The Host
Julie Rovner
KFF Well being Information
Julie Rovner is chief Washington correspondent and host of KFF Well being Information’ weekly well being coverage information podcast, “What the Well being?” A famous knowledgeable on well being coverage points, Julie is the writer of the critically praised reference ebook “Well being Care Politics and Coverage A to Z,” now in its third version.
Thousands and thousands of individuals in Republican-dominated states are amongst these seeing their Reasonably priced Care Act plan premiums spike for 2026 as enhanced, pandemic-era subsidies expire. But Republicans within the White Home and on Capitol Hill are firming up their opposition to extending these extra funds — not less than for now.
In the meantime, Democrats might not have achieved their shutdown objective of renewing the subsidies, however they’ve returned well being care — certainly one of their prime points with voters — to the nationwide agenda.
This week’s panelists are Julie Rovner of KFF Well being Information, Paige Winfield Cunningham of The Washington Put up, Joanne Kenen of the Johns Hopkins Bloomberg College of Public Well being and Politico Journal, and Shefali Luthra of The nineteenth.
Panelists
Paige Winfield Cunningham
The Washington Put up
Joanne Kenen
Johns Hopkins College and Politico
Shefali Luthra
The nineteenth
Among the many takeaways from this week’s episode:
- Democrats’ concentrate on insurance coverage prices has pushed well being care again into the nationwide highlight. However removed from a bipartisan compromise, lawmakers stay cut up over tips on how to deal with the problem, with the improved premium ACA subsidies nonetheless set to run out and prime Republicans musing about as a substitute placing that cash into well being financial savings accounts.
- A brand new change to the Facilities for Illness Management and Prevention web site suggests a hyperlink between vaccines and autism, amplifying the unsubstantiated declare championed by Well being and Human Companies Secretary Robert F. Kennedy Jr. In the meantime, the Trump administration is dealing with blowback over a significant report on transgender well being that was written by critics of such care — and with out peer overview.
- And a few Republicans are in search of to tie ACA subsidies to abortion restrictions, offering solely the most recent instance of how the problem usually turns into tangled in authorities spending battles. Democrats are unlikely to comply with such adjustments, particularly if Republicans push to direct subsidies into well being financial savings accounts — which means, theoretically, that any abortion limitations there can be focusing on residents’ non-public funds.
Additionally this week, Rovner interviews Avik Roy, a GOP well being coverage adviser and co-founder and chair of the Basis for Analysis on Equal Alternative.
Plus, for “additional credit score” the panelists recommend well being coverage tales they learn this week that they suppose it is best to learn, too:
Julie Rovner: CNBC’s “Cheaper Medicines, Free Seaside Journeys: U.S. Well being Plans Faucet Prescriptions That Feds Say Are Unlawful,” by Scott Zamost, Paige Tortorelli, and Melissa Lee.
Paige Winfield Cunningham: The Wall Road Journal’s “Medicaid Insurers Promise Numerous Docs. Good Luck Seeing One,” by Christopher Weaver, Anna Wilde Mathews, and Tom McGinty.
Joanne Kenen: ProPublica’s “What the U.S. Authorities Is Dismissing That May Seed a Hen Flu Pandemic,” by Nat Lash.
Shefali Luthra: ProPublica’s “‘Ticking Time Bomb’: A Pregnant Mom Saved Getting Sicker. She Died After She Couldn’t Get an Abortion in Texas,” by Kavitha Surana and Lizzie Presser.
Additionally talked about on this week’s podcast:
Click on to open the transcript
Transcript: The GOP Circles the Wagons on ACA
[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: Hiya from KFF Well being Information and WAMU Public Radio in Washington, D.C., and welcome to “What the Well being?” I’m Julie Rovner, chief Washington correspondent for KFF Well being Information, and I’m joined by among the greatest and smartest well being reporters in Washington. We’re taping this week on Thursday, Nov. 20, at 10 a.m. As at all times, information occurs quick, and issues may need modified by the point you hear this. So, right here we go.
At this time, we’re joined by way of video convention by Paige Winfield Cunningham of The Washington Put up.
Paige Winfield Cunningham: Hello, Julie.
Rovner: Shefali Luthra of The nineteenth.
Shefali Luthra: Hiya.
Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg College of Public Well being and Politico Journal.
Joanne Kenen: Hello, everyone.
Rovner: Later on this episode, we’ll have my interview with Avik Roy, longtime Republican well being care adviser and chair of the Basis for Analysis on Equal Alternative. However first, this week’s information.
So, Democrats might not have “gained the shutdown,” however they undoubtedly bought well being reform again on the nationwide agenda. The final time we had such a full-scale well being debate was in 2017, which didn’t finish notably nicely for Republicans. For some time, it appeared like there is perhaps sufficient Republicans who have been apprehensive about — oh, I don’t know — their voters seeing their ACA [Affordable Care Act] insurance coverage made successfully unaffordable that there is perhaps a compromise within the offing. However now it appears that evidently ship has sailed, and the 2 sides have retreated to their respective corners. That actually appeared to be the case on the Senate Finance Committee listening to on Wednesday, the place Republicans and Democrats principally talked previous one another for 3 hours. Am I lacking one thing? Is there some glimmer of hope right here that I’m not seeing that after they have this vote in a few weeks, the Republicans are all going to say, Yeah, let’s prolong these subsidies?
Winfield Cunningham: It’s humorous, Julie, I used to be pondering, was it final weekend, I believe, that Trump tweeted about we have to bypass the insurers and ship the cash on to shoppers? And for a few days, there was all this buzz round Is that this going to be one more likelihood for Republicans to do one thing massive on well being care? And the entire time I used to be pondering: Was anyone round in 2017? This isn’t going to go anyplace. And particularly, you could possibly type of predict this simply because calls to redirect the subsidies — that are a core a part of the ACA — away from the marketplaces, additionally a core a part of the ACA — instantly into tax-free financial savings accounts clearly [were] at all times going to be a no-go with Democrats. So the concept this was type of what Republicans have been speaking about, this isn’t even within the realm of prospects that could possibly be a bipartisan settlement on well being care.
