{"id":1010,"date":"2023-04-11T00:15:49","date_gmt":"2023-04-11T00:15:49","guid":{"rendered":"https:\/\/healthynewsusa.com\/?p=1010"},"modified":"2023-04-11T00:15:50","modified_gmt":"2023-04-11T00:15:50","slug":"the-unwinding-of-medicaid-kaiser-health-news-2","status":"publish","type":"post","link":"https:\/\/healthynewsusa.com\/?p=1010","title":{"rendered":"The \u2018Unwinding\u2019 of Medicaid | Kaiser Health News"},"content":{"rendered":"

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\n\t\tThe Host\t<\/h3>\n
\tJulie Rovner
\n\tKHN<\/p>\n
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\n\t\t\t\t@jrovner\t\t\t<\/a><\/p>\n
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\n\t\t\t\tRead Julie’s stories.\t\t\t<\/a><\/p>\n
\t\t\tJulie Rovner is chief Washington correspondent and host of KHN\u2019s weekly health policy news podcast, \u201cWhat the Health?\u201d A noted expert on health policy issues, Julie is the author of the critically praised reference book \u201cHealth Care Politics and Policy A to Z,\u201d now in its third edition.\t\t<\/p>\n
Several states have begun the herculean task of redetermining how many of an estimated 85 million Americans currently receiving health coverage through the Medicaid program are still eligible. To receive federal covid-19 relief funds, states were required to keep enrollees covered during the pandemic. As many as 15 million people could be struck from the program\u2019s rolls \u2014 many of whom are still eligible, or are eligible for other programs and need to be steered to them.<\/p>\n
Meanwhile, the trustees of the Medicare program report that its Hospital Insurance Trust Fund should remain solvent until 2031, three years longer than it projected last year. That allows lawmakers to continue to put off what are likely to be politically unpleasant decisions, although they will eventually have to deal with Medicare\u2019s underlying financial woes (and those of Social Security).<\/p>\n
This week\u2019s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Amy Goldstein of The Washington Post, and Rachel Roubein of The Washington Post.<\/p>\n

\n\t\tPanelists\t<\/h3>\n
\tAlice Miranda Ollstein
\n\tPolitico<\/p>\n
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\n\t\t\t\t@AliceOllstein\t\t\t<\/a><\/p>\n
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\n\t\t\t\tRead Alice’s stories\t\t\t<\/a><\/p>\n
\tAmy Goldstein
\n\tThe Washington Post<\/p>\n
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\n\t\t\t\t@goldsteinamy\t\t\t<\/a><\/p>\n
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\n\t\t\t\tRead Amy’s Stories\t\t\t<\/a><\/p>\n
\tRachel Roubein
\n\tThe Washington Post<\/p>\n
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\n\t\t\t\t@rachel_roubein\t\t\t<\/a><\/p>\n
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\n\t\t\t\tRead Rachel’s stories\t\t\t<\/a><\/p>\n
Among the takeaways from this week\u2019s episode:<\/p>\n
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The Medicaid \u201cunwinding\u201d is likely to strip health coverage not just from millions of people who are no longer eligible for the program, but also from millions of people who still are. States are supposed to take their time reevaluating eligibility, but some are rushing to disenroll people.<\/li>\n
Another complication in an already complicated task is that many Medicaid workers hired during the pandemic have never actually redetermined Medicaid eligibility for anyone, because states had been required to keep people who qualified on the program.<\/li>\n
Grimly, some of the extra years of solvency gained in the Medicare Hospital Insurance Trust Fund are a result of pandemic deaths in the 65-and-older population.<\/li>\n
The Department of Health and Human Services has issued payment rules for Medicare Advantage Plans for 2024. The agency ended up conceding at least somewhat to private plans that for years have been receiving more than they should have from the U.S. Treasury. The new rules will work to shrink those overpayments going forward, but not try to recoup those from years past.<\/li>\n
The situation with \u201cfirst-dollar coverage\u201d of preventive services by commercial health plans is becoming a bit clearer following last week\u2019s decision in Texas that part of the Affordable Care Act\u2019s preventive services mandate is unconstitutional. Judge Reed O\u2019Connor (who in 2018 ruled the entire health law unconstitutional) issued a nationwide stay on coverage requirements from the U.S. Preventive Services Task Force, saying it is a volunteer organization not subject to the oversight of the Health and Human Services secretary. The federal government is already appealing that ruling.<\/li>\n
But O\u2019Connor\u2019s decision is not quite as sweeping as first thought. He banned required coverage only of the task force\u2019s recommendations made after March 23, 2010 \u2014 the day the ACA was signed into law. Earlier recommendations stand. O\u2019Connor also did not strike preventive services recommended by the Health Resources and Services Administration and the Centers for Disease Control and Prevention\u2019s Advisory Committee on Immunization Practices, since those agencies are overseen by an official appointed by the president and confirmed by the Senate.<\/li>\n
In abortion news, the liberal candidate for a Supreme Court seat in Wisconsin, Janet Protasiewicz, defeated her conservative opponent to switch the majority on the court from 4-3 conservative to 4-3 liberal. That ideological shift is likely to preserve abortion rights in the state, and possibly stem the ability of the GOP legislature to continue to draw maps that favor Republicans.<\/li>\n
Meanwhile, states in the South are continuing to pull back on abortion access. The Florida legislature is moving rapidly on a bill that would ban the procedure after six weeks of pregnancy, while in North Carolina, a single legislator\u2019s switch from Democrat to Republican has given the latter a supermajority in the legislature large enough to override any veto of the Democratic governor, Roy Cooper.<\/li>\n<\/ul>\n
Also this week, Rovner interviews Daniel Chang, who reported and wrote the latest KHN-NPR \u201c Bill of the Month<\/a>\u201d feature about a child who had a medical bill sent to collections before he started to learn to read. If you have an outrageous or exorbitant medical bill you want to share with us, you can do that here<\/a>.<\/p>\n
Plus, for \u201cextra credit,\u201d the panelists suggest health policy stories they read this week that they think you should read, too:<\/p>\n
Julie Rovner:<\/strong> New York Magazine\u2019s \u201cThe Shared Anti-Trans and Anti-Abortion Playbook<\/a>,\u201d by Irin Carmon.<\/p>\n
