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What the Health? From 鶹Ů Health News

GOP Mulls More Health Cuts

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What the Health? From 鶹Ů Health News: GOP Mulls More Health Cuts

The Host

Julie Rovner 鶹Ů Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of 鶹Ů 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.

Recent polling finds that health costs are a top worry for much of the American public, while Republicans in Congress are considering still more cuts to federal health spending on programs such as Medicaid and the Affordable Care Act.

Meanwhile, the Supreme Court ruled that Colorado cannot ban mental health professionals from using “conversion therapy” to treat LGBTQ+ minors, a decision that’s likely to affect other states with similar laws.

This week’s panelists are Julie Rovner of 鶹Ů Health News, Jessie Hellmann of CQ Roll Call, Alice Miranda Ollstein of Politico, and Sandhya Raman of Bloomberg Law.

Panelists

Jessie Hellmann CQ Roll Call Alice Miranda Ollstein Politico Sandhya Raman Bloomberg Law

Among the takeaways from this week’s episode:

  • Republicans reportedly are weighing still more cuts to federal health spending. With the war in Iran draining military coffers, GOP leaders in Congress are eying a drop in health funding — a decision that could exacerbate problems following the passage of legislation expected to lead to major reductions in Medicaid spending, as well as the expiration of enhanced ACA premium subsidies that were not renewed by lawmakers last year. And President Donald Trump’s budget could include another sizable reduction in funding to the National Institutes of Health.
  • The Supreme Court this week struck down a Colorado law prohibiting licensed professionals from practicing a form of therapy that tries to change the sexual orientation or gender identity of LGBTQ+ minors. States have long had the power to regulate medical care, with the goal of restricting treatments that can be harmful. Also, the Idaho Legislature passed a bill requiring teachers and doctors to out transgender minors to their parents.
  • Meanwhile, the Department of Health and Human Services is studying whether to make private Medicare Advantage plans the default option for seniors enrolling in Medicare, a change that would seem to conflict with the Trump administration’s scrutiny of overpayments to the private insurance plans. And a tech nonprofit’s lawsuit seeks to reveal more about the administration’s pilot program testing the use of artificial intelligence in prior authorization in Medicare.

Also this week, Rovner interviews 鶹Ů Health News’ Elisabeth Rosenthal, who wrote the last two 鶹Ů Health News “Bill of the Month” stories. If you have a medical bill that’s outrageous, infuriating, or just inscrutable, you can submit it to us here.

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

Julie Rovner: New York Magazine’s “,” by Helaine Olen.

Jessie Hellmann: The Texas Tribune’s “,” by Colleen DeGuzman, Stephen Simpson, Terri Langford, and Dan Keemahill.

Sandhya Raman: Science’s “,” by Jocelyn Kaiser.

Alice Miranda Ollstein: The New York Times’ “,” by Ed Augustin and Jack Nicas.

Also mentioned in this week’s podcast:

Click to open the transcript Transcript: GOP Mulls More Health Cuts

[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, from 鶹Ů Health News and WAMU Public Radio in Washington, D.C. Welcome toWhat the Health?I’mJulie Rovner, chief Washington correspondent for 鶹Ů Health News, andI’mjoined by some of the best and smartesthealthreporters covering Washington.We’retaping this week on Thursday,April 2, at 10a.m.As always, news happens fast, and things might have changed by the time you hear this. So here we go.

Today, we are joinedviavideo conference by Alice MirandaOllsteinof Politico.

Alice MirandaOllstein:Hello.

Rovner:Jessie Hellmannof CQRoll Call.

Jessie Hellmann:Thanks for having me.

Rovner:And SandhyaRaman,now at Bloomberg Law.

Sandhya Raman:Hello, everyone.

Rovner:Later in this episode,we’llhave my interview with鶹Ů Health News’Elisabeth Rosenthal, who reported and wrote the lasttwo鶹Ů Health News“Bills of theMonth.”One is about a patient who got caught in the crossfire over prices between insurers and drug companies. The other is about a woman who, and this is not an April Fools’joke, got her insurance canceled forfailing to paya bill for1cent. But first,this week’s news.

SoCongress is on spring break, but when they come back,healthpolicy will be waiting. A new Gallup poll out this week found 61% of those surveyed said they worry about the availability and affordability of health care, quote,“a great deal.”That was 10 percentage points more than the economy,inflation,and the federal budget deficit, and it topped a list of 15 domestic concerns. And while we are still waiting for final enrollment numbers for Affordable Care Act plans, we do know that the share of people paying more than $500 a month for their coverage doubled from last year to 2026.Yet Axios this week is reporting that Republicans are considering still more cuts to the Affordable Care Act to potentially pay for a$200 billionwar supplemental. What exactly are they thinking? Andit’slooking more like Republicans are going to try for another budget reconciliation bill this spring. Isn’t that, right,Jessie?