There appears for a short time to be a semi-earnest effort within the Senate to provide you with some type of bipartisan plan. I do know I spoke with people for Sen. [Jeanne] Shaheen [D-N.H.] earlier this week who say they’ve been speaking to 10 to 12 Republican places of work who say they’re excited by some type of deal and lengthening the subsidies. However actually, if you begin stacking up all of the obstacles that might be in the best way of getting a deal, certainly one of them is abortion funding. I imply, this appears —
Rovner: We’ll get to that later. Don’t soar the gun on that.
Winfield Cunningham: However that’s an enormous one. After which additionally, simply the shortcoming, and simply how far aside the events are on speaking about well being care affordability and the way you handle to carry down prices for individuals. It’s simply actually exhausting to see this going anyplace. So, my prediction is that we see Republicans type of coalesce round their very own factor. Democrats coalesce round their very own factor. And finally, we don’t see an extension of the subsidies.
Rovner: What occurs in January, although, when individuals truly begin coming to city corridor conferences and saying: Hey, we had to surrender our medical insurance as a result of it was going up $4,000 a month? Would possibly this construct when these cuts truly happen in January?
Kenen: The Republicans have floated well being financial savings accounts for truly a couple of a long time now.
Rovner: Because the Nineties.
Kenen: Proper, that’s a long time.
Rovner: The primary pilot undertaking was in HIPAA [Health Insurance Portability and Accountability Act] in 1996.
Kenen: And it’s not what individuals need. I imply, it’s what some individuals need together with an HSA alone. There are plans which are a mixture of — within the alternate it might be a “bronze” — however this isn’t what the American individuals have. … They haven’t been saying: Please, take away my well being care, and provides me a few thousand bucks as a substitute. That’s not what we’re listening to, or my well being insurance coverage, I ought to say, and take away.
Rovner: That’s the purpose. Additionally, I’m seeing all these Republicans now saying we shouldn’t be giving cash to the large, wealthy, bloated insurance coverage corporations, who we do know are unpopular as a substitute —
Kenen: Aside from Medicare Benefit.
Rovner: Thanks for ending my sentence. So, end my sentence for me, Joanne.
Kenen: Medicare Benefit, which has bipartisan help now — not with out some {qualifications} and criticism — Medicare Benefit is right here. Many Democrats use it, and lots of Democratic lawmakers help it. However Medicare Benefit is non-public insurers who’re being paid greater than government-traditional Medicare to pay for individuals’s well being care. So it’s not a coherent, well-thought-out ideologically, or technically, or politically savvy plan that’s going to resolve the Republicans’ issues on Jan. 1, Jan. 2, Jan. 3, and also you title the date after that. Individuals who bought subsidies for well being care insurance coverage are going to lose them, and lots of of them are [President Donald] Trump voters. And that’s a actuality, interval.
Rovner: Paige, I do know you’ve been wanting into this fairly intently. Is there something new right here? I imply, it does appear that giving individuals cash to exit and discount on their very own has been the Republican mantra, I do know, because the Nineties. They’ve had all this time. The place is the plan?
Winfield Cunningham: Let’s simply take into consideration the numbers right here on HSA. So, I believe the common subsidy [that] the common market client will get is round $6,500. OK, that’s high quality — nice — if you’re wholesome. In case you’re sick — in case you have diabetes, or you have got most cancers — say you have got $6,500 in your account, [and] you don’t have well being insurance coverage, that’s not going to come back anyplace near the associated fee that you must cowl your value of care. So this entire dialog isn’t about the wholesome individuals, proper? The dialog is concerning the sick individuals who carry up the prices, who want the insurance coverage, who can’t afford the care. And HSAs and FSAs [flexible spending accounts] — particularly HSAs, although — I suppose are largely used by wealthier individuals, more healthy individuals, and it’s a technique to possibly put a couple additional hundred bucks in your pocket to pay for well being care. It isn’t a sweeping long-term resolution to creating positive that individuals can afford the price of care.
Rovner: Proper. It’s a good way to pay in your eyeglasses and your dental care, possibly, if you don’t want numerous dental care.
Kenen: It’s not simply sick individuals. It’s additionally being pregnant. It’s additionally people who find themselves wholesome till they get sick. You can —
Rovner: I maintain saying this: I fell and broke my wrist, and it value $30,000. $6,500 wouldn’t have begun to place a dent in it. Sorry, Shefali. You wished to say one thing?
Luthra: No, I used to be simply going to say to Joanne’s level about being pregnant and your level about breaking bones: A few of the people who find themselves most susceptible in this type of state of affairs [are] households. Perhaps you give beginning, one thing the administration actually talks about supporting. Perhaps, I don’t know, you employ fertility therapy. Perhaps you have two youngsters. One will get the flu; one breaks a bone. These will not be bills you anticipated. And the very core of this pronatalist, conservative ideology of supporting households, serving to it turn out to be simpler to boost youngsters, turns into rather a lot tougher if you don’t have inexpensive medical insurance.
Kenen: I imply, there are some. [Louisiana Republican Sen. Bill] Cassidy’s plan is a bit totally different. Democrats are nonetheless not going to find it irresistible. It’s cash in your pocket of a well being financial savings account or a versatile spending account — I maintain studying totally different particulars of what it’s — mixed with some type of medical insurance in order that the publicity is just not infinite, however it’s additionally not nothing. It’s not the identical as Trump’s plan. There’s extra safety for individuals in his model. However we haven’t actually seen what his model seems to be like intimately. I maintain studying about all these proposals, and I can’t determine precisely what they appear like as a result of I don’t suppose they know but.
Rovner: Proper, I don’t suppose they’ve been placed on paper but.