Alice Miranda Ollstein:<\/strong> The Los Angeles Times\u2019 \u201cHorrifying Stories of Women Chased Down by the LAPD Abortion Squad Before Roe vs. Wade<\/a>,\u201d by Brittny Mejia.<\/p>\n
Rachel Roubein:<\/strong> KHN\u2019s \u201c\u2018Hard to Get Sober Young\u2019: Inside One of the Country\u2019s Few Recovery High Schools<\/a>,\u201d by Stephanie Daniel of KUNC.<\/p>\n
Amy Goldstein:<\/strong> The Washington Post\u2019s \u201cAfter Decades Under a Virus\u2019s Shadow, He Now Lives Free of HIV<\/a>,\u201d by Mark Johnson.<\/p>\n
Also mentioned in this week\u2019s podcast:<\/p>\n
\t\t\t\t\tClick to Open the Transcript\t\t\t\t<\/p>\n
\t\t\t\t\t\tTranscript: The \u2018Unwinding\u2019 of Medicaid<\/strong>\t\t\t\t<\/p>\n
KHN\u2019s \u2018What the Health?\u2019Episode Title:<\/strong> The \u2018Unwinding\u2019 of MedicaidEpisode Number:<\/strong> 292Published:<\/strong> April 6, 2023<\/p>\n
[Editor\u2019s note:<\/strong> This transcript, generated using transcription software, has been edited for style and clarity.]<\/em><\/p>\n
Julie Rovner: <\/strong>Hello and welcome back to KHN\u2019s \u201cWhat the Health?\u201d I\u2019m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I\u2019m joined by some of the best and smartest health reporters in Washington. We\u2019re taping this week on Thursday, April 6, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.<\/p>\n
Alice Miranda Ollstein: <\/strong>Good morning.<\/p>\n
Rovner: <\/strong>Rachel Roubein of The Washington Post.<\/p>\n
Rachel Roubein:<\/strong> Good morning.<\/p>\n
Rovner:<\/strong> And we welcome back to the podcast, after a bit of a break, Amy Goldstein, also of The Washington Post.<\/p>\n
Amy Goldstein: <\/strong>Good to be back.<\/p>\n
Rovner: <\/strong>Later in this episode, we will have the latest KHN-NPR \u201cBill of the Month\u201d interview, with my colleague Daniel Chang. This month\u2019s patient had a medical bill sent to collections before he was old enough to read. Impressive. But first, this week\u2019s news. We\u2019re going to start this week with Medicaid. During the pandemic, as most health policy nerds know, the federal government required states to keep anyone who qualified for the Medicaid program on the rolls, even if they became ineligible. But as of April 1, last week, states were free to start, quote, \u201cunwinding\u201d that Medicaid coverage. Now, states are facing the daunting task of determining who\u2019s still eligible for the program and who can be removed and how those who are losing that Medicaid coverage can be steered to other programs, which they might be eligible. This is, to quote then-Vice President Biden when the ACA got passed, a BFD. So, what are some of the potential problems here? We\u2019re talking about a lot of people, right, Amy? You wrote about this.<\/p>\n
Goldstein: <\/strong>We are talking about a lot of people. It\u2019s unclear how many people are going to lose Medicaid. But if you go by the Biden administration\u2019s estimates, they\u2019re thinking perhaps 15 million people out of 85 million people who are on Medicaid. So that\u2019s a lot of low-income people who could end up without insurance or scrambling to see if they can find other insurance if they know to do that. And obviously, Medicaid is a joint federal-state enterprise, and states are the ones that carry it out. States set their eligibility rules to a large extent, and states have each had to write and submit to the federal government a plan for how they\u2019re going to go about this unwinding. And the issue is that, with so many different plans, there are some things that CMS, Centers for Medicare & Medicaid Services, want states to do \u2014 for instance, to try as much as possible to check whether people are eligible by trying to match up with other records, say, from food stamps or wage records that the states might have.<\/p>\n
Rovner: <\/strong>So basically, don\u2019t count on them responding to a letter that says you need to reestablish your eligibility for this program.<\/p>\n
Goldstein: <\/strong>Exactly. But how assertively states are going to 1) do that, and secondly, how hard they\u2019re going to try to reach people in how many different ways \u2014 time will tell.<\/p>\n
Rovner: <\/strong>Yeah, I\u2019ve noticed. I mean, some states are doing things like sending out special colored envelopes. It\u2019s Easter week; we\u2019ve got robin\u2019s-egg blue envelopes. I think that was Massachusetts. Somebody\u2019s sending out pink envelopes and magenta envelopes. But, you know, Alice, you covered when they were doing the Medicaid work requirements, and Arkansas discovered that the problem wasn\u2019t so much that people weren\u2019t working; it\u2019s that people literally had trouble navigating the reporting system. And that\u2019s kind of what we\u2019re looking at writ large here, right?<\/p>\n
Ollstein: <\/strong>Yeah. And the people who are most likely to be flagged for removal, they could be very low income. They could have unstable housing, move around a lot, stay with family. They might not receive mail at the address that was on file a few years ago. They might not have reliable phone or internet access to be reachable in those ways. So, as Amy said, it really makes a difference how much and what kind of an effort states make to let people know this is even happening. Because as we saw with work requirements and even just, like, the regular pre-pandemic periodic Medicaid eligibility checks, people fall through the cracks all of the time for reasons that are not their fault at all. And so, with this all happening at once, with so many more people than normal, the risk of that just grows.<\/p>\n
Goldstein:<\/strong> And if I could just throw in one more complicating factor: If you think about what\u2019s happened to workforces over the pandemic, a lot of the Medicaid agencies in the states have lost workers, and there are shortages in a lot of places. And people who\u2019ve been hired in the last couple years have never had to do renewals or, as the lexicon goes, redeterminations before. So what\u2019s going on inside the places where these decisions are going to have to get made for all these people is a bit of a problem in many, many states.<\/p>\n
Roubein:<\/strong> I think how I\u2019ve been sort of thinking about it in my mind is there\u2019s 1) that issue of ensuring people who are still eligible don\u2019t lose coverage. And then there\u2019s the other issue of people who aren\u2019t eligible for Medicaid anymore, but having states and navigators and groups help them find coverage elsewhere, whether that\u2019s on the exchange, or some people might actually be now eligible for employer insurance. And some of that breakdown from that 15 million from that Department of Health and Human Services report \u2014 they had projected 6.8 million will lose Medicaid coverage despite being still eligible and that roughly 8.2 million people expected to leave the program because they\u2019re no longer eligible for the program.<\/p>\n
