that we know that he could do some of these things because he did them in his first term.
Ollstein: He did them the first time, and they had an impact. The uninsured rate went up for the first time under Trump’s first term, for the first time since Obamacare went into effect. So it can really make a difference.
Rovner: And then it obviously went down again. But that was partly because Congress added these extra subsidies and even the Republican Congress required people to stay on Medicaid during the pandemic. Well, I know elsewhere, like on abortion, Trump has been all over the place, both since he was in office and then since he left office. And then now, Alice, do we have any idea where he is on this whole very sensitive abortion issue?
Ollstein: He has been doing something very interesting recently, which is he’s sort of running the primary message and the general message at the same time. So we’re used to politicians saying one thing to a primary audience. These are the hard-core conservatives who turn out in primaries and they want to hear abortion is going to be restricted. And then the general audience — look at how all of these states have been voting — they don’t want to hear that. They want to hear a more moderate message and so Trump has been sort of giving both at once. He’s both taking credit for appointing the Supreme Court justices, who overturned Roe v. Wade. He has said that he is pro-life, blah, blah, blah. But he has also criticized the anti-abortion movement for going too far in his view. He criticized Ron DeSantis’ six-week ban for going too far. He has said that any restrictions need to have exemptions for rape and incest, which not everyone in the movement agrees with. A lot of people disagree with that in the anti-abortion movement. And so it has been all over the place.
But his campaign is in close contact with a lot of these groups and the groups are confident that he would do what they want. So I think that you have this interesting tension right now where he is saying multiple mixed messages.
Rovner: Which he always does, and which he seems to somehow get away with. And again, just like with the ACA, we know that all of these things that he could do just from the executive branch about reproductive health, because he did them when he was president the first time. Meanwhile, President Biden, in addition to taking a victory lap on the Affordable Care Act enrollment, is doubling down on abortion and contraception, which is pretty hard because, first, as executive, he doesn’t have a ton of power to expand abortion rights the way Trump would actually have a lot of power to contract them.
And, also, because as we know, Biden is personally uncomfortable with this issue. So Alice, how well is this going to work for the Biden administration?
Ollstein: So what was announced is mostly sort of reiterating what is already the law, saying we’re going to do more to educate people about it and crack down on people who are not following it. So this falls into a few different buckets. Part of it is Obamacare’s contraception mandate. There have been lots of investigations showing that a lot of insurers are denying coverage for contraceptives they should be covering or making patients jump through hoops. And so it’s not reaching the people it should be reaching. And so they’re trying to do more on that front.
And then, on the abortion front, this is mostly in this realm of abortions in medical emergencies. They’re trying to educate patients on “you can file this complaint if you are turned away.” Of course, I’m thinking of somebody experiencing a medical emergency and needing abortion and being turned away, and I don’t think “I’m going to file an EMTALA [Emergency Medical Treatment and Active Labor Act] complaint with the federal government and hope that they do something” is maybe the first thing on their mind. But the new executive order also includes education for providers and hospitals on their obligations.
This is also something a Trump administration could completely change. They could come in and say, “Forget that guidance. Here’s our guidance, which is no abortions in these circumstances.” So this is a really sensitive issue, but I think that the Biden campaign has seen how people have been voting over the last two years and feels that this is a really good message for them to do something on.
Rovner: Meanwhile, one issue both Republicans and Democrats are trying to campaign on is bringing down the cost of prescription drugs. Stat News has a story this week suggesting that all the lawsuits against the Medicare drug negotiation program could actually help Biden with voters because it shows he’s going after Big Pharma. Frankly, it could also tell voters that the Biden administration actually did something to challenge Big Pharma. Polls show most people have no idea, but Trump can point to lots of lawsuits over things he tried to do to Big Pharma.
Does one or the other of them have an advantage here, Anna? I mean, I know they’re going in different directions, but when you sort of boil it into campaign-speak, it’s going to sound pretty similar, right?
Edney: I think that that’s true, but one of the differences is, at least currently, what Biden’s done and doing some price negotiation through Medicare so far for 10 drugs under his administration is going forward. And you can name the drugs, name the prices, talk about it a little bit more specifically. What Trump ran up against was the lawsuits not falling in his favor. So he wanted more transparency as far as the drug companies having to say the price of their drugs in TV ads, and that wasn’t able to happen. And also reference pricing, so that the prices would be benchmarked to other countries. And certainly that never went forward either. And Trump really used the going after pharma hard in the last campaign, I would say, in 2016. And it worked in the beginning, and you would see the stock of these companies start going down the second he said pharmaceutical companies are getting away with murder or whatever big comment he was making. But it eventually lost any real effect because there didn’t seem to be plans to do anything drastic.
He talked about potentially doing negotiation, like is happening currently, but then that never came to fruition once he was in office. So I don’t know if that will come across to voters, but certainly the pharma industry doesn’t seem to be as afraid of Trump as what Biden’s doing right now.
Rovner: Jessie, I know Congress is still working on this PBM [pharmacy benefit managers] transparency, big bill. Are we getting any closer to anything? I think members of Congress would also like to run on being able to say they’ve done something about prescription drug prices.
Hellmann: I was just talking to [Sen.] Chuck Grassley [R-Iowa] about this because he is the “OG PBM hater.” And he was like, “Why is nothing happening?” He was just very frustrated. There are several bills that have passed House and Senate committees, and so I think, at this point, it’s just a matter of cobbling them all together, finding ways to pay for things. And since there’s also so many other health care things that people want to get done, it’s a matter of “Do we have enough money to pay for everything? What’s going to save money? What’s going to cost money?”
There’s also these health care transparency measures that Congress is looking at. There’s this site-neutral hospital payments thing that could be a money saver. So I think there’s just a lot going on in trying to figure out how it all fits together. But PBMs, I could definitely see them doing something this year.
Rovner: Sometimes, I mean, often it’s like you can’t get things onto the agenda. In this case, it sounds like there’s lots of things on the agenda, but they’re going to need to pay for all of them and they’re going to fight over the few places where they could presumably get some savings.
Edney: I was going to say, I saw that Grassley and some other senators wrote the Federal Trade Commission because they are due for a report on PBMs they’ve been working on for about a year and a half. And I think that the senators who want to go after PBMs are kind of looking for that sort of backup and that deep dive into the industry to make those statements about cost savings and what this would do for pharmaceutical prices.
Rovner: Well, to ratchet this up one more step, the Biden administration has proposed a framework for when march-in rights might be used. Is this the real deal or a threat to get pharma to back down on complaints about the Medicare price negotiations? Anna, why don’t you explain what march-in rights are?
Edney: March-in rights, which have never been used on a pharmaceutical company, were something that were put into law — I think it was around 1980 with the Bayh-Dole Act — and what it allows the government to do is say we invested a ton of money, either through giving money to university research or in the company itself, to do the very basic science that got us to this breakthrough that then the company took across the finish line to get a drug on the market. But usually, I think the main reason you might use it is because then the company does nothing with it.
Say they bought it up and it could be a competitor to one of their drugs, so they don’t use it. But it seems like it could also be used if the price is prohibitive, that it’s something that’s really needed, but Americans aren’t getting access to it. And so the government would be able to take that patent back and lower the price on the drug. But I haven’t heard a specific drug that they want to use this on. So I don’t know if they’re serious about using the march-in rights.
There is a request for information to find out how people feel about this, how it might affect the industry. The argument being that it could hamper the innovation, but we hear that a lot from the pharmaceutical industry as well. So unclear if that’s a true defense to not using march-in rights.
Rovner: Although march-in rights are a pretty big gun. There’s a reason they’ve never been used. I’ve seen them … lawmakers sometimes trot it out kind of as a cudgel, but I’ve never … the only time I think I saw them come close was after the anthrax scare, right after 9/11, when there was potentially a shortage of the important antibiotic needed for that. There was muttering about this, but then I think the drug company decided on its own to lower the price, which got us over that.
Well, yet another tack is being pursued by Sen. Bernie Sanders, chairman of the Senate Health Committee. He’s going to make the committee vote next week on whether to subpoena the CEOs of Johnson & Johnson and Merck to require them to “provide testimony about why their companies charge substantially higher prices for medicine in the U.S. compared to other countries.” Well, we all know the answer to that. Other countries have price controls and the U.S. does not. So is this a stunt or not? And is he even going to get the rest of the committee to go along with the subpoena?
Edney: This wouldn’t be the first hearing on high drug prices pulling in CEOs. And it’s so opaque that you never get an answer. You never get something … I mean, certainly, they’ll blame PBMs and talk about that, and the finger-pointing will go somewhere else, but you never have some aha insight moment. So when the CEOs are coming in, it does feel a bit more like a show. And Bernie Sanders, the ones he wants to subpoena are from companies that are suing the Biden administration.
So there’s talk about whether that’s sort of a bit of a revenge him for that as well. I don’t know what exactly he would expect to hear from them that would change policy or what legislation they’re trying to work out by having this hearing.
Rovner: For an issue that everybody cares about, high drug prices. It sure has been hard to figure out a way into it for politicians.
Ollstein: We have seen public shaming, even without legislation behind it, can have a difference. I think we’ve seen that on the insulin front. And so I think it’s not completely a fool’s errand here, what Bernie’s trying to do. It will be interesting to see if the rest of the committee goes along with it. There’s been some tensions on the committee. There’s been bipartisan support for some of his efforts, and then others — less on the health front, I think more on the labor front — you’ve had a lot of pushback from the Republican members, and so it’ll be very telling.
Rovner: I was actually in the room when the tobacco industry CEOs came to testify at the House Energy and Commerce Committee, and that was pretty dramatic, but I feel like that was a very different kind of atmosphere than this is. I know everybody’s been trying to repeat that moment for — what is it? — 25, 30 years now. It was in the early 1990s, and I don’t think anybody really successfully has, but they’re going to keep at it.
All right, well, let us turn to abortion. Last Saturday would have been the 51st anniversary of Roe v. Wade, and the day before was the annual March for Life, the giant annual anti-abortion demonstration that used to be a march to the Supreme Court to urge the justices to overrule Roe. Well, that mission has been accomplished. So now what are their priorities, Alice?
Ollstein: Lots of things. And a lot of the effort right now is going towards laying the groundwork, making plans for a potential second Trump administration or a future conservative president. They see not that much hope on the federal level for their efforts currently, with the current president and Congress, but they are trying to do the prep work for the future. They want a future president to roll back everything Biden has done to expand abortion access. That includes the policies for veterans and military service members. That includes wider access to abortion pills through the mail and dispensing at retail pharmacies, all of that.
So they want to scrap all of that, but they also want to go a lot further and are exploring ways to use a lot of different agencies and rules and bureaucratic methods and funding mechanisms to do this, because they’re not confident in passing a bill through Congress. We’ve seen Congress not able to do that even under one-party rule in either direction. And so they’re really looking at the courts, which are a lot more conservative than they were several years ago.
Rovner: Largely thanks to Trump.
Ollstein: Exactly, exactly. So the courts, the executive branch, and then, of course, more efforts at the state level, which I know we’re going to get into.
Rovner: We are. Before that, though, one of the things that keeps coming up in discussions about the anti-abortion agenda is something called the Comstock Act. We have talked about this before, although it’s been a while, but this is an 1873 law, which is still on the books, although largely unenforced, that banned the mailing of anything that could be used to aid in an abortion, among other things. Could an anti-abortion administration really use Comstock to basically outlaw abortion nationwide?
I mean, even things that are used for surgical abortion tend to come through … it’s not just the mail, it’s the mail or FedEx or UPS, common carrier.
Ollstein: Yes. So this is getting a lot more attention now and it is something anti-abortion groups are absolutely calling for, and people should know that this wouldn’t only prohibit the mailing of abortion pills to individual patients’ homes, which is increasingly happening now. This would prevent it from being mailed to clinics and medical facilities. The mail is the mail. And so because abortion medication is used in more than half of all abortions nationwide, it could be a fairly sweeping ban.
And so the Biden administration put out a memo from the Justice Department saying, “Our interpretation of the Comstock Act is that it does not prohibit the mailing of abortion pills.” The Trump administration or whoever could come in and say, “We disagree. Our interpretation is that it does.” Now, how they would actually enforce it is a big question. Are you going to search everyone’s mail in the country? Are you going to choose a couple of people and make an example out of them?
That’s what happened under the original Comstock Act. Back in the day, they went after a few high-profile abortion rights activists and made an example out of them. I think nailing them down on how it would be enforced is key here. And of course there would be tons of legal challenges and battles no matter what.
Rovner: Absolutely. Well, let us turn to the states. It’s January, which is kind of “unveil your bills” time in state legislatures, and they are piling up. In Tennessee, there’s a bill that would create a Class C felony, calling for up to 15 years in prison, for an adult who “recruits, harbors or transports a pregnant minor out of state for an abortion.” There’s a similar bill in Oklahoma, although violators there would only be subject to five years in prison.