Winfield Cunningham: Effectively, yeah, I requested Cassidy’s workplace for particulars earlier this week, and so they didn’t reply. I don’t know if they’re ready to see what polls nicely amongst colleagues. However I used to be going to say: On the politics, I’m by no means nice on political evaluation as a result of I really feel like I’m at all times fallacious. However I’d say [the] final time Republicans tried to go after ACA in 2017, Democrats actually efficiently leveraged that within the following 12 months. They talked about attempting to go after protections for preexisting situations. And you’ve already seen, I believe, [that] the DCCC [Democratic Congressional Campaign Committee] already put out some adverts on the subsidies. So, that is going to be an enormous, large level for Democrats. They’re going to be speaking about this nonstop subsequent 12 months. So, I think about it might damage Republicans.
I’d additionally add, I believe that Democrats typically have extra to lose on well being care than Republicans solely as a result of well being care is just not a prime concern for Republican voters in the best way that it’s for Democratic voters. So, typically, Republicans could make missteps, after which their voters are extra forgiving of it than possibly they can be of Democrats.
Rovner: Though we’ll see, as a result of as we maintain saying, there’s numerous Republicans in numerous these states which have been utilizing these additional subsidies. After they go away, they’re going to be actually ticked off.
Kenen: May I simply say one very last thing? And we’ve mentioned this once more, we’ve mentioned this repeatedly, however it’s price bearing, repeating is: Congress often offers individuals advantages. Taking away advantages is just not actually a politically savvy strategy. After which, sure, Medicaid isn’t till after the election, after the 2026 elections. However there’s going to be repercussions from the Medicaid legislation that [are] additionally going to be felt within the close to time period by way of how are hospitals getting ready, and responding, and slicing again, and what’s out there in communities, and debates of their state legislatures about how they fill funds holes, and what companies can be reduce. That is turning right into a well being care 12 months on each the ACA well being prices and affordability and the influence of Medicaid that often helps Democrats. However we live in a time of intense brief consideration spans. We’re not residing in … the parallels don’t at all times apply to the present state of affairs, however it’s a Democratic concern.
Rovner: Yeah. Effectively, persevering with on my theme of possibly Democrats didn’t actually lose the shutdown regardless of what a lot of them mentioned, I’m type of shocked in any respect the issues that did get into the persevering with decision that handed final week and reopened the federal government. Democrats bought all of the federal staff again pay, which, regardless of being the legislation, was not a given. They bought the federal employee firings through the shutdown reversed with a promise of no extra RIFs [reductions in force] till not less than the tip of the subsequent CR on the finish of January. As a result of the CR additionally included full-year funding for the Division of Agriculture, in addition they bought SNAP [Supplemental Nutrition Assistance Program] totally funded via subsequent September.
However two different actually nerdy issues have been tucked into the invoice that might flip into an enormous deal. One is the express rejection of a proposal to chop in half the funds of the Authorities Accountability Workplace, GAO, and preserving the correct of the GAO’s head, the comptroller common, to sue the administration for violating the Impoundment Act, which is what protects Congress’ energy of the purse. That is actually the struggle over the funding payments, proper? We’ve bought the Trump administration saying, Congress, we don’t truly care what you do in these spending payments. We’re going to determine tips on how to spend this cash. — which isn’t what the Structure says.
Kenen: However the Congress has its goal. I imply because the administration —
Rovner: The GAO has, and they’re suing.
Kenen: Proper. However on the finish of the day, what’s occurring within the courts is just not actually altering conduct all that a lot, so it’s nonetheless —
Rovner: As a result of it hasn’t all been resolved but.
Kenen: It’s a TBD [to be determined]. I believe we’ll know extra after the tariffs ruling. However after they do undergo a defeat in courtroom, they only type of discover one other approach round. Even when they do one thing, the courtroom says they only discover one other approach of doing what they wished to accomplish.
Rovner: Sure, which we’ve got seen. And apparently they did. I noticed a narrative this week that they have been attempting to place in a provision that might cease what we name the pocket rescissions. Proper now, the administration can say, We don’t need to spend this cash, after which Congress votes on whether or not or not to agree with the administration. But when they do it on the finish of the fiscal 12 months, it’s too late. And that’s referred to as a pocket rescission. There was some language to cease that, which additionally seems on its face to be unlawful. And apparently Russell Vought of OMB [Office of Management and Budget] complained, and it was taken out of the invoice earlier than it was handed. In order that struggle [is] going to nonetheless proceed.
Effectively, there’s one other much more nerdy provision that resets one thing referred to as the PAYGO [pay-as-you-go] scorecard to zero. Amongst different issues, this cancels the required cuts to Medicare that would’ve been the results of the Republicans failing to offset the price of the tax cuts in final summer time’s massive funds invoice. You could have heard Democrats referring to those cuts and thought they meant Medicaid, thought they have been misspeaking. They weren’t. There truly was a half-a-billion-dollar reduce to Medicare that was within the offing. However canceling this type of cuts each methods as a result of it takes away a speaking level for Democrats, proper?
Kenen: Sure, however I don’t know that that one’s going to matter a lot in six, 10, 12 months. As a result of additionally, we’re used to them not doing the cuts to Medicare that they’ve mentioned. I imply, they stroll to the very edge of the plank and soar again into the boat again and again since 2012 not less than, most likely earlier than that. So I don’t know that that has the staying energy. It’s exhausting. Just like the phrase sequester, sadly we perceive it, however lots of people suppose it’s a jury. I imply cuts that didn’t occur —
Rovner: Proper, and cuts that aren’t going to occur. We’ll see how lengthy it takes the Democrats to wipe the Medicare cuts out of their speaking factors, which they now must do as a result of that was within the invoice. Effectively, in the meantime, even with the federal government again open, the chaos continues at Robert F. Kennedy Jr.’s Division of Well being and Human Companies, the place simply this morning we’ve seen a change to the CDC [Centers for Disease Control and Prevention] web site suggesting that vaccines would possibly trigger autism. They don’t. And a brand new large-scale examine exhibiting that fluoride in typical doses doesn’t decrease youngsters’ IQs, which is the precise reverse of what RFK Jr. has been saying. Paige and Shefali, you’re following this report on transgender care, which is one other type of massive controversial concern over at HHS.
