The Host

Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The public health emergency in effect since the start of the covid-19 pandemic will end on May 11, the Biden administration announced this week. The end of the so-called PHE will bring about a raft of policy changes affecting patients, health care providers, and states. But Republicans in Congress, along with some Democrats, have been agitating for an end to the “emergency” designation for months.

Meanwhile, despite Republicans’ less-than-stellar showing in the 2022 midterm elections and broad public support for preserving abortion access, anti-abortion groups are pushing for even stronger restrictions on the procedure, arguing that Republicans did poorly because they were not strident enough on abortion issues.

This week’s panelists are Julie Rovner of KHN, Victoria Knight of Axios, Rachel Roubein of The Washington Post, and Margot Sanger-Katz of The New York Times.

Panelists

Victoria Knight Axios @victoriaregisk Read Victoria's stories. Rachel Roubein The Washington Post @rachel_roubein Read Rachel's stories. Margot Sanger-Katz The New York Times @sangerkatz Read Margot's stories.

Among the takeaways from this week’s episode:

• This week the Biden administration announced the covid public health emergency will end in May, terminating many flexibilities the government afforded health care providers during the pandemic to ease the challenges of caring for patients.
• Some of the biggest covid-era changes, like the expansion of telehealth and Medicare coverage for the antiviral medication Paxlovid, have already been extended by Congress. Lawmakers have also set a separate timetable for the end of the Medicaid coverage requirement. Meanwhile, the White House is pushing back on reports that the end of the public health emergency will also mean the end of free vaccines, testing, and treatments.
• A new KFF poll shows widespread public confusion over medication abortion, with many respondents saying they are unsure whether the abortion pill is legal in their state and how to access it. Advocates say medication abortion, which accounts for about half of abortions nationwide, is the procedure’s future, and state laws regarding its use are changing often.
• On abortion politics, the Republican National Committee passed a resolution urging candidates to “go on the offense” in 2024 and push stricter abortion laws. Abortion opponents were unhappy that Republican congressional leaders did not push through a federal gestational limit on abortion last year, and the party is signaling a desire to appeal to its conservative base in the presidential election year.
• This week, the federal government announced it will audit Medicare Advantage plans for overbilling. But according to a KHN scoop, the government will limit its clawbacks to recent years, allowing many plans to keep the money it overpaid them. Medicare Advantage is poised to enroll the majority of seniors this year.

Also this week, Rovner interviews Hannah Wesolowski of the National Alliance on Mental Illness about how the rollout of the new 988 suicide prevention hotline is going.

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

Julie Rovner: Axios’ “Republicans Break With Another Historical Ally: Doctors,” by Caitlin Owens and Victoria Knight

Margot Sanger-Katz: The New York Times’ “Most Abortion Bans Include Exceptions. In Practice, Few Are Granted,” by Amy Schoenfeld Walker

Rachel Roubein: The Washington Post’s “I Wrote About High-Priced Drugs for Years. Then My Toddler Needed One,” by Carolyn Y. Johnson

Victoria Knight: The New York Times’ “Emailing Your Doctor May Carry a Fee,” by Benjamin Ryan

Also mentioned in this week’s podcast:

• KFF’s “KFF Health Tracking Poll: Early 2023 Update on Public Awareness on Abortion and Emergency Contraception,” by Grace Sparks, Shannon Schumacher, Marley Presiado, Ashley Kirzinger, and Mollyann Brodie
• USA Today’s “Biden Seeks to Bolster the Affordable Care Act’s No-Cost Contraception Rule,” by Ken Alltucker
• The National Review’s “To Reduce Abortions, Should Giving Birth Be Free?” by Wesley J. Smith
• The New York Times’ “New Medicare Rule Aims to Take Back $4.7 Billion From Insurers,” by Reed Abelson and Margot Sanger-Katz
• KHN’s “Government Lets Health Plans That Ripped Off Medicare Keep the Money,” by Fred Schulte

Click to open the transcript Transcript: Au Revoir, Public Health Emergency

KHN’s ‘What the Health?’Episode Title: Au Revoir, Public Health EmergencyEpisode Number: 283Published: Feb. 2, 2023

Tamar Haspel: A lot of us want to eat better for the planet, but we’re not always sure how to do it. I’m Tamar Haspel.

Michael Grunwald: And I’m Michael Grunwald. And this is “Climavores,” a show about eating on a changing planet.

Haspel: We’re here to answer all kinds of questions. Questions like: Is fake meat really a good alternative to beef? Does local food actually matter?

Grunwald: You can follow us or subscribe on Stitcher, Apple Podcasts, Spotify, or wherever you listen.

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 2, 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 Margot Sanger-Katz of The New York Times.

Margot Sanger-Katz: Good morning, everybody.

Rovner: Rachel Roubein of The Washington Post.

Rachel Roubein: Hi, good morning.

Rovner: And Victoria Knight of Axios.

Victoria Knight: Hi! Good morning.