Hellmann:HouseBudgetchair Jodey Arrington has kind of been pushing this ideareally hardof going after what he says is fraudinmandatory programs like Medicare and Medicaid.He’salso talked about fundingcost-sharingreductions, which is an idea that slipped out of the last reconciliation bill, andit’sa wonky kind of idea…

Rovner:ButI think the best way to explainitis that it will raise premiums for many people.That’showI’vejust been doing it.

Hellmann:Yeah, exactly.

Rovner:Let’snot get into the details.

Hellmann:It wouldreduce spending for the federal government butwouldn’treally help people who buy insuranceonthe marketplace. Hehasn’tbeenvery specific.He’salso talked about,like,site-neutralpoliciesinMedicare, butit’shard to see how all of this could make a seriousdent ina$200 billionIran supplemental.There’salso a new development.I think President[Donald]Trump threw a wrench in things yesterday when he said he wanted the reconciliation bill to focus on border spending and immigration spending to cover a three-year period, and now Senate Majority Leader John Thune is saying that there’s probably not room for much else in the bill. So,unclear what the path forward is for all of that.

Rovner:Yeah, and of course, that was part of the deal to free up the Department of Homeland Security’s budget in the appropriation.It’sall one sort of big, tied-up mess at this point.Alice, I seeyou’renodding.

Ollstein:Yeah.I mean, what often happens with these reconciliation bills is it starts out with a tight focus and everyone’s unified, and then, because it can often be the only legislative train leaving the station,everybody gets desperate to get their pet issue on board, and then the more and more things get piled onto it, then they start losing votes, and people start disagreeing more. AndsoI think even though this is still in the ideas phase,you’realready seeing some signs of that happening. And when it comes to health care, it can be particularly fraught. And of course, you have lawmakers, especially in theHouse, with wildlydifferent needs. Some of them need to fend off a primary from the right, and so they want to be as conservative as possible. Some are fighting to hang on in swing districts, and so they want to be more moderate. And these things are in conflict. Andsothese proposals to cut health spending, even more than the massive amount that was cut last year,are already, you know, raising some red flags among some moderate Republican members.Andit’svery possible the whole thing falls apart.

Rovner:Well, along those lines,we’resupposed to get thepresident’s budget on Friday, which is only two months late. It was due in February.And while Ihaven’tseen much on it, Jessie, your colleagues atRollCallare reporting that the budget will seek a 20% cut to the National Institutes of Health.That’sonly half the cut that the administration proposed last year. But given that Congress actually boosted theagency’sbudget slightly this year, that feels kind of unlikely.

Hellmann:Yeah, Idon’tthink that the appropriators are likely togo along with this.They have really strong advocates, and Sen.Susan Collins, who’s chair of the Senate Appropriations Committee.And,likeyousaid, they rejected cuts last year.Kind of surprised.Twenty percentis not as deep as the Trump administration went last year.I was actually kind of surprised it wasn’tabigger proposed cut.But either way, Idon’tthink Congress is going to go along with that.

Rovner:Meanwhile, I sawa late headline that FDA is looking to hire back people afterDOGE [Department of Government Efficiency]cutthousandsof people last year. Sandhya,HHS[Department of Health and Human Services]is just in this sort of personnel churn at this point, isn’t it?

Raman:Yeah, I think that HHS is kind of gettingbitin the foot from, you know, we’ve had so many of these layoffs, and we’ve also had a lot of people just flee the various agencies over the past year because of some of this instability and all of these changes. And aswe’regettingcloser and closerto, you know, deadlines of things that they need to get done,they’rerealizing that they do need more personnel to get some of those things done,aswe’vebeen passing deadlines.SoIdon’tthinkit’ssomethingthat’sunique to just FDA.But I think the way to solve this—it’snot an overnight thing for the federal government to staff up.It’sa longer process, butit’sreally showing in a lot of areas right now.

Rovner:Yeah, I would say this is not like TSA[Transportation SecurityAdministration], where you can, you know, hire newpeopleand train them up in a couple of months. These are…many of them scientistswho’vegot years and years of training and experience at doing some of these jobs that,you know,the federal government is ordered to do by legislation.

Raman:Yeah, thosestatutes are things that,you know, if theydon’tmeet thosedeadlines,thoseare things that aregoing to be challenged, and just further tie things up in litigation.And we already see so many of those right now that are making things more complicated.

Rovner:Well, in news that is not from Congress or the administration, the Supreme Court this week said Colorado could not ban licensed mental health professionals from using so-calledconversion therapy aimed at LGBTQ individuals, at least not on minors.What’sthe practical impact here? It goes well beyond Colorado,Iwould think.

Ollstein:Interesting,because a lot of people think of this as regulating health care, restricting providers from providing health care that is not helpful andmaybe activelyharmful to the health of the patients.

Rovner:And that’s…I would saythat’sbeen a state…

Ollstein:Power.