Winfield Cunningham: Yeah. So what we noticed yesterday was principally the closing launch of this report, which was ordered up by Trump by way of government order earlier this 12 months. And so they had launched an preliminary draft final spring, however at the moment, they didn’t launch the names of the authors on the report, nor did it have any peer reviewers. And that was the main target of numerous the criticism of the report — that there wasn’t transparency there to see who was truly reviewing all of this proof round gender-transition care for youths. So, we noticed the names of the 9 authors have been launched yesterday, in addition to about eight peer reviewers. This additionally, not shockingly, didn’t engender numerous broad confidence within the medical group about this report. And the authors of the report all have prior histories of criticizing how gender-transition care is delivered within the U.S. And critics have pointed to that saying: Effectively, the report’s not reliable as a result of principally the individuals have been handpicked by the administration to ship a selected conclusion.
And so I’ve been speaking to among the authors. They’re after all defensive. They are saying, Look on the analysis. Have a look at the report. The report does skew very crucial of transition care and recommends counseling first, which is one thing that among the main medical organizations are pushing again towards. So, I don’t know the place all that is going to go. I believe the talk [is] going to proceed, however actually we’re going to see the administration use this report back to attempt to undergird its arguments for a dramatic crackdown on transition care. They’re truly working on two guidelines at CMS [Centers for Medicare & Medicaid Services] proper now which might penalize hospitals for offering transition care for youths. These guidelines are being reviewed I believe by the White Home proper now, however we’re most likely going to see these finalized someday subsequent 12 months.
Luthra: I believe some actually vital context for us to contemplate right here — on this dialog in addition to what the precise actuality of well being care seems to be like for trans youth — and particularly, the factor that basically stands out to me as we take a look at this report and take a look at these criticisms that these authors are levying, is that already, for younger people who find themselves getting gender-affirming care, it’s a really concerned course of. There aren’t numerous suppliers who provide this to start with. There’s numerous counseling. The concept younger persons are getting these gender-affirming surgical procedures at a younger age with none type of long-thought, lengthy dialog simply isn’t actually borne out by proof. There’s numerous dialog, a lot of counseling. Lots of youth begin with issues which are reversible. You begin with possibly one thing that doesn’t have that very same stage of permanence earlier than guaranteeing that that is one thing that individuals actually do need. And I believe that’s actually vital.
The opposite factor that basically sits with me on this dialog — which I believe it is a dialog that has been actually constructed up by numerous social conservatives who’re searching for a brand new goal after they type of misplaced the conflict on homosexual marriage — is that younger persons are type of a place to begin. And we’ve already seen numerous efforts in some states to broaden restrictions on gender-affirming care — not just for younger individuals, however for individuals of all ages who’re trans. It jogs my memory rather a lot, truly, of the dialog round abortion, the place you started with restrictions for younger individuals as a pathway to limiting it writ giant. And I believe we must be actually conscious of that context after we take a look at how this political and coverage struggle unfolds.
Rovner: Yeah, there’s additionally rather a lot much less of this care you’re saying. It’s exhausting to get. There’s much less out there than there was at first of the 12 months. We’ve seen so many of those universities and hospitals knuckle below and say, We simply don’t need to be a part of this as a result of they’re threatening to remove all of our funding. There’s a brand new examine in JAMA Inside Medication this week that discovered that HHS cuts from earlier this 12 months disrupted greater than 400 scientific trials, and therapy for greater than 74,000 sufferers who have been taking part in these trials. Most impacted, based on the report, have been trials on infectious illnesses and prevention. However a second examine chronicled the deep cuts to gender-affirming care. So, it’s not even how it’s being delivered, it’s if it’s being delivered at this level, proper?
Luthra: The people who find themselves getting this well being care have gone via numerous hoops to get this care already. They’ve proven an actual … need is the fallacious phrase. They’ve labored very, very exhausting to get right here in a approach that you just don’t do if this isn’t one thing you have got thought of rather a lot.
Rovner: It’s not like quitting smoking.
Winfield Cunningham: However I additionally add, this isn’t a dialog that’s solely occurring within the U.S. That is occurring world wide. You will have seen an enormous surge of younger individuals in search of this care. So it’s type of a comparatively new factor. And in a approach, simply by way of the variety of individuals, and you’ve seen. … I believe New Zealand truly this week introduced that they’re placing new restrictions on puberty blockers for younger individuals. You’ve additionally seen comparable issues within the U.Ok. [United Kingdom] and the Netherlands. And they’ve additionally carried out evaluations, simply elevating questions round how a lot proof we’ve got across the long-term advantages or harms of giving these remedies to youngsters. So I believe it’s an vital dialog for researchers to be having. And I believe it’s unlucky it’s gotten so politicized, as a result of that is, to Shefali’s level, actually vital for lots of kids within the U.S. and world wide. And yeah, it’s actually vital for researchers to have a actually clear image of one of the best ways to assist them.
Rovner: Yeah, I used to be going to say that is a type of issues that’s each a tradition conflict concern, and a reliable medical scientific concern that we’re taking a look at.
Effectively, in the meantime, it’s not simply coverage that’s a bit chaotic at HHS. In line with The Wall Road Journal, the secretary reportedly thought of sidelining FDA [Food and Drug Administration] Commissioner Marty Makary due to his lack of ability to regulate infighting between a few of his division administrators. But it seems like FDA is type of the least of Kennedy’s worries proper now. Additionally ongoing are fights between supporters of MAGA, the Make America Nice Once more motion, and MAHA, the Make America Wholesome Once more motion, over who ought to be accountable for well being coverage. Is that this simply normal infighting, or is that this type of new and totally different and [at] a extra important stage than we usually see?
Kenen: I’m undecided we all know but, as a result of some of these things is boiling up fairly shortly. However we’re seeing all types of splits and fractures on the Republican facet that we’ve got not been accustomed to seeing. Trump is superb at unifying his get together, and papering over issues, and altering the topic. He’s a really, very gifted controller of narrative. And the truth that we’re seeing coverage splits in addition to the [Jeffrey] Epstein scandal, and all types of different issues, it’s not one crack. There’s a bunch. And crack is perhaps too robust a phrase — we don’t know but — however we’re seeing extra dissent, and extra disagreement effervescent over in public than we had earlier than.