Rovner: Later in this episode we’ll play my interview with Hannah Wesolowski of the National Alliance on Mental Illness. She’s going to update us on the rollout of 988, the new national suicide prevention hotline. And because it’s February, we’re asking for your best health policy valentines. You can write a poem or haiku and tweet it, tagging @KFFHealthNews, and use the hashtag #healthpolicyvalentines, all one word. We’ll choose some of our favorites for that week’s podcast and the winner will be featured on Valentine’s Day on kffhealthnews.org with its own illustration. But first, this week’s news. So we’re going to start with covid, which we actually haven’t talked about very much for a couple of weeks. But this week there’s some real actual news, which is that President [Joe] Biden has announced he will be ending the public health emergency, as well as the national covid emergency, which is a different thing, on May 11. Depending on who you believe, the president’s hand was forced by the Republican House this week voting on a bunch of bills that would immediately end the emergencies — or that May had always been the administration’s plan. I’m guessing it’s probably a bit of both. But let’s start with what’s going to happen in May, because it’s a bit confusing. We’ve talked at some length over the months about the Medicaid “unwinding.” So let’s start with that. How is that going to roll out, as we will?

Sanger-Katz: So that is actually not going to be affected at all by this change. When Congress passed the CARES Act, it tied a lot of these pandemic programs to the public health emergency. And I think what Congress has been doing in recent months is trying to untie some of those policies from the public health emergency, because I think it has identified that some of them are worth keeping and some of them are worth eliminating, and that it ought to make up its own mind about the right timeline and process for that — instead of just leaving it in the hands of the president to end the public health emergency when he sees fit. So what happened in the omnibus legislation, the big spending bill that passed at the end of the year, is that Congress said, OK, there has been this provision in the CARES Act that said that states need to keep everyone who is enrolled in Medicaid continuously enrolled in Medicaid until the end of the public health emergency, or they risk losing this extra Medicaid funding that they have been getting — and that, I think, has been beneficial to state budgets. And what Congress did is they said, OK, we’re going to create a date certain, starting in April, [that] this policy is going to go away, but we’re going to do it sort of incrementally. So the money’s not going to go away all at once. It’s going to go away in a couple of stages to make it a little easier on states. And they also created a lot of procedures and what they call guardrails to prevent states from just dumping everyone out of Medicaid all at once. So they’re requiring them to do various things to make sure they have the right address and that they’ve contacted people in Medicaid. They will punish them. There’s new penalties that the secretary can use to punish them if it seems like they’re doing things too arbitrarily, and there are other provisions. So as a result, the public health emergency doesn’t have any effect on this. But this policy and Medicaid is going to start unwinding right around the same time. In April and May we’re going to start seeing states probably phasing down their enrollment of some Medicaid beneficiaries as this extra funding that is tied to that goes away.

Rovner: And just a reminder, I mean, there’s now more than close to 90 million people on Medicaid, many of whom are probably no longer still eligible. So the concern is that states are going to have to basically reevaluate the eligibility of all of those people to see who’s still eligible and who’s not and who may be eligible for other government programs. And it’s just going to be a very long process. And I know health advocates are really worried about people falling through the cracks and losing their health insurance entirely.

Sanger-Katz: I think it’s still a huge risk and there still are a lot of people who are likely to lose their insurance as a result of this transition. But it was a weird situation that we were in, where you kind of went from all or nothing, just by the president deciding that the public health emergency was over. And I do understand why Congress decided, OK, look, why don’t we take some leadership over how this policy is going to phase down instead of just leaving it as this looming cliff that we don’t know exactly when it will come and where we don’t have control over the procedure for it.

Rovner: And Margot, you also mentioned things that Congress thought they might want to keep. And I guess a big one of those is telehealth, right? Because that was also in the end-of-year omnibus bill.

Sanger-Katz: Yeah, that’s proved to be really popular, because of the pandemic, because it was dangerous for people to get into doctors’ offices and hospitals early in the pandemic. Medicare loosened some rules and then Congress kind of cemented that. That allowed people to get doctors’ visits using video conferencing, telephone, other kinds of remote technologies, and Medicare paid for that. And that’s been super popular. It has a lot of bipartisan support. And now Congress has extended that benefit for longer. So I think we’re going to see telehealth become a more permanent part of how Medicare benefits are delivered.

Rovner: But not permanent yet. I think there’s still some concern that if it …

Sanger-Katz: Just for two years right now.

Rovner: Well, if it gets too popular, it could get really expensive. I think there’s a worry about …

Sanger-Katz: I do think that the two years will create some infrastructure — I think even just the temporary provision. A lot of doctors and hospitals … I was talking to folks that worked in medicine, they just weren’t set up for it at all. And they had to figure out, how are we going to do it? How are we going to build for it? What systems are we going to use? How are we going to make it secure? So some of that has already happened. But I also think two years is a long-enough runway that you start to imagine that there will be more start-ups, more health care providers that are really orienting their practice around this method of delivering care because they have some sense of permanence now.

Rovner: And I can’t imagine that this won’t become one of those, quote-unquote, “extenders” that Congress renews whenever it expires, which they do now. Rachel, you wanted to say something?

Roubein: Oh, yeah. To your point, I just think once there’s infrastructure built, it’s really hard to take things away. But I guess while we’re on the train of things that aren’t impacting, Congress also in their big government spending bill made a change to Paxlovid, allowing Medicare to continue to cover it under emergency use authorization. So that also won’t be impacted by an end to the public health emergency.

