\t\t\t<\/p>\n
\tEmmarie Huetteman
\n\tKFF Health News<\/p>\n
\t\t\tEmmarie Huetteman,\u00a0senior editor, oversees a team of Washington reporters, as well as “Bill of the Month”\u00a0and “What the Health? From KFF Health News.” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.\u00a0\t\t<\/p>\n
The longest federal government shutdown in history is over, after a handful of House and Senate Democrats joined most Republicans in approving legislation that funds the government through January. Despite Democrats’ demands, the package did not include an extension of the expanded tax credits that help most Affordable Care Act enrollees afford their plans \u2014 meaning most people with ACA plans are slated to pay much more toward their premiums next year.<\/p>\n
Also, new details are emerging about the Trump administration’s efforts to use the Medicaid program \u2014 for low-income and disabled people \u2014 to advance its immigration and trans health policy goals. And President Donald Trump has unveiled deals with two major pharmaceutical companies designed to increase access to weight loss drugs for some Americans.<\/p>\n
This week’s panelists are Emmarie Huetteman of KFF Health News, Anna Edney of Bloomberg News, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.<\/p>\n
\t\t\t<\/p>\n
\tAnna Edney
\n\tBloomberg News<\/p>\n
\t\t\t \t\t\t \t\t\t \t\t\t \tShefali Luthra \t\t\t \t\t\t \t\t\t \tSandhya Raman \t\t\t \t\t\t \t\t\t Among the takeaways from this week’s episode:<\/p>\n Also this week, KFF Health News’ Julie Rovner interviews KFF Health News’ Julie Appleby, who wrote the latest “Bill of the Month<\/a>” feature, about a doctor who became the patient after a car accident sent her to the hospital \u2014 and $64,000 into debt. Do you have an outrageous medical bill? Tell us about it<\/a>!<\/p>\n Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:<\/p>\n Emmarie Huetteman:<\/strong> KFF Health News’ “Immigrants With Health Conditions May Be Denied Visas Under New Trump Administration Guidance<\/a>,” by Amanda Seitz.<\/p>\n Anna Edney:<\/strong> Bloomberg News’ “Bayer Weighs Roundup Exit as Cancer Legal Bill Nears $18 Billion<\/a>,” by Tim Loh, Hayley Warren, and Julia Janicki.<\/p>\n Shefali Luthra:<\/strong> The 19th’s “Detransition Is Rare, but It’s Driving Anti-Trans Policy Anyway<\/a>,” by Orion Rummler.<\/p>\n Sandhya Raman:<\/strong> BBC’s “Canada Loses Its Measles-Free Status, With US on Track To Follow<\/a>,” by Nadine Yousif.<\/p>\n Also mentioned in this week’s episode:<\/p>\n \t\t\t\t\tClick to open the transcript\t\t\t\t<\/p>\n \t\t\t\t\t\tTranscript: The Government Is Open<\/strong>\t\t\t\t<\/p>\n [<\/em>Editor’s note:\u00a0<\/em><\/strong>This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]<\/em>\u202f<\/strong>\u00a0<\/p>\n Emmarie Huetteman:<\/strong>\u00a0Hello and welcome to “What the Health?” from KFF Health News and WAMU.\u00a0I’m\u00a0Emmarie Huetteman, a senior editor for KFF Health News, filling in for host Julie Rovner this week.\u00a0I’m\u00a0joined by some of the best and smartest health reporters in Washington.\u00a0We’re\u00a0taping this week on Thursday, Nov.\u00a013,\u00a0at 10\u00a0a.m.\u00a0As always, news happens fast,\u00a0and things\u00a0might’ve\u00a0changed\u00a0by the time you hear this. So,\u00a0here we go.\u00a0<\/p>\n Today,\u00a0we’re joined\u00a0via video conference by Sandhya Raman of CQ Roll Call.\u00a0<\/p>\n Sandhya Raman:<\/strong>\u00a0Good morning.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Anna\u00a0Edney of\u00a0Bloomberg News.\u00a0<\/p>\n Anna Edney:<\/strong>\u00a0Hi, everyone.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0And Shefali Luthra of\u00a0The\u00a019th.\u00a0<\/p>\n Shefali Luthra:<\/strong>\u00a0Hello.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Later in this episode,\u00a0we’ll\u00a0have Julie’s interview with KFF Health News’\u00a0Julie Appleby, who wrote our latest\u00a0“Bill of the\u00a0Month”\u00a0story about a doctor who became the patient after a car accident sent her to the hospital and $64,000 into debt. But first, this week’s news.\u00a0<\/p>\n The longest federal government shutdown in history is over. Late Wednesday, six\u00a0House Democrats joined most Republicans in approving legislation that funds the government through January. That vote came after a handful of Senate Democrats broke ranks with their party last weekend and brokered a deal to end the shutdown. Although the Trump administration was still fighting earlier this week\u00a0not<\/em>\u00a0to fully fund food stamps, the White House has said those benefits would be fully restored within hours of the shutdown’s end. That said, food banks and other safety-net programs have warned the\u00a0shutdown’s\u00a0consequences could linger, especially for those who were forced to redirect rent money, dip into savings, and make other sacrifices to feed their families. Notably, despite Democrats’\u00a0demands, the deal does not include an extension of the expanded tax credits that help people afford Affordable Care Act plans. That means those enhanced subsidies are still slated to expire at the end of the year. Sandhya, you were on Capitol Hill last night. What was included in the deal? And now that the shutdown’s\u00a0over,\u00a0can we expect a vote on extending the tax credits?