Rovner: Sure, and that’s what’s so uncommon to me. Have these individuals had lengthy knives out for one another? Completely. Have we seen massive front-page tales about it? Not a lot.
Kenen: And it’s heightened because the New Jersey and Virginia races. It’s extra blame-gaming going round. So I believe we’re seeing a barely totally different inside panorama amongst Republicans, as we simply mentioned, it’s obvious how a lot these well being care versus public well being versus vaccine versus MAHA versus MAGA, these … how a lot they splinter and keep splintered. It’s attention-grabbing to observe proper now. I imply, Kennedy hasn’t been that engaged on the well being coverage facet, the insurance coverage struggle, the HSAs, FSAs, subsidies. That’s not the place his public power is.
Rovner: He’s left that to Dr. [Mehmet] Oz principally.
Kenen: Proper. And we all know what’s vital to him. There’s an extended checklist of adjustments he needs to make on that facet. So, I believe it’s attention-grabbing. I believe it’s important. I don’t know what it’s going to appear like in a month.
Rovner: OK. We’re going to take a fast break, and we are going to be proper again.
OK. We’re again. Effectively, there may be additionally information, lastly, this week on the reproductive well being entrance, as you tried to leap the gun, Paige. Circling again for a minute to the approaching vote on extending the improved ACA subsidies, abortion seems to be an enormous impediment to any potential compromise, even when there was one available. This shouldn’t actually be shocking. Abortion very almost scuttled the passage of the ACA itself in 2010 —
Luthra: On the final minute.
Rovner: On the final minute. And anti-abortion forces nonetheless suppose the legislation is simply too lenient, despite the fact that it’s much more restrictive than abortion-rights backers had wished and fought for. Shefali, are Republicans actually going to refuse to cease premium will increase for voters simply to please the anti-abortion motion?
Luthra: I don’t see why not. It looks as if that is … I imply, actually, although, the anti-abortion motion in some methods took a fairly massive loss getting Trump because the Republican president. That is somebody who does not likely need to capitalize on the post-ops momentum with a nationwide ban. And so they’re wanting the place they can to try to limit abortion via different means — whether or not that meant the Deliberate Parenthood defunding, whether or not meaning attempting to get this mifepristone reviewed, or if it means attempting to enact extra restrictions via ACA subsidies. It actually looks as if type of a no brainer. In case you can’t get this win for a vital constituency from the president, you do what you may all over the place else to try to get it, or get not less than what you may.
Rovner: OK. Paige, now you get to say what you wished to say earlier than.
Winfield Cunningham: Effectively, no, I assume I was simply going to say once more, I’ve simply been pondering rather a lot about 2017 and the way well being reform by no means appears to go ahead. However yeah, it is a perennial concern. It’s all concerning the Hyde [Amendment] language and anti-abortion people, and Republicans have at all times been very resentful of how the talk concerning the ACA went about. And they’re upset as a result of they suppose these plans are that taxpayer {dollars} are nonetheless going to abortions, et cetera, et cetera. And really, I was pondering with this HSA concept of rerouting the subsidies to the HSAs, the issue would truly be much more pronounced, as a result of they’re going to demand that you just connect then abortion restrictions to cash that individuals have in their very own accounts that they’re alleged to be utilizing for well being care. And that simply looks as if much more of a no-go with Democrats. I believe all of us knew this was an enormous impediment, nevertheless it takes a bit little bit of time for individuals on [Capitol] Hill to determine this out, however I believe it’s changing into an increasing number of clear that that is only a actually huge barrier.
Rovner: Yeah, it’s. All proper, nicely the abortion struggle additionally continues within the states. South Carolina lawmakers this week held a listening to on what would’ve been the strictest abortion ban within the nation, permitting judges to ship girls who’ve abortions to jail, and doubtlessly limiting IVF [in vitro fertilization] and a few types of contraception. Apparently, that invoice went a bit too far, even for some Republicans on the subcommittee. The invoice didn’t advance, not less than for now. Are we prone to see extra legal guidelines like this, although, as states attempt to prime each other in pleasing what the anti-abortion forces need?
Luthra: I believe we are going to. This can be a actually long-standing and deep debate within the state-based anti-abortion motion, and particularly the debates over contraception, the debates over IVF, and particularly round whether or not you ship somebody who will get an abortion to jail, whether or not they’re held criminally liable. And there’s a very excessive motion; they name themselves abortion abolitionists. They are introducing payments and rising numbers yearly, attempting to construct up help. Even among the fairly conservative abortion opponents say, Oh, these persons are too excessive for me. However they’re gaining affect. And I see this as a dialog and a debate that the anti-abortion motion solely continues to have, particularly as that is one thing that progresses on the state stage and never essentially the federal one.
Winfield Cunningham: I do surprise, although, how far more room there may be for state bans, since you noticed this large surge in pink states inserting bans after Dobbs [Dobbs v. Jackson Women’s Health Organization]. At this level, I believe round 17 or so states have almost-complete bans on abortion. So in a approach, I believe there’s been numerous work accomplished there. And I believe the chance that the anti-abortion people see is on the federal stage, however after all they’re working into prime appointees — Kennedy, among the others at HHS, who, for them, that is actually not a precedence — and it doesn’t sound like anti-abortion people would like to see them roll again entry to mifepristone, for instance. I’m not satisfied that’s going to occur anytime quickly as a result of the parents pulling the levers there aren’t essentially within the camp.
Rovner: Yeah, apparently one of the explanations that individuals aren’t indignant with Marty Makary at FDA is as a result of he seems to be slow-walking this mifepristone examine, and he accredited, despite the fact that he needed to, one other generic of the treatment. So, I do know that that’s additionally a part of this.
Luthra: If I can add yet one more factor, Julie?
Rovner: Sure, please.