Rovner: So what are the things that will be impacted by the end of the public health emergency?

Knight: Really the biggest thing — and my colleague Maya [Goldman] has been pioneering at writing about this — is that it’s really CMS [the Centers for Medicare & Medicaid Services gave providers a lot of flexibilities that were tied to the PHE [public health emergency]. So it’s a bunch of different small things. It’s, like, reporting requirements, physical environment standards, even things like where radiologists can read X-rays. It’s small stuff like that that a lot of providers have kind of gotten used to and relied on during covid. And so those may go away. It’s possible also that HHS [the Department of Health and Human Services] could allow some of those to remain in place. When I talked to congressman Brett Guthrie, who is the one who introduced the bill to end the PHE, he said he wants to talk to HHS and figure out what are some things that he knows providers enjoy on these flexibilities. There was something about nurses’ training that he wants to keep in place. So they’re making it sound like it’s the end of the world end to this. I’m not sure that that’s actually true.

Rovner: Yeah, and I know the administration’s been pushing back on some of the stories that said that this will be an end to free vaccines and the actual covid testing. But that’s not even really true, right?

Roubein: I think one of my colleagues had talked a little bit about this to Jen Kates from the Kaiser Family Foundation, and that was a concern of hers. So I think some of it is dependent on what policies … and see what the next few months …

Rovner: My impression is that federal government has purchased all of these things. So it’s not … so much the end of the public health emergency. It’s when they run out of supply that they have now. So it’s not so much linked to a date. It’s linked to the supply, because I guess at the end of the public health emergency, they won’t be buying anymore. If nobody wants to answer this question, please don’t. But I’m confused about how this all affects the controversial Title 42, which is a public health requirement that was put in by the Trump administration that limited how many people could come across the border because of covid. I’m still confused about who’s for ending it and who’s not for ending it, and whether ending the emergency ends it or whether it’s in court. And if nobody knows, that’s fine because it’s not totally a health issue. But if anybody does, I’m dying to know.

Sanger-Katz: So my understanding on this one — which I also want to say I’m not like 1,000% sure, but this is what I’ve been told — is that it is related to public health authority and assessment that there is a health emergency, but that it is not part of that CARES framework where … when the public health emergency ends, it ends. It is a separate declaration by the CDC [and Health and Human Services] secretary. And so what I have been told is that it is not directly linked to this, but obviously it is the policy of the Biden administration that we are no longer experiencing a public health emergency. Then I do think the continued use of that policy starts to come under question because the justification for it is quite similar, even if the mechanism is different.

Knight: And I have to tell you, Julie, some of my immigration reporter friends on the Hill were also confused. I think everyone was a little confused because the Biden administration was saying this will lift Title 42 immediately, and Republicans were saying, no, it doesn’t. Brett Guthrie literally came to me and was like, “It is not ending yet.” So I think …

Rovner: I’m not the only one confused?

Knight: Yeah, you’re not the only one confused. And people were calling lawyers, being like, what does this mean when that was going on this week? So, yeah.

Roubein: I think it’s going to be a continuation of this big political fight that we’ve seen over Title 42. An administration official argued to my White House colleague Tyler Pager that essentially because Title 42 is a public health order, the CDC is determining that [there] would no longer be a need for the measure once the coronavirus no longer presents a public health emergency. So we’ll see wrangling over this.

Rovner: Yes, this will go on.

Sanger-Katz: I mean, it’s the same administration, you would think that they would be making a similar judgment about these different things. But the politics around this immigration policy are quite fraught. And it’s possible that they will be de-linked in some way. We’ll see.

Rovner: We will see.

Roubein: And the fight over this held up millions of dollars of covid aid last year. So it’s just been really political.

Rovner: That’s right. Well, moving along and speaking of the Republican-led House, they have, shall we say, refocused the special committee on covid that was set up in the last Congress. Rather than looking at how the nation flubbed preparedness in the early response to the pandemic. The Republican panel is now expected to concentrate on complaining about mask and vaccine mandates, trying to figure out the virus’s origins, and, at least so they’ve said, roasting scientists and public health leaders like the now-retired Anthony Fauci. Among the new Republican members appointed to the panel are the outspoken Marjorie Taylor Greene and former Trump White House doctor, now congressman, Ronny Jackson of Texas. I imagine, if nothing else, these hearings will be very lively to watch, right?

Knight: They definitely are going to be lively to watch. We did just find out yesterday that congressman Raul Ruiz is going to be the Democratic ranking member [of the Select Subcommittee on the Coronavirus Pandemic]. He’s also a doctor. Congressman Brad Wenstrup [R-Ohio] is the chairman of the committee. He’s also a doctor. So it is not only some members who have pushed forward misinformation about covid; there are also members that agree with vaccines and things like that. So I think it’ll be interesting to see how they play this out. I’ve been talking to a lot of them on what they’re going to focus on the committee, what the goal is. So it may not be as wild as we’re anticipating. There may be some members that want it to be, but I think that they want to look at covid origins for sure and the Biden administration’s rollout of vaccines and mandates and things like that. But there’s also Democrats on the committee. So we’ll see how it goes.