Meanwhile, in Iowa, Republican lawmakers who are writing guidelines for how to implement that state’s six-week ban, which is not currently in effect, pending a court ruling, said that the rape exception could only be used if the rape is “prosecutable,” without defining that word. Are these state lawmakers just failing to read the room or do they think they are representing what their voters want?
Edney: I don’t really know. I think clearly there are a lot of right-wing Republicans who are elected to office and feel that they have a higher calling that doesn’t necessarily reflect what their constituents may or may not want, but more is that they know better. And I think that that could be some of this, because certainly the anti-abortion bills or movements have been rejected by voters in places you might not exactly expect it.
Rovner: It feels like we’re getting more and more really “out there” ideas on the anti-abortion side at the same time that we’re getting more and more ballot measures of voters in both parties wanting to protect abortion rights, at least to some extent.
Ollstein: And I think going off what Anna said, I think that anti-abortion leaders, including lawmakers, are being more upfront now, saying that they don’t believe that this should be something that the democratic process has a voice in. The framing they use is that fetuses are an oppressed minority and their rights should not be subject to a majority vote. That’s their framing, and they’re being very upfront saying that these kinds of ballot referendums shouldn’t be allowed, and that states that do allow them should get rid of that. We’ll see if that happens. There are obviously lots of attempts to thwart specific state efforts to put abortion on the ballot. There are lawsuits pending in Nevada and Florida. There are attempts to raise the signature threshold, raise the vote threshold, just make it harder to do overall. But I found it very interesting and a pretty recent development that folks are coming out and saying the quiet part out loud. Saying, “We don’t believe The People should be able to decide this.”
Rovner: Well, obviously not an issue that is going away anytime soon. All right, well that is this week’s news. Now we will play my interview with Sarah Somers, and then we will come back and do our extra credits.
I am pleased to welcome to the podcast Sarah Somers, legal director of the National Health Law Program. She’s going to explain, in English hopefully, what’s at stake in the big case the Supreme Court heard earlier this month about herring fishing. Sarah, welcome to “What the Health?”
Sarah Somers: Thank you for having me, Julie. I’m glad to be here.
Rovner: So this case, and I know it’s actually two cases together, is really about much more than herring fishing, right? It seems to be about government regulation writ large.
Somers: That’s right. The particular issue in the case is about a national marine fisheries regulation that requires herring fishing companies to pay for observers who are on board — not exactly an issue that’s keeping everyone but herring fishermen up at night. And the fishing company challenged the rule, saying that it wasn’t a reasonable interpretation of the statute. But what they also asked the court to do was to overrule a Supreme Court case that requires courts to defer to reasonable agency interpretations of federal statutes. That’s what’s known as “Chevron deference.”
Rovner: And what is Chevron deference and why is it named after an oil company?
Somers: Why aren’t we talking about oil now? Yes, Chevron deference is the rule that says that courts have to defer to a reasonable agency interpretation of a federal statute. So, under Chevron, there’s supposed to be a two-step process when considering whether, say, a regulation is a reasonable interpretation. They say, “Does the statute speak directly to it?” So in this case, did the statute talk about whether you have to pay for observers on herring boats? It didn’t.
So the next question was, if it doesn’t speak directly to it or if it’s ambiguous or unclear, then the court should defer to a reasonable interpretation of that statute. And what’s reasonable depends on what the court determines are sort of the bounds of the statute, whether the agency had evidence before it that supported it, whether it showed the proper deliberation and expertise.
Rovner: One of the reasons that regulations are sometimes 200 pages long, right?
Somers: Exactly. And sometimes courts do say, “You know what? The statute spoke right to this. We don’t have to go any further. We know what Congress wanted.” Other times they take a step further. And the reason it’s called Chevron is it’s named after a case that was decided 40 years ago in 1984 during the Reagan administration, and it was Chevron Inc. USA v. the Natural Resources Defense Council. That case was about a regulation interpreting the Clean Air Act and about regulating air pollution.
Rovner: So, as you point out, you helped write one of the amicus briefs in the case about what overturning Chevron would mean for health care. It’s not just about herring fishing and Clean Air Act. Can you give us the CliffsNotes version of what it would mean for health care?
Somers: One of the purposes of our amicus brief was just to give another angle on this, because we were talking a lot about regulations in the context of air pollution, clean water, and the environment, but it touches so many other things, and this is just one aspect of it. So this brief, which we authored along with the American Cancer Society Action Network, and a Boston law firm called Anderson Kreiger, was signed by other health-oriented groups: the American Lung Association, American Heart Association, Campaign for Tobacco-Free [Kids], and then the American Academy of Pediatrics, American Academy of Public Health.
You get the picture. These are all groups that have a vested interest in programs of the Department and Health and Human Services. The brief talks about regulations promulgated by the Centers for Medicare & Medicaid Services. I’m going to call them CMS for short when we’re talking. And CMS is responsible for regulating the vast and complex Medicare and Medicaid programs. And, as you know, Medicare and Medicaid cover more than half of the population and touch the lives of almost everyone, regulating hospitals, some aspects of insurance, some aspects of practice of medicine.
You can’t escape the consequences of problems with these programs. And so that’s why the agency … Congress specifically gave HHS and CMS the power to regulate all of the issues in its purview. So that already have the power, and so the question is whether they use it wisely. We are arguing in this brief that for 40 years it’s worked just fine. That Congress has set the outer limits and been content to let the agency determine the specifics of these programs to fill in the gaps, as one Supreme Court case said. And this has implications for how hospitals operate, how insurance programs operate, and whether they operate smoothly.
And in our brief, we’re not really arguing for or against a particular interpretation or either for or against what the agency says. It’s just a matter of stability and certainty. The agency has the expertise, has the time, has the resources, and has the duty to figure out what these particular terms and statutes mean and how the programs should work. Just two examples we gave in the brief of the kind of issues that the agency should be determining are: What’s the definition of geographic area in the Medicaid Act for the purpose of setting hospital wages?
If your listeners are still listening, I hope, because that is boring, arcane, hyper-technical, and courts don’t have the expertise, much less the time, to do that. And CMS does. Or another question in a different area, whether feeding activities in a nursing home regulated by Medicaid: Are those nursing or nursing related services? The court’s not going to know. The courts doesn’t have expertise or time. And again, that’s what CMS is for.
So not only is this something that you need these interpretations in these rules to have the programs operate smoothly and consistently, and that’s the first part that’s important. But the second part is that you need consistency across the country. As you know well, there are hospital systems that operate across multi-states. There are Medicaid managed-care plans operating across multi-states. All aspects of health care is nationalized. If you have hundreds of district courts and courts of appeals coming up with different interpretations of these terms, you’re going to have a lot of problems. It’s not going to operate smoothly. So I heard some of the justices arguing, “Well, Congress just needs to do its job.”
Congress has obstacles to doing even the big, mega issues that are before them, these kinds of arcane specific issues. They don’t have the time or again, the expertise. That’s why they said, “CMS, you go do this.”
Rovner: When they were writing the Affordable Care Act, there were so many times in that legislation where it says, “The secretary shall” or “The secretary may.” It’s like, we’re going to punt all this technical stuff to HHS and let them do what they will.
Somers: Exactly. You figure out what the definition of a preventive service is, that’s not something that we are going to do. And there are also questions raised about is this … these unelected agency personnel, well, agencies — they are political appointees, and they also serve at the pleasure of the head of the agency. So they’re accountable to the executive branch and indirectly to the voters. The courts, at this point, once they’re on the court and the federal courts, they’re not accountable to the voters anymore. And so this would be a big shift of power towards the courts, and that is what we argued would be antithetical to the system working well.
Rovner: What would be an example of something that could get hung up in the absence of Chevron?
Somers: I thought that Justice [Ketanji Brown] Jackson, during the argument, gave a really good example. Under the Food and Drug Administration’s power to regulate new drugs and determining what is an adequate and well-controlled investigation. The idea of courts, every single drug that’s challenged in every single forum, having to delve into what that means without deference to the agency would be just a recipe for chaos, really.
Rovner: So some people have argued that Chevron is already basically gone, as far as the Supreme Court is concerned, that it’s been replaced by the major questions doctrine, which is kind of what it sounds like. If a judge thinks a question is major, and they will assume that the Congress has not delegated it to the agency to interpret. So what difference would it make if the court formally overturned Chevron or not here? I guess what you’re getting at is that we’re more worried about the lower courts at this point than the Supreme Court, right?
Somers: That’s right. The Supreme Court has not cited Chevron in something like 15 years. And they talked about that in the argument, but it’s for the lower courts. The lower courts still follow it. It is still very commonly cited and gives them a lot of guidance not to have to decide these issues in the first instance. It’s true that the major questions doctrine — and there are other threats to the power of the administrative agencies, and we should all be concerned about them. But this one is really the grease that keeps the machine going and keeps these systems going. And throwing all that up in the air would make a big difference. If only because the question in all of these Chevron cases, and so many of them was not the ultimate issue — about whether the regulation was a good policy — but the question was, was the statute ambiguous or not? And so that’s the part that would be up in the air and everyone can go back and re-litigate these, including the big interests that have a lot of time and resources to devote to litigation. And that would cause a great deal of uncertainty, a lot of disruption, and a lot of problem for the courts and for all the entities that function under these systems.
Rovner: And that’s a really important point. It’s not just going forward. People who are unhappy with what a regulation said could go back, right?
Somers: Oh yeah. They could go back. They could go to different courts. We’ve seen how litigants can forum-shop. They can find a judge that they think is going to be sympathetic to their argument and make a determination that affects the whole country.
Rovner: Well, we will be watching. Sarah Somers, thanks so much for joining us.
Somers: My pleasure. Thank you for having me.
Rovner: We are back, and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the <a href="https://kffhealthnews.org/news/tag/podcast/">podcast page</a> at <a href="https://kffhealthnews.org/">kffhealthnews.org</a> and in our show notes on your phone or other mobile device. Jessie, you were the first to join in this week. Why don’t you tell us about your extra credit?
Hellmann: Yeah. Mine is from North Carolina Health News. They <a href="https://www.northcarolinahealthnews.org/2024/01/24/congenital-syphilis-nc-baby-deaths/">wrote about how congenital syphilis is killing babies</a> in the state. They had eight cases of deaths last year — compared to a decade ago, they had one. So it’s something that’s been on the rise in North Carolina, but also nationwide, and it’s caused a lot of alarm among public health officials because it’s pretty preventable. It’s something that doesn’t need to happen, but the story is about what the state is doing to improve their outreach to pregnant people. They’re doing media campaigns, they’re trying to make sure that people are doing their prenatal care and just trying to stop this from happening. So I thought that was a good story. It’s definitely kind of an under-reported issue. It’s something that public health officials have been raising an alarm about for a while now, but there’s just not enough funding or attention on the issue.
Rovner: For all the arguing about abortion, there’s not been a lot of discussion about maternal and child health, which obviously appears to be the one place that both sides agree on. Anna.
Edney: Mine’s in The New Yorker by Rachael Bedard. It’s “<a href="https://www.newyorker.com/news/annals-of-inquiry/what-would-it-mean-for-scientists-to-listen-to-patients">What Would It Mean for Scientists to Listen to Patients?</a>” And it’s interesting, it’s about two Yale researchers who are doing a long-covid study, but it’s unique in the sense that when the CDC or anyone else does a long-covid study, they typically are trying to say, “Here are the exact symptoms. We’re going to work with 12 of them.” Whereas we know long covid, it’s seemingly a much more expansive symptom list than that, but researchers really like to have kind of metrics to go by.
But what these Yale researchers are doing is letting all of that go and just letting anybody in this and talking to them. They’re holding monthly town halls with people who are in this, whoever wants to show up and come and just talk to them about what’s going on with them and trying to find out, obviously, what could help them. But they’re not giving medical advice during these, but just listening. And it just was so novel, and maybe it shouldn’t be, but I found it fascinating to read about and to get their reactions. And it’s not always easy for them. I mean, the patients get upset and want something to happen faster, but just that somebody is out there doing this research and including anybody who feels like they have long covid. It was really well-written too.
Rovner: It’s a really good story. Alice.
Ollstein: So I’m breaking my streak of extremely depressing, grim stories and sharing kind of a funny one, although it could have some serious implications. <a href="https://www.statnews.com/2024/01/23/white-house-pharmacy/">This is from Stat</a>, and it’s from an inspector general report about how the White House pharmacy, which is run by basically the military, functioned under President Trump. And it functioned like sort of a frat house. There was no official medical personnel in charge of handing out the medications, and they were sort of handed out to whoever wanted them, including people who shouldn’t have been getting them. People were just rifling through bins of medications and taking what they wanted. These included pills like Ambien and Provigil, sort of uppers and downers in the common parlance. And so I think this kind of scrutiny on something that I didn’t even know existed. The White House pharmacy is pretty fascinating.