Luthra: Frankly, a actually good litmus take a look at for the place states are heading is coming in just a few weeks when Texas’ new abortion legislation takes impact. And this is likely one of the most formidable efforts to cease telehealth and defend legislation provision of abortion. And that is an space the place state-based abortion opponents are very pissed off, as a result of they see it as breaking or essentially incapacitating their abortion bans when individuals can nonetheless get treatment via the mail from medical doctors who haven’t been efficiently prosecuted for doing so. And so, when this legislation takes impact, it allows civil lawsuits towards individuals who make treatment abortion out there in Texas. I believe we are going to see: Are there civil fits filed by abortion opponents, for occasion. Is there any actually concerted effort to make use of this new device to cease telehealth? And if that’s the case, does that unfold to different states? Particularly since Texas has for thus lengthy been an actual pioneer in abortion restrictions and making it even tougher to get.
Rovner: Yeah, the place Texas goes, so go the remainder of the pink states.
All proper, that’s on a regular basis we’ve got for the information this week. Now we are going to play my interview with Republican well being knowledgeable Avik Roy, after which we are going to come again and do our additional credit.
I’m so happy to welcome to the podcast Avik Roy right here in individual in our studio at KFF. Avik is co-founder and chairman of the Basis for Analysis on Equal Alternative, which research and recommends social insurance policies for the half of the inhabitants that earns lower than the U.S. median. However he’s additionally a longtime well being coverage wonk and well being adviser to Republicans, together with a number of Republican presidential candidates through the years. And full disclosure, he’s, like me, a fellow Michigan Wolverines fan.
Avik Roy: Go, Blue.
Rovner: Avik, welcome to “What the Well being?”
Roy: Nice to see you, Julie.
Rovner: So, how did you come to well being coverage? It was a little bit of a winding highway, wasn’t it?
Roy: Yeah, I type of fell into it. I used to be working as a well being care investor, truly, at Bain Capital and a pair of different locations like that, as a well being care investor. In 2008, [Barack] Obama will get elected and begins to speak about what we now name the Reasonably priced Care Act, or Obamacare. And I wasn’t studying something I agreed with. At the moment, you had Ezra Klein, then at The Washington Put up, and also you had Jonathan Cohn at The New Republic. You had that group of younger bloggers who’re writing, Hey, there’s this good MIT economist named Jonathan Gruber, and he’s bought all of it found out, and all the things’s going to work nice, and premiums are going to go down. And Obama himself promised that premiums for the common household of 4 would decline by $2,500 per 12 months. That’s what he campaigned on in 2008. Then on the conservative facet, you had lots of people writing issues like, It’s massive authorities. It’s unconstitutional. It’s welfare.
And I discovered these arguments type of like empty energy, as a result of for the common American who’s struggling to afford medical insurance and well being care, I simply don’t see how that individual goes to reply to that type of argument. They’re going to be like, Look, if one facet is telling me they’re going to scale back my premiums by $2,500 per household per 12 months, and the opposite facet is simply saying, ignore this all as a result of it’s massive authorities, which facet is the common individual going to decide on? They’re going to decide on a facet that’s going to attempt to cut back their well being care payments. And my viewpoint was not aligned with both of these positions. My viewpoint was truly: Well being care payments are going to proceed to extend, and the design of the ACA has numerous flaws that aren’t being referred to as out as a result of the conservative critics simply weren’t digging into the technical design — the structure of the invoice. And despite the fact that I’m not as eminent as Jonathan Gruber, I did go to MIT. And so I possibly felt a bit extra prepared to have interaction in that debate.
Rovner: And you’re a physician.
Roy: Effectively, I went to med faculty. I by no means practiced, don’t have a license.
Rovner: However you have got, not less than, the medical schooling. So you have got an excellent little bit of background on this. I need to suppose broadly. Each different developed nation has some type of nationwide medical insurance scheme. Most of them are hybrids of public and non-public. A few of them extra public; a few of them extra non-public. Why hasn’t the U.S. been in a position to resolve this downside that each different developed nation has?
Roy: We truly do numerous work on this on the Basis for Analysis on Equal Alternative. We have now a complete annual analysis product we put out referred to as the World Index of Healthcare Innovation, the place we examine 32 nations world wide with the very best GDP [gross domestic product] per capita which have a inhabitants over 5 million on high quality, alternative, science and know-how, and monetary sustainability. So, numerous different individuals do these sorts of comparisons, however our examine is totally different for 2 causes. One, we don’t simply take a look at OECD [Organization for Economic Co-operation and Development] nations, which is often the place most teachers get their knowledge. We take a look at nations which are outdoors the OECD, notably in Asia. And we additionally once more rating nations not merely on well being outcomes and equity-type measures, however we additionally take a look at issues like fiscal sustainability, which we expect issues for long-term fairness, and science and know-how. One of many defenses of the American system that you just at all times hear is, Effectively, sure, our system is so costly, however we’re additionally the innovation middle of the world, and also you can’t have one with out the opposite.
So, one factor that we wished to check was: Is that actually true? Can you have got innovation at a U.S.-like stage however with a common system that covers everyone and has good high quality? And the system that has ranked No. 1 in our examine yearly is Switzerland. The explanation that’s actually attention-grabbing is as a result of there’s a false impression, each on the left and the correct, that to realize common medical insurance you must have a single-payer system. And that’s not truly true. There are many nations — they are a minority of the industrialized nations, however it’s a strong and important minority — which have achieved common protection utilizing non-public insurance coverage, not essentially a single-payer, government-run insurer. And Switzerland is, in our view, the most effective instance of that as a result of Switzerland is a spot the place there’s an modern pharmaceutical and biotech, and med gadgets ecosystem. They’ve common protection. It’s principally like Medicare Benefit for all, or Obamacare for all. It’s a common particular person market the place the market is regulated and backed, nevertheless it works.
Rovner: I’d say massive subsidies. I’ve been to Switzerland. I’ve studied the Swiss well being care system.