Rovner: I will point out, though, when you point out how many doctors are there that Andy Harris of Maryland, who’s also a doctor, a Johns Hopkins anesthesiologist, came under fire for prescribing ivermectin. So we’ve got doctors and we’ve got doctors in the House.

Knight: But I listened to the covid origins hearing yesterday — they did the first one, the Energy and Commerce [ Committee], and I covered it — and I was expecting it to be, like, very intense. And it actually was pretty measured and nothing too wild happened, so …

Rovner: But we shall see. All right. Well, let’s move on to abortion. This is where I get to say that if you didn’t listen to last week’s two-parter on the state of the abortion debate and you’re at all interested in this subject, you should definitely go back and do that. But, obviously, I wish more people would listen to it because a new poll this week from my colleagues over the firewall at KFF finds that a large portion of the public is still confused over whether medication abortion is legal in their state, about whether it requires a prescription (it does), and about how it works compared to emergency contraception. The first one can terminate an early pregnancy. The second one can only prevent pregnancy. Given how fast things are changing in various states, I suppose this confusion is predictable. But is there any way to make this even a little bit clearer? I mean, we have a public that honestly is getting ready to throw its hands up because they can’t figure out what’s what.

Sanger-Katz: I think there’s a good role for journalism here. The abortion pill is a very mature technology. It’s been around for a very long time. It’s become the means for more than half of abortions in America. But I still think, you know, a lot of people don’t know about it. I think when they think about abortion, a lot of Americans are thinking about a surgical procedure that happens in a clinic. Advocates on both sides of the abortion debate are very clear that medication abortion is likely the future of abortion for a lot of Americans because it is easily transportable, because it is able to be prescribed through telemedicine, because it is less expensive than clinic abortion. But I do think just a lot of Americans just don’t have a lot of familiarity with this. And so I think we just have to keep telling them about it, explaining how it works, what the safety profile of it is, how you can get it, what the laws are around it. And, you know, this is a bit of a shifting ground beneath our feet because states are actively regulating and restricting this technology. And I have a team of colleagues at The New York Times in the graphics department who are amazing, who are just like every day updating a page on our website about what is the state of laws surrounding abortion in this country? And it’s really remarkable how often the laws, particularly about abortion pills, are changing. You know, several times a week they are updating that page. So I think all of us just have to keep educating the public about this.

Rovner: And my required reminder that the “morning-after pill” is not the same as the abortion pill. The morning-after pill is now available over the counter. And we now know — thank you, FDA, for changing the label — that it cannot actually interrupt an existing pregnancy. It can only prevent pregnancy. So that’s my little PSA. Meanwhile, we have talked a lot about how anti-abortion forces are pushing harder than ever for a national abortion ban. The Republican National Committee passed a resolution last week, pushed by some of the more strident anti-abortion groups, calling for Republicans to, quote, “go on the offense” in 2024 to work for the most restrictive abortion laws possible. Given that polling still shows a majority of Americans and even a majority of swing voters still think abortion should be legal, are the Republicans driving themselves politically off a cliff here, or do they really think that revving up their base will help them win elections?

Roubein: I think that this is notable from the RNC because, as you mentioned, anti-abortion advocates were really, really mad at people like Senate Majority Leader Mitch McConnell, other Republicans who were saying that it was a state issue and had been pushing for them to paint Democrats as extreme, pushing a very different message. So this is ahead of 2024. Obviously, anti-abortion advocates are, when they’re looking at who they’re going to endorse in the presidential race, are going to be looking for candidates that support some kind of federal gestational limit on abortion.

Knight: I know Alice [Miranda Ollstein], who has been on here a lot, she was reporting that these anti-abortion groups are also pushing Republicans to put bills on the House floor to vote on restricting abortion. So there’s a six-week bill that’s already been introduced, maybe some other weeks. And so I think depending on if they actually do floor votes on this, that’s going to be something Democrats will use to attack them, I’m sure, in the upcoming election and maybe also something Republicans want to promote. So I think that it’s definitely notable, and we’re going to have to see if it’s the same as it was in the midterms when it didn’t seem to be a winning message for Republicans. But the anti-abortion groups are saying double down more. So we’ll see.

Rovner: Well, speaking of anti-abortion groups, they’ve been quietly pushing something new: a campaign to, as they call it, quote, “make birth free.” The idea is that a pregnant woman shouldn’t be swayed to have an abortion because she thinks she can’t afford to give birth. It’s been quite a few years since the anti-abortion side tried to advocate for benefits for pregnant women. I remember in the mid-1980s, congressman Henry Hyde — yes, he of the Hyde Amendment — joined with one of the most liberal members of the House, former California Democrat Henry Waxman, to sponsor a bill to reduce infant mortality. It turned out to be the beginning of Medicaid’s benefit for pregnant women, for prenatal delivery and postnatal care, something that’s now extremely popular. Do we expect to see more for this, more of this, or for this to catch on? … I’ve seen the group asking for this. I haven’t really seen any lawmakers suggesting this. It would be pretty expensive to basically pay for every birth in the country. We have a lot of shaking heads.