Rovner: <\/strong>And before somebody writes me and asks \u2026 [unintelligible] \u2026 I know states weren\u2019t absolutely required to keep these people on the rolls, but they were required to keep these people on the rolls if they wanted the extra pandemic money. So every state did it. So every state basically has this task ahead of them to try to figure out how it works, and we shall keep tabs on this. I want to turn to Medicare. Last week, we got the annual report of Medicare\u2019s trustees, which found, a little unexpectedly I think, that the program\u2019s Hospital Insurance Trust Fund should continue to be able to pay all of its bills until 2031. That\u2019s three years longer than it was projected to last year. Kind of grimly, apparently some of the improvement is due to many older people on Medicare dying during the covid pandemic. But this also does take some pressure off of lawmakers to fix what ails Medicare financially, right? They tend to only act when it\u2019s within this four- or five-year window.<\/p>\n
Ollstein:<\/strong> I would say yes and no. I haven\u2019t seen a huge shift in the talk on Capitol Hill in response to this report. It\u2019s only pushing back the deadline a few years. And it\u2019s true, Congress only acts when there\u2019s an imminent crisis and sometimes not even then. But I think the people really saying, \u201cHey, we need to do something,\u201d are not going to stop saying that because of this.<\/p>\n
Rovner: <\/strong>I\u2019m going to put that on a T-shirt: Congress only acts when there\u2019s an imminent crisis and sometimes not even then.<\/p>\n
Roubein: <\/strong>Oh, yeah. I mean, I think that\u2019s frustrated budget experts because Congress isn\u2019t particularly doing anything in terms of financial solvency. And I mean, it\u2019s really political, as we\u2019ve seen \u2014 Biden during his State of the Union and how he got Republicans to talk about basically his ad-libbed Medicare conversation. But it\u2019s kind of this tradition.<\/p>\n
Rovner:<\/strong> \u201cWe\u2019re not going to touch Medicare or Social Security.\u201d<\/p>\n
Roubein:<\/strong> Yeah. Off the table, this kind of tradition of \u201cMediscare.\u201d No one wants to kind of be putting their foot out there with a proposal that would change Medicare.<\/p>\n
Goldstein:<\/strong> This looming insolvency of Medicare is not at all a new problem. And ducking the problem is not a new phenomenon. Julie, you may remember, along with me, in the late 1990s, as a result of the big Balanced Budget Act of 1997 \u2014 this goes back a way \u2014 Congress created a bipartisan commission on the future of Medicare, and it was led by members of Congress. It was a big deal, it got a lot of attention, and it tried for many, many, many months to map out the future of Medicaid. And in the final analysis, it just dissolved in disagreements.<\/p>\n
Rovner: <\/strong>Yeah, Medicare, not Medicaid,<\/p>\n
Goldstein:<\/strong> Yes, Medicare.<\/p>\n
Rovner:<\/strong> They did recommend a drug benefit that did eventually come to pass, but \u2014<\/p>\n
Goldstein:<\/strong> That\u2019s right. But that was not the solvency solution.<\/p>\n
Rovner:<\/strong> No, it was not. And I will say, my bookcase here at home is littered with reports of these various commissions that Congress punted to. It\u2019s like, well, you guys solve it. And of course, no one ever has. We are still at this. But obviously this year, Rachel \u2014 you kind of hinted at this \u2014 some of this is going to come to a head because it\u2019s part of the debt ceiling debate, that Congress is going to have to do something about the debt ceiling, lest the U.S. actually default on its debt. Republicans want to have spending cuts as part of this. They had said they wanted to do something about Medicare as part of this. Is there any update on that debate? We still seem to be in the \u201cafter you, Alphonse\u201d portion of this, with both Biden saying he\u2019s ready to talk to the Republicans and Republicans saying they\u2019re ready to talk to Biden and nobody really talking to each other yet.<\/p>\n
Roubein: <\/strong>Yeah, I mean, I think both sides are pretty dug in here at the moment. McCarthy a month or two ago had said no cuts to Medicare and Social Security. And Kevin McCarthy, I think it was the end of last month, had demanded a meeting with Biden. And then, you know, kind of the Biden team came back and said, \u201cOK, well, we put out a budget. So, you know, Republicans need to produce their budget document.\u201d And, you know, that\u2019s kind of the political argument that we\u2019ve been hearing for a little while here.<\/p>\n
Rovner:<\/strong> Well, to paraphrase Alice, this crisis is about to get imminent, but not quite.<\/p>\n
Goldstein:<\/strong> Before we leave Medicare, let me just make a couple more points. One is that this affects hospital care. So it\u2019s not all parts of Medicare. And when the insolvency date comes \u2014 as you say, now projected to be 2031 \u2014 it\u2019s not as if the program is going to be unable to pay any of its bills. This year its trustees said that it\u2019s going to be able to pay 89% of the hospital benefits to which Medicare are entitled. The other point is, I mean, there\u2019s a long-standing reason why politicians have been reluctant to fix something despite the many, many, many years of cries of, \u201cWe better fix it soon because it\u2019s going to be harder to fix the longer we wait.\u201d And that is that, older Americans \u2014 I mean, to state the obvious \u2014 are a very active voting bloc and they do not like the prospect of federal benefits being eroded. So there is politics behind why both parties have been reticent.<\/p>\n
Rovner:<\/strong> Yes, there\u2019s four ways to make Medicare solvent. You can pay providers less, which is what they usually end up doing, and they fight back. You can make the benefits less, either by having people wait longer to get on them or having to pay more for them. Or you can require the taxpayers to pay more money. So everything is kind of unpleasant here. And I think that\u2019s why Congress would just as soon not do this. But while we still have Medicare teed up, we talked at some length a few weeks ago about Medicare Advantage plans, the private alternative to the government fee-for-service Medicare, and how those plans are technically being overpaid, which has prompted quite the TV advertising campaign from the plans, which I suspect very few people understand. There\u2019s just all these sort of old people saying, \u201cThey\u2019re going to cut our Medicare.\u201d So the Department of Health and Human Services finally issued its Medicare Advantage payment rule for next year, and it appears to split the difference, stopping plans from continuing to overstate how sick their patients are, which is what\u2019s responsible for a lot of the overpayments. But it limits the ability of the government to look back to recoup some of those overpayments that have been made. Is that basically a one-sentence explanation of what they\u2019ve done here?<\/p>\n