Rovner: It was a really, really interesting story. Well, I also have something relatively hopeful. My extra credit this week is a journal article from Health Affairs with the not-so-catchy headline “<a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.01041">‘Housing First’ Increased Psychiatric Care Office Visits and Prescriptions While Reducing Emergency Visits</a>,” by Devlin Hanson and Sarah Gillespie. And if they will forgive me, I would rename it, calling it maybe “Prioritizing Permanent Housing for Homeless People Provides Them a Better Quality of Life at Potentially Less Cost to the Public.”
It’s about a “Housing First” experiment in Denver, which found that the group that was given supportive housing was more likely to receive outpatient care and medications and less likely to end up in the emergency room. The results weren’t perfect. There was no difference in mortality between the groups that got supportive housing and the groups that didn’t. But it does add to the body of evidence about the use of so-called social determinants of health, and how medicine alone isn’t the answer to a lot of our social and public health ills.
OK. That is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, <a href="https://twitter.com/jrovner">@jrovner</a>, or <a href="https://bsky.app/profile/julierovner.bsky.social">@julierovner</a> at Bluesky or <a href="https://www.threads.net/@julie.rovner">@julie.rovner</a> at Threads. Anna, where are you these days?
Edney: Mostly just on Threads, so <a href="https://www.threads.net/@anna_edneyreports?igshid=MzRlODBiNWFlZA==">@anna_edneyreports</a>.
Rovner: Alice?
Ollstein: <a href="https://twitter.com/AliceOllstein">@AliceOllstein</a>.
Rovner: Jessie.
Hellmann: <a href="https://twitter.com/jessiehellmann">@jessiehellmann</a> on Twitter.
Rovner: We will be back in your feed next week. Until then, be healthy.
<h3>
Credits </h3>
Francis Ying
Audio producer
Emmarie Huetteman
Editor
To hear all our podcasts, <a href="https://kffhealthnews.org/news/tag/podcast/">click here</a>.
And subscribe to KFF Health News’ “What the Health?” on <a href="https://open.spotify.com/show/32EdsB662C3oyIrqLMmBXI?si=TQhRjzzLTgWtK3crfbOFtA">Spotify</a>, <a href="https://podcasts.apple.com/us/podcast/what-the-health/id1253607372?mt=2">Apple Podcasts</a>, <a href="https://play.pocketcasts.com/web/podcasts/a379e280-3f57-0135-9028-63f4b61a9224">Pocket Casts</a>, or wherever you listen to podcasts.
<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/podcast/what-the-health-340-supreme-court-mifepristone-march-28-2024/view/republish/">details</a>).]]></content:encoded>
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<title>The Colonoscopies Were Free. But the ‘Surgical Trays’ Came With $600 Price Tags.</title>
<link>https://kffhealthnews.org/news/article/bill-of-the-month-free-colonoscopies-random-supplies-charge/</link>
<dc:creator><![CDATA[Samantha Liss]]></dc:creator>
<pubDate>Thu, 25 Jan 2024 10:00:00 +0000</pubDate>
<category><![CDATA[Cost and Quality]]></category>
<category><![CDATA[Health Care Costs]]></category>
<category><![CDATA[Health Industry]]></category>
<category><![CDATA[Multimedia]]></category>
<category><![CDATA[The Health Law]]></category>
<category><![CDATA[Bill Of The Month]]></category>
<category><![CDATA[Illinois]]></category>
<category><![CDATA[Insurers]]></category>
<guid isPermaLink="false">https://kffhealthnews.org/?post_type=article&p=1804314</guid>
<description><![CDATA[Health providers may bill however they choose — including in ways that could leave patients with unexpected bills for “free” care. Routine preventive care saddled an Illinois couple with his-and-her bills for “surgical trays.”]]></description>
<content:encoded><![CDATA[
Chantal Panozzo and her husband followed their primary care doctors’ orders last year after they both turned 45, now the recommended age to start screening for colorectal cancer. They scheduled their first routine colonoscopies a few months apart.
Panozzo said she was excited to get a colonoscopy, of all things, because it meant free care. The couple run a business out of their suburban home near Chicago and purchase coverage costing more than $1,400 each month for their family of four on the exchange, which was created by the Affordable Care Act.
By law, preventive services — including routine colonoscopies — are available at zero cost to patients. So Panozzo said she expected their screenings would be fully covered.
“This was our chance to get our free preventative care,” she said.
Their results came back normal, she said.
Then the bills came.
The Patients: Chantal Panozzo, who uses her maiden name professionally, now 46, and Brian Opyd, 45, are covered by Blue Cross and Blue Shield of Illinois.
Medical Services: Two routine colonoscopies (one for him, one for her), as recommended by the U.S. Preventive Services Task Force for patients beginning at age 45.
Service Provider: Illinois Gastroenterology Group in Hinsdale. The practice is part of the private equity-backed GI Alliance, which has more than 800 gastroenterologists working in 15 states, including Florida, Missouri, and Texas.
Total Bill: For each colonoscopy, the gastroenterology group charged $2,034 before any insurance discounts or reductions. After discounts, Blue Cross and Blue Shield of Illinois said it was responsible for paying $395.18 for Brian’s screening and $389.24 for Chantal’s.
But apart from the screening costs, the total included a $600 charge for each patient — though insurance documents did not identify what the charge was for. This left Chantal and Brian each with a $250 bill, the amount allowed by BCBS of Illinois, which was applied to their deductibles.
What Gives: Panozzo and her husband’s experience exposes a loophole in the law meant to guarantee zero-cost preventive services: Health care providers may bill how they choose as long as they abide by their contracts with insurance — including for whatever goods or services they choose to list, and in ways that could leave patients with unexpected bills for “free” care.
After their screenings, Panozzo said she and her husband each saw the same strange $600 charge from the Illinois Gastroenterology Group on their insurance explanation of benefits statements. Bills from the gastroenterology group explained these charges were for “surgical supplies.” Her insurer eventually told her the codes were for “surgical trays.”
At first, she was confused, Panozzo said: Why were they receiving any bills at all?
The Affordable Care Act requires preventive care services to be fully covered without any cost sharing imposed on patients — procedures such as colonoscopies, mammograms, and cervical cancer checks.
Policymakers included this hallmark protection because, for many patients, cost can deter them from seeking care. A KFF poll in 2022 found that roughly <a href="https://www.kff.org/health-costs/report/kff-health-care-debt-survey/">4 in 10 adults skipped or postponed care</a> they needed due to cost concerns.
Under the law, though, it is the insurer’s responsibility to make preventive care available at zero-cost to patients. Providers may exploit this loophole, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
“The insurance company is supposed to pay the full claim, but there is no requirement on the provider to code the claim correctly,” Corlette said.
In this case, BCBS of Illinois covered the full cost of the screenings the couple received, according to its own documents. But those documents also showed that each patient was on the hook for a portion of their separate, $600 charges.
Panozzo thought a phone call with her insurer, BCBS of Illinois, would quickly fix the mistake. But she said she spent most of her time on hold and could not get an answer as to why the colonoscopy came with a separate charge for supplies. She said she learned in later communications with her insurer that the $600 was specifically for “surgical trays.”
BCBS of Illinois declined to comment despite receiving a waiver authorizing the insurer to discuss the case.
Panozzo said that she called the gastroenterology practice and was told by a billing representative that the extra charge was part of an arrangement the practice has with BCBS: She recalled being told that the practice was accustomed to keying in a billing code for “surgical trays” in lieu of a separate fee, which was described to Panozzo as a “use cost” for the doctor’s office.
“I was getting a different story from any person I talked to,” Panozzo said.
She said she was stuck in “no man’s land,” with each side telling her the other was responsible for removing the charge.
<img src="https://kffhealthnews.org/wp-content/uploads/sites/2/2024/01/JAN_BOTM_Opyd_020_3840.jpg" />
The Resolution: Panozzo went wide with her objections, contesting the total $500 they owed by filing appeals with her insurer; lodging a complaint with the Illinois Department of Insurance; and writing to her elected officials, warning that Illinois consumers were being “taken advantage of” and “ripped off.”
Ultimately, BCBS approved both appeals, saying neither Panozzo nor her husband was expected to pay the charges.
An administrative employee reached by phone at the Illinois Gastroenterology Group location where the couple was treated said they could not comment and directed KFF Health News to contact an executive with GI Alliance, the national group that manages the practice. Neither the executive nor media relations representatives responded to multiple requests for comment.
Panozzo said that, in the past, she would have paid the bill to avoid wasting time haggling with the doctor, insurer, or both. But getting hit with the same bill twice? That was too much for her to accept, she said.
<h4>
MORE FROM BILL OF THE MONTH </h4>
<ul>
<li>
<a href="https://kffhealthnews.org/news/article/telehealth-surprise-bill-december-bill-of-the-month/">
When a Quick Telehealth Visit Yields Multiple Surprises Beyond a Big Bill
</a>
</li>
<li>
<a href="https://kffhealthnews.org/news/article/routine-bloodwork-lab-work-tests-surprise-bill/">
Out for Blood? For Routine Lab Work, the Hospital Billed Her $2,400
</a>
</li>
<li>
<a href="https://kffhealthnews.org/news/article/bill-of-the-month-annual-physical-surprise-charge/">
When That Supposedly Free Annual Physical Generates a Bill
</a>
</li>
</ul>
<a href="https://kffhealthnews.org/news/tag/bill-of-the-month/">
READ MORE </a>
“If change is ever going to happen, I need to stop accepting some of these bills that I knew were potentially incorrect,” Panozzo said.
The Takeaway: Medical providers have broad leeway to determine how they bill for care, including by deciding how to identify what goods or services are provided. This means patients may get stuck with charges for unfamiliar or downright bizarre things.
And because the law doesn’t address how providers bill patients for preventive services, odd charges can crop up even for care that should be fully covered.
Research also shows private equity ownership, which has been <a href="https://fortune.com/2022/05/27/investors-buy-up-gastroenterology-practices-colonoscopies-private-equity/">increasing in specialties like gastroenterology</a>, can lead to <a href="https://www.bmj.com/content/382/bmj-2023-075244">higher costs for patients</a>, as well as lower quality care.
For patients, “under federal law, there is no recourse,” Corlette said. State regulatory bodies may go after these providers for billing patients for covered services, but that can be a mixed bag, Corlette said.
Insurers should crack down on this kind of practice with the providers participating in their networks, Corlette said. Otherwise, patients are stuck in the middle, left to contest what should be “free” care — and at the mercy of the insurance appeals process.
Health plans may not catch billing oddities — after all, for a major insurer, a charge of $600 may not be worth investigating. That leaves patients ultimately responsible for keeping track of what they’re being asked to pay — and speaking up if something seems suspicious.
Panozzo said the experience left her feeling defeated, exhausted, and distrustful of America’s health care system.
Having lived abroad with her family for almost 10 years, she said, “I could function in a health care system in German better than I could here in English.”
KFF Health News senior producer Zach Dyer reported the audio story.
Bill of the Month is a crowdsourced investigation by <a href="https://kffhealthnews.org/news/tag/bill-of-the-month/">KFF Health News</a> and <a href="https://www.npr.org/sections/health-shots/2018/02/16/585549568/share-your-medical-bill-with-us">NPR</a> that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? <a href="https://khn.org/send-us-your-medical-bills/">Tell us about it</a>!
<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/article/federal-lawsuit-unauthorized-aca-obamacare-plan-enrollment-switching/view/republish/">details</a>).]]></content:encoded>
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<title>Mary Lou Retton’s Explanation of Health Insurance Takes Some Somersaults</title>
<link>https://kffhealthnews.org/news/article/mary-lou-retton-uninsured-aca-olympic-gymnast-missed-bar/</link>
<dc:creator><![CDATA[Julie Appleby, KFF Health News]]></dc:creator>
<pubDate>Fri, 12 Jan 2024 20:05:00 +0000</pubDate>
<category><![CDATA[Health Care Costs]]></category>
<category><![CDATA[Insurance]]></category>
<category><![CDATA[The Health Law]]></category>
<category><![CDATA[Uninsured]]></category>
<category><![CDATA[Obamacare Plans]]></category>
<guid isPermaLink="false">https://kffhealthnews.org/?post_type=article&p=1799250</guid>
<description><![CDATA[The gold-medal gymnast’s explanation of why she remained uninsured has health policy experts doing mental gymnastics — because it makes little sense.]]></description>
<content:encoded><![CDATA[
Former Olympic gymnast Mary Lou Retton spoke out last week <a href="https://www.today.com/video/mary-lou-retton-breaks-silence-on-pneumonia-hospitalization-201518661835">on the NBC “Today” show</a> about what she said was a rare pneumonia that almost killed her and resulted in an expensive, monthlong hospital stay.
It was a shocking reveal. One key comment jumped out for those who follow health policy: Retton said she was uninsured, blaming that lack of coverage on 30 orthopedic surgeries that count as “preexisting conditions,” a divorce, and her poor finances.