Roy: Massive subsidies. It will depend on your vantage level. Relative to the American system, the subsidies are truly fairly low. So what Switzerland spends subsidizing well being care is about 45% of what the U.S. spends per capita subsidizing well being care. We truly subsidize well being care per capita greater than every other nation within the world, as a result of the price of well being care is so excessive in America that the price of subsidizing well being care is so excessive.
Rovner: Which was going to be my second level about Switzerland is that it’s far more regulated than numerous Republicans suppose.
Roy: Effectively, it’s about as regulated as Medicare Benefit, or the ACA plans by way of the insurance coverage plan to signal. There are different issues — and we don’t must spend all of our time on Switzerland right here — however you ask the query, it’s like, Why can’t we do that in America? That was your authentic query, and there’s numerous causes for that. One is path dependence. With any well being care system, as soon as you’ve established it, it’s exhausting to vary. The one factor I’ll say that we did within the mid-Twentieth century that basically put us on this path was after we excluded from taxation employer-sponsored insurance coverage, as a result of in World Battle II there have been wage and value controls. Employers found out tips on how to get round that by providing employer-sponsored insurance coverage that wasn’t regulated by wage and value controls. After which after the conflict, [Dwight D.] Eisenhower mentioned, Yeah, let’s not tax these insurance coverage insurance policies as a result of they appear to be vital for individuals.
And it was type of an offhanded determination. Nobody actually knew that that was going to be this massive factor. However positive sufficient — 80 years later, or 70 years later — right here we’re. And I’d argue that’s the largest driver of well being care inflation, as a result of we don’t merely have third-party fee for well being care. Each nation has third-party fee for well being care. However we’ve got third-party fee of third-party fee of well being care. We have now ninth-party fee of well being care principally. And no surprise that nobody has any sense of why all the things is so costly. However that’s the core driver. And sadly, Medicare, particularly, constructed on that system. When the Medicare legislation was handed in 1965, a key aspect of Medicare was to construct upon and drive the advantages based mostly on the standard Blue Cross employer-based plan, which had by that time already ballooned into one thing resembling what we’ve got now.
Rovner: So why has well being care been such a low precedence for Republicans? I at all times hear, Effectively, Republicans don’t actually work on this as a result of it’s not vital to their voters. That can’t presumably be true anymore.
Roy: I believe all the things you mentioned is excellent. I believe that traditionally, Republicans didn’t really feel that it was related to their voters. And their voters weren’t actually pushing for it as a result of their voters have been — relative to the median constituent — maybe extra prone to be employed, or extra prone to be on Medicare — and due to this fact didn’t really feel like they needed to fear about affordability. However affordability, as everyone at KFF is aware of, and the viewers that listens to your program is aware of, affordability is an enormous deal for everybody. Premiums within the employer-sponsored market have gone up, and other people don’t essentially discover that. However they discover that their paychecks have been flat. They discover their deductibles going up, and their copays going up, and that’s been an enormous downside each within the ACA markets, and the employer market.
However affordability is an enormous deal. And now that the Trump GOP has turn out to be extra of a working man and lady’s get together — and also you see it in all of the exit polls that should you truly take a look at who’s voting for Democrats and who’s voting for Republicans in presidential election years — the Republican citizens is now a bit extra lower-income than the Democratic constituency, which has much more of these school grads, and grad faculty grads. I believe you’re beginning to see extra of that populist concern concerning the affordability of well being care, however there’s nonetheless an infinite quantity of mental catch-up to get there. And I believe due to this expertise of finding out the worldwide well being care world, I’ve been far more optimistic concerning the skill to realize common protection in a approach that’s pleasant to free marketeers, individuals who consider in private-sector competitors.
Whereas I believe the standard Republican view, which you type of alluded to earlier — and I bumped into this rather a lot within the 2017 repeal-and-replace debate — was it’s not the federal authorities’s job to make sure that everyone has inexpensive medical insurance. That’s what I heard from numerous the type of old-line Republicans and Republican staffers within the 2010s. It’s not the federal authorities’s job to ensure inexpensive medical insurance for individuals. That ought to be as much as bizarre individuals to make sufficient cash to afford medical insurance. And I disagree with that very strongly. And the explanation I disagree with that very strongly is as a result of it was the federal authorities that screwed it up within the first place. It was the tax exclusion for employer-sponsored insurance coverage, after which among the issues across the design of Medicare that drive all of the well being care inflation that we’ve seen during the last 80 years.
So the federal authorities created the mess, and it’s the federal authorities’s job to scrub up the mess. And I assume you could possibly say an enormous function of my work is to attempt to persuade extra Republicans to agree with me on that.
Rovner: So why has it been so exhausting for Republicans to come back collectively on something? The Democrats have massive divisions, too, on well being care. They’ve an enormous chunk of Democrats who would really like “Medicare for All,” and one other chunk of Democrats who want to construct on the present system. Republicans presumably have the identical sorts of divisions, simply within the different path, and but we nearly by no means see Republican proposals, and we do see Democratic proposals.
Roy: Effectively, I’ll quibble with you a bit bit, Julie, in that there are Republican proposals. They don’t at all times get the identical quantity of media protection that the Democratic proposals get. There’s a invoice that’s been launched in each the Home and the Senate, based mostly on our work at FREOPP, referred to as the Honest Care Act, which might obtain voluntary common protection. It wouldn’t power anybody to purchase protection, however everybody who needs to purchase medical insurance can be assured to have an inexpensive choice. It could cut back the deficit, improve protection by about 9 to 10 million, and in addition cut back federal spending. It could cut back taxes, and cut back federal spending, as a result of it might cut back the underlying value of well being care.
Rovner: How?
Roy: By, particularly, tackling the ability of hospital monopolies, and being extra aggressive about excessive drug costs. And it might additionally means-test the subsidies. And by means-testing, I don’t simply imply means-testing Medicare, which is commonly what individuals discuss, but additionally means-testing the employer tax break for medical insurance, for instance, and actually having —
Rovner: So extra like Switzerland.