\u00a0<\/p>\n Raman:<\/strong>\u00a0So\u00a0part of that deal was that sometime in the middle of next month, the Senate is going to be able to vote on a health bill of Democrats’\u00a0choosing\u00a0to extend the Affordable Care Act enhanced subsidies that are set to expire at the end of the year.\u00a0There’s\u00a0been a decent amount of talk already in\u00a0both chambers about what a health\u00a0care bill could look\u00a0like, because\u00a0it would need to be bipartisan to pass.\u00a0There’s\u00a0some multiple camps right now.\u00a0<\/p>\n I think in the Senate, Republicans are coalescing around putting money into flexible savings accounts instead of doing an extension of the credits as something that they would want to do instead. There are other Republicans that are still open to extending the credits with some reforms attached. The\u00a0House,\u00a0we figured out last\u00a0night,\u00a0was a little bit more fragmented.\u00a0They’re\u00a0less united in the way the House is around doing something with\u00a0the flexible\u00a0spending accounts.\u00a0So\u00a0a lot of them are still anti-extending the credits at all. They are working on a health package, but\u00a0it\u00a0remains to be seen what they want to do with that, given the short amount of time they have. But I think a lot of them are also looking for the same reforms that the Senate is on the Republican side, if they do sign on to extend them.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Yeah, short is right.\u00a0We’re\u00a0already looking at that\u00a0Dec.\u00a031 deadline\u00a0to extend the existing credits. And of course,\u00a0we’re\u00a0already in the open enrollment period at this point. People are already\u00a0getting their plans\u00a0for next year. Polls show that most Americans blamed Republicans for the shutdown. A tracking poll from my KFF colleagues out last week showed most Americans\u00a0want<\/em>\u00a0Congress to extend the tax credits. Republicans are aware of this heading into the midterms next year, no?\u00a0<\/p>\n Raman:<\/strong>\u00a0I think that’s\u00a0definitely been\u00a0a big factor when talking to folks, especially ones that I think have been more interested in extending the credits\u00a0are set\u00a0up for our competitive races next year. There has been talk at\u00a0different times\u00a0of\u00a0doing a one-year extension.\u00a0But that puts us\u00a0pretty close\u00a0to the midterms, which might not be in everyone’s best interest depending on how things shake out.\u00a0So,\u00a0I think it’s\u00a0definitely in\u00a0a lot of folks’\u00a0minds, just because it is a lot more popular than it has been in previous years.\u00a0But there are a lot of the more conservative folks that just have been anti-ACA for so\u00a0long,\u00a0that they\u00a0don’t\u00a0want to extend something that was \u2026 The enhanced subsidies were started by Democrats during\u00a0covid. They think\u00a0it’s\u00a0a\u00a0covid-era thing that needs to be phased out.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Yeah,\u00a0and also\u00a0notably, you\u00a0might’ve\u00a0noticed I said that they only funded the government through January. Does that mean\u00a0we’re\u00a0getting ready to do this again in a couple of months?\u00a0<\/p>\n Raman:<\/strong>\u00a0There’s\u00a0a chance.\u00a0So\u00a0part of the\u00a0deal\u00a0got done this week is that they\u00a0did\u00a0three of the 12 spending bills that they do every year to fund the government. But they usually do them in order\u00a0of\u00a0which ones are easiest to get done.\u00a0So\u00a0we still\u00a0have to\u00a0come to\u00a0agreements\u00a0on some of the bigger ones,\u00a0including Labor,\u00a0HHS\u00a0[Health and Human\u00a0Services].\u00a0Education is what funds most of the health activities, and\u00a0that’s\u00a0usually a tougher one. So,\u00a0I think it\u00a0depends on a few things. Are folks sticking to their\u00a0word? Do they get that health\u00a0care vote that they\u00a0were promised? Do other things shake out that make people at odds with each other over the next bit? But we could\u00a0possibly be\u00a0in the same situation if we\u00a0don’t\u00a0make inroads on funding the government for a\u00a0yearlong\u00a0situation before then.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Oh goodness. Well, it sounds like\u00a0we’ll\u00a0be back again having this conversation soon. Meanwhile, months after the president\u00a0[Donald Trump]\u00a0signed into law the One Big Beautiful Bill with\u00a0big changes\u00a0to Medicaid,\u00a0new details\u00a0are\u00a0emerging\u00a0about how the Trump administration is using the Medicaid program to promote its policy goals.\u00a0My KFF Health News colleague Phil Galewitz recently reported on how\u00a0the Trump administration has ordered state Medicaid agencies to investigate the immigration status of certain enrollees\u00a0\u2014\u00a0providing states with lists of names to re-verify\u00a0\u2014\u00a0and effectively roping the health program into the president’s immigration crackdown.