Knight: I had not heard any lawmakers talking about that. I don’t know if others have. I know there has been some push from some Republicans to put more safeguards in place for women who give birth, like just more supportive programs, but like, I haven’t heard like making birth completely free. And I know also that’s not maybe a widely held view within — I know there are some Republicans pushing for it. There’s a really good Washington Post article about this recently, about paid leave also. But they seem to be in the minority. And so there’s not enough movement to, like, make the party actually do anything on that.

Roubein: I think it’s sort of the beginning. Like Americans United for Life, a big anti-abortion group that’s written a lot, a lot of model laws that states have adopted. They had released a white paper about this. I think that’s sort of the beginning of the push and that’s what we tend to see with the anti-abortion movement is, you know, sometimes we see these policies come out from different groups and then they advocate and then potentially it goes to legislation and they try and find different lawmakers’ ears. So I think it’s a little bit TBD at this point.

Sanger-Katz: I also think it highlights how there’s a growing movement in the Republican Party — and I would say this is not a majority of Republicans yet — but we do see a significant minority that really are pursuing these pro-family policies, policies that we often think about as being pursued by Democrats. Family leave is an example of that, interest in day care, the child tax credit. There are a number of Republicans that were really champions of that policy in the last few years. And I think this feels like it’s a piece with that, that a lot of Republicans, they want to encourage people to have families, to have children, to be able to care for their children. And they understand that it’s hard and it’s expensive. But I do think that those ideas tend to bump up against the more libertarian elements in the Republican Party that are opposed to a lot of government spending, a lot of government intervention in people’s family lives and just concerned about the deficit and debt as well. And so this continues to be an interesting development. My colleague Claire Cain Miller at The Upshot has written a lot about this debate within the Republican Party as it relates to some of these other policies. And I wonder if this idea of making birth free could start to become part of that package of policies that you see some Republicans really interested in, even though you might think of the issue as being something that is more classically a Democratic issue.

Rovner: Although I’m wondering if the Democrats are going to pick up on this and try to hold the Republicans’ feet to the fire on it. It’s like, see, your base would like to make this free. Don’t you want to join them? I could see that happening although hard to know. All right. Well, finally this week on the reproductive health agenda, the Biden administration undid another Trump regulation, this one to eliminate employers with, quote-unquote, “moral objections to birth control” from having to offer it under the Affordable Care Act. Those with religious objections would still have a workaround to ensure that their employees get the coverage, according to the Department of Health and Human Services. Actually, only a handful of employers have used the moral exception. Actually, I think the more important part of this regulation would create a new pathway for employees of religiously objecting employers, like religious schools and colleges, to get coverage without involving the employer at all, nor making the employer pay for it. This has been a big sticking point and created a giant backlash early on in the Affordable Care Act’s rollout — and two separate Supreme Court cases — because the employers didn’t want to be seen to be facilitating people getting birth control that they didn’t believe in. Now that they’re going to totally separate this from the employer, might this put that little fight to rest? Not a little — a big fight to rest? [pause] We have no predictions?

Sanger-Katz: This feels like one of those policies that is just going to flip-flop back and forth when we have different presidents. The Trump administration, you know, went really far. This idea of a moral objection, I think doesn’t have a particularly strong basis in law or at least didn’t historically. But the Supreme Court said that they had the authority to do it. And so I think that then creates a precedent that future administrations can do it. I do think that there is a concern from the religious community that this requirement imposes too much of a moral stricture on them. And so they are always pushing for more and wider exceptions to this contraceptive coverage policy. To me, the big surprise in this is just that it took so long. The Trump administration rolled out this particular policy almost immediately upon taking office. And now we’re more than two years into the Biden administration and they have finally rolled it back.

Rovner: Yes. And I am keeping track. And I will update my little infographic about how long it’s taking the Biden administration to change some of these policies. Well, finally, this week, Medicare Advantage, as we’ve mentioned before, private Medicare plans have become very popular, particularly because they often offer extra benefits, mostly because they’re being paid extra by the federal government. But it seems some of these companies have also figured out how to game the system. Surprise. So this week, the federal government announced a crackdown by way of new audits that’s predicted to recoup nearly $5 billion. Medicare’s always … things with lots of zeros. Margot, you wrote about this this week. What are they going to do?