Roy: Precisely. So all these random digressions that I’ve been coming … there may be truly a coherent concept right here that I’m attempting to get to, and I thanks for reminding me on that.
Rovner: Effectively, we’re again in the thick of it. Avik Roy, hope we are able to have you ever again once more.
Roy: Thanks, Julie. I’d find it irresistible.
Rovner: OK. We’re again. It’s time for our extra-credit section. That’s the place we every acknowledge a story we learn this week we expect it is best to learn, too. Don’t fear should you miss it. We will put the hyperlinks in our present notes in your cellphone or different cellular system. Paige, why don’t you go first this week?
Winfield Cunningham: Positive. Yeah. Effectively, I used to be actually struck by this story in The Wall Road Journal referred to as “Medicaid Insurers Promise Numerous Docs. Good Luck Seeing One.” And this was only a actually, actually intensive take a look at among the struggles confronted by Medicaid sufferers after they go to their plan, they give the impression of being up medical doctors, they attempt to get appointments, nevertheless it seems that numerous the medical doctors listed within the directories for these Medicaid plans don’t see sufferers anymore, or they’re distant. And there’s an actual mismatch right here between the suppliers’ insurer networks’ declare to supply and what’s truly out there to individuals. And naturally, numerous Medicaid sufferers dwell in medically underserved areas. So I simply thought this text, that they had truly appeared at some sufferers that dwell close to St. Louis, my hometown, and the way tough it was for them to search out a well timed appointment with a specialist. I simply thought it was a actually good, intensive take a look at among the actual challenges right here within the Medicaid program.
Rovner: Yeah, supplier directories are type of an underappreciated large downside in the whole well being care system. Joanne?
Kenen: This can be a piece from ProPublica, “What the US Authorities Is Dismissing That May Seed a Hen Flu Pandemic,” by Nat Lash, with fairly cool graphics by Chris Alcantara. And principally, they’re arguing that the USDA [United States Department of Agriculture] for 3 and others previous to Trump — it’s not only a Trump administration coverage — has been emphasizing sanitation, and what they name biosecurity practices to cease chook flu getting into. They blame it on type of dangerous management, just like the farms let dangerous stuff in. And in reality, there’s growing proof — and ProPublica labored with researchers and consultants on local weather and wind patterns and all the things — that it’s airborne. That it’s coming in on wind and mud. That it’s not simply what’s tracked on the ground. It’s on the feathers. And that the entire strategy is due to this fact insufficient. And additionally the USDA has refused to do vaccination, which many European nations are doing. So the mixture of underemphasizing the function of wind and air present, and the reluctance has to do with import insurance policies and the financial system of poultry and eggs, is admittedly placing us at higher threat.
Rovner: Yeah, very scary story. Shefali?
Luthra: My piece is from ProPublica. It’s by Kavitha Surana and Lizzie Presser. It’s referred to as “Ticking Time Bomb: A Pregnant Mom Saved Getting Sicker. She Died After She Couldn’t Get an Abortion in Texas.” The story actually wrecked me. It’s actually vital journalism. It’s a story about one lady, particularly, however then will get into the truth that there are a lot of circumstances like this of people who find themselves pregnant, have medical situations that make their being pregnant very excessive threat. So their well being is threatened however not their lives. And as such, they don’t qualify for an exception below an abortion ban like Texas’. And the lady on this story, Tierra Walker, died. She already had a child who now doesn’t have his mother as a result of she couldn’t get an abortion.
And I believe what this story actually will get at is a number of vital issues. One is that the exceptions that states have handed don’t account for the truth that being pregnant could make your well being actually in danger, even when there’s not one thing actually dramatic like sepsis. It’s simply merely all the opposite issues that make you at higher threat of dying. The opposite factor that’s actually vital is that each one these medical doctors who handled her by no means prompt an abortion. That’s vital as a result of it underscores that years later, there remains to be numerous concern for well being care suppliers working in these states that is very apparent that being pregnant was a threat for this affected person. And there was a dialog that she might have had along with her medical supplier, a alternative that she and her household might have made about her circumstances and what was greatest for her. Docs didn’t really feel secure having that dialog due to state legal guidelines. And now she’s useless.
Rovner: And yeah, it is a continuation of a ProPublica sequence that gained a Pulitzer this 12 months. So they’ve been monitoring this via a number of states and many sufferers, sadly.
All proper, my additional credit score this week is from CNBC. It’s by Scott Zamost, Paige Tortorelli, and Melissa Lee. It’s referred to as “Cheaper Medicines, Free Seaside Journeys: U.S. Well being Plans Faucet Prescriptions That Feds Say Are Unlawful,” and it’s a beautiful tackle how the U.S. well being system has turn out to be such a multitude that employers can now rent third-party corporations who pay for sufferers to take all-expense paid journeys to the Bahamas or the Cayman Islands to purchase costly prescribed drugs at a value that also saves sufficient cash from what’s charged within the U.S. to pay for the journey. There’s only one catch, although. Whereas it’s not unlawful to go to a different nation to get your personal treatment, a few of these third events additionally import medication themselves, and that is unlawful. For the umpteenth time, if the united statesregulated drug costs the best way all these different nations do, medication right here can be rather a lot inexpensive. Though I’ll say, I’ve been to each the Bahamas and to the Caymans, and they’re each beautiful.
OK, that’s this week’s present. Thanks as at all times to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Well being?” is now out there on WAMU platforms, the NPR app, and wherever you get your podcasts, as nicely as, after all, kffhealthnews.org. Additionally, as at all times, you may e-mail us your feedback or questions. We’re at whatthehealth@kff.org. Or you’ll find me on X @jrovner, or on Bluesky @julierovner. The place are you guys hanging round as of late? Shefali?
Luthra: I’m on Bluesky @Shefali.
Rovner: Paige?
Winfield Cunningham: I’m on X @PW_Cunningham.
Rovner: Joanne?
Kenen: I’m both at LinkedIn or Bluesky @JoanneKenen.
Rovner: We’ll be again in your feed early subsequent week for the Thanksgiving vacation. Till then, be wholesome.
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