\u00a0<\/p>\n Also, NPR reports the Trump administration plans to dramatically restrict access to medical care for transgender youth. New proposals that could be released as soon as this month would block federal money from being spent on trans care. Policy experts say that would make it difficult, if not impossible, to access that care, in large part because government funding is a huge source of\u00a0revenue, and\u00a0losing it could force hospitals to end the programs entirely.\u00a0Both of these\u00a0programs are\u00a0pretty striking:\u00a0enlisting Medicaid to perform spot checks of immigration status,\u00a0and also\u00a0potentially blocking funding for trans care. Have we seen other presidential administrations use Medicaid like this? And since\u00a0we’re\u00a0talking about funding, is there a role for Congress here?\u00a0<\/p>\n Luthra:<\/strong>\u00a0My understanding is that this approach, specifically with gender-affirming care and with immigration,\u00a0doesn’t\u00a0really have a precedent. And what I think is\u00a0really important\u00a0about these\u00a0is\u00a0these are decisions that will be litigated, challenged, argued in court. But, even if and as that happens,\u00a0there’s\u00a0a real chilling effect that I think is\u00a0really important. Already, we know that a lot of immigrants are very afraid to sign up even for benefits they are entitled to, because\u00a0they’re\u00a0worried it could count against them. We already know that a lot of immigrants with health needs are skipping their health\u00a0care because they are so worried about what happens if ICE\u00a0[Immigration and Customs Enforcement]\u00a0shows up at a hospital.\u00a0This only threatens to add to that. On the vantage of gender-affirming care,\u00a0already we have\u00a0seen some major hospitals and health providers drop the offering, even in anticipation of this policy coming into effect.\u00a0So\u00a0I think what’s\u00a0really important\u00a0is to understand that no matter what happens, already, people’s health is really being affected,\u00a0and people are suffering as a result.\u00a0<\/p>\n Raman:<\/strong>\u00a0I think\u00a0we’ve\u00a0seen little sprinkles of some of these things that have happened in the past, but this is elevated at such a level that\u00a0it’s\u00a0different. Even in the first Trump administration, there were some things put in place with the public charge to crack down on what benefits immigrants could be entitled to. But I think,\u00a0as with a lot of the things that\u00a0we’re\u00a0seeing,\u00a0it’s\u00a0really been amped up. I think one thing that Shefali was saying that made me think of was,\u00a0we’ve\u00a0already seen a lot of this chilling effect with a lot of things in abortion and reproductive care, where even if laws or regulations\u00a0don’t\u00a0go into effect,\u00a0they’re\u00a0being talked about or litigated. It already has that effect of people not wanting to show up or not knowing\u00a0what’s\u00a0available to them.\u00a0So\u00a0we have a little bit of that to look at as well.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Yeah, absolutely. All right, well,\u00a0we’re\u00a0going to take a quick break.\u00a0We’ll\u00a0be right back with more health news.\u00a0<\/p>\n We’re\u00a0back. In an Oval Office announcement last week,\u00a0President Trump unveiled agreements with the pharmaceutical giants Eli Lilly and Novo Nordisk to offer\u00a0some Americans lower prices on their weight loss drugs. Under the deals, the Trump administration says, most eligible patients on Medicare and Medicaid, or those who use the planned\u00a0TrumpRx\u00a0website, would pay a few hundred dollars a month for some of the most popular GLP-1 drugs.\u00a0That’s\u00a0compared to current price tags, which can be\u00a0$1,000\u00a0or more. Anna, these are only some of the most recent deals between the Trump administration and drugmakers. What does this mean for Americans who take these weight loss drugs, and what do the companies get in exchange?\u00a0<\/p>\n Edney:<\/strong>\u00a0Yeah, I think for Americans who take these or are hoping to take these, I think,\u00a0is probably where it really\u00a0opens up. Because \u2026 Medicare was not covering these. Now that\u00a0they’ve\u00a0come to the table and made a deal, it might open it up to some Medicare beneficiaries. I\u00a0don’t\u00a0think\u00a0you’re\u00a0going to see everyone on Medicare who wants it\u00a0be\u00a0able to get it. I think\u00a0it’ll\u00a0be a little stricter on what BMI\u00a0[body mass index]\u00a0and comorbidities and things that they need to meet, but it will\u00a0open access\u00a0to some Americans. Medicaid, I think,\u00a0it\u00a0might not\u00a0be as\u00a0beneficial for people’s pocketbooks because\u00a0they’re\u00a0already paying extremely low out-of-pocket prices, and Medicaid already negotiates\u00a0very low\u00a0prices. That might not be the\u00a0big change\u00a0that it was\u00a0hyped\u00a0up to be.\u00a0<\/p>\n But on the Medicare side, certainly, the companies\u00a0benefit\u00a0from that,\u00a0too, because that opens a new patient population to them.\u00a0And through\u00a0TrumpRx\u00a0\u2014\u00a0that’s\u00a0the other place where they made this deal for lowered\u00a0prices on the\u00a0GLP-1s\u00a0\u2014\u00a0a\u00a0lot of people have employer coverage that they might be trying to already get these drugs through,\u00a0and then\u00a0they’re\u00a0not paying a whole lot out-of-pocket.