Rovner:… power.For generations.

Ollstein:Absolutely.Right,I mean, you don’t want people selling sketchy snake oil pills on the street, etc. So many people view this as akin to that.But it has morphed in the hands of conservative courts into a free speech issue, and that, you know, these laws are restricting the speech of mental health workers who are against people transitioning. And so, yes, itdefinitely hasnational implications. And of course, we are in a national wave right now of both state and federal entities, you know, moving in the direction of rolling back trans rights in the health care space and beyond.

Rovner:Yeah. In related news,regardingColorado and minors and gender,that Children’s Hospital Colorado has not yet resumed providing gender-affirming care for transgender youth.That’sdespite a federal judge in Oregon having struck down an HHS declaration that would have punished hospitals for providing such services.Apparently, thehospital in Colorado is concerned that thejudge’srulingdoesn’tprovide it with enough legal cover for them to resume that care.I’mwondering, is this the administration’s strategy here to get organizations to do what they want, even if they might lack the legal authority to do it?Just by making them worry that they might come after them?

Raman:I think the chilling effect is definitely a big part of this broader issue.I mean, we’ve seen it in other issues in the past, but just that if there is this worry that it’s a)going to stop on the provider side, new folks taking part in providing care, and also just it’s going to make patients, even if there are opportunities,even less likely to want to go because of the fears there. I mean, it goes broader than that.We’vehad FTC[Federal Trade Commission]complaints,where they have gone and investigateddifferent placesthat provide gender-affirming care or endorse it.SoI thinkit’sbroader than this, and really part of that chilling effect.

Rovner:And Alice, as you were saying, I mean, the subject of transgender rights, or lack thereof,remainsa political hot topic. The IdahoLegislature this week passed a bill that now goes to the governor that would require teachers and doctors to out transgender minors to their parents. Parents could sue teachers, doctors,andchild careproviders who, quote,“facilitate the social transformation of the minor student.”That includes using pronouns or titles thatdon’talign with their sex at birth.I don’t know about teachers, but that definitely seems to violate patient privacy when it comes todoctors, right?

Ollstein:There’s definitely patient privacy issues there. I also think, you know,it’sinteresting thatthis kind of nonmedicaltransitioningis now coming under attack. Because, you know, you would think that there would be some support for letting a kid, you know, go by a different name for a few weeks, test it out, see how it feels.Maybe it’s a phase, then they discover that they don’t want to actually pursue taking medications and going through a medical transition.But this is sort of shutting down that avenue as well.Youcan’teven change your appearance, change how you present in the world, at a time when kids are really trying to figure out who they are.SoI think the broad acceptance of hostility to medical transitioning for youth is now spilling over into this kind of social transitioning, and I wonder ifwe’regoing to see more of that in the future.

Rovner:Yeah, I feel like we started withminorsshouldn’thave surgery.Theyshouldn’tdo anythingthat’snot easily reversible.And nowwe’vegotten down to,inthe Idaholaw,there’sactually mentionof nicknames. Youcan’t… akidcan’tchange his or her nickname. It feels like we’vesort ofreducedthis way, way, way down.

Ollstein:And I thinkwe’veseen theselaws,laws related to bathrooms.We’veseen these have negative impacts on people who are not trans at all, people who just are a tomboy or not looking like people’s stereotypes of what different genders may look like. Andsothere’sa lot of policing of people who are not trans in any way. You know, there’s media reports of people being confronted by law enforcement for going into a bathroom that does align with their biological sex. Andsoit’simportant to keep in mind that these laws have an effectthat’smuch broader than just thevery smallpercentage of people who do consider themselves trans.

Rovner:Yeah,it’skind of theopposite of not beingwoke. Allright,we’regoing to take a quick break. We will be right back.

Sowhilewe’vehad lots of news out of the Department of Health and Human Services the past few weeks,it’sbeen mostly publichealth-related.Butthere’sa lot going on in the Medicare and Medicaid programs too. ItemA:Stat Newsis reportingthat HHS is studying whether to make the private Medicare Advantage program the default for seniors when they qualify for Medicare. Right now, you get the traditional fee-for-service plan that allows you to go to any doctor or hospital that accepts Medicare, which is most of them.You have to affirmatively opt into Medicare Advantage, which often provides extra benefits but also much narrower networks.What would it mean to make Medicare Advantage the default,that people would go into private plans instead of thegovernmentplan, unless they affirmatively opted for the traditional fee-for-service?

Hellmann:Someone’s experience with…can varygreatly betweenbeing on traditional Medicare and Medicare Advantage. Ifyou’rein Medicare Advantage, you could be exposed to narrow networks. You can only see certain doctors that are covered by your plan. You can be exposed to higher cost sharing. A lot of people arekind of finewith their plans until they have a medical issue and need to go to the hospital or they need skilled nursing care.Somaking this the default could definitely be a challenge for some people, especially people that have complex health needs. Some people on the early side of their Medicare eligibility are fine with Medicare Advantage, and then they getolderandthey’renot fine with it anymore.Soit’sinteresting that the administration wouldkind of floatthisideabecausethey’vebeen criticalof Medicare Advantage.