“I just couldn’t afford it,” Retton told host Hoda Kotb, who did not challenge the assertion.
Retton, who after winning the gold medal in 1984 became a well-known figure — “America’s sweetheart,” appearing on <a href="https://www.usatoday.com/picture-gallery/sports/2019/06/26/athletes-featured-wheaties-boxes/1570202001/">Wheaties boxes</a> and claiming a variety of other endorsements — did not provide details of her income, the illness, the hospital where she was treated, or the type of insurance she was seeking, so it’s hard to nail down specifics.
Nonetheless, her situation can be informative because the reasons she cited for not buying coverage — preexisting conditions and cost — are among the things the Affordable Care Act directly addresses.
Under the law, which has offered coverage through state and federal marketplaces since 2014, insurers are barred from rejecting people with preexisting conditions and cannot charge higher premiums for them, either. This is one of the law’s <a href="https://www.kff.org/health-reform/poll-finding/5-charts-about-public-opinion-on-the-affordable-care-act-and-the-supreme-court/">most popular provisions</a>, according to opinion surveys.
The ACA also includes subsidies that offset all or part of the premium costs for the majority of low- to moderate-income people who seek to buy their own insurance. An estimated “four out of five people can find a plan for $10 or less a month after subsidies on HealthCare.gov,” Health and Human Services Secretary Xavier Becerra said <a href="https://www.cms.gov/newsroom/press-releases/more-45-million-select-affordable-health-coverage-aca-marketplace-coverage-start-open-enrollment">in a written statement</a> when kicking off the annual open enrollment period in November.
<a href="https://www.kff.org/health-reform/issue-brief/explaining-health-care-reform-questions-about-health-insurance-subsidies/">Subsidies are set on a sliding scale</a> based on household income with a sizable portion going to those who make less than twice the federal poverty level, which this year is $29,160 for an individual, or $60,000 for a family of four. Premium costs for consumers are capped at 8.5% of household income.
Still, “we know from surveys and other data that, even 10 years on, a lot of people are unaware there are premium subsidies available through ACA marketplaces,” said <a href="https://gufaculty360.georgetown.edu/s/contact/00336000014RXPVAA4/sabrina-corlette">Sabrina Corlette</a>, co-director of the Center on Health Insurance Reform at Georgetown University.
Those subsidies are one of the reasons cited for <a href="https://www.cbsnews.com/news/affordable-care-act-record-enrollment-20-million-americans-2024/">record enrollment in 2024 plans</a>, with more than 20 million people signing up so far.
To be sure, there are also many Americans whose share of the premium cost is still a stretch, especially those who might be higher on the sliding subsidy scale. Looking at the <a href="https://www.kff.org/interactive/subsidy-calculator/#state=&zip=&income-type=dollars&income=100%2C000&employer-coverage=0&people=1&alternate-plan-family=&adult-count=1&adults%5B0%5D%5Bage%5D=60&adults%5B0%5D%5Btobacco%5D=0&child-count=0">KFF subsidy calculator</a>, a 60-year-old with a $100,000 income, for example, would get a $300 monthly subsidy but still have to pay $708 a month toward their premium, on average, nationally. Without a subsidy, the monthly cost would be $1,013.
And even with insurance, many U.S. residents struggle to afford the deductibles, copayments, or out-of-network fees included in some ACA or job-based insurance plans. The ACA does offer subsidies to offset deductible costs for people on the lower end of the income scale. For those with very low incomes, the law expanded eligibility for Medicaid, which is a state-federal program. However, 10 states, including Texas, where Retton lives, have chosen not to expand coverage, meaning some people in this category cannot get either Medicaid or ACA subsidies.
“If her income was below poverty, she could have been caught in the coverage gap,” said Larry Levitt, executive vice president for health policy at KFF. 
Attempts to reach a representative for Retton were not immediately successful.
One last point — ACA enrollment generally must occur during the annual open enrollment, which for 2024 plans opened Nov. 1 and <a href="https://www.kff.org/policy-watch/what-to-watch-in-2024-aca-open-enrollment/#:~:text=This%20year's%20open%20enrollment%20season,Open%20Enrollment%20to%20January%2016">runs until Jan. 16</a> in most states. But Retton provided no details on what kind of health insurance she shopped for, or when. And there are types of plans and coverage, for example, that fall outside of the ACA rules.
Those include <a href="https://kffhealthnews.org/news/trump-administration-loosens-restrictions-on-short-term-health-plans/">short-term plans</a>, which offer temporary coverage for people between jobs, for example. There are also coverage efforts dubbed “<a href="https://www.commonwealthfund.org/publications/fund-reports/2018/aug/health-care-sharing-ministries">health care sharing ministries</a>,” in which people pool money and pay one another’s medical bills. Neither is considered comprehensive insurance because they generally offer limited benefits, and both can exclude people with preexisting conditions.
If she was considering insurance during a time of year that wasn’t during the open enrollment period, Retton might have still been able to sign up for an ACA plan if she met requirements for a “<a href="https://www.healthcare.gov/glossary/special-enrollment-period/">special enrollment</a>.” Qualifying reasons include a residential move, loss of other coverage, marriage, divorce, and other specific situations.
Retton excelled in landing difficult moves as a gymnast, but she may have missed the bar when it came to buying insurance coverage.
“You can be a very successful person in your other life and not understand American health care and get into a situation that maybe you could have prevented,” said <a href="https://www.aei.org/profile/joseph-antos/">Joseph Antos</a>, a senior fellow at the American Enterprise Institute.
<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/article/federal-lawsuit-unauthorized-aca-obamacare-plan-enrollment-switching/view/republish/">details</a>).]]></content:encoded>
<post-id xmlns="com-wordpress:feed-additions:1">1799250</post-id>
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<title>Biden Wants States to Ensure Obamacare Plans Cover Enough Doctors and Hospitals</title>
<link>https://kffhealthnews.org/news/article/obamacare-aca-biden-new-state-rules/</link>
<dc:creator><![CDATA[Julie Appleby, KFF Health News]]></dc:creator>
<pubDate>Wed, 06 Dec 2023 10:00:00 +0000</pubDate>
<category><![CDATA[Insurance]]></category>
<category><![CDATA[The Health Law]]></category>
<category><![CDATA[Biden Administration]]></category>
<category><![CDATA[Obamacare Plans]]></category>
<guid isPermaLink="false">https://kffhealthnews.org/?post_type=article&p=1781968</guid>
<description><![CDATA[The regulatory proposal was announced Nov. 15 and is likely one of the last major ACA policy efforts of the president’s first term.]]></description>
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The Biden administration plans to push states to boost oversight of the number of doctors, hospitals, and other health providers insurers cover in Obamacare plans, under rules proposed in November.
The annual regulatory proposal, known as the payment parameters rule, also seeks to expand access to adult dental coverage in Affordable Care Act marketplaces and would require states to hold open enrollment periods for Obamacare plans at the same time of year. It’s likely one of the last major ACA policy efforts of President Joe Biden’s first term — and, if he loses reelection, could represent his final touches on the landmark health program created when he was vice president.
Biden has been a staunch supporter of Obamacare and has <a href="https://www.healthaffairs.org/content/forefront/mid-term-assessment-president-biden-s-promise-build-affordable-care-act">taken steps</a> during his own first term in the White House to expand the program through rules and legislation, including measures that <a href="https://www.kff.org/policy-watch/five-things-to-know-about-renewal-of-extra-affordable-care-act-subsidies-in-inflation-reduction-act/#:~:text=As%20part%20of%20the%20Inflation,the%20Affordable%20Care%20Act%20Marketplaces.">increased premium subsidies</a>. In part because of those subsidies, enrollment has <a href="https://www.kff.org/health-reform/state-indicator/marketplace-enrollment/?activeTab=graph&currentTimeframe=0&startTimeframe=9&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">increased steadily and hit records</a> under his watch.
The proposal for 2025 would continue administration efforts to expand coverage, making it easier for states to offer plans that include adult dental care. The rules also set additional guardrails on the growing number of states that have chosen to run <a href="https://www.kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">their own ACA marketplaces</a>.
The rules need to be finalized in the spring and would affect plans starting in January 2025, not long before Inauguration Day.
So expect some controversy.
Already, the ACA has entered the political debate, with the current GOP front-runner, former President Donald Trump, taking to his Truth Social site on Thanksgiving weekend to call the failure of the GOP to repeal the ACA “<a href="https://www.axios.com/2023/11/26/trump-obamacare-affordable-care-act">a low point for the Republican Party</a>.”
Trump also said he was “seriously” considering alternatives, which harked back to his presidency when <a href="https://kffhealthnews.org/news/back-to-the-future-trumps-history-of-promising-a-health-plan-that-never-comes/">he frequently promised</a> an Obamacare replacement was soon to be revealed. It never was.
Biden quickly seized on Trump’s comments, <a href="https://www.washingtonpost.com/politics/2023/11/27/obamacare-biden-trump/">saying on Nov. 27</a> that “my predecessor has once again — God love him — called for cuts that could rip away health insurance for tens of millions of Americans.”
Many of the changes made during Biden’s term, especially to rules that spell out how the law is to be implemented, could be altered if a Republican wins the White House — just as occurred in the transition from the Obama administration to the Trump term and, again, when Biden took office.
When Trump came into office, for example, he made a number of moves to roll back ACA rules set by the program’s namesake, President Barack Obama, including <a href="https://www.wsj.com/articles/trump-administration-slashes-funds-for-aca-outreach-1531272043">sharply reducing funding</a> for enrollment assistance, <a href="https://www.nbcnews.com/politics/white-house/obamacare-not-dead-600-000-people-just-signed-n819351">shortening the annual sign-up period</a>, and allowing less expensive but less protective <a href="https://kffhealthnews.org/news/trump-administration-loosens-restrictions-on-short-term-health-plans/">short-term plans</a> to cover longer periods of time. Biden’s team, in turn, expanded funding for enrollment, added special enrollment periods, and has a proposal awaiting final approval that would <a href="https://www.politico.com/news/2023/07/07/biden-short-term-health-plans-00105055">restore restrictions on short-term plans</a>, which don’t cover many of the benefits included in ACA plans and are often called “junk insurance” by critics.
“If the past is any guide, and the next administration is different, the first thing they will do is roll things back,” said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
Politics may be one reason the administration’s latest proposal doesn’t include larger changes to the ACA. Doing anything more aggressive in an election year “might disrupt a program that Biden fully supports,” said Joseph Antos, senior fellow at the American Enterprise Institute, a right-leaning think tank.
But the proposal from the Department of Health and Human Services does respond to concerns about “network adequacy,” or whether insurers’ doctor and hospital networks <a href="https://kffhealthnews.org/news/article/aca-record-enrollment-smaller-networks-health-insurance/">are large enough</a> to meet demand. The rules would <a href="https://www.healthaffairs.org/content/forefront/proposed-2025-payment-rule-marketplace-standards-and-insurance-reforms#:~:text=Under%20this%20proposal%2C%20SBMs%20and%20the%20SBM%2DFPs%20would%20have%20to%20establish%20their%20own%20quantitative%20time%20and%20distance%20network%20adequacy%20standards%20for%20Marketplace%20plans%20that%20are%20%E2%80%9Cat%20least%20as%20stringent%E2%80%9D%20as%20those%20in%20place%20in%20the%20FFMs.">require states</a> to set numerical standards, such as a maximum “time and distance” that patients must travel to access in-network care, that are at least as rigorous as federal limits that kicked in this year.
The proposal would affect the 18 states, plus the District of Columbia, that <a href="https://www.kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">run their own</a> ACA marketplaces.
While many of them already set some network parameters, <a href="https://www.ncsl.org/health/health-insurance-network-adequacy-requirements">the standards vary</a>. The administration’s latest proposal notes that 25% of existing state rules fail to set any quantitative requirements, such as how long or far a patient might have to drive to find a participating provider, or the acceptable ratio of the number of enrollees in a plan to the number of covered medical providers.
Requiring standards at least as tough as federal exchange rules across all states “would enhance consumer access to quality, affordable care,” the document says.
Some states “may not be doing enough to ensure compliance,” said Corlette. “States will have to step up their game.”
States would also have to review insurer networks to see if they meet the standards before giving the go-ahead to sell their plans. While the federal marketplace will, beginning in 2025, require insurers to meet new rules aimed at limiting patients’ wait times for appointments, especially for primary care and behavioral health, state marketplaces won’t yet have to impose similar standards.
More prescriptive state requirements for ACA insurers might draw some pushback during the public comment period for the rules, which runs through Jan. 8. They could also be a target for change if the GOP wins the White House, said Chris Condeluci, a health law attorney who worked as counsel to the Senate Finance Committee when the ACA was drafted.