Sanger-Katz: So just a little bit of background. Medicare pays Medicare Advantage plans a set amount per person to take care of them. And the idea is the insurance company can try to do a better job and provide less medical care and keep people healthier and save the remainder as profits. And when Medicare Advantage started, there was this problem where the plans had this huge incentive to just pick all the healthy seniors, because if you pick all the healthy people, they don’t need a lot of medical care and then you get to keep a lot of that payment as profits. And so Congress came up with a new system where if you take care of someone who is sick, who has diabetes, who has substance abuse problems, who has COPD [chronic obstructive pulmonary disease], you get a little bonus payment so that the insurer has an incentive to cover that person. They have a little bit of extra money to take care of their health needs. And what we’ve seen over the years that the Medicare Advantage program has become mature, is that the plans have gotten extremely good at finding every single possible thing that is wrong with every single possible person that they enroll. And in some cases, they just kind of make things up that don’t seem to be justified by that person’s medical records. And so the amount that the Medicare system is paying to these plans has just gone up and up and up. And there are all kinds of estimates of how much they’ve been overpaid that are kind of eye-popping. And there are quite a lot of serious fraud lawsuits that are making their way through the federal courts. There have been some settlements, but basically every major insurer in this program is facing some kind of legal scrutiny for the way that they are diagnosing their patients to get these payments. And you know, what’s interesting to me about it is there’s been quite a lot of good journalism about this problem. Julie, your colleague Fred Schulte, I think, has been a real leader on this and had actually a big, big scoop recently. And the GAO has written about it. The HHS inspector general has done audits and written about it. There have been these lawsuits. This is not really a secret, but there has been very little action by CMS over the last decade on this problem. And I think there are a few reasons for that. One, I think it’s hard to fix. I will give them some credit. The policy levers are complicated, but I also think there is just a big political disincentive to do anything about this. Medicare Advantage has become more and more popular over the years. It is poised to enroll a majority of seniors, of Medicare beneficiaries, this year, and those people are very diffuse across the country. It’s not the case that there’s just Medicare Advantage in one or two markets where you have a couple members of Congress who care about it. They’re kind of everywhere. And they’re not just in Republican districts. Even though Republicans created this program, there are a lot of them in Democratic districts, too. And people like these plans. They have some downsides, which we could talk about another time. But they tend to have lower premiums for seniors. They tend to cover benefits like hearing, vision, and dental benefits that the traditional Medicare program does not cover. And so people really like these plans. And the more the plans are paid, the more they can afford to give all these goodies to their beneficiaries. And so I think there has been a lot of political pressure on CMS to not aggressively regulate the plans. And that’s part of why what they did this week is actually pretty striking. They did something pretty aggressive. They have been conducting these audits where they take 200 patients — which is a very, very small fraction of the total number of patients in any one plan — and they look at the diagnoses and they compare them to the medical records for those patients and they say, hey, wait a minute, I don’t think that this patient really has lung cancer. I think this patient doesn’t have that. So you shouldn’t have gotten that payment. And so that has been the system for some time where they look at a couple of records and they go back to the plans and they say, hey, pay us back this lung cancer payment. You can’t justify this based on the medical record.

Rovner: And they extrapolate from that, right? And it’s not …

Sanger-Katz: No. So what this new rule says is it says, you know, if in your 200 people that we look at, we find that you have an error rate of whatever, 5%, we are now going to ask you to pay back the money across your whole book of business, that you can’t just pay us back for the five people that we found, you have to pay back for everyone because we assume that whatever kinds of mistakes or sketchy things that you’ve done to create these errors in this small sample, probably you’ve done them to other patients, too. So that’s like the big thing that the rule does. It says “Pay back more money.” And then the other thing that it says is it says we’re going to reach back in time and you’re got to pay back all the extra money you got in 2018, in 2019, in 2020, and in 2021. So it’s not just forward-looking, but it’s also backward-looking, trying to recover some of what CMS believes are excessive payments that the plans received.

Rovner: Although, as my colleague Fred Schulte points out, they don’t go back in time as far as they could. So they’re basically leaving a fair bit of money on the table for … I guess that’s part of the balancing that they’re trying to do with being aggressive in recouping some of this money and noting that this is a very popular program that has a lot of bipartisan support.

Sanger-Katz: Yeah, it’s been interesting. The market reaction was very muted. So this suggests to me that the plans, even though it is aggressive relative to what we have seen in the past, that it was not as aggressive as what the plans and their shareholders were worried about.

Rovner: Exactly. All right. Well, that is as much time as we have for the news this week. Now, we will play my interview with Hannah Wesolowski of NAMI. Then we will come back and do our extra credits.

I am pleased to welcome back to the podcast Hannah Wesolowski of the National Alliance on Mental Illness. You may remember we spoke to Hannah last February in anticipation of the launch of the new three-digit national suicide hotline, 988. Hannah, welcome back.

Hannah Wesolowski: Thanks, Julie. It’s great to be here.

Rovner: So the 988 hotline officially launched last July. It’s been up and running now for just about seven months. How’s it going?

Wesolowski: Largely, it’s going great. We’re really excited to see that not only are more people reaching out for help — overall, there’s about a 30% to 40% increase, year over year, when we look at every month of the helpline — but they’re talking to people quickly. They’re getting that help. They’re getting connected to crisis counselors in their state. And that really displays the tremendous work that’s happened across the country to build up capacity in anticipation of the lifeline.

Rovner: Is there anything that surprised you about the rollout, something that was unexpected — or that you expected that didn’t happen?

Wesolowski: I had a few sleepless nights there, worried about: Would people be able to get through? What would demand look like? And would call centers have that capacity? This was a quick turnaround. Congress passed this in late 2020, and it went live in mid-2022. That’s not a lot of time in the real world to actually stand up call centers that have a 24/7 capacity to answer calls, texts, and chats. And yet, when we look at the numbers, they’re amazing. The number of texts alone has grown exponentially, when we look at people who were texting the lifeline previously and are now texting 988. They’re getting through. They’re talking to people quickly, and there’s tens of thousands of them that are doing it every month.