Rovner:Thank you.That’sexactly what I was thinking.

Hellmann:Yeah,they’vetalked about the federal governmentpaysthese plans too much, andit’snot for better quality in a lot of cases, andthey’vetalked about reforms in that area.SoI was a littlesurprised to see that.

Rovner:Yeah, Republicans have been super ambivalent. I mean, Medicare Advantage was their creation. They overpaid them at the beginning when they, you know,sort of redidthe program in 2003.And they purposely overpaid them to get people into Medicare Advantage. And then the Democrats pointed out that this is wasting money becausewe’reoverpaying them. And now the Republicans seem to have joined a lot of their—at least some Republicans—seem to have joined a lot of the Democrats in saying,Yes,we’reoverpaying them.We’repayingthem too much. And you know, they talk about the big, powerful insurance companies, and yetthey’renowfloatingthis idea to make Medicare Advantage the default.Sopick a side, guys.

All right, well, in other Medicare news, the Electronic Frontier Foundation is suing Medicare officials to learn more about the pilot programthat’susing artificial intelligence to oversee prior authorization requests in the traditional Medicarefee-for-serviceprogram.The idea here is to cut down on,quote,“low-value services,”things that doctors might be prescribing that aren’t either particularly necessary or shown to actually work.But the fear, of course, is that needed care for patients will be delayed or denied, which is whatwe’veseen with prior authorization in Medicare Advantage. This is the perennial push-pull of our health care system, right? If you do everything that doctors say,it’sgoing to be too expensive, and if you second-guess them,it’sgoing to be,you know, itmight turn out to be too constraining.

Hellmann:Well, I was just going to saythisis another issue that waskind of alittle surprising to me, becausethere’sbeen so much criticism of the use of prior authorization and Medicare Advantage. And CMS[Centers for Medicare & Medicaid Services]looked at that and said,Oh, what if we did it in traditional Medicare?Like it was never going to go over well politically,andI think thereare even some Republican members of Congress who are not in support of this, but theyhaven’treally made a huge stink about it.Yeah, thiswasn’tsomething I really expectedto see.

Rovner:Yeah,we’llsee howthis one playsout too.Well, meanwhile,regardingMedicaid, tworeally goodstories this week from my鶹Ů Health News colleagues PhilGalewitz, Rachana Pradhan,and Samantha Liss.Phil’s storyfound that efforts in multiple states to find enrollees who were not eligible for the program due to their immigration status turned up very few violators. WhileSamantha andRachanadetailedthe hundreds of millions of dollars states and the federal government are spending to set up computer programs to trackMedicaid’s new work requirement, despite the fact that we already know that most people on Medicaid either already work or they are exempt from the requirements under the new law. Is it just me, or are we spending lots of time and effort onboth of thesepolicies that are going tohave nota very bigreturn?

Ollstein:Well,that’swhatwe’veseen in the few states that have gone ahead andattemptedthis before,that it costs a lot, and you insure fewer people. Andthat’snot because those people got great jobs with great healthcare. You insure fewer people, and the level of employment does not meaningfully change.

Rovner:I wouldsay you insure fewer people who may well still be eligible. They just get caught in the bureaucratic red tape of allof this.

Ollstein:Exactly.These tech systems that are being set up are challenging to navigate, if people even have a means to do it, if they even have a smartphone or a computer or access to Wi-Fi.There are not that many physical offices they cangototowork it out if they need to. And some of those arevery farfrom where they live. Andsoyou see some of these tech vendors,you know, are set to make off very well out of this system, and people who need the care not so much. And then, of course, you know,it’snot just the patients who will feel the impact. You have these hospitals around the country that are on the brink of closure. And if they have people who used to be insured—they used to be able to bill and get reimbursed for their services, suddenly they’re uninsured—and they’re coming in for emergency care that they can’t pay for, that the hospital has to throw out-of-pocket for, that puts the strain that some of these facilities can barely cope with.Andsoyou’reseeing a lot of state hospital associationssoundingthe alarm as well.

Raman:I would also say the timing is interesting. You know, we spent so much time and energy last year going through the reconciliation process to tighten these areas, to get in the work requirements, to reduce immigrant eligibility for Medicaid. And then, you know, as they’re gearing up to possibly do this again, to defer their crackdown on health care as part of that, instead of it saving money—that it’s not having as much of an effect and costing so much, in the case of the work requirements, where we’re not expected to see the return of it.