“On the one hand, it makes sense to have standardized rules so everyone is working off the same song sheet,” said Condeluci. But he said there’s support for the idea that state marketplaces were not “to be nationally run or overly prescriptive from a federal government regulatory perspective.”
The HHS proposal also seeks to expand access to routine adult dental coverage by eliminating a prohibition against states including the care as an “essential health benefit” in their <a href="https://www.healthinsurance.org/glossary/benchmark-plan/#:~:text=The%20law%20delegated,state%20to%20state">benchmark plans</a>. The rules would also standardize open enrollment periods across all states, requiring them to begin Nov. 1 and run through at least Jan. 15. Most states already do that, although Idaho’s period currently begins Oct. 15 and ends Dec. 15, and New York’s begins Nov. 16 and ends Jan. 31.
The payment parameter notices, though dryly named, are a big deal not only for insurers, who plan their benefits and set their rates based in part on such rules, but also for consumers.
The ACA marketplaces “cover millions of people and it’s very important to make sure they are working and people understand what they are buying,” said Bethany Lilly, executive director of public policy at the Leukemia & Lymphoma Society.
<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/article/federal-lawsuit-unauthorized-aca-obamacare-plan-enrollment-switching/view/republish/">details</a>).]]></content:encoded>
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<title>FTC Chief Gears Up for a Showdown With Private Equity</title>
<link>https://kffhealthnews.org/news/article/ftc-chair-lina-khan-private-equity-regulation/</link>
<dc:creator><![CDATA[Harris Meyer]]></dc:creator>
<pubDate>Thu, 30 Nov 2023 10:00:00 +0000</pubDate>
<category><![CDATA[Health Care Costs]]></category>
<category><![CDATA[Health Care Reform]]></category>
<category><![CDATA[The Health Law]]></category>
<category><![CDATA[Biden Administration]]></category>
<category><![CDATA[Colorado]]></category>
<category><![CDATA[Hospitals]]></category>
<category><![CDATA[New York]]></category>
<category><![CDATA[Texas]]></category>
<guid isPermaLink="false">https://kffhealthnews.org/?post_type=article&p=1773976</guid>
<description><![CDATA[Lina Khan, chair of the FTC, says a recent lawsuit is meant to chill the consolidation of medical groups that results in higher prices for consumers. But it may be too late to curb price hikes.]]></description>
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A recent Federal Trade Commission civil lawsuit accusing one of the nation’s largest anesthesiology groups of monopolistic practices that sharply drove up prices is a warning to private equity investors that could temper their big push to snap up physician groups.
Over the past three years, <a href="https://www.ftc.gov/system/files/documents/public_statements/1577783/p110014hsrannualreportchoprastatement.pdf">FTC and</a> <a href="https://news.bloomberglaw.com/us-law-week/DOJ-FTC-Scrutiny-Tests-Private-Equity-Firms">Department of Justice officials</a> have signaled they would apply more scrutiny to private equity acquisitions in health care, including roll-up deals in which larger provider groups buy smaller groups in a local market.
Nothing happened until September, when the <a href="https://www.ftc.gov/news-events/news/press-releases/2023/09/ftc-challenges-private-equity-firms-scheme-suppress-competition-anesthesiology-practices-across">FTC sued</a> U.S. Anesthesia Partners and the private equity firm Welsh, Carson, Anderson & Stowe in federal court in Houston, alleging they had rolled up nearly all large anesthesiology practices in Texas. In the first FTC legal challenge against a private equity purchase of medical practices, the federal agency targeted one of the most aggressive private equity firms involved in building large, market-dominating medical groups.
In an interview, FTC Chair Lina Khan confirmed that her agency wants to send a message with this suit. Welsh Carson and USAP “bought up the largest anesthesiology practices, then jacked up prices and entered into price-setting and market-allocation schemes,” said Khan, who was appointed by President Joe Biden in 2021 to head the antitrust enforcement agency, with a <a href="https://kffhealthnews.org/news/article/ftc-interview-antitrust-health-care-hospital-mergers-human-impact/">mandate to combat</a> health care consolidation. “This action puts the market on notice that we will scrutinize roll-up schemes.”
The large and growing volume of private equity <a href="https://jamanetwork.com/journals/jama/fullarticle/2761076">acquisitions of physician groups</a> in recent years has raised mounting concerns about the impact on health costs, quality of care, and providers’ clinical autonomy. A <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2789280">JAMA Internal Medicine study</a> published last year found that prices charged by anesthesiology groups increased 26% after they were acquired by private equity firms.
“Now we’re seeing that scrutiny with this suit,” said Ambar La Forgia, an assistant professor of business management at the University of California-Berkeley, who co-authored the JAMA article. “This suit will cause companies to be more careful not to create too much local market power.”
The FTC’s lawsuit alleges that USAP and Welsh Carson engaged in an anti-competitive scheme to gain market power and drive up prices for hospital anesthesiology services. The FTC also accuses USAP and Welsh Carson — which established the medical group in 2012 and has expanded it to eight states — of cutting deals with competing anesthesiology groups to raise prices and stay out of one another’s markets.
USAP now controls 60% of Texas’ hospital anesthesia market, and its prices are double the median rates of other anesthesia providers in the state, according to the lawsuit. Learning that USAP would boost rates following one acquisition, a USAP executive wrote, “Awesome! Cha-ching,” the <a href="https://www.ftc.gov/system/files/ftc_gov/pdf/2010031usapcomplaintpublic.pdf">civil complaint</a> said.
In a written statement, Welsh Carson, which <a href="https://www.wcas.com/healthcare/companies">also holds sizable ownership shares</a> in radiology, <a href="https://kffhealthnews.org/news/article/more-orthopedic-physicians-sell-out-to-private-equity-firms-raising-alarms-about-costs-and-quality/">orthopedic</a>, and primary care groups, called the FTC lawsuit “without merit in fact or law.” It said USAP’s commercial rates “have not exceeded the rate of medical cost inflation for close to 10 years.”
The New York firm also said its investment in USAP “has allowed independent anesthesiologists to deliver superior clinical outcomes to underserved populations” and that the FTC’s action will harm clinicians and patients. Welsh Carson declined a request for interviews with its executives.
“This is a pretty common roll-up strategy, and some of the big private equity companies must be wondering if more FTC complaints are coming,” said Loren Adler, associate director of the Brookings Schaeffer Initiative on Health Policy. “If the FTC is successful in court, it will have a chilling effect.”
Since the FTC filed the USAP lawsuit, Khan said, the agency has received information from people in other health fields about roll-ups it should scrutinize. “We have limited resources, but it’s an area we are interested in,” she said. “We want to focus on where we see the most significant harm.”
In physician acquisition deals, PE firms <a href="https://www.modernhealthcare.com/physicians/specialty-physician-groups-attracting-private-equity-investment">typically use mostly borrowed money</a> to acquire a controlling interest in a large medical group, pay the physician owners a substantial upfront sum in exchange for sharply cutting their future compensation, and install a management team. Then they seek to acquire smaller groups in the same geographic market and bolt them onto the original medical group for more bargaining clout and operating efficiencies.
The PE firm’s goal is to garner at least 20% dividends a year and then sell the group to another investor for at least three times the purchase price in three to seven years. Critics say this short-term investment model spurs the investors and medical groups to boost prices and cut staffing to generate large profits as fast as possible.
“Private equity is trying to extract value quickly and sell the company for a profit, so there’s a lot more incentive to increase prices quickly and extract higher revenue,” La Forgia said.
In the two years after a sale, PE-owned practices in dermatology, gastroenterology, and ophthalmology charged insurers 20% more per claim on average than did practices not owned by private equity, according to <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2795946">a JAMA study</a> published last year.
There are similar concerns about hospital systems acquiring physician practices, which also have <a href="https://pubmed.ncbi.nlm.nih.gov/29727744/#:~:text=We%20find%20that%20the%20prices,share%20of%20its%20inpatient%20market.">raised prices</a>. “The evidence shows that both private equity and hospital acquisitions of physician practices are bad for consumers, and scrutiny should be applied to all acquirers,” Adler said.
Critics warn that private equity roll-ups of medical groups can jeopardize quality of care, too. Chris Strouse, a Denver anesthesiologist who served on USAP’s national board of directors but left the company’s Colorado group out of disapproval in 2020, cited patient safety issues arising from short staffing and mismanagement. He said USAP would schedule shifts so that three or four providers would hand off to each other a single surgical procedure, which he said is risky. In addition, USAP frequently asked anesthesiologists to work the day after working a 24-hour on-call shift, he said. “The literature shows that’s outside the safety range,” he said. As a result, many providers have left USAP, he added.
The FTC has long been lax in monitoring roll-ups of physician groups, in part because federal law does not require public reporting of these deals unless they exceed <a href="https://www.ftc.gov/news-events/news/press-releases/2023/01/ftc-announces-2023-update-size-transaction-thresholds-premerger-notification-filings-interlocking">$111.4 million in value</a>, a threshold adjusted over time. Lowering the threshold would require congressional action. As a result, regulators may be unaware of many deals that lead to gradual market concentration, which allows providers to demand higher prices from insurers and employer health plans.
Recognizing that problem, the FTC proposed in June to <a href="https://www.ftc.gov/news-events/news/press-releases/2023/06/ftc-doj-propose-changes-hsr-form-more-effective-efficient-merger-review">beef up its reporting requirements</a> for companies planning mergers, in hopes of spotting previous acquisitions of smaller groups that could lead to excessive market power and higher prices. In addition, in a draft of their <a href="https://www.justice.gov/atr/d9/2023-draft-merger-guidelines">merger review guidelines</a>, issued in July, the FTC and the Department of Justice said they would consider the cumulative effect of a series of smaller acquisitions.
“The ways PE firms are making serial acquisitions, each individual acquisition is under the radar, but in aggregate they roll up the whole market,” Khan said. “Between the merger reporting form and the new merger guidelines, we want to be able to better catch unlawful roll-up schemes. … This would enable us to stop roll-ups earlier.”
But Brian Concklin, a lawyer with the law firm Clifford Chance, whose clients include private equity firms, said the FTC’s proposed reporting requirements would hamper many legitimate mergers. “The notion that they need all that information to catch deals that lessen competition seems overblown and false, given that the vast majority of these deals do not lessen competition,” he said. “It will be a substantial burden on most if not all clients to comply.”
Researchers and employer groups, however, were encouraged by the FTC’s action, though they fear it’s too little, too late, because consolidation already has reduced competition sharply. Some even say the market has failed and price regulation is needed.
“Providers have been able to extort higher prices on services with no improvement in quality or value or access,” said Mike Thompson, CEO of the National Alliance of Healthcare Purchaser Coalitions. “The FTC stepping up its game is a good thing. But this horse is out of the barn. If we don’t have better enforcement, we won’t have a marketplace.”
<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/article/federal-lawsuit-unauthorized-aca-obamacare-plan-enrollment-switching/view/republish/">details</a>).]]></content:encoded>
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<title>Health Care Is Front and Center as DeSantis and Newsom Go Mano a Mano</title>
<link>https://kffhealthnews.org/news/article/gavin-newsom-ron-desantis-health-care-debate-comparison/</link>
<dc:creator><![CDATA[Daniel Chang and Angela Hart]]></dc:creator>
<pubDate>Mon, 27 Nov 2023 10:00:00 +0000</pubDate>
<category><![CDATA[California]]></category>
<category><![CDATA[Elections]]></category>
<category><![CDATA[Health Care Costs]]></category>
<category><![CDATA[Insurance]]></category>
<category><![CDATA[Mental Health]]></category>
<category><![CDATA[Pharmaceuticals]]></category>
<category><![CDATA[Public Health]]></category>
<category><![CDATA[States]]></category>
<category><![CDATA[The Health Law]]></category>
<category><![CDATA[Abortion]]></category>
<category><![CDATA[Drug Costs]]></category>
<category><![CDATA[Florida]]></category>
<category><![CDATA[Georgia]]></category>
<category><![CDATA[Homeless]]></category>
<category><![CDATA[Immigrants]]></category>
<category><![CDATA[LGBTQ+ Health]]></category>
<category><![CDATA[Prescription Drugs]]></category>
<category><![CDATA[Substance Misuse]]></category>
<category><![CDATA[Transgender Health]]></category>
<guid isPermaLink="false">https://kffhealthnews.org/?post_type=article&p=1777696</guid>
<description><![CDATA[Florida’s Republican Gov. Ron DeSantis and California’s Democratic Gov. Gavin Newsom will square off in a first-of-its-kind debate on Nov. 30. KFF Health News compared the political rivals’ health care positions, showing how their policies have helped — or hindered — the health of their states’ residents.]]></description>
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Florida
Gov. Ron DeSantisAge: 45Florida population: 22.2 million
California
Gov. Gavin NewsomAge: 56California population: 39 million
Republican presidential candidate Ron DeSantis and Democratic Gov. Gavin Newsom — political rivals from opposite coasts and proxies for red and blue America — are set to square off for a first-of-its-kind debate Nov. 30 in Georgia.