Rovner: And I imagine, particularly, younger people might well prefer to text than to actually talk to someone on the phone.

Wesolowski: Exactly. This is about making sure this resource is accessible to anyone and makes it as easy for them to get the help they need in the way that they prefer to get it. It is hard to get a young person to pick up the phone. So texting is absolutely critical to reach a population that is in crisis. There’s a youth mental health crisis in this country. And so making sure that we are responsive to the needs of youth and young adults is absolutely critical.

Rovner: So I see that mental health, in general, and the 988 program, in particular, got big funding boosts in the most recent omnibus spending bill. Republicans in the House, however, say they want to roll back funding for all of these domestic discretionary programs to fiscal 2022 levels. What would that mean for this program and for mental health in general?

Wesolowski: You’re right. 988 got [an] exponential increase in funding in the omnibus. It grew from $101.6 million in fiscal year 2022 to $501.6 million in fiscal year 2023. So nearly five times the funding. And it’s still not everything we estimated that is needed out there. Just to fund the local call centers alone, it would probably be more than $560 million. That doesn’t include the cost of operating the national network, the data integrity, the technical platforms, the backup networks, you know, all the resources that are needed to do this, plus public awareness. There still hasn’t been a widespread public awareness campaign of 988. So while $501.6 million is amazing, it’s still only a fraction of what we ultimately need. So thinking about future cuts to this … this is something that saves lives. There’s very clear data that lifelines save lives, and we’re telling people that this resource is there; to cut funding would mean that people [who need] help wouldn’t be able to connect to somebody when they need it most.

Rovner: So I know there’s been some resistance to using 988. Some folks, particularly on social media, warn that callers could be subject to police involvement or involuntary treatment or confinement. Tell us how it really works when someone calls. And are some of those concerns well placed or not?

Wesolowski: Every concern that is made about this system comes from a real place of people who have been in crisis and gotten a horrific and traumatic response. With 988, the thing that is important for people to understand is there is no way to know your location. There is no tracking of your information. This is 100% anonymous. In fact, right now we have the challenge of calls being routed based on area code and not somebody’s general geographic location. So, for example, I have a New Hampshire area code, love the great state of New Hampshire, but live in Virginia and have for many years — I would get routed to New Hampshire. I’m still talking to a crisis counselor. That’s wonderful. But we want to be connected locally. So there is no way that police can be dispatched or somebody can be taken to a hospital. Now, there are situations where the crisis counselor determines a person may be at imminent risk. They may be having thoughts of suicide, and the counselors are trained to look for that, in which case they’ll initiate emergency protocol to try to get the individual to share their location. And it’s less than 2% of contacts that an individual is at imminent risk. And many of those voluntarily share their location. So it’s a lengthy process when they don’t. And that means many minutes where we could lose a life. So it’s a challenging situation, but we know that that location is not available when somebody calls 988. And the intention is very much for this to be an anonymous resource that provides the least invasive intervention.

Rovner: So I’ve also seen concerns about just the lack of resources to back up the call centers, particularly in rural areas. What’s being done to build up the capacity?

Wesolowski: That’s one of the biggest challenges with this. 988 should be the entry point to a crisis continuum of care. When you call 911, you are connected to existing services: law enforcement, fire, EMS. 988 — we’re trying to build that system at the same time this resource is available. Many states already have robust mobile crisis response, which is a behavioral health-based response, rather than relying on law enforcement, which is unfortunately often the response that people see in their communities.

Rovner: And often doesn’t end well.

Wesolowski: Right. Often very tragic and traumatic circumstances — and it doesn’t get people the mental health care that they need. Unfortunately, [in] many communities, that’s still the main option. But more and more communities are getting mobile crisis response online, social workers, peer support specialists, nurses, EMTs, psychologists who staff those and provide a mental health-based response. But it’s much harder in rural areas. It takes longer to get to people. You’re covering a much bigger geographic area. And so that still is a challenge. You know, communities are looking at innovative ways that they can leverage existing emergency response to connect to behavioral health providers, like having law enforcement with iPads so they can leverage telehealth if somebody is in a crisis. But certainly, it’s a challenge and a solution that has to be very localized to the needs of that community.

Rovner: So what still is most needed? I know the law that created 988 also allows states to assess a fee on cellphones to help pay to boost mental health services. Are any states doing that yet?

Wesolowski: We have five states that have passed laws since 2020 to assess a monthly fee on all phone bills. That’s similar to how we fund 911. Everyone across the country already pays a 911 fee. Virginia, Colorado, Nevada, California, and Washington state all currently have legislation that has implemented a small fee on phone bills. It ranges from $0.12 to $0.40 per phone line per month. And that really is helping build out not just the 988 call centers, but that range of crisis services that can respond when somebody needs more help; it can be provided over the phone.

Rovner: Well, it sounds like it’s off to a good start. Hannah Wesolowski, thank you for coming back to update us, and I’m sure we’ll have you back again.

Wesolowski: Thank you so much, Julie. Always a pleasure.