Rovner:Yeah, that may be, althoughI guess the returnis that people will not have insurance anymore, and so the federal government,the states,won’tbe spending moneyfortheir medical care.They’llbe spending money on other things. All right, of course,there’smore news from HHS than just Medicare and Medicaidthis week.We also have a lot of news about the Make AmericaHealthyAgain movement, which is a sentencethat 2023mewoulddefinitely notrecognize.about a new poll that finds the MAHA voteisn’tnecessarily locked in with Republicans. Tell us about it.

Ollstein:Yeah,that’sright.SoPolitico did our own polling on this, because wehadn’treally seen good data out there on who identifies as MAHAand what do they even believe about the different parties and about different issues. Andsowe found that,OK, yes, most people associate MAHAwith the Republican Party—most, but not all. But a lot of voters who identify as MAHA, and a lot of voters who voted for Trump in 2024don’tthink that the Trump administration has donea good jobmaking America healthy again.And they rank the Democratic Party above the Republican Party on a lot of their top priority issues, like standing up to influence from the food industry and the pharmaceutical industry. They rank Democrats as caring more about health. So, you know, we found this very fascinating, and it supports what we’ve been hearing anecdotally, where Democratic candidates, a handful of them, andDemocratic electoral groups, are really seeing a lot of opportunity to go after MAHAvoters and win them over for this November. And you know, we should remember that even if youdon’tseea big swing of peoplevoting for Democrats, even if MAHAvoters are disillusioned and stay home, that alone could decide races. You know, midterms are decided by very narrow margins.

Rovner:Well, two other really interesting MAHAtakes this week..It’sabout the tension in and among medical groups, about how to deal with HHS Secretary[RobertF.]Kennedy[Jr.]and the MAHA movement. The American Medical Association seems to be trying to play nice, at least on things it agrees with thesecretary about, lest it risk things like its giant contract to supply the CPT billing codes to Medicare. On the other hand, the American Academy of Pediatrics and the American College of Physicians have been more confrontational to the point of going to court.The other story,frompushing MAHA.One thing I noticed is thatall ofthe teens in the story seem to suffer from physical problems that are not well understood by the mainstream medical community, and so they turned online to seek advice instead, which is understandable in each individual case. But then they turn around and try to influence others. And you can see how easily misinformation can spread. It makes me not so much wonder—it makes me see how, oh, this is how this stuff sort of gets out there, because you see so much… and Alice, thisgoes back to what you were saying about MAHAis not a movement that’s allied with one particular political party.It’smore of sortof a mindset thatdoesn’ttrustexpertise.

Ollstein:I think itspans people who identify as Democrats, identify as Republicans. And, you know,we’renot really interested in politics until the rise of Robert F Kennedy Jr., and so I think it does show a lot of malleability. And there is a fight for this, for this cohort right now, on the airwaves, on the internet, etc.

Rovner:And,asThe New York Times pointed out, you know,we’vethought of this as beingsort of ayoung men cohort.It’snow also a young woman cohort,too.Sothere’slots of people out there togo and get,for these people who are pursuing votes.

Well, turning to reproductive health, we have a couple of follow-ups to things we covered earlier. The big one isTitleX, the federal family planning program, whose grants were set to end as of April 1. Sandhya, it looks like the federal government is going to fund the program after all?

Raman:Yeah, the family planning grantees in this space have been on edge for so long, you know, waiting to see would they finally just issue the grant applications.And then it was such a short timeline for them to get them done. And then everyone that I talked to in thelead-upwas expecting some sort of delay, just because it was such a shorttimeframebefore they were set to run out of money. AndsoI think that theywere all pleasantly surprised that HHS was able to turn things around when they confirmed that the moneyisgoing to go out the day before the deadline. It does take a coupleofdays to go through the process and get that done. But I think the new worry now is also that in the statements that the White House and HHS have made is just that they are still at work on gettingTitleXrulemaking out so that a lot of these groups would be ineligible if they alsoprovideabortions.Or we alsodon’tknow what will be in the rule—if it will be broader than what was under the lastTrump administration, if it encompasses other restrictions.Soa little bit of both there.

Rovner:Yeah. And I also wasgonnasay, I mean, we know that anti-abortion groups are unhappy with the administration, so this would be one place where they couldpresumably throwthem a bone, yes?

Ollstein:Sopeople on both sides have been a little mystified why wehaven’tseen a newTitleXrule yet.They were expecting that near the beginning of last year, especially if the administration was just planning to reimpose his 2019 version, that would be pretty straightforward and simple.And yet, here we are, more than a year into the administration, and wehaven’treally seen this yet. The administration did confirm to me—we put this in our newsletter—that a new rule is coming.And they said it willalign with pro-life values. And the White House’s comments to some conservative media outlets were very explicit that this will be the last time Planned Parenthood can get funding. Now I wonder if that statement will come back to bite them in court, because the rule previously wasvery carefulnot to name Planned Parenthood or name any specific organization. It just imposed criteria that applied to a lot of Planned Parenthood facilities, andin order tomake them ineligible forTitleXfunding. AndsoI wonder if that will help Planned Parenthoodsuelater on.Butwe’llput a pin in that and come back to it.But we have confirmed that some sort of new rule is coming, but we don’t know when, and we don’t know what it would entail.There’sa lot of speculation that this could go way beyond an attempt to kick Planned Parenthood out. There’s speculation it could involve restrictions onparticular formsof birth control. There’s speculation that it could entail restrictions on gender-affirming care. There’s speculation that it could involve rules around parental consent, stricter parental consent requirements, which are currently something that’s not part ofTitleX. Andsowe justdon’tknow, you know,in order tomollify the anti-abortion groups that are upset, they are saying,Don’tworry, new rule is coming.But again, we don’t know when, and we don’t know what’s going to be in it.