\u00a0But there\u00a0are\u00a0employer coverage plans that\u00a0aren’t\u00a0covering GLP-1s because\u00a0they’re\u00a0just so expensive.\u00a0So\u00a0it could be a place where some people might go to try to comparison\u00a0shop\u00a0and get their GLP-1s that they\u00a0didn’t\u00a0have access to before.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0I also noticed,\u00a0in looking at the Trump administration’s fact sheet on this, that they were heralding that the companies had agreed to some extra American manufacturing.\u00a0Let’s\u00a0say concessions. Am I correct about that? Is this connected to tariffs by any chance?\u00a0<\/p>\n Edney:<\/strong>\u00a0Yeah, I\u00a0think that\u00a0that’s\u00a0been going on in conjunction with some of these deals. As you usually hear the companies say,\u00a0And\u00a0we’re\u00a0opening a new factory in Virginia\u00a0<\/em>or somewhere.\u00a0<\/em>And\u00a0certainly\u00a0they’re\u00a0trying to avoid the tariffs. As with a lot of these things, some of\u00a0it,\u00a0in some cases, they\u00a0have been factories that the companies were already planning to open,\u00a0and then they just pumped up for this purpose. I think for so many of this\u00a0\u2014\u00a0and even for the prices, the lower prices that these companies are negotiating\u00a0\u2014\u00a0we just haven’t seen the details that will matter on what the company’s got,\u00a0and what the American people\u00a0actually benefit\u00a0from for all of this, and what these factories will mean or will be making.\u00a0These are things that might not come online for several years.\u00a0So\u00a0you can say\u00a0you’re\u00a0building something, but will we see it once Trump is out of office?\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Exactly. And a lot of the framing has been:\u00a0We’re\u00a0helping Americans by bringing this work back to America, so that Americans can do the work, so that Americans can\u00a0benefit\u00a0from the drug prices.<\/em>\u00a0But it seems like\u00a0there’s\u00a0at best a lag\u00a0on\u00a0that sort of benefit.\u00a0Right?\u00a0<\/p>\n Edney:<\/strong>\u00a0Definitely.\u00a0Definitely a\u00a0lag\u00a0on\u00a0being able to bring some of that stuff online. I think with a lot of the Trump administration’s health policies\u00a0\u2014\u00a0and I use that word loosely\u00a0\u2014\u00a0it is that it is a lot of negotiation and handshakes. And\u00a0so\u00a0we don’t really know how solid those efforts will be in the years to come.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Well, we can\u00a0definitely keep\u00a0an eye on that.\u00a0In other news:\u00a0Drama, drama, drama at the Food and Drug Administration. With a steady stream of controversial policy reversals, unexplained dismissals, and\u00a0just plain\u00a0unflattering stories, concerns are growing that mismanagement at the FDA is undermining the usually cautious agency’s credibility. In some of the latest developments, Stat reported the FDA’s top drug regulator resigned after being accused of using his position to punish a former associate.\u00a0Stat also reported that dozens of scientists are considering leaving the already diminished FDA office that regulates vaccines, biologics,\u00a0and the blood supply\u00a0to get away from a toxic work environment. What are the ramifications of problems at the FDA?\u00a0Is the internal drama interfering with business there?\u00a0<\/p>\n Edney:<\/strong>\u00a0I think the pharmaceutical industry would say\u00a0yes, definitely.\u00a0They’re\u00a0feeling like their applications for new drugs\u00a0aren’t\u00a0getting reviewed in time.\u00a0They’re\u00a0worried that\u00a0they’re\u00a0not going to be reviewed in time. And this starts with the administration letting go hundreds of workers in those offices,\u00a0but also,\u00a0is\u00a0now \u2026\u00a0There’s\u00a0just been such chaos at the top. You had Vinay Prasad,\u00a0who is the head of vaccines and biologic drugs there, who has been let go and then brought back. And then now we have the head of the drug center, George Tidmarsh, who resigned under investigation for\u00a0basically using\u00a0his position to fulfill a vendetta against an old colleague who pushed him out of some companies. And\u00a0so\u00a0I think,\u00a0certainly,\u00a0there’s\u00a0a lot of potential for disruption, as people are trying to avoid retaliation, avoid getting in the crosshairs of all of this.\u00a0<\/p>\n And recently, the FDA has now put Rick\u00a0Pazdur, who was the head of their cancer center, in charge of the drug center to try to show some stability to encourage the pharmaceutical industry. Because he is someone who’s really pushed for innovation, pushed for trying to get drugs to the market faster. And\u00a0he’s\u00a0been at the FDA for,\u00a0I think,\u00a026 years. So,\u00a0they’re\u00a0trying to show some stability with that. But\u00a0we’ll\u00a0have to see how that goes because\u00a0he’s\u00a0also been highly criticized in the past by Prasad,\u00a0and\u00a0they’ll\u00a0be working closely together at the head of those two centers.