Newsom, a liberal firebrand in his second term as governor of California, isn’t running for president in 2024. But he goaded DeSantis, in his second term as governor of Florida, to go mano a mano. “I’ll bring my hair gel. You bring your hairspray,” he <a href="https://twitter.com/GavinNewsom/status/1570902190964998145">taunted on social media</a>.
The matchup promises to be a heated brawl between rising political stars who lead two of the nation’s most populous and diverse states. And it will mark the first time the politicians meet in person even as they have very publicly traded barbs and insults, in recent weeks attacking each other in <a href="https://twitter.com/lara_korte/status/1724177237724086639/video/2">fundraising videos</a> and <a href="https://calmatters.bluelena.io/lt.php?s=ef472a7c4c91248f630a7dd3b3b259a6&i=905A432A31A29920">campaign ads</a>.
Front and center will be homelessness and health care, top priorities for voters — and issues that have largely defined the governors’ policies and leadership styles. From abortion to covid-19 vaccines, Newsom and DeSantis could not be further apart.
Earlier this year, DeSantis blasted California for being too generous with public benefit programs, such as Medicaid, which the Golden State has expanded to all eligible residents regardless of immigration status. That sweeping policy takes effect in January and goes well beyond the optional expansion of Medicaid that the Affordable Care Act offered states. In Florida, one of <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">10 states that have refused</a> to expand Medicaid under Obamacare, DeSantis wears the state’s <a href="https://www.census.gov/library/visualizations/interactive/percentage-without-health-insurance-coverage-by-state-2021-2022.html">11% rate of uninsured</a> residents as a badge of honor.
“We’re not going to be like California and have massive numbers of people on government programs without work requirements,” DeSantis said at a presidential <a href="https://kffhealthnews.org/news/article/gop-presidential-primary-debate-2-angry-rematch/">primary debate</a> in Southern California earlier this year.
DeSantis has led his state to restrict abortion and gender-affirming care and to ban covid-related mask and vaccine mandates.
Newsom, a slick and brash surrogate for Democratic President Joe Biden, has slammed DeSantis for putting Floridians in danger and stripping them of their rights.
“Join us in California, where we still believe in freedom,” Newsom said in <a href="https://www.cnn.com/videos/politics/2022/07/03/gavin-newsom-florida-ron-desantis-political-ad-ip-vpx.cnn">a political ad</a> earlier this year.
Newsom has earned the moniker of “health care governor” by catapulting the issue to the top of his policy priorities. He made California an abortion sanctuary and is dramatically expanding health care benefits. He had promised to bring <a href="https://kffhealthnews.org/news/article/the-demise-of-single-payer-in-california-trips-up-efforts-in-other-states/">single-payer health care</a> to the nation’s most populous state while campaigning for his first term, but that idea hit stiff political opposition early in his tenure. And now Newsom boasts about bringing the state’s uninsured rate to an <a href="https://www.coveredca.com/newsroom/news-releases/2023/11/07/record-financial-assistance-helps-bridge-the-gap-as-covered-california-launches-2024-open-enrollment-campaign/#:~:text=Since%20Covered%20California's%20first%20open,period%2C%20according%20to%20federal%20data">all-time low of 6.5%</a> by expanding coverage in other ways.
These issues are expected to take center stage during the nationally televised 90-minute debate on Fox News, which could have major reverberations for the presidential contest next year and could even help shape the 2028 field of White House contenders.
In advance of the showdown, KFF Health News analyzed 10 of the governors’ top health care positions and how their policies have improved — or hindered — the health of the residents they represent.

<h3>Obamacare</h3>
Florida
DeSantis has refused to expand Medicaid eligibility to more people under the Affordable Care Act. Partly as a result, more than <a href="https://www.cms.gov/files/document/early-2023-and-full-year-2022-effectuated-enrollment-report.pdf">3 million Floridians</a> had coverage through the federal Obamacare exchange as of February, more than any other state. Florida does not have a state-based exchange or offer state-sponsored subsidies.
California
The state has enthusiastically embraced the Affordable Care Act, expanding Medicaid while setting up its own insurance exchange, Covered California. Under Newsom, it has also <a href="https://kffhealthnews.org/news/article/california-medicaid-makeover-newsom-california-medi-cal-homeless-public-funds/">gone well beyond</a> the provisions of Obamacare and <a href="https://kffhealthnews.org/news/article/california-stockpiles-penalties-from-uninsured-residents-instead-of-lowering-care-costs/">created a state requirement</a> for Californians to have health insurance after the federal mandate was eliminated.
<h3>Abortion</h3>
Florida
DeSantis <a href="https://www.flgov.com/2023/04/13/governor-ron-desantis-signs-heartbeat-protection-act/">approved legislation</a> in April banning abortions after six weeks of pregnancy. However, the Florida Supreme Court has <a href="https://acis.flcourts.gov/portal/court/68f021c4-6a44-4735-9a76-5360b2e8af13/case/693c27ad-f040-4da1-9c9e-b52e62e960a2">taken up a challenge</a> to the 15-week ban introduced in 2022, which will determine if the six-week ban can take effect.
California
Newsom spearheaded the effort in 2022 to <a href="https://lao.ca.gov/BallotAnalysis/Proposition?number=1&year=2022">amend the state constitution</a> to enshrine the right to abortion and birth control. He also approved <a href="https://www.gov.ca.gov/2023/04/18/ahead-of-likely-u-s-supreme-court-decision-governor-newsom-announces-new-efforts-to-protect-medication-abortion-access-in-california/#:~:text=Of%20this%2C%20%2440%20million%20is,people%20forced%20to%20come%20to">$60 million</a> to help uninsured patients and people from out of state pay for abortions in California, and signed reproductive health care laws, including <a href="https://apnews.com/article/california-abortion-pill-gavin-newsom-b7e392be628411230319215d7c010f21">one protecting doctors</a> who mail abortion pills to other states.
<h3>Transgender Care</h3>
Florida
Under DeSantis, Florida passed a law this year <a href="https://www.flsenate.gov/Session/Bill/2023/254">banning gender-affirming health care</a> for trans minors and mandating that adult patients sign <a href="https://flboardofmedicine.gov/forms/Masculinizing-Medications-for-Patients-with-Gender-Dysphoria-Patient-Information-and-Informed-Consent.pdf">informed consent forms</a> before starting or continuing hormone treatment. The law also restricts who can order hormone therapy to physicians and prohibits the use of telehealth for new prescriptions. A federal lawsuit challenging the law is set to go to trial in mid-December.
California
Newsom and other state leaders have amended state law to ensure all <a href="https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220SB107">California adults and children</a> are entitled to gender-affirming health care services. And insurance companies doing business in California <a href="https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220SB923">must include</a> information on in-network providers for gender-affirming services by 2025. State health care agencies are designing “enforceable quality standards” to ensure trans patients have access to comprehensive care.
<h3>Homelessness</h3>
Florida
DeSantis has not declared homelessness a priority. In a video filmed on the streets of San Francisco and posted to social media in June, DeSantis used the topic as <a href="https://twitter.com/RonDeSantis/status/1671300453521408001">a campaign cudgel</a> to criticize what he called “leftist policies” in California. Florida <a href="https://www.medicaid.gov/sites/default/files/2021-02/fl-mma-ca.pdf">is experimenting</a> with using Medicaid funds to address homelessness, but the program is limited. Nearly <a href="https://files.hudexchange.info/reports/published/CoC_PopSub_State_FL_2022.pdf">26,000 people</a> are homeless in Florida, or <a href="https://www.huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf#page=18">12 of every 10,000 residents</a>.
California
Newsom <a href="https://kffhealthnews.org/news/article/california-homeless-crisis-governor-gavin-newsom-political-future/">has plowed</a> more than $20 billion into the homelessness crisis, with billions more for health and social services. For example, some homeless Californians can get social services through the state’s Medicaid program, such as money for rental security deposits, utility payments, and first and last month’s rent. Newsom also led a new state initiative that could force some homeless people into mental health or addiction treatment. More than <a href="https://files.hudexchange.info/reports/published/CoC_PopSub_State_CA_2022.pdf">171,000 people</a> are homeless in California, or 44 of every 10,000 residents.
<h3>Mental Health</h3>
Florida
DeSantis has kept his pledge to advocate for mental health treatment programs as governor, although Florida still <a href="https://miamifoundationformentalhealth.org/about-us/">ranks 43rd nationally</a> in access to mental health care and has the fourth-highest rate of adults with mental illness who are uninsured, according to the Miami Center for Mental Health and Recovery. Under DeSantis, Florida has increased state funding for <a href="https://www.flgov.com/wp-content/uploads/2020/06/2020-Budget-Highlights.pdf">mental health programs in schools</a> and peer-to-peer mental health <a href="https://www.flgov.com/2021/12/03/first-lady-casey-desantis-announces-12-million-to-expand-peer-to-peer-mental-health-services-for-first-responders/">services for first responders</a>, and directed funding to suicide prevention.
California
Newsom in 2020 signed one of the nation’s strongest <a href="https://calmatters.org/health/2020/08/california-leader-mental-health/">mental health parity</a> laws, which requires insurance companies to cover mental health and substance use disorders just as they would physical health conditions. He is funding a <a href="https://www.gov.ca.gov/wp-content/uploads/2022/08/KidsMentalHealthMasterPlan_8.18.22.pdf">$4.7 billion initiative</a> to provide mental health treatment in schools. Newsom is also leading the campaign for a statewide, <a href="https://www.gov.ca.gov/2023/10/12/governor-newsom-puts-historic-mental-health-transformation-on-march-2024-ballot/#:~:text=Governor%20Newsom%20signed%20Senate%20Bill,treatment%20settings%20across%20the%20state.">$6.4 billion bond</a> measure in 2024 to revamp and expand community-based behavioral health programs, including thousands of new treatment beds.
<h3>Addiction</h3>
Florida
Florida’s drug overdose death rate was <a href="https://www.cdc.gov/nchs/pressroom/states/florida/fl.htm">37.5 per 100,000 people</a> in 2021. In August, DeSantis announced a new <a href="https://www.flcorenetwork.com/about-core-network/">statewide addiction recovery program</a> billed as a “first of its kind” in the United States, using peer counselors, medication-assisted treatment, and a coordinated network of support services. DeSantis also <a href="https://www.floridahealth.gov/programs-and-services/idea/index.html">authorized Florida counties</a> to adopt needle exchange programs in 2019 to reduce the spread of blood-borne diseases and encourage addiction treatment.
California
California’s drug overdose rate was <a href="https://www.cdc.gov/nchs/pressroom/states/california/ca.htm">26.6 per 100,000</a> people in 2021. Newsom is sending the state Highway Patrol and National Guard into San Francisco to combat the open-air fentanyl trade and is boosting addiction recovery programs statewide. But <a href="https://www.nytimes.com/2022/08/22/us/gavin-newsom-vetoes-drug-injection-sites.html">he vetoed legislation</a> last year that would have allowed Los Angeles, San Francisco, and Oakland to establish safe injection sites.
<h3>Prescription Drugs</h3>
Florida
A DeSantis proposal submitted to the FDA in 2020 includes allowing <a href="http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0300-0399/0381/Sections/0381.02035.html#:~:text=(1)%20PROGRAM%20ESTABLISHED.,(2)%20DEFINITIONS.">imported medications from Canada</a>. A new state law also sets <a href="https://www.flsenate.gov/Session/Bill/2023/1550">price limits for pharmacy benefit managers</a> — intermediaries between insurers, pharmacies, and manufacturers — and creates new rules for them around pricing transparency. The law also requires pharmaceutical companies to disclose significant price hikes.
California
Newsom is spearheading a <a href="https://esd.dof.ca.gov/Documents/bcp/2223/FY2223_ORG4140_BCP5779.pdf?page=14">$100 million</a>, first-in-the-nation initiative that puts California in the <a href="https://kffhealthnews.org/news/article/california-generic-insulin-contract-civica-rx-newsom/">generic drugmaking business</a>, beginning with insulin and the opioid reversal drug naloxone. California already had a pricing transparency law when Newsom took office. This year, he signed a law <a href="https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240SB786">that tightens state regulations</a> for pharmacy benefit managers.
<h3>Health Care Affordability</h3>
Florida
In 2019, DeSantis signed the <a href="https://flsenate.gov/Session/Bill/2019/1113/?Tab=Analyses">Patient Savings Act</a>, which allows health insurers to share cost savings with enrollees who shop for health care services, such as imaging and diagnostic tests. Under his leadership, Florida lawmakers have also <a href="https://www.flsenate.gov/Session/Bill/2019/322/BillText/er/PDF">allowed short-term health plans</a> lasting less than a year and <a href="https://www.flsenate.gov/Session/Bill/2019/843/">direct health care agreements</a> between a patient and a health care provider that are not considered insurance and are not subject to Florida’s insurance code.