Roubein:<\/strong> The industry waged a pretty fierce battle here, but they phased in their plan. So essentially the Centers for Medicare & Medicaid Services had proposed switching to a more updated coding system, which included eliminating approximately 2,000 codes. And insurers claimed that this could lead to substantial pay cuts. The administration fiercely disputed that. But they did, as you say, kind of split the difference, in terms of saying, \u201cOK, well, we\u2019re going to phase in these changes over three years,\u201d which CMS officials and other experts have said is something that they kind of tend to do when there is controversial policy.<\/p>\n
Rovner:<\/strong> Right. When they don\u2019t want to irritate anybody too much, although I did notice that there\u2019s also some rules about deceptive advertising for Medicare Advantage plans. So maybe it\u2019ll make me stop screaming at the TV when these ads come on. Moving along, last week we were able to bring you the breaking news about the preventive care ruling out of Texas from federal District Judge Reed O\u2019Connor. What else have we learned since those first breaking hours? I know the decision doesn\u2019t cover preventive care recommended by groups that report directly to someone in the federal government who is appointed by the president and confirmed by the Senate \u2014 at least it doesn\u2019t at the moment. But it only limits preventive care that\u2019s recommended by the U.S. Preventive Services Task Force. But it could still be expanded at the appeals level, right?<\/p>\n
Goldstein:<\/strong> That\u2019s right. This affects a lot of people: everybody with private health insurance, which is estimated by federal health officials to be about 150 million people. It\u2019s not killing all free preventive services. It\u2019s ending the mandate that they\u2019re provided at no cost to consumers for those preventive services that the U.S. Preventive Services Task Force has either defined or updated since the Affordable Care Act was passed in 2010. So that leaves intact a few important categories of things: 1) earlier preventive services, like mammograms, which were required to be covered for free before, are still intact. It also leaves intact services that are required by two different parts of HHS. Within HRSA [Health Resources and Services Administration], they have jurisdiction over women\u2019s health services, so that\u2019s why things like contraception are not touched by \u2014 at the moment, as you say \u2014 by this court ruling. And similarly, an advisory body to the CDC, which has jurisdiction over vaccinations, whether it\u2019s childhood vaccinations, covid vaccinations \u2014 so those aren\u2019t touched. But what\u2019s happened in the past week is, predictably, the day after Judge O\u2019Connor \u2014 who, as I\u2019m sure you discussed last week, was the same judge who a few years ago held that the entire ACA was unconstitutional and was ultimately overruled by the Supreme Court \u2014 anyhow, O\u2019Connor last week said this applies nationwide, not just to places where the plaintiffs are. And the next day, the Biden administration, the Justice Department, very quickly filed a notice of appeal. It was one paragraph. It wasn\u2019t laying out the appeal, but it was getting on the record that the administration is going to appeal to the 5th Circuit Court of Appeals, which is a conservative circuit based in New Orleans that hasn\u2019t been entirely friendly to the ACA in the past. What the administration did not yet do is say that it wants to stay the judge\u2019s ruling, but it\u2019s very likely that that\u2019s going to be requested as well.<\/p>\n
Rovner:<\/strong> Even if the judge\u2019s ruling doesn\u2019t get stayed, it\u2019s likely to have very little immediate impact, right? Because insurance contracts are already kind of set for the year. If insurers wanted to stop covering this \u2014 and they\u2019re probably not going to stop covering it \u2014 but if they wanted to make it \u2014 institute copays or say this is part of your deductible \u2014 they\u2019re likely not to do that until the next plan year, right? Alice, I see you nodding.<\/p>\n
Ollstein:<\/strong> Yeah, but that isn\u2019t uniform. So the folks I talked to said that, while most plans are baked in for the year and what we really should be looking for is when the new 2024 things start coming out in the summer into the fall, that\u2019s what we should be watching in terms of, you know, what could change there. But that isn\u2019t uniform. It\u2019s possible that some plans could change earlier. There are all different kinds of possibilities, but I was kind of surprised to see the Biden administration not rush to file an appeal right away. They filed a notice of appeal, but they haven\u2019t actually filed the appeal yet or asked for the stay, but I think that is stemming from this not being seen as an imminent threat to people\u2019s health coverage. The piece of it I\u2019ve really been interested in is the impact on HIV and STDs, because, like Amy said, a lot of the basic cancer screenings and other things will continue to be protected in some form because they were recommended prior to 2010. But a lot of the STD and HIV stuff is a lot more recent, so it\u2019s a lot more vulnerable to being rolled back, and plans and employers \u2014 for a lot of these things \u2014 covering preventive services for free with no out-of-pocket costs is good; it\u2019s really cheap to cover and it prevents a lot of expensive care down the road. But that\u2019s sort of less true with some of these things. PrEP, the HIV prevention drug, is really expensive. A lot of the lab costs for STD testing are still expensive. And so you could see folks\u2019 plans and employers wanting to save money by shifting some of those costs to patients. And public health experts are worried about that.<\/p>\n