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Well, finally, in reproductive health news, a federal judge ruled late last month that the FDA violated federal law by restricting access to mifepristone. While the government’s restrictions\u00a0remain\u00a0in place for the politically controversial medication, which is used to manage miscarriages as well as abortions, the judge did order the FDA to consider the relevant evidence\u00a0in order to\u00a0“provide a reasoned explanation for its restrictions.”\u00a0And a\u00a0major anti-abortion group, Susan B. Anthony Pro-Life America, announced plans for it and its super PAC\u00a0[political action committee]\u00a0to spend about $80 million in at least four states to support anti-abortion candidates in the midterm elections next year. Shefali, what does this say about how abortion opponents see this moment? What are they looking to gain in the midterms and beyond?\u00a0<\/p>\n Luthra:<\/strong>\u00a0It’s\u00a0so interesting to me to see how\u00a0much\u00a0anti-abortion groups are really\u00a0\u2014\u00a0and,\u00a0in particular,\u00a0SBA\u00a0\u2014\u00a0leaning into this moment. And they really see this as a reversal of last year’s election, where Trump certainly won. But we do know from polling that voters\u00a0largely opposed\u00a0abortion restrictions, supported abortion rights.\u00a0I think some\u00a0really useful\u00a0context\u00a0is to consider that the president, despite being backed by\u00a0abortion\u00a0opponents, has not really been the champion many of them\u00a0would’ve\u00a0hoped for. He\u00a0hasn’t\u00a0actually done\u00a0very much on abortion, has not taken the very meaningful steps that you\u00a0might’ve\u00a0expected in a post-Dobbs<\/em>\u00a0landscape\u00a0[Dobbs v. Jackson Women’s Health Organization<\/em>]\u00a0to remarkably restrict it, beyond the normal things any Republican president does. And\u00a0so\u00a0I think what\u00a0we’re\u00a0seeing here is an effort to reposition the anti-abortion movement beyond this presidential administration. Thinking ahead to\u00a0what does it look like if there is a post-Trump GOP?<\/em>\u00a0<\/p>\n How do you\u00a0build out\u00a0a movement that is a\u00a0more staunch\u00a0ally to the anti-abortion movement going forward? One other thing that I think is\u00a0really noteworthy\u00a0is: A\u00a0lot of abortion opponents are looking at polling that says that voters who support abortion rights\u00a0aren’t\u00a0prioritizing it in the same way they might have a year ago. And\u00a0they’re\u00a0really hoping that things can revert to how they used to be.\u00a0Or the voters who were these single-issue abortion voters were on their side, were supportive of restrictions, and then might be mobilized by these kinds of\u00a0really seismic\u00a0investments in elections.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Yeah, absolutely.\u00a0I’m\u00a0thinking about now how there was such a reaction about a month ago\u00a0\u2014\u00a0check me on the timing\u00a0\u2014\u00a0when a generic version of the abortion pill was put out. What was the reaction like then,\u00a0and what does that say about how they feel the Trump administration is reacting to their needs?\u00a0<\/p>\n Luthra:<\/strong>\u00a0A lot of abortion opponents were\u00a0really livid\u00a0about this,\u00a0and approving this generic was\u00a0pretty standard. It was not that complicated of a process. This drug has been available for so long in other forms. But it\u00a0underscored\u00a0that a lot of people who oppose abortion feel like they’re\u00a0really just\u00a0waiting. The HHS and the FDA have promised this review of mifepristone that they say could\u00a0ultimately lead\u00a0to restrictions. But all it has really\u00a0been\u00a0has\u00a0been\u00a0a promise\u00a0this review is ongoing, is coming.\u00a0There will eventually be results, but there\u00a0haven’t\u00a0been any.\u00a0So\u00a0to be waiting for some kind of policy that people keep telling you is coming, and then at the same time, to see\u00a0actually the\u00a0FDA moving to make abortion medication more available\u00a0\u2014\u00a0not less\u00a0\u2014\u00a0is really frustrating for a lot of people who hope that this administration\u00a0would\u00a0be an ally to them.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Absolutely. OK.\u00a0That’s\u00a0it for\u00a0this week’s news. Now,\u00a0we’ll\u00a0have Julie’s interview with KFF Health News’\u00a0Julie Appleby. And then\u00a0we’ll\u00a0do our extra credits.\u00a0<\/p>\n Julie Rovner:<\/strong>\u00a0I am pleased to welcome back to the podcast, KFF Health News’ other Julie, Julie Appleby, who reported and wrote the latest KFF Health News\u00a0“Bill of the\u00a0Month.”\u00a0Julie, welcome back.\u00a0<\/p>\n Julie Appleby:<\/strong>\u00a0Thanks for having me.\u00a0<\/p>\n Rovner:<\/strong>\u00a0So\u00a0this month’s patient is\u00a0actually a\u00a0doctor, so she knows how the system works.\u00a0But,\u00a0as so often happens, she was in a car accident and ended up in an out-of-network hospital. Tell us who she is and what kind of care she\u00a0needed.\u00a0<\/p>\n Appleby:<\/strong>\u00a0OK. Her name is Lauren Hughes,\u00a0and she was heading to see patients at a clinic about 20 miles from where she lives in Denver back in February when another driver T-boned her car, totaling it. She was taken by ambulance to the closest hospital, which turned out to be Platte Valley Hospital, where she was diagnosed with bruising, a deep cut on her knee,\u00a0and a broken ankle. Physicians there recommended immediate surgical repair because they wanted to wash out that wound on her knee.