Rovner:Well,we’llbe here when it happens. Another topicwe’vetalked about at some length is crisis pregnancy centers, which are anti-abortion organizations that sometimes offer some medical services.who was told after an ultrasound at a crisis pregnancy center that she had a normal pregnancy, and three days later, ended up in emergency surgery because the pregnancy was not normal, but rather ectopic—in other words, implanted in her fallopian tube rather than her uterus, which could have been fatal if not caught. This is not the first such case, but it again raises this question of whether these centers should be treated as medical facilities, whichwe’vetalked about many statesdo.

Raman:And I think a lot of the rationale that people have for trying to do some of thesemandatory ultrasounds, you know, encouraging people to go to this is because the talking point is thatyou don’t know if you have an ectopic pregnancy, you don’t have another complication, so you should go here to instead of just taking a medication abortion. So…we’recoming full circle here, where this is also not helping thecase, ifyou’renot finding the full information there.SoI think thatwas an interesting point to me…

Rovner:Yeah,it’sgoing on bothsidesbasically.It is fraught, and we will continue to cover it.

All right, that is this week’s news. Nowwe’llplay my interview with Elisabeth Rosenthal at鶹Ů Health News, and then we will come back and doourextra credits.

I am pleased to welcome back to the podcast鶹Ů Health News’Elisabeth Rosenthal, who reported and wrote the lasttwo“Bills of theMonth.”Libby, thanks for coming back.

Elisabeth Rosenthal:Thanks for having me.

Rovner:Solet’sstart with our drug copay card patient.Before we get into the particulars,what’sadrug copay card?

Rosenthal:Well, copay cards, orcopayment programs, are things that the drug companies give patients. You know,when it says you could pay as little as $0,where theypayyour copayment, which is usuallypretty big—when you see a copay card, it meanstheprice is big, andthey’llbill your insurance for the rest.Sofor patients, it sounds like a good deal, and it is a good deal when they work.

Rovner:Sotell us about this patient, and what drug did he need that cost so much that herequireda copay card?

Rosenthal:Well, the funny thing is—his name is Jayant Mishra, and he hasa psoriaticarthritis. And the doctor told him, you know,there’sthis drug called Otezla that would really help you.And he was, he was a little cautious, because he knew it could be expensive, so he did wait a few months, and his symptoms, his joint pain, in particular, got worse.He was like,OK,I’llstart it.Sohe started it the first month, and it workedreally well.

Rovner:“It”the drug, or“it”the copay card, or both?

Rosenthal:Both seemed to work very well.Sothe copay card covered his copay of over $5,000 and he was like,Oh, this is great. And then what happened was, the next month, he tried to fillit,and it was like,Wait, the copay carddidn’twork!And really what happens is copaycards,they are often limited in time and in the amount of money that’s on them.Sodepending on how much the copay is,they can run out,basically expire. You used all the money, and you have a drug thatyou’veused that is workingreally wellfor you, and then suddenlyyou’rehit with a big bill.Sotheykind of getpeople addicted to drugs,which they thencan’tafford.

Rovner:And what happenedin this case was the insurance company charged more than expected, right?

Rosenthal:Well, Otezla, you know,there’sso many things about this, and many“Bill of theMonth”stories that,you know,are eye-rollers. Otezla—there are biosimilars that were approved by the FDA in…2021?…whicheveryone’stalking about, faster approval of biosimilars. Well, this was approved, but the drugmaker filed multiple suits and patent infringement, and so in the U.S., itwon’tbe on the market, thebiosimilar,until 2028,sothat’sa problem too.

Rovner:Soif you want this drug,it’sgoing to be expensive.

Rosenthal:It’sgoing to be expensive. And the other problem is copay cards. Insurers used to say,OK, that will count towards your deductible, right?Soyoudidn’treally feel it,right?Because you got a $5,000 copay card,and you had a $5,000 deductible if you had a high-deductible plan.And everything was good. Now, insurerskind of said,Whoa,we’renot sure we like these things.Soyeah, you can use them, but itwon’tcount towards your deductibles.Sothey’renotnearly asuseful as they might have been in the past. But patients are really stuck, because these arereally expensivedrugs that most peoplecouldn’tafford without copay cards.