Rovner: OK, we’re back and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it; we will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Victoria, why don’t you kick us off this week?

Knight: My extra credit is “Emailing Your Doctor May Carry a Fee.” That’s the name of the article by Benjamin Ryan in The New York Times. So it basically was documenting how doctors practices are starting to charge for sending an email correspondence with a patient. I think we’ve all probably done that, especially during covid. It can be really helpful sometimes when you’re not feeling well and you don’t want to go into the office. But these doctors practices are starting to sometimes charge up to $30, $50 for this, and it’s going to become a new revenue stream for some clinics. And the example they gave in the story was the Cleveland Clinic that was doing this for some people.

Rovner: And the Cleveland Clinic, for people who don’t know, has a lot of patients. It’s a very large organization.

Knight: Yes. Yes, absolutely. So clinics are saying their doctors are spending time on this and so they need to be reimbursed for it. But the critics of this are saying it could discourage people from getting care when they need it. It also could contribute to health inequities, and also can contribute to doctor burnout, because they’re having to now really do these emails to contribute to the revenue stream. So anyway, super interesting, hasn’t happened to me yet, but I hope it doesn’t.

Rovner: The continued tension over doctors getting paid and patients having to pay and insurers having to pay. Rachel.

Roubein: My extra credit, it’s by my colleague, she’s a health and science reporter, Carolyn Y. Johnson, and it’s titled “I Wrote About High-Priced Drugs for Years. Then My Toddler Needed One.” And in her story, she describes her effort of essentially getting lost in the health care system and having to deal with a really complex system to get a pricey medication for her 3-year-old son. So her 3-year-old son was diagnosed with a rare type of childhood arthritis, which can cause young kids to suffer from daily spiking fevers, a fleeting rash, and arthritis. And doctors had recommended a really pricey drug, which required approval from her insurer. Aetna denied the request. In September, doctors wrote another test, which the insurer wanted. The denial was upheld again. She was able to get the medication through a free program offered by the drugmaker, but she was really worried because she was close to using up the last dose. She was calling it the insurer, etc., just really, really often. And, ultimately, the resolution was she was able to get a different high-cost drug that worked in a similar way approved because the request was subject to different rules. And the big-picture point that she makes is that this isn’t a unique story. It’s something that a lot of Americans deal with, a really frustrating, routine process known as prior authorization and step therapy, etc., trying to get coverage of medication that doctors think are needed.

Rovner: And boy, if it takes a professional health reporter that much time and effort to get this, just imagine what people who know less about the system have to go through. It was a really hard piece to read, but very good. Margot.

Sanger-Katz: I wanted to recommend an article from my colleague Amy Schoenfeld Walker called “Most Abortion Bans Include Exceptions. In Practice, Few Are Granted.” And I know that this connects with the abortion discussion that you guys had in the last episode, but I thought what she did was really remarkable. You know, we talk a lot in the political debate about abortion, about exceptions to protect the health of the mother, exceptions for fetuses that cannot survive outside the womb. And, of course, these very politically heated discussions about exceptions for rape and incest. And her article actually looked at the numbers of abortions that are being granted due to these exceptions and states that have them on the books and found that, you know, it’s so minimal that it’s almost not happening at all. If you are a woman who has been raped, if you are a woman who has a really serious health complication in a state where abortion has been banned, you almost always have to travel out of state, despite the existence of these exceptions. And I think this is not a huge surprise. It makes sense that medical providers are scared of getting in trouble when the sanction for being wrong is so high. And also that there aren’t a lot of abortion providers available in states that have banned abortion because there’s no place for them to practice. But I thought she did a really nice job of really putting numbers to this intuition that we all had about what was going to happen and showing how limited access is, and how meaningless in some ways these talking points are that, you know, legislators say that they are providing exceptions, but they’re not actually providing any infrastructure to provide care for the people who qualify.

Rovner: And yet we’re seeing these huge political fights in a lot of states about these exceptions, which, as we now know, don’t actually result in that much in actual practice. Well, my story this week is from Axios by former podcast panelist Caitlin Owens and Victoria here. It’s called “Republicans Break With Another Historical Ally: Doctors,” and it’s about the growing discord between the American Medical Association, long the bastion of male white Republican M.D.s, and Republicans in Congress, particularly Republican M.D.s themselves. The AMA has been moving, I won’t say left, but at least towards the center in recent years, reflecting in large part the changing demographics of the medical profession itself. And if you go back to our podcast of July 21 of last year, you can hear the “not that AMA-like” list of priorities from Jack Resnick, who’s the AMA’s current president. Well, the very conservative Republicans in Congress aren’t too thrilled and are describing the AMA as, quote, “woke” and prioritizing things that lawmakers don’t support, like the right to practice reproductive health according to their medical expertise and to treat teens with gender issues. I never thought I would say it, but it seems the Republicans in the AMA might actually be heading for a divorce. It’s a really great story. You really should read it.

OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Margot?

Sanger-Katz: @sangerkatz

Rovner: Victoria?

Knight: @victoriaregisk

Rovner: Rachel.

Roubein: @rachel_roubein

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

Credits

Francis Ying Audio producer Emmarie Huetteman Editor

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