\u00a0And also, she needed some screws in her ankle to hold it in place.\u00a0<\/p>\n Rovner:<\/strong>\u00a0So then after the surgery and an overnight stay, she goes home,\u00a0and then the bills start to come. How much did it end up\u00a0costing?\u00a0<\/p>\n Appleby:<\/strong>\u00a0Well, she was billed $63,976 by the hospital.\u00a0<\/p>\n Rovner:<\/strong>\u00a0And the insurance company denied her claim. What was their argument?\u00a0<\/p>\n Appleby:<\/strong>\u00a0Yeah, this is where it gets complicated, as many of these things often do. Her insurer, Anthem, fully covered the\u00a0nearly $2,400\u00a0ambulance ride and some smaller radiology charges from the ER. But it denied the surgery and the overnight stay charges from the hospital,\u00a0which did happen\u00a0to be out-of-network. Four days after her surgery, Anthem\u00a0notified Hughes\u00a0in a letter that after consulting clinical guidelines for her type of ankle repair, its reviewer\u00a0determined\u00a0that it\u00a0wasn’t\u00a0medically necessary for her to be fully admitted for an inpatient hospital stay. So,\u00a0the note said that if\u00a0she’d\u00a0needed\u00a0additional\u00a0surgery or had other problems such as vomiting or fever, an inpatient stay\u00a0might’ve\u00a0been\u00a0warranted. But they\u00a0didn’t\u00a0have that in this case.\u00a0And generally, people\u00a0don’t\u00a0stay overnight in the hospital after broken ankle surgery.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Of course, she had no car and she\u00a0\u2026\u00a0<\/p>\n Appleby:<\/strong>\u00a0Right?\u00a0Her\u00a0car\u00a0was\u00a0totaled. She had no way to get home. She had nobody to pick her up. And it turns\u00a0out,\u00a0there’s a couple more little quirks.\u00a0So\u00a0the surgery charges were denied\u00a0because\u00a0this quirk that under Anthem’s agreement with the hospital, all claims for services before and after a patient are approved or denied together. So,\u00a0since the hospital stay was\u00a0generally not\u00a0required\u00a0after the ankle surgery, the\u00a0surgery charges\u00a0itself\u00a0were\u00a0denied as well. Even though Anthem said they always felt that that was medically necessary\u00a0\u2014\u00a0that she needed the ankle surgery\u00a0\u2014\u00a0it all came down to this overnight hospital stay.\u00a0<\/p>\n Rovner:<\/strong>\u00a0So,\u00a0isn’t this exactly what the federal surprise billing law was supposed to eliminate\u00a0\u2014\u00a0being in an accident, getting taken to an out-of-network hospital for emergency care? How did it not apply here?\u00a0<\/p>\n Appleby:<\/strong>\u00a0Right. Well,\u00a0that’s\u00a0where\u00a0it’s\u00a0so interesting because initially,\u00a0that’s\u00a0what everybody thought:\u00a0The No Surprises Act\u00a0would cover it. And\u00a0the\u00a0No Surprises Act\u00a0from\u00a02022,\u00a0it’s\u00a0aimed at preventing these so-called surprise bills, which come when you go to an out-of-network hospital or provider. And in those cases, it limits your financial liability for emergency care to the exact same\u00a0cost\u00a0sharing as if you had been\u00a0in\u00a0an in-network hospital.\u00a0<\/p>\n So\u00a0in this case, it applies to emergency care,\u00a0and we saw that it did\u00a0actually cover\u00a0some of her emergency room charges, and that kind of thing. But\u00a0generally\u00a0though, emergency care is defined as treatment needed to stabilize a patient.\u00a0So\u00a0once she was stabilized before the surgery, she\u00a0enters\u00a0this post-stabilization situation. And if your provider\u00a0determines\u00a0that you can travel using\u00a0nonmedical\u00a0transport to an in-network facility, you might lose those No Surprises Act protections.\u00a0Generally, you’re\u00a0asked to sign some paperwork saying you want to stay at the out-of-network facility,\u00a0and you want to continue treatment,\u00a0and you waive your rights in that case. Hughes does not remember getting anything like that. And this case\u00a0didn’t\u00a0come down to the No Surprises Act. It was a question of medical necessity. Your insurer has broad power to\u00a0determine\u00a0medical necessity.\u00a0And if they review a situation and\u00a0determine\u00a0that\u00a0it’s\u00a0not medically necessary, and\u00a0you’re\u00a0post-stabilization, that trumps any No Surprises Act protections.\u00a0<\/p>\n Rovner:<\/strong>\u00a0So\u00a0what eventually happened with this bill?\u00a0<\/p>\n Appleby:<\/strong>\u00a0So\u00a0what eventually happened was that the hospital resubmitted the charges as outpatient services. And that\u00a0seemed to be\u00a0the crux of the matter here. It was\u00a0that\u00a0inpatient overnight hospital\u00a0stay. If she was\u00a0kept\u00a0[on]\u00a0an observation status\u00a0\u2014\u00a0which is a lower level of care, hospitals get paid a little bit less\u00a0\u2014\u00a0that\u00a0would’ve\u00a0seemed to solve the problem. And\u00a0that’s\u00a0what happened here. Platte Valley resubmitted the bill,\u00a0and her insurer paid about $21,000\u00a0of\u00a0that bill. There was another\u00a0$40,000 that was knocked off by an Anthem discount.