Rovner:Sowhat eventually happened to this patient, and how can other people avoid falling into the copay card trap?

Rosenthal:So basically, because he had used up the amount on the copay card, which was$9,400 for the year,by the second month, he tried for the third month to kind of ration his drugs to take half as much, and his symptoms came back. And then the lucky thing for him was then it was January,right,copay cardsare usually done for the year.Sohe got a new copay card for another $9,400 and he was good for January, and he paid with his health savings account for the first month’scopay,with the copay card the second month, with the copay card and his health savings account. And when this went to press, hewasn’tsure how he was going to pay for the rest of the year. And for him,it’snot a huge problem, because he has a verywell-fundedhealth savings account, which few of us do, but he wasreally upin the air for the rest of the year when we wrote about this.

Rovner:Sosort of moral of this story, be careful if you want to take an expensive drug, and the theory that when the drugmaker promises,Oh, you can have this for as little as$0copay.

Rosenthal:Well, Ithink it’syou have to understand what a particular card does.You have to understand what’s the limit on how much is on the copay card.You have to understand how many months it’s good for.Youhave tounderstand, from your insurer’s point of view,ifthat will count as your deductible or not. And then, man, you know,you’rekind of onyour own,right?Sometimes your copay card will work great for you, and at other times it will work for a shorter amount of time. And yougotto figure out what to do. I think the third,bigger lesson is getting biosimilars, which are thesevery expensivedrugs approved,is not really the big problem in our country. The problem is the patent thickets that surround so many of these drugs that prevent them from getting to the patients who need them.

Rovner:In other words,you can make a copy of this drug, but you might not be able to get it onto the market.

Rosenthal:Right.You can make acopythis drug—it[a generic]was approved in 2021—but that won’t help patients until 2028,which is really terrible. You know,it’savailable in other countries, but not here.

Rovner:Somovingon,our March patient had insurance through the Affordable Care Act exchange and wasbenefitingfrom one of those zero-premium plans until she got caught in aliterally Kafkaesquemess over a1-cent bill that turned into a5-cent bill. Who is she and what happened here?

Rosenthal:Yeah, her name in this wonderful, terrible story isLorena Alvarado Hill. And what happened here is she was on one of these $0 insurance plans through the Obamacare exchanges with that great subsidy, the Biden-era subsidy, and she and her mother were on the same plan, and her mother went on to Medicare,turned 65.SoLorenadidn’tneedthe familycoverage and told the insurer that. And the insurance, of course, automatically recalculates your subsidy, and her premium went from being zero to1cent. Now,no human would make that, you know, would say,Oh, that makes sense. And to Lorena, itdidn’treally make sense either. She was like,I’mnot sure how to pay1cent, like, will it work on my credit card? And some of the bills said, youknow,you understand that this couldimpactthe continuation of your insurance, but, you know, she was like,1cent,Idon’tthink so. And then she kept going to doctors, and the insurance still worked, and then at some point, four months later, shegota letter in November saying,Oh, your insurance was canceled in July, and you owe money for all these bills.

Rovner:And what happened with this case?

Rosenthal:Well, you know, like many of our“Bill of theMonth”patients, I celebrate them for being real fighters, because her bill, since her premium was1cent a month, went from1cent to2cents to3cents to4cents to5cents,when they sent her the note saying your insurance has been canceled for the last four months.And what turns out, which is really interesting,is this is a known glitch in the way the subsidies were calculated, were administered.There’sa recalculation of subsidies every timethere’sa life event, a kid goes off the plan, you change jobs, get married, youget divorced.Sothe recalculationhappens automatically.And the Biden administration, understanding that this glitch could exist, they gave the insurers theoptionnot to cancel insurance if the amount owed was less than $10.And there wereapparently 180,000people caught in this situation where their insurance could have been canceled for under $10of arecalculated premium. The Trump administration revoked that rule because their feeling was, you owe something, you pay something.Soit’spart of their“stamp out fraud and abuse,”and this was, in their view, abuse of a system when peopledidn’tpay what they owed.

Rovner:One cent.

Rosenthal:One cent,right.Sowhat happenedwithher is, you know,agood bill-payingcitizen sending her daughter to college with loans. She wrote her insurers, she wrote to the state, she wrote to everyone. And as a last resort, of course, someone said,Well,there’sthis thing calledBill of theMonth you could write to.Sowhen welooked intothis,at firstHealthFirst, which was her insurer in Florida, said,Oh,she’snot insured through us.And I was like,Yeah, because you canceled her insurance. And then I gave them her insurance number, and they said,Well, yes, according to law, we did the right thing.Shedidn’tpay,so it was canceled. Somehow, through all of this,word got back to the hospital and the insurer,and they worked together, and her bills were suddenly zero on her portal. Sothat’sthe good news for Lorena AlvaradoHill. Itdoesn’treally help all those other people whose insurance may have been canceled for premiums that were under $10.