Rovner:<\/strong> I think another quirk of this that we didn\u2019t realize right away is what the decision says is that it only affects USPSTF rulings that were made after the date that the Affordable Care Act was signed, March 23, 2010. But what that ends up doing is leaving in effect prior recommendations that are not necessarily up to date. So you could end up rolling back to things that medical experts no longer think is the appropriate interval or type of preventive service being required. And then, of course, you have the insurers who are going to be required to put out their bids for next year in the coming months. Now, this is not the first time insurers have had to stab in the dark at what they think the rules are going to be and how much they\u2019re going to want to charge for that. So we\u2019re having yet another round of insurers kind of having to throw their hands out and throw darts against the wall, right?<\/p>\n
Goldstein:<\/strong> Yes. And this \u2014 Alice mentioned employers are a big constituency in this. There is some survey evidence, I mean not terribly systematic survey evidence, but a little bit of survey evidence that was done last fall with this case pending, that showed that most insurers, a high, high proportion of insurers, wanted to keep these benefits. So that may influence, as you\u2019re saying, Julie, what the bids come in looking like while this is all still kind of murky.<\/p>\n
Rovner:<\/strong> Yeah, we know it\u2019s popular and we know in most cases it\u2019s relatively cheap. So one would assume that this decision might not have too much impact, although as I sort of alluded to, and I haven\u2019t heard whether this is happening yet, the plaintiffs could also appeal because they didn\u2019t get everything they wanted. They also wanted to have the women\u2019s health stuff out of HRSA and the immunization stuff out of CDC stayed as, you know \u2014 or the requirements gotten rid of, and the judge did not do that. So one presumes they could also appeal and we would see what happens at the 5th Circuit Court of Appeals. But I think everybody assumes at this point that it\u2019s going to end up at the Supreme Court, yes? I see nods all around. Oh, boy. I can\u2019t wait. All right. Well, let\u2019s turn to abortion. The big abortion news this week comes from Wisconsin in a race for state Supreme Court, of all things, which was supposed to be nonpartisan or technically was nonpartisan. Still, the strong showing by the judge who was associated with the liberal side of the ledger could have some major impact, right? This was expected to be a very close race, and it really wasn\u2019t.<\/p>\n
Ollstein:<\/strong> No, it wasn\u2019t close at all. The progressive candidate really took it away, and the campaign really heavily focused on abortion. This is because the state\u2019s ban, which has been in place, you know, since long before Roe<\/em> was enacted, is likely to come before the court. But the implications go way beyond that. This could change how the legislature makeup is in the future because of challenges to the gerrymandered state maps. That could, you know, open the door to Medicaid expansion and all kinds of other things, you know, related to abortion, related to all kinds of things. Because right now, you know, you have a Democratic governor who is on his second term who can\u2019t really do very much because of the state legislature. So this could have tons and tons of repercussions going forward in Wisconsin.<\/p>\n
Rovner: <\/strong>And we should point out, because I meant to say, this election flipped the state Supreme Court from 4-3 conservative to 4-3 liberal.<\/p>\n
Roubein: <\/strong>It was really interesting because you saw the liberal candidate, Janet Protasiewicz, really leaning into abortion rights. And, you know, obviously she\u2019s a judge, but in multiple ads from her campaign it said, you know, women should have the freedom to make their own decisions on abortion. That was a quote from the ads. And now, you know, kind of, she was \u2026 [unintelligible] \u2026 from the other side, like, can she be impartial when she rules? And, you know, she said like, \u201cNo, I have not promised any of these major groups, Emily\u2019s List, etc., that are backing me, how I will rule.\u201d But, you know, we did see the judge, as she called it, her personal beliefs and be really open about that.<\/p>\n
Rovner:<\/strong> And her opponent was also pretty open about it, too. He was a very conservative guy who was pretty much promising to go down the line with what the conservatives wanted. Alice, you were about to say something.<\/p>\n
Ollstein:<\/strong> Yeah, well, it\u2019s been fascinating now that we\u2019re a day out from the election results. There is sort of a freakout going on on the right about it and about what it means for abortion specifically. And you\u2019re seeing a lot of very prominent people on the right publicly saying, \u201cWe have a message on abortion that voters don\u2019t like and we need to change it right now.\u201d People are saying that the right needs to moderate and stop pushing for near-total bans with no exceptions, which is going on in a lot of states right now. That debate was already happening on the right, but I think this just pours fuel on it. I think with the Florida governor about to be confronted with whether or not to sign a six-week ban, this really is going to squeeze a lot of people.<\/p>\n
Rovner: <\/strong>Yes, I feel very smug about my extra credit story from last week, which was the Rebecca Traister long read in New York Magazine about how Democrats have underestimated how winning an issue abortion may be. And I saw her sort of also smugly tweeting late Tuesday night. It\u2019s like, \u201cSee, I\u2019m telling you this.\u201d While the Upper Midwest may be getting more supportive of abortion rights, also this week Michigan Governor Gretchen Whitmer formally signed the repeal of the state\u2019s nearly hundred-year-old pre-Roe<\/em> ban. But in the South, the trend is going the other way, as you mentioned, Alice. Florida\u2019s legislature is moving quickly on a six-week abortion ban, while in North Carolina a Democratic state legislator who ran on abortion rights is switching parties, giving the Republicans there a supermajority that will let them override the Democratic governor\u2019s vetoes. Are we looking at, fairly imminent, abortion being unavailable throughout the South?<\/p>\n
Roubein:<\/strong> I think Florida, North Carolina, Nebraska is also considering a similar limit \u2014 were all states that in the two months after Roe v. Wade<\/em> was overturned \u2014 were states that saw an increase in abortions. I think North Carolina is particularly interesting because in early February all the Democrats had signed on to a bill to codify Roe v. Wade<\/em>. But I was reporting at the time with my colleague Caroline Kitchener on this, and she talked to one of the Democrats there, who said, well \u2014 after he signed on to it \u2014 like, \u201cWell, that doesn\u2019t preclude me from voting for abortion restrictions.\u201d He had said this is, quote, \u201cThis is still the first quarter.\u201d So I think even before we saw the state Democrat switch to Republican, you know, what happened in North Carolina where there is a Democratic governor was an open question even beforehand.<\/p>\n