\u00a0And in the end, Hughes only owed a $250 copayment.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Wow.\u00a0<\/p>\n Appleby:<\/strong>\u00a0Yeah.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Of course, you left out the part where we\u00a0actually called\u00a0and made it\u00a0\u2026\u00a0<\/p>\n Appleby:<\/strong>\u00a0Well, there was that,\u00a0too. And she was very savvy, as you mentioned. She also got her HR department at\u00a0her employer\u00a0involved. She wrote letters. She was not going to give up on this.\u00a0That’s\u00a0one of the\u00a0advice\u00a0that she gave is not to wait\u00a0\u2014\u00a0not to delay too long if you get a notice of not medical\u00a0necessity\u00a0\u2014\u00a0but to\u00a0quickly and aggressively question insurance denials\u00a0once\u00a0they’re\u00a0received.\u00a0Make sure you understand\u00a0what’s\u00a0going on.\u00a0Try to get it escalated to the insurers and the hospital’s leadership.\u00a0All of\u00a0those things. And I think another takeaway for folks is\u00a0\u2014 and this is harder because,\u00a0look,\u00a0you’re\u00a0in the emergency\u00a0room,\u00a0you\u00a0don’t\u00a0know\u00a0what’s\u00a0going on\u00a0\u2014\u00a0but it might be worth asking,\u00a0Hey, am I post-stabilization? Am I being admitted as an\u00a0inpatient? Am I being held for an observation stay?\u00a0Is there some kind of difference with that in terms of my insurance coverage?<\/em>\u00a0And you could\u00a0perhaps try\u00a0to put this\u00a0to\u00a0the\u00a0hospital\u00a0billing department. But\u00a0it’s\u00a0even better if\u00a0there’s\u00a0a way you can call your insurer. But\u00a0that’s\u00a0not always realistic in these kinds of emergency situations.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yeah, and just out of curiosity, if somebody totals my car and I end up\u00a0[in]\u00a0an ambulance needing surgery,\u00a0I’m\u00a0going to assume that the other driver’s insurance is going to pay my medical bills. Why didn’t that happen?\u00a0<\/p>\n Appleby:<\/strong>\u00a0Well, in this case, the way it was explained to me is the other driver had the minimum coverage needed in the state of Colorado. And\u00a0so\u00a0it did pay\u00a0nearly $5,000\u00a0toward some of these charges. But\u00a0that’s\u00a0about all it paid.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Wow. Well, now,\u00a0obviously,\u00a0as you said, Lauren Hughes is a doctor. Savvy about the way the system\u00a0works, or\u00a0doesn’t\u00a0in this case. Even then, it took her months and called us to work this all out. How should somebody with less\u00a0expertise\u00a0handle a situation like this?\u00a0Is there somebody they can turn to help,\u00a0assuming that\u00a0they’re not cognizant enough to start asking questions about their admission status while they’re still in the emergency room waiting for surgery?\u00a0<\/p>\n Appleby:<\/strong>\u00a0Right. Again, that is so complicated. If you can, call your\u00a0insurer\u00a0and see what they have to say. And again, it may be after hours.\u00a0It may\u00a0be not\u00a0possible. Perhaps see if you can chat with the hospital billing department. But again, some of this is going to be after\u00a0the\u00a0fact. And remember, the billing in this situation came down to how the hospital coded the billing. They coded it as an inpatient hospital stay, and\u00a0that’s\u00a0after the fact. And\u00a0there’s\u00a0not a lot you can do about it. But in the end, it was resubmitted as an outpatient service, and that made all the difference in this case.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Wow. Another complicated one. Or\u00a0I guess\u00a0you can just write to us. Julie Appleby, thank you very much.\u00a0<\/p>\n Appleby:<\/strong>\u00a0Thanks for having me.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0All right, now\u00a0it’s\u00a0time for our\u00a0extra-credit\u00a0segment.\u00a0That’s\u00a0where we each recognize\u00a0a\u00a0story we read this week that we think you should read,\u00a0too.\u00a0Don’t\u00a0worry if you miss it.\u00a0We’ll\u00a0put the links in our show notes on your phone or other mobile device. Anna, how about you\u00a0go first\u00a0this week?\u00a0<\/p>\n Edney:<\/strong>\u00a0Sure. This\u00a0story is from a few of my colleagues\u00a0at\u00a0Bloomberg.\u00a0“Bayer Weighs Roundup Exit\u00a0as Cancer Legal Bill Nears\u00a0$18 Billion<\/a>.”\u00a0And I thought this was an interesting story, not just because there is the possibility that the world’s\u00a0most-used\u00a0weed killer could be going away because\u00a0it’s\u00a0just folding under so many legal challenges related to cancer. But\u00a0it’s\u00a0also just a deep dive to look at this herbicide that has affected\u00a0all of\u00a0our lives and how it came to be,\u00a0what’s\u00a0going on with it now, why\u00a0it’s\u00a0not working.\u00a0And also\u00a0at this company, Bayer, that in the middle of these legal challenges, bought the company that owned Roundup.\u00a0So\u00a0I just think it’s an interesting look at\u00a0the\u00a0whole situation and something that we’ve\u00a0probably all consumed before in certain ways, through just fruits and vegetables and different seeds and things.