California
One of Newsom’s first health care initiatives was to fund state-financed health insurance subsidies for low- and middle-income residents who purchase insurance through Covered California. Newsom this year <a href="https://kffhealthnews.org/news/article/covered-california-patient-costs-lawmakers-win-funding-newsom/">also agreed</a> to lower copays and get rid of some deductibles for plans sold through the exchange. California’s newly created <a href="https://hcai.ca.gov/get-the-facts-about-the-office-of-health-care-affordability/">Office of Health Care Affordability</a> is capping industry cost increases and could potentially regulate health industry consolidation. California bans short-term health plans.
<h3>Public Health</h3>
Florida
DeSantis <a href="https://www.flgov.com/2021/11/18/governor-ron-desantis-signs-legislation-to-protect-florida-jobs/">signed legislation</a> in 2021 banning government, schools, and private employers from requiring covid vaccinations. In 2023, he <a href="https://www.flgov.com/2023/01/17/governor-ron-desantis-announces-initiative-to-make-protections-from-covid-mandates-permanent-enact-new-protections-for-free-speech-for-medical-practitioners/">pushed legislators to adopt laws</a> prohibiting certain vaccine and mask requirements. He also formed a <a href="https://www.floridahealth.gov/about/ssg/public-health-integrity-committee/index.html">Public Health Integrity Committee</a> led by his hand-picked surgeon general, Joseph Ladapo, whose official guidance on covid vaccines contradicts the CDC’s recommendations. The Sunshine State’s covid-19 <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-booster-percent-pop5">vaccine booster rate</a> for residents age 5 and older is 12.4%.
California
Newsom became the first U.S. governor to issue a statewide stay-at-home order at the start of the covid-19 pandemic. He pushed strong vaccination and mask mandates and accused DeSantis of being weak on public health. Newsom has also signed laws strengthening childhood vaccination mandates, including a measure that cracks down on <a href="https://www.latimes.com/california/story/2019-09-21/sb276-california-vaccine-law-fight-gavin-newsom-legislature-how-it-happened">bogus medical exemptions</a> granted by doctors. The Golden State’s covid-19 vaccine booster rate for residents ages 5 and older is 21.9%.
<h3>Immigrant Health Care</h3>
Florida
With DeSantis making immigration a priority, legislators passed a <a href="https://laws.flrules.org/2023/40">state law</a> requiring all Florida hospitals to ask on their admission forms whether a patient is a U.S. citizen or lawfully present in the country. Doctors, nurses, and health policy experts say the <a href="https://kffhealthnews.org/news/article/doctors-patient-immigration-status-new-florida-law/">law targets marginalized people</a> who already have difficulty navigating the health care system and will further deter them from seeking care.
California
Beginning in January, all <a href="https://laborcenter.berkeley.edu/californias-uninsured-in-2024/">immigrants who meet income qualifications</a> will be eligible for the state’s Medicaid program. Before Newsom took office, California had already expanded eligibility to immigrant children through age 18 living in the state without authorization. Newsom then signed laws expanding the program to young adults up to age 26, adults 50 and older, and, later, immigrants of any age who otherwise meet eligibility requirements.
This article was produced by <a href="https://kffhealthnews.org/about-us">KFF Health News</a>, which publishes <a href="http://www.californiahealthline.org/">California Healthline</a>, an editorially independent service of the <a href="http://www.chcf.org/">California Health Care Foundation</a>. 
<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/article/federal-lawsuit-unauthorized-aca-obamacare-plan-enrollment-switching/view/republish/">details</a>).]]></content:encoded>
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<title>La atención de salud, en el centro del debate entre DeSantis y Newsom</title>
<link>https://kffhealthnews.org/news/article/la-atencion-de-salud-en-el-centro-del-debate-entre-desantis-y-newsom/</link>
<dc:creator><![CDATA[Daniel Chang and Angela Hart]]></dc:creator>
<pubDate>Mon, 27 Nov 2023 10:00:00 +0000</pubDate>
<category><![CDATA[California]]></category>
<category><![CDATA[Elections]]></category>
<category><![CDATA[Health Care Costs]]></category>
<category><![CDATA[Insurance]]></category>
<category><![CDATA[Mental Health]]></category>
<category><![CDATA[Noticias En Español]]></category>
<category><![CDATA[States]]></category>
<category><![CDATA[The Health Law]]></category>
<category><![CDATA[Abortion]]></category>
<category><![CDATA[Drug Costs]]></category>
<category><![CDATA[Florida]]></category>
<category><![CDATA[Homeless]]></category>
<category><![CDATA[Immigrants]]></category>
<category><![CDATA[LGBTQ+ Health]]></category>
<category><![CDATA[Prescription Drugs]]></category>
<category><![CDATA[Substance Misuse]]></category>
<category><![CDATA[Transgender Health]]></category>
<guid isPermaLink="false">https://kffhealthnews.org/?post_type=article&p=1779074</guid>
<description><![CDATA[El candidato presidencial republicano Ron DeSantis y el gobernador demócrata Gavin Newsom —rivales políticos y representantes de la América roja y azul— se enfrentarán en un debate sin precedentes el 30 de noviembre en Georgia.]]></description>
<content:encoded><![CDATA[
Florida
Gobernador Ron DeSantisEdad: 45Población de Florida: 22.2 million
California
Gobernador Gavin NewsomEdad: 56Población de California: 39 million
El candidato presidencial republicano Ron DeSantis y el gobernador demócrata Gavin Newsom —rivales políticos y representantes de la América roja y azul— se enfrentarán en un debate sin precedentes el 30 de noviembre en Georgia.
Newsom, un agitador liberal en su segundo mandato como gobernador de California, no se presenta a las elecciones presidenciales de 2024. Pero incitó a DeSantis, en su segundo mandato como gobernador de Florida, a un cara a cara. “Yo llevaré mi gomina. Tú trae tu laca”, bromeó <a href="https://twitter.com/GavinNewsom/status/1570902190964998145">en las redes sociales</a>.
El enfrentamiento promete ser una acalorada pelea entre estrellas políticas en ascenso que lideran dos de los estados más poblados y diversos del país. Y será la primera vez que los políticos se vean las caras, a pesar de que en las últimas semanas han intercambiado insultos en <a href="https://twitter.com/lara_korte/status/1724177237724086639">videos para recaudar fondos</a> y <a href="https://www.youtube.com/watch?v=TOmKmkU8EG0">anuncios de campaña</a>.
Los temas principales serán la falta de vivienda y la salud, prioridades de los votantes y cuestiones que han definido, en gran medida, las políticas y los estilos de liderazgo de los gobernadores. Desde el aborto hasta las vacunas contra covid-19, Newsom y DeSantis no podrían ser más opuestos.
A principios de este año, DeSantis criticó a California por ser demasiado generosa con los programas públicos como Medicaid, que el Estado Dorado ha ampliado a todos los residentes elegibles, independientemente de su estatus migratorio. Esa política de gran alcance entra en vigencia en enero y va mucho más allá de la expansión opcional de Medicaid que la Ley de Cuidado de Salud a Bajo Precio (ACA) ofreció a los estados. En Florida, <a href="https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/">uno de los 10 estados que se ha negado a ampliar Medicaid</a> bajo ACA o Obamacare, DeSantis alardea de la tasa de residentes del estado sin seguro de salud, que es <a href="https://www.census.gov/library/visualizations/interactive/percentage-without-health-insurance-coverage-by-state-2021-2022.html">del 11%</a>, como si fuera una medalla de honor.
“No vamos a ser como California y tener un número masivo de personas en programas gubernamentales sin requisitos de trabajo”, dijo DeSantis en un <a href="https://kffhealthnews.org/news/article/gop-presidential-primary-debate-2-angry-rematch/">debate de primarias</a> presidenciales en el sur de California a principios de este año.
DeSantis ha llevado a su estado a restringir el aborto y la atención médica de afirmación de género, y a prohibir las máscaras relacionadas con covid y los mandatos de vacunación.
Newsom, un hábil e impetuoso sustituto del presidente demócrata Joe Biden, ha arremetido contra DeSantis por poner a los floridanos en peligro y despojarlos de sus derechos.
“Únete a nosotros en California, donde todavía creemos en la libertad”, expresó Newsom en un <a href="https://edition.cnn.com/videos/politics/2022/07/03/gavin-newsom-florida-ron-desantis-political-ad-ip-vpx.cnn">anuncio político</a> a principios de este año.
Newsom se ha ganado el apodo de “gobernador de la atención de salud” al catapultar este asunto a lo más alto de sus prioridades políticas. Ha hecho de California un santuario del aborto y está ampliando drásticamente las prestaciones de salud. Durante su primera campaña, prometió estabecer el sistema de salud de <a href="https://kffhealthnews.org/news/article/the-demise-of-single-payer-in-california-trips-up-efforts-in-other-states/">pagador único</a> al estado más poblado del país, pero esa idea encontró una dura oposición política al principio de su mandato. Y ahora Newsom se jacta de haber conseguido que la tasa de personas sin seguro en el estado haya alcanzado un <a href="https://www.coveredca.com/newsroom/news-releases/2023/11/07/record-financial-assistance-helps-bridge-the-gap-as-covered-california-launches-2024-open-enrollment-campaign/#:~:text=Since%20Covered%20California's%20first%20open,period%2C%20according%20to%20federal%20data">mínimo histórico del 6,5%</a> al ampliar la cobertura de otras maneras.
Se espera que estas cuestiones sean el centro del debate de 90 minutos televisado a todo el país por Fox News. Un debate que podría tener importantes repercusiones en la contienda presidencial del próximo año, e incluso ayudar a conformar el grupo de aspirantes a la Casa Blanca en 2028.
Con miras al debate, KFF Health News analizó 10 de las principales posiciones de los gobernadores en materia de salud y cómo sus políticas han mejorado —o perjudicado— la salud de los residentes a los que representan.


<h3>Obamacare</h3>
Florida
DeSantis se ha negado a ampliar la elegibilidad de Medicaid a más personas bajo la Ley de Cuidado de Salud a Bajo Precio (ACA). Una de las consecuencias es que, hacia febrero, <a href="https://www.cms.gov/files/document/early-2023-and-full-year-2022-effectuated-enrollment-report.pdf">más de 3 millones</a> de floridanos tenían cobertura a través del mercado de seguros federal del Obamacare, más que cualquier otro estado. Florida no cuenta con un mercado estatal, ni ofrece subsidios patrocinados por el estado.
California
El estado ha adoptado con entusiasmo la Ley de Cuidado de Salud a Bajo Precio (ACA), ampliando Medicaid y creando su propio mercado de seguros, Covered California. Con Newsom, se <a href="https://kffhealthnews.org/news/article/california-medicaid-makeover-newsom-california-medi-cal-homeless-public-funds/">ha ido mucho más allá</a> de las disposiciones del Obamacare y se ha creado un <a href="https://kffhealthnews.org/news/article/california-acumula-multas-de-residentes-sin-seguro-en-lugar-de-reducir-los-costos-de-la-atencion/">requisito estatal</a> que obliga a los californianos a tener un seguro de salud, después de que se eliminara el mandato federal.
<h3>Aborto</h3>
Florida
DeSantis aprobó en abril una ley que <a href="https://www.flgov.com/2023/04/13/governor-ron-desantis-signs-heartbeat-protection-act/">prohíbe los abortos</a> después de las seis semanas de embarazo. Sin embargo, la Corte Suprema de Florida <a href="https://acis.flcourts.gov/portal/court/68f021c4-6a44-4735-9a76-5360b2e8af13/case/693c27ad-f040-4da1-9c9e-b52e62e960a2">ha tomado un</a> recurso de apelación sobre la prohibición de las 15 semanas introducida en 2022, lo que determinará si la prohibición de las seis semanas puede entrar en vigencia.
California
Newsom encabezó en 2022 la iniciativa de <a href="https://lao.ca.gov/BallotAnalysis/Proposition?number=1&year=2022">enmendar la constitución estatal</a> para consagrar el derecho al aborto y al control de la natalidad. También aprobó <a href="https://www.gov.ca.gov/2023/04/18/ahead-of-likely-u-s-supreme-court-decision-governor-newsom-announces-new-efforts-to-protect-medication-abortion-access-in-california/#:~:text=Of%20this%2C%20%2440%20million%20is,people%20forced%20to%20come%20to">$60 millones</a> para ayudar a pacientes sin seguro y a personas de fuera del estado a pagar abortos en California, y firmó leyes de atención a la salud reproductiva, incluida una que <a href="https://apnews.com/article/california-abortion-pill-gavin-newsom-b7e392be628411230319215d7c010f21">protege a los médicos</a> que envían píldoras abortivas por correo a otros estados.