Rovner:<\/strong> Yeah, this reminds me of Virginia trying to expand Medicaid, and there\u2019s constantly this sort of one member, another member. I mean, it literally didn\u2019t happen until the last vote<\/em> allowed it to happen, I think.<\/p>\n
Ollstein:<\/strong> Yeah. I mean, this also really puts a spotlight on the tactic of doing a ballot referendum on abortion, because \u2014<\/p>\n
Rovner:<\/strong> That was my next question, Alice.<\/p>\n
Ollstein:<\/strong> Ta-da.<\/p>\n
Rovner:<\/strong> Tell us about your story about that.<\/p>\n
Ollstein: <\/strong>The relation to this is, yes, you have a lot of Republican lawmakers and some Democrats, or some former Democrats, as we\u2019ve seen, who are moving very aggressively to continue to pass abortion restrictions, whether it\u2019s total bans or something short of that. But the referendums often show that that doesn\u2019t necessarily reflect all of the Republican electorate, which is not always aligned with their representatives on this issue. And based on the results of the six referendums last year in which the pro-abortion-rights side won all six out of six, folks are hoping to get that going in more states this year, and it\u2019s already underway \u2014 not as much in the South, and not every state can do a referendum legally. It varies state to state what the rules are, but where it\u2019s possible, people are trying to do it. My story this week reported on an internal fight on the left<\/a> about how to go about it. So most of the referendums that are moving forward in these red and purple states right now, trying to get on the ballot in the next few years, say that basically they would only restore the protections of Roe v. Wade<\/em>, so only protect abortion up to the point of fetal viability. And you have a lot of folks \u2014 you know, medical groups, activists \u2014 saying, Why are we doing that? Why are we sort of pre-compromising? We keep seeing over and over at the ballot box this is a winning issue; why aren\u2019t we being bold? Like the right is going for total bans. Why aren\u2019t we going for total legalization? But the folks who want the viability limit in there are saying, Look, we want to put something forward that we know is going to pass. We\u2019ve done research and focus groups and polling. You know, this is the way we think is smartest to go. Plus, you know, the vast majority of abortions take place prior to viability anyways. And right now we have no abortion at all. So isn\u2019t legalizing most better than nothing? And so it\u2019s a really interesting debate.<\/p>\n
Rovner: <\/strong>It\u2019s literally the mirror image of the debate that\u2019s going on on the right, which has been happening over the years. It\u2019s just that it\u2019s all kind of, you know \u2014 now that we\u2019re in this sort of odd place \u2014 it\u2019s all magnified. So, you know, the right is trying to decide between do we restrict abortion a little or do we just allow, you know, the end of Roe v. Wade<\/em> and states to make up their mind? Or do we go for a national ban? Where the left is saying, do we just want to bring things back to where they were when we had Roe<\/em>, or do we want to go further and allow and basically have public funding and sort of other things to assure what they call reproductive justice? So obviously, this fight is going to continue on both sides.<\/p>\n
Goldstein: <\/strong>Let me just say that this tension between the electorate and lawmakers in fairly conservative states is a real echo of what has happened over the years with Medicaid expansion, when there have been several states in which legislators were really dug in that they weren\u2019t going to expand Medicaid under the ACA, and public ballot initiative and it expanded. So it\u2019s sort of turning to the exact same tactic.<\/p>\n
Rovner: <\/strong>That\u2019s right. And again, in a lot of these Republican states, the voters were very happy to expand Medicaid. So that, yes, we\u2019ve seen this particular book before. Well, before we go, there were a couple of stories that got kicked over from last week when we had our breaking news. But I really wanted to mention about artificial intelligence in health care or at least in health insurance. One story from ProPublica details how the health insurance giant Cigna is using an algorithm to reject thousands of claims<\/a> for care that\u2019s kind of between cheap and very expensive, and then letting medical director physicians basically batch-approve those rejections on the theory, likely correct, that even if most of the care is medically appropriate, most people won\u2019t bother to appeal a bill of just a couple of hundred dollars and will just pay it. The other story, from Stat News, is kind of strikingly similar. It\u2019s about a Medicare Advantage plan that\u2019s using AI to pinpoint<\/a> the exact moment it can stop paying for some care, particularly expensive care, in a hospital or nursing home. Now, it would appear that the Medicare Advantage case is more egregious because it seeks to actually cut off care, where Cigna is just denying payment after the fact. But it seemed to make it pretty clear that while a) it might improve care and save money, sometimes it\u2019s just saving money for people other than the patients, right? That\u2019s what it certainly looks like in these cases.<\/p>\n
Ollstein: <\/strong>I mean, as we\u2019ve seen with other uses of algorithms, algorithms reflect the values of the people creating the algorithms. And you say, \u201cOh, it\u2019s a robot, it\u2019s completely impartial.\u201d Why are there racial discrimination implications then? But we do keep seeing this and it\u2019s like, it was created by humans, it\u2019s going to have human failings and require oversight and accountability mechanisms.<\/p>\n
Rovner: <\/strong>Yeah. And finally, one more story from the \u201cbe careful what you wish for.\u201d There\u2019s a story in The Atlantic this month about the downside of telehealth that at least some of us saw coming. Now that doctors can charge for and be reimbursed for virtual care by video, more and more doctors are starting to charge<\/a> for other forms of communication that used to be free, like telephone calls and emails. Now, lawyers have long charged for phone calls advising clients. I always kind of wondered why doctors didn\u2019t. I guess I have my answer now. Is this another case of anything \u2014 that any technology that\u2019s good is probably also going to have its downsides?<\/p>\n