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Definitely. Shefali, how about your story?\u00a0<\/p>\n Luthra:<\/strong>\u00a0Sure.\u00a0So\u00a0I picked a four-part series by my colleague\u00a0at\u00a0The\u00a019th, Orion Rummler. The headline for the piece I picked is\u00a0“Detransition\u00a0Is\u00a0Key\u00a0to\u00a0Politicians’\u00a0Anti-Trans\u00a0Agenda. But\u00a0What\u00a0Is\u00a0It\u00a0Really\u00a0Like?<\/a>”\u00a0I think this is a\u00a0really smart\u00a0package of stories because,\u00a0as Orion notes, people who have\u00a0“detransitioned”\u00a0\u2014\u00a0transitioned\u00a0and then transitioned back\u00a0\u2014\u00a0are a\u00a0really central\u00a0part of the modern conservative movement’s efforts to target trans health and,\u00a0in particular, trans\u00a0health for young people. Saying, look at these people who transitioned and then came back and regretted it.\u00a0But there hasn’t been a lot of journalism\u00a0actually looking\u00a0at people who navigate this experience beyond those who are these political tokens.\u00a0So\u00a0Orion does exactly that. He talked to people who have had\u00a0the experience\u00a0of transitioning and then\u00a0detransitioning\u00a0in some way.\u00a0<\/p>\n He notes that this is a\u00a0pretty rare\u00a0experience to have this journey with one’s gender, but that the people he interviewed, he profiled, said that they felt really frustrated with how the conversation has unfolded.\u00a0In fact, their transitioning was an important part of their journey to discover their gender, and that they are deeply concerned that restrictions on trans health could be harmful to them and their loved ones as well.\u00a0I think this is\u00a0really valuable\u00a0journalism, and I’m so excited that Orion did it, and I hope everyone reads it.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0That’s\u00a0really interesting.\u00a0Thank you for sharing that one. Sandhya, what\u00a0do\u00a0you\u00a0have\u00a0this week?\u00a0<\/p>\n Raman:<\/strong>\u00a0So\u00a0I pick,\u00a0“Canada\u00a0Loses\u00a0Its\u00a0Measles-Free\u00a0Status,\u00a0With US\u00a0on\u00a0Track\u00a0To\u00a0Follow<\/a>,”\u00a0and\u00a0it’s\u00a0by Nadine Yousif for the BBC.\u00a0So\u00a0this week, the Pan-American Health Organization, Canada is no longer measles-free.\u00a0And so that means that the Americas region\u00a0as a whole has\u00a0lost its elimination status.\u00a0I thought this was important because in the U.S.,\u00a0we’re\u00a0at a 33-year high with measles. And Mexico has also seen a surge in cases. And just an interesting way to look at\u00a0what’s\u00a0happening a little broader than just the U.S. lens, as all these places are seeing fewer people vaccinated against measles.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Thanks for sharing that story, Sandhya. My extra credit this week is a great scoop from my KFF Health News colleague Amanda Seitz. The headline is,\u00a0“Immigrants\u00a0With\u00a0Health\u00a0Conditions\u00a0May\u00a0Be\u00a0Denied\u00a0Visas\u00a0Under\u00a0New Trump\u00a0Administration\u00a0Guidance<\/a>.”\u00a0Amanda got her hands on a State Department cable that expands the list of reasons that would make visa applicants ineligible to enter the country, including now age or the likelihood they might rely on government benefits. And it gives visa officers quite a bit of power to make those calls.\u00a0\u00a0<\/p>\n Now immigrants,\u00a0they’re\u00a0already screened for communicable diseases and mental health problems.\u00a0But the new guidance goes further and emphasizes that chronic diseases should be considered. And it calls on those visa officers to assess whether applicants can pay for their own medical care, noting that certain medical conditions can\u00a0“require hundreds of thousands of dollars’\u00a0worth of care.”\u00a0<\/p>\n All right, that’s this week’s show.\u00a0Thanks\u00a0this week to our editor,\u00a0Stephanie Stapleton,\u00a0and our producer-engineers, Taylor Cook and\u00a0Francis Ying.\u00a0“What the Health?”\u00a0is available on WAMU platforms, the NPR app, and wherever you get your podcasts. And,\u00a0as always, on\u00a0kffhealthnews.org<\/a>. Also, as always, you can\u00a0email\u00a0us\u00a0your comments or questions.\u00a0We’re\u00a0at\u00a0whatthehealth@kff.org.\u00a0Or you can find me on\u00a0LinkedIn<\/a>. Where are you folks these days? Sandhya?\u00a0<\/p>\n Raman:<\/strong>\u00a0I’m\u00a0on\u00a0X<\/a>\u00a0and on\u00a0Bluesky<\/a>\u00a0@SandhyaWrites.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0Shefali?\u00a0<\/p>\n Luthra:<\/strong>\u00a0I’m\u00a0on Bluesky\u00a0@Shefali<\/a>.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0And Anna?\u00a0<\/p>\n Edney:<\/strong>\u00a0X<\/a>\u00a0or\u00a0Bluesky<\/a>\u00a0@AnnaEdney.\u00a0<\/p>\n Huetteman:<\/strong>\u00a0We’ll\u00a0be back in your feed next week. Until then, be healthy.\u00a0<\/p>\n \tFrancis Ying \tStephanie Stapleton Click here to find all our podcasts.<\/a><\/em><\/p>\n And subscribe to “What the Health? From KFF Health News” on Apple Podcasts<\/a>, Spotify<\/a>, the NPR app<\/a>, YouTube<\/a>, Pocket Casts<\/a>, or wherever you listen to podcasts.<\/em><\/p>\n\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n
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