<h3>Atención transgénero</h3>
Florida
Bajo DeSantis, Florida aprobó este año una ley que prohíbe la <a href="https://www.flsenate.gov/Session/Bill/2023/254">atención médica de afirmación de género</a> para menores trans y obliga a los pacientes adultos a <a href="https://flboardofmedicine.gov/forms/Masculinizing-Medications-for-Patients-with-Gender-Dysphoria-Patient-Information-and-Informed-Consent.pdf">firmar formularios de consentimiento</a> informado antes de iniciar o continuar un tratamiento hormonal. La ley también limita la capacidad de los médicos para ordenar la terapia hormonal y prohíbe el uso de la telesalud para nuevas recetas. Está previsto que a mediados de diciembre se celebre un juicio por una demanda federal contra esta ley.
California
Newsom y otros líderes estatales han modificado la ley estatal para garantizar que <a href="https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220SB107">todos los adultos y niños</a> de California tengan derecho a servicios de atención médica de afirmación de género. Y las compañías de seguros que operan en California deben <a href="https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220SB923">incluir información</a> sobre los proveedores de la red de servicios de afirmación de género para 2025. Las agencias de salud estatales diseñan “normas de calidad aplicables” para garantizar que los pacientes trans tengan acceso a una atención integral.
<h3>Vivienda</h3>
Florida
DeSantis no ha declarado que la falta de vivienda sea una prioridad. En un video grabado en las calles de San Francisco, y publicado en redes sociales en junio, utilizó el tema como un <a href="https://twitter.com/RonDeSantis/status/1671300453521408001">arma de campaña</a> para criticar lo que llamó “políticas de izquierda” en California. Florida <a href="https://www.medicaid.gov/sites/default/files/2021-02/fl-mma-ca.pdf">experimenta con el uso de fondos</a> de Medicaid para hacer frente a la falta de vivienda, pero el programa es limitado. Casi <a href="https://files.hudexchange.info/reports/published/CoC_PopSub_State_FL_2022.pdf">26,000 personas</a> carecen de hogar en Florida, es decir, <a href="https://www.huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf#page=18">12 de cada 10,000 residentes</a>.
California
Newsom <a href="https://kffhealthnews.org/news/article/california-homeless-crisis-governor-gavin-newsom-political-future/">ha destinado</a> más de $20,000 millones a la crisis de los sin techo, y miles de millones más a servicios sociales y de salud. Por ejemplo, algunos californianos sin hogar pueden obtener servicios sociales a través del programa estatal de Medicaid, como dinero para depósitos de alquileres, pagos para servicios públicos, y para el primer y último mes de alquiler. Newsom también lideró una nueva iniciativa estatal que podría obligar a algunas personas sin hogar a someterse a tratamientos de salud mental o de adicciones. En California hay más de <a href="https://files.hudexchange.info/reports/published/CoC_PopSub_State_CA_2022.pdf">171,000 personas sin hogar</a>, es decir, 44 de cada 10,000 residentes.
<h3>Salud mental</h3>
Florida
DeSantis ha reiterado su promesa de abogar por programas de tratamiento de salud mental como gobernador, aunque Florida todavía ocupa el <a href="https://miamifoundationformentalhealth.org/about-us/">puesto 43 a nivel nacional</a> en el acceso a la atención de salud mental y tiene la cuarta tasa más alta de adultos con enfermedades mentales sin seguro, según el Miami Center for Mental Health and Recovery. Con DeSantis, Florida ha aumentado la financiación estatal para <a href="https://www.flgov.com/wp-content/uploads/2020/06/2020-Budget-Highlights.pdf">programas de salud mental en las escuelas</a> y servicios de salud mental entre pares para <a href="https://www.flgov.com/2021/12/03/first-lady-casey-desantis-announces-12-million-to-expand-peer-to-peer-mental-health-services-for-first-responders/">personal de primeros auxilios</a>, y ha canalizado fondos para la prevención del suicidio.
California
Newsom firmó en 2020 una de las leyes de <a href="https://calmatters.org/health/2020/08/california-leader-mental-health/">paridad en salud mental</a> más estrictas del país, que obliga a las compañías de seguros a cubrir los trastornos mentales y las adicciones de la misma forma que lo harían con las afecciones físicas. Financia una iniciativa de $4,700 millones para proporcionar tratamiento de salud mental en las escuelas. Newsom también lidera en 2024 la campaña a favor de una medida de bonos estatales de <a href="https://www.gov.ca.gov/2023/10/12/governor-newsom-puts-historic-mental-health-transformation-on-march-2024-ballot/#:~:text=Governor%20Newsom%20signed%20Senate%20Bill,treatment%20settings%20across%20the%20state.">$6,400 millones</a> para renovar y ampliar los programas comunitarios de salud mental, incluidas miles de nuevas camas para tratamientos.
<h3>Addicciones</h3>
Florida
La tasa de muertes por sobredosis de drogas en Florida fue de <a href="https://www.cdc.gov/nchs/pressroom/states/florida/fl.htm">37,5 por cada 100,000 personas</a> en 2021. En agosto, DeSantis anunció un nuevo <a href="https://www.flcorenetwork.com/about-core-network/">programa estatal para recuperarse de las adicciones</a>, calificado como “el primero de su tipo” en Estados Unidos, que utiliza consejeros pares, tratamiento asistido con medicamentos y una red coordinada de servicios de apoyo. DeSantis también <a href="https://www.floridahealth.gov/programs-and-services/idea/index.html">autorizó a los condados de Florida</a> a adoptar programas de intercambio de agujas en 2019 para reducir la propagación de enfermedades por transmisión sanguínea y fomentar el tratamiento de adicciones.
California
La tasa de muertes por sobredosis de drogas en California fue de <a href="https://www.cdc.gov/nchs/pressroom/states/california/ca.htm">26,6 por cada 100, 000 habitantes</a> en 2021. Newsom ha enviado a la Patrulla de Carreteras del estado y a la Guardia Nacional a San Francisco para combatir el comercio de fentanilo al aire libre e impulsa programas de recuperación de adicciones en todo el estado. Pero el año pasado <a href="https://www.nytimes.com/2022/08/22/us/gavin-newsom-vetoes-drug-injection-sites.html">vetó una ley</a> que habría permitido a Los Angeles, San Francisco y Oakland establecer sitios seguros para inyectarse.
<h3>Medicamentos recetados</h3>
Florida
Una propuesta de DeSantis, presentada a la FDA en 2020, incluye permitir <a href="http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0300-0399/0381/Sections/0381.02035.html#:~:text=(1)%20PROGRAM%20ESTABLISHED.,(2)%20DEFINITIONS.">la importación de medicamentos de Canadá</a>. Una nueva ley estatal también establece <a href="https://www.flsenate.gov/Session/Bill/2023/1550">límites de precios para los administradores de beneficios farmacéuticos</a> —intermediarios entre aseguradoras, farmacias y fabricantes— y crea nuevas normas para ellos en torno a la transparencia de precios. La ley también obliga a las farmacéuticas a revelar aumentos de precios significativos.
California
Newsom encabeza una iniciativa de <a href="https://esd.dof.ca.gov/Documents/bcp/2223/FY2223_ORG4140_BCP5779.pdf?page=14">$100 millones</a>, la primera en el país, que sitúa a California en el negocio de la <a href="https://kffhealthnews.org/news/article/california-eligio-a-la-compania-de-genericos-civica-para-producir-insulina-de-bajo-costo/">fabricación de medicamentos genéricos</a>, empezando por la insulina y la naloxona, un fármaco para revertir el efecto de los opioides. California ya contaba con una ley de transparencia de precios cuando Newsom asumió el cargo. Este año, firmó una ley que <a href="https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240SB786">endurece la normativa estatal</a> para los administradores de beneficios farmacéuticos.
<h3>Cuidado de salud asequible </h3>
Florida
En 2019, DeSantis firmó la <a href="https://flsenate.gov/Session/Bill/2019/1113/?Tab=Analyses">Ley de Ahorro del Paciente</a>, que permite a las aseguradoras de salud compartir los ahorros de costos con los afiliados que compran servicios de atención médica, como imágenes y pruebas de diagnóstico. Bajo su liderazgo, los legisladores de Florida también <a href="https://www.flsenate.gov/Session/Bill/2019/322/BillText/er/PDF">han permitido planes de salud a corto plazo</a>, que duran menos de un año, y <a href="https://www.flsenate.gov/Session/Bill/2019/843/">acuerdos de atención médica directa</a> entre un paciente y un proveedor de salud que no se consideran seguros, y no están sujetos al código de seguros de Florida.
California
Una de las primeras iniciativas de Newsom en materia de salud consistió en financiar subvenciones estatales al seguro médico para residentes ingresos bajos y medios que contraten un seguro a través de Covered California. También <a href="https://kffhealthnews.org/news/article/covered-california-reducira-los-costos-de-los-pacientes-cuando-los-democratas-obtengan-fondos-de-newsom/">acordó este año</a> reducir los copagos y eliminar algunos deducibles de los planes vendidos a través del mercado. La recién creada <a href="https://hcai.ca.gov/get-the-facts-about-the-office-of-health-care-affordability/">Office of Health Care Affordability</a> de California limita los aumentos de costos del sector y podría regular la consolidación de la industria de la salud. California prohíbe los planes de salud a corto plazo.
<h3>Salud Pública</h3>
Florida
DeSantis <a href="https://www.flgov.com/2021/11/18/governor-ron-desantis-signs-legislation-to-protect-florida-jobs/">firmó una ley</a> en 2021 que prohíbe al gobierno, las escuelas y los empleadores privados exigir la vacunación contra covid. En 2023, <a href="https://www.flgov.com/2023/01/17/governor-ron-desantis-announces-initiative-to-make-protections-from-covid-mandates-permanent-enact-new-protections-for-free-speech-for-medical-practitioners/">presionó a los legisladores</a> para que aprobaran leyes que prohibieran ciertos requisitos de vacunas y uso de máscaras. También estableció un <a href="https://www.floridahealth.gov/about/ssg/public-health-integrity-committee/index.html">Comité de Integridad de Salud Pública</a> dirigido por su cirujano general elegido a dedo, Joseph Ladapo, cuya orientación oficial sobre las vacunas de covid contradice las recomendaciones de los CDC. La <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-booster-percent-pop5">tasa de vacunación de refuerzo</a> contra covid-19 en el Estado del Sol para los residentes de 5 años en adelante es del 12,4%.
California
Newsom fue el primer gobernador de Estados Unidos en emitir una orden para permanecer en casa en todo el estado al comienzo de la pandemia de covid-19. Impulsó fuertes mandatos de vacunación y máscaras, y acusó a DeSantis de ser débil en materia de salud pública. Newsom también ha firmado leyes que refuerzan los mandatos de vacunación infantil, incluida una severa medida contra las <a href="https://www.latimes.com/california/story/2019-09-21/sb276-california-vaccine-law-fight-gavin-newsom-legislature-how-it-happened">falsas exenciones médicas</a> concedidas por los doctores. La tasa de vacunación de refuerzo contra covid-19 en el Estado Dorado para los residentes de 5 años en adelante es del 21,9%.
<h3>Atención de salud del inmigrante</h3>
Florida
Al tener DeSantis la inmigración como una prioridad, los legisladores aprobaron <a href="https://laws.flrules.org/2023/40">una ley estatal</a> que obliga a todos los hospitales de Florida a preguntar en sus formularios de admisión si un paciente es ciudadano estadounidense o se encuentra legalmente en el país. <a href="https://kffhealthnews.org/news/article/medicos-son-reacios-a-preguntar-el-estatus-migratorio-de-pacientes-a-pesar-de-nueva-ley-de-florida/">Médicos, enfermeras y expertos</a> en políticas de salud afirman que la ley afecta a personas marginadas, que ya tienen dificultades para desenvolverse en el sistema de salud, y que los disuadirá aún más de buscar atención médica.
California
A partir de enero, <a href="https://laborcenter.berkeley.edu/californias-uninsured-in-2024/">todos los inmigrantes que cumplan los requisitos de ingresos</a> podrán acogerse al programa estatal de Medicaid. Antes que Newsom asumiera el cargo, California ya había ampliado la elegibilidad a los niños inmigrantes indocumentados hasta los 18 años. Newsom firmó luego leyes que ampliaron el programa a adultos jóvenes hasta los 26 años, a adultos mayores de 50 años y, más tarde, a los inmigrantes de cualquier edad que cumplieran con los requisitos de elegibilidad.
Esta historia fue producida por <a href="https://kffhealthnews.org/about-us">KFF Health News</a>, que publica <a href="http://www.californiahealthline.org/">California Healthline</a>, un servicio editorialmente independiente de la <a href="http://www.chcf.org/">California Health Care Foundation</a>. 
<a href="https://kffhealthnews.org/about-us">KFF Health News</a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://kffhealthnews.org/news/article/federal-lawsuit-unauthorized-aca-obamacare-plan-enrollment-switching/view/republish/">details</a>).]]></content:encoded>
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