Goldstein: <\/strong>Well, it\u2019s also a reflection that fewer and fewer doctors work on their own. They\u2019re working for health systems that have the bottom line in mind, which is not to say they only have the bottom line in mind, but they\u2019re less autonomous in terms of their pricing policies.<\/p>\n
Rovner: <\/strong>And yeah, are being asked to see more patients, so it takes more time to actually, you know \u2014 one of the interesting things in this in the story was that a phone call may only be five minutes for you, but it\u2019s probably 20 minutes for your doctor who has to go make a notation in your chart and maybe call in a prescription. And it\u2019s more than just the quick phone call for the doctor. I think this is something that used to be a courtesy and now it\u2019s just a charge. All right, well, that is this week\u2019s news. Now we will play my \u201cBill of the Month\u201d interview with Daniel Chang and then we\u2019ll come back with our extra credit. We are pleased to welcome to the podcast Daniel Chang, who reported and wrote the latest KHN-NPR \u201cBill of the Month.\u201d Daniel, welcome to \u201cWhat the Health?\u201d<\/p>\n
Daniel Chang:<\/strong> Hi, Julie. I\u2019m glad to be here.<\/p>\n
Rovner:<\/strong> So this month\u2019s patient wasn\u2019t even old enough for kindergarten when he got a medical bill sent to collection for care he didn\u2019t even receive. Who is this kid? Why did he need medical care? And this is very impressive, I\u2019ve got to say.<\/p>\n
Chang:<\/strong> So, at the time \u2014 this happened last Memorial Day weekend \u2014 Keeling McLin was his name, and he was 4 years old. And according to his mom, Sara McLin, who\u2019s a dentist in central Florida, she had just finished cooking something on the stove and Keeling had gotten up to get something. And on his way down he put his hand on the hot stove. That was pretty painful, from what she described. And so she took him to the emergency room for care.<\/p>\n
Rovner:<\/strong> First she took him to urgent care, right?<\/p>\n
Chang:<\/strong> Well, it was a stand-alone emergency room, so it\u2019s one of those hybrid ones, I guess you might call it. No inpatient, of course.<\/p>\n
Rovner:<\/strong> And therein is about to be our problem. So Mom did everything right here, right? She made sure that she went to a facility in her network, and then they sent her off to another hospital. But the problem is, where is the first visit, right?<\/p>\n
Chang:<\/strong> Correct. The first visit was a problem. It was part of the HCA system. And they didn\u2019t have, I guess, the resources there to treat Keeling\u2019s burn. So they referred him to a HCA hospital with a burn center, which was about a 90-minute drive away from the stand-alone ER.<\/p>\n
Rovner:<\/strong> And they managed to deal with the burn, right? The kid\u2019s OK.<\/p>\n
Chang:<\/strong> They did. He\u2019s OK. It turned out to be not as bad as suspected. And Sara McLin told me that they drained his blisters, wrapped his hand, and sent her home with instructions on how to care for it. And she didn\u2019t think about it again.<\/p>\n
Rovner:<\/strong> Until she got the bill.<\/p>\n
Chang:<\/strong> Exactly.<\/p>\n
Rovner:<\/strong> This gets pretty Kafkaesque, doesn\u2019t it? What were the bills here?<\/p>\n
Chang:<\/strong> So, the first bill that she received was from the physician provider group; Envision Healthcare employed the physician in the stand-alone emergency room. That bill was for about $72. She called her insurer, which was UnitedHealthcare, and they told her that \u2014 essentially not to worry about it. And the bill itself is labeled as a surprise out-of-network bill, although when I reached out to Envision Healthcare, they said that it was not, it was part of her cost sharing. In any case, that bill didn\u2019t cause her any problems. Shortly after that, she got a bill from the stand-alone emergency room, and this bill was considerably higher, although her share was about $129. But the reason that she was a little confused about this is because she said that the physician at the stand-alone emergency room told her, \u201cYou know what, this won\u2019t even count as a visit because we can\u2019t do anything for him.\u201d So she left with that thought. And later on she said she wished she had gotten that in writing, but that was the problem bill.<\/p>\n
Rovner:<\/strong> Yes. So what eventually happened?<\/p>\n
Chang:<\/strong> So what eventually happened is that the bill was in Keeling\u2019s name and it did not include his mom or his dad on there. It was just simply to Keeling. And for reasons that HCA didn\u2019t explain, and we can\u2019t explain, Envision got his insurance information correct, but HCA had him as an uninsured person responsible for his own bills. And it\u2019s odd because his date of birth is on that bill. And you would think that somewhere along the line someone would catch that. But they didn\u2019t. And so what happened is that Sara fell into this sort of twilight zone where she couldn\u2019t speak to anyone about the bill because it wasn\u2019t in her name. And so, according to her conversations with folks at HCA and later at Medicredit, they couldn\u2019t talk to her because her name wasn\u2019t on the bill. So this was the one thing that she was trying to get resolved. And she tried for months and got nowhere, which is when she reached out to us.<\/p>\n
Rovner:<\/strong> And as you point out, that Medicredit is the collections agency, right? This 5-year-old\u2019s bill got sent to collections.<\/p>\n
Chang:<\/strong> That\u2019s correct. That just kind of compounded the frustration because Sara had worked for a couple of months to get HCA to add her name onto the bill. And she had even written them a letter, she says, and they told her they were going to do it and she was waiting for the bill. But then the next letter she got was from the collection agency, for the same amount and with the same problem. Her name wasn\u2019t on the bill. So when she called the collection agency to try to dispute the bill, they told her, \u201cSorry, we can\u2019t talk to you. You\u2019re not the authorized representative on this bill.\u201d<\/p>\n
Rovner:<\/strong> It feels like the biggest problem here is not so much that mistakes happen. They do. Obviously, they\u2019ve happened a lot in our \u201cBill of the Month\u201d series. But they are so very hard to fix \u2014 I mean, even when you say, \u201cLook, this is a 5-year-old.\u201d<\/p>\n