Rovner:So,basically, if you get a bill for5cents, you should pay it.

Rosenthal:Yeah, you know, it was funny when this story went up, manypeople were sympathetic, but other commenters said,Well, she should have just paid $1 because you can pay that.Andmaybe therewas a way to pay1cent. AndI’mkind of withher, like, if I got a bill for1cent, life is busy. This is a woman who is a teacher’s aide and works on weekends at a store to help pay for her daughter’s college. Life is busy. You justcan’tsweat over1-cent bills and spend a lot of time figuring out how to pay them. AndI guess the lessonis,what’sthe worst that can happen in a very dysfunctional system where so much is automatednow?Theworstthat can happen is always really bad. Your insurance could be canceled.

Rovner:So basically, stayon top of it, I guess,is the message forboth of thesestories this month. Elisabeth Rosenthal, thank you so much.

Rosenthal:Thanks,Julie,for having me.

Rovner:OK, weare back.It’stime for ourextra-creditsegment.That’swhere we each recognize a story we read thisweekwe think you should read,too.Don’tworry if you miss it. We will post the links in our show notes on your phone or other mobile device. Jessie, why don’t you gofirst this week?

Hellmann:My story is fromThe Texas Tribune, from a group of reporters who Ican’tname individually.There’stoo many of them. But it isin Texas after the governor issued an executive order a few years ago requiring that hospitals check patients’citizenship.Sothe story found that hospital visits by undocumented people dropped by about a third, and the story also got into how this is bleeding into other types of health care at other facilities, free vaccine clinics are not being attended as widely anymore. Peoplearen’tattending their preventive care appointments,like cancer screenings or prenatal care checkups. Some of these other health facilitiesare required tocheck citizenship status, butit’sdefinitely achilling effect over the broader healthcare landscape in Texas.

Rovner:Yeah. There have been a lot of good stories about that. Sandhya.

Raman:My extra credit is fromScience, andit’sby Jocelyn Kaiser, and the story is“.”In her story, she talks about how last year, you know, the administration cut a lot of staff at the Agency for Healthcare Research and Quality. They’ve canceled all of the open grants, but Congress still appropriated $345 million for the agency this year, and so supporters kind of want to revive what should be going onatthe agency, which hasn’t been issuing any of the grants since the start of the fiscal year, and just kind of make progress on some of the things that this agency does do, like running the U.S.Preventive Services Task Force, which has been, you know, something that has been talked about this year. So thought it was an interesting piece.

Rovner:Yeah,I’mold enough to remember whenAHRQwas bipartisan. Alice.

Ollstein:Soavery harrowing story in The New York Times titled“.”And I will say, since this piece ran, we have seen that an oil shipment from Russia is going through to the island, but I don’t think that will be sufficient to completely wipe away all of the upsetting conditions that this piece really gets into,what is happening as a result of the ramped-up U.S.embargo and blockade of the island. Peoplecan’tget food, theycan’tget medicine, theycan’tget electricity, and that is having a devastating effect on healthcare. The Cuban healthcare system has beenreally miraculousover the years, just the pride of the government.It has meant,prior to this blockade,that their life expectancy was better than ours, and a lot of their outcomes were better. Andsothis has been really devastating. There’s, you know, harrowing scenes of people on ventilators having to be hand-pumped when the electricity cuts out,babiesinincubators, you know, losing power.You know, peoplehavingto skip medications, etc. Andsothis is really shining a light on a foreign policy situation that this administrationis behind.

Rovner:Yeah,that’sreally been an under-covered story, too,I think, you know, right off our shores.My extra credit this week is one I simply could not resist.It’sfrom New York Magazine, andit’scalled“,”byHelaine Olen. And as the headlinerather vividlypoints out, we arewitnessingthe rise of pet medical tourism, along with human medical tourism, which has been a thing for a couple of decadesnow.It seems that veterinary medicineis gettingnearly asexpensive as human medicine, and that one way to find cheaper care is to cross the border, which is obviously easier if you live near the border.I’mnot sure how much cheaper veterinary care is in Canada, but as the owner of two corgis, I may have to do some investigating of my own.

OK, that is this week’s show.As always, thanks to our editor,Emmarie Huetteman,and our producer-engineer,Francis Ying.Areminder:What theHealth?is now available on WAMU platforms, the NPR app,and wherever you get your podcasts—as well as, of course,kffhealthnews.org.Also,as always, you can emailusyour comments or questions.We’reat whatthehealth@kff.org.Or you can find me still on X, or on Bluesky.Where are you folks hanging these days?Sandhya.

Raman:Onand on.

Rovner:Alice.

Ollstein:On Blueskyand on X.

Rovner:Jessie.

Hellmann:I’mon LinkedIn under Jessie Hellmannand on X.

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

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