Chang:<\/strong> I agree. It sounded so frustrating. And I think, ultimately, of course, that\u2019s why she reached out to us. But she tried repeatedly and not only did she tell me this, but the bills that she provided to us had a lot of her handwritten notes in the margins and the dates that she had spoken to individuals. And it just \u2014 it\u2019s really hard. None of the experts that we spoke with could understand why HCA couldn\u2019t just simply fix this before they sent it to collections. And HCA acknowledged the error, and they apologized to her. And they ultimately canceled the debt. But the system clearly doesn\u2019t seem to work in favor of patients when you have these sort of odd complications that really they didn\u2019t have anything to do with what she owed or what they said she owed; it was all a matter of identification.<\/p>\n
Rovner:<\/strong> So is there anything she could have done differently? I\u2019m not saying, you know \u2014 she obviously couldn\u2019t prevent the mistake from being made. But was there some better way for her to try to navigate this?<\/p>\n
Chang:<\/strong> You know, neither the insurer or the providers gave us an explanation of what she could have done differently or what individuals who find themselves in a similar position could do. And so I think she did everything that she reasonably could, short of perhaps hiring an attorney? I\u2019m not sure; maybe that would have worked, but you shouldn\u2019t have to go to that length and that cost just to get your name on your minor child\u2019s bill so that you can take care of it and speak to the people who say you owe them the money. It\u2019s just \u2014 it\u2019s crazy.<\/p>\n
Rovner:<\/strong> And she\u2019s a dentist, so she\u2019s a health care professional. She obviously had some, you know, knowledge of the system and how it works. And even she had trouble \u2014<\/p>\n
Chang:<\/strong> That\u2019s correct.<\/p>\n
Rovner:<\/strong> \u2014 getting it done. So I guess basically the lesson is, watch your bills closely and be ready to take action.<\/p>\n
Chang:<\/strong> And potentially, when I think about this situation, ensuring perhaps that the stand-alone ER had all of the information, but I can also see where she was told that, \u201cLook, this doesn\u2019t even count as a visit. We couldn\u2019t treat him here. You\u2019ve got to take him to the burn center. We won\u2019t count this as a visit.\u201d I think she left comfortable in that knowledge, only to realize later that, oops, it wasn\u2019t that way. Yeah.<\/p>\n
Rovner:<\/strong> Get it all in writing.<\/p>\n
Chang:<\/strong> Yes.<\/p>\n
Rovner:<\/strong> Daniel Chang, thank you so much.<\/p>\n
Chang:<\/strong> You\u2019re very welcome. Thanks for having me on.<\/p>\n
Rovner: <\/strong>OK, we\u2019re back. And it\u2019s time for our extra credit segment. That\u2019s when we each recommend a story we read this week we think you should read too. As always, don\u2019t worry if you miss it. We will post the links on the podcast page at khn.org<\/a> and in our show notes on your phone or other mobile device. Alice, why don\u2019t you go first this week?<\/p>\n
Ollstein: <\/strong>Sure. So I picked a really fascinating history piece from the LA Times<\/a> by Brittny Mejia, and it\u2019s about what law enforcement\u2019s role was pre-Roe v. Wade<\/em> in cracking down on illegal abortions. All abortions were illegal. And it just really vividly describes how cops would conduct raids on doctors who were operating clandestinely and performing abortions, you know, the tactics they would use. It was just really fascinating. And so I think it\u2019s worth resurfacing this history, thinking, OK, so abortion is illegal again; what does enforcement look like? What could enforcement look like? And this is a very disturbing picture of what it used to look like.<\/p>\n
Rovner: <\/strong>Amy, you have a story that\u2019s kind of related to Alice\u2019s story, also looking at history, but updated.<\/p>\n
Goldstein: <\/strong>That\u2019s right. I chose a story by my colleague at the Post, Marc Johnson, with the headline, \u201cAfter Decades Under a Virus\u2019s Shadow, He Now Lives Free of HIV<\/a>.\u201d And it\u2019s an interview with one of only five people in the world who\u2019ve had stem cell transplants that have cured them of cancer but also gotten rid of any evidence of HIV in their bodies. And it\u2019s not a hugely long story, but it\u2019s just a beautiful trajectory reminding us of what the early bad world of AIDS was, with this individual\u2019s friends dying all around him in San Francisco, to the decades when he was on a lot of AIDS drugs, and suddenly being unexpectedly liberated from all that. It\u2019s a good read.<\/p>\n
Rovner: <\/strong>Yeah, it is. Rachel.<\/p>\n
Roubein: <\/strong>My extra credit is titled \u201c\u2018Hard to Get Sober Young\u2019: Inside One of the Country\u2019s Few Recovery High Schools<\/a>,\u201d by Stephanie Daniel of KUNC. And basically it takes the reader inside a Denver recovery high school, which mixes high school education with treatment for drug and alcohol addiction. And so this high school in Colorado \u2014 it\u2019s one of 43 nationwide, and she kind of details the history of recovery high schools, which, the first one opened up in Silver Spring, Maryland, in 1979. And she also kind of goes through what I thought was interesting, which was kind of, the challenges of recovery high schools, most being publicly funded charter or alternative schools, and they have a higher ratio of mental health and recovery personnel, so there\u2019s really not a ton of them nationwide.<\/p>\n
Rovner: <\/strong>I had never heard of them until I saw this story. It was really interesting. Well, for the second week in a row, my story is from New York Magazine. It\u2019s by Irin Carmon, and it\u2019s called \u201cThe Shared Anti-Trans and Anti-Abortion Playbook<\/a>.\u201d And she points out that not only are there many of the same people fighting abortion who are also fighting trans health care, but there\u2019s also a similarly long-term strategy, as Irin wrote. They\u2019re focusing on youth first, because they understand that it\u2019s much harder to convince the public to restrict the lives of adults. As someone who\u2019s spent years covering the fight over whether or not teen girls should be able to access sex education, birth control, or abortion, it does feel familiar. OK, that is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We\u2019d appreciate it if you left us a review. That helps other people find us too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We\u2019re at whatthehealth@kff.org<\/a>. Or you can tweet me. I\u2019m @jrovner<\/a>. Rachel?<\/p>\n
Roubein: <\/strong>@rachel_roubein<\/a>.<\/p>\n
Rovner:<\/strong> Alice?<\/p>\n
Ollstein: <\/strong>@AliceOllstein<\/a>.<\/p>\n
Rovner:<\/strong> Amy?<\/p>\n
Goldstein: <\/strong>@goldsteinamy<\/a>.<\/p>\n
Rovner: <\/strong>We will be back in your feed next week. Until then, be healthy.<\/p>\n
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