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 change at the top of the likely Democratic presidential ticket is prompting both abortion rights and anti-abortion organizations to recalibrate their campaigns, even as they fight over finalizing fall ballot proposals in many states.

Meanwhile, former President Donald Trump’s campaign is trying to distance itself from “Project 2025,” the controversial plan reportedly designed for the next GOP administration and put together by the conservative Heritage Foundation and former Trump administration officials. Although the head of the project’s policy arm was pushed out this week, the part of the project creating a database of Trump loyalists to staff a potential new administration remains up and running.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Lauren Weber of The Washington Post, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

• Vice President Kamala Harris is promising to “restore reproductive freedom” if elected president; her campaign says that means restoring the constitutional right to an abortion under Roe v. Wade. Despite that goal having slim prospects in Congress, some abortion rights supporters are hoping the federal government would expand abortion access even beyond Roe under her presidency.
• President Joe Biden this week recommended a sweeping overhaul of the Supreme Court, including term limits for justices. Famously an institutionalist, Biden stopped short of embracing the progressive call to add more justices to the high court. Nonetheless, his proposal has been considered politically dangerous, even as the conservative-tilted court has overturned its own precedents and shrugged at its ethics policies — and shifts in the national conversation about the court could have a long-term effect.
• The Trump campaign’s attempts to distance itself from the controversial ideas of Heritage’s Project 2025 are more savvy marketing than anything: Even without adopting the document, the conservative policy personnel behind it could well become the conservative policy personnel of a second Trump administration.
• GOP state officials and anti-abortion groups are launching their next attempts to block potential abortion rights victories at the ballot box. The next few weeks will reveal whether voters in certain influential states — like Arizona and Florida — weigh in on abortion this fall.

Also this week, Rovner interviews KFF Health News’ Elisabeth Rosenthal, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment about a preauthorized surgery that generated a six-figure bill.

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

Julie Rovner: The Washington Post’s “Online Portals Deliver Scary Health News Before Doctors Can Weigh In,” by Fenit Nirappil.  

Alice Miranda Ollstein: ProPublica’s “A Lab Test That Experts Liken to a Witch Trial Is Helping Send Women to Prison for Murder,” by Duaa Eldeib.  

Lauren Weber: The Tributary’s “Testimony: Florida Wrongly Cut People From Medicaid Due to ‘Computer Error,’ Bad Data,” by Charlie McGee.  

Sarah Karlin-Smith: KFF Health News’ “Why Many Nonprofit (Wink, Wink) Hospitals Are Rolling in Money,” by Elisabeth Rosenthal; and The Hollywood Reporter’s “New York’s Largest Hospital System Is Setting Its Sights on the Entertainment Business,” by Alex Weprin. 

Also mentioned on this week’s podcast:

Politico’s “States Break Out New Tactics To Thwart Abortion Ballot Measures,” by Alice Miranda Ollstein.

click to open the transcript Transcript: Abortion Heats Up Presidential Race 

KFF Health News’ ‘What the Health?’ Episode Title: ‘Abortion Heats Up Presidential Race’Episode Number: 358Published: Aug. 1, 2024

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Mila Atmos: The future of America is in your hands. This is not a movie trailer. And it’s not a political ad. But it is a call to action. I’m Mila Atmos, and I’m passionate about unlocking the power of everyday citizens. On our podcast “Future Hindsight,” we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday, we talk to bold activists and civic innovators to help you understand your power, and your power to change a status quo. Find us at futurehindsight.com, or wherever you listen to podcasts.

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 1, at 10 a.m. As always, news happens fast and things might change by the time you hear this, so here we go.

We are joined today via video conference by Lauren Weber, of The Washington Post.

Lauren Weber: Hello, hello.

Rovner: Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: And Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Elisabeth Rosenthal, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” It’s about a woman who had a cochlear implant surgery that was preapproved by her insurer, but still, and say it with me, got an enormous bill anyway. But first, this week’s news.

We’re going to start this week with presidential politics, because I think everyone, or at least me, is still kind of processing the idea that the race is no longer Biden versus Trump, but Harris versus Trump. One thing we have already seen from Vice President [Kamala] Harris is a new focus on reproductive rights. As we mentioned last week, Iowa’s six-week abortion ban took effect this past Monday, making it the 22nd state to impose what the vice president is now calling a “Trump abortion ban,” referring to total bans as well as restrictions that wouldn’t have been allowed under Roe [v. Wade]. Alice, how are abortion rights groups refocusing themselves now that Harris, rather than Biden, is at the top of the ticket?

Ollstein: Well, in one sense, a lot has changed, and in another sense, nothing has changed. I mean, these groups were already holding events with Harris around the country. They stressed that when they endorsed Biden, they also endorsed Harris. They endorsed the ticket, and so it wasn’t a surprise or much of an internal discussion to decide to come out strong and endorse. What’s been sort of interesting for me is the politics and the messaging versus the policy on this front. So these activist groups were really excited about Harris and were saying that they’re confident that she’s going to both campaign and govern more aggressively in favor of abortion rights. And we haven’t really seen concrete signs that that’s the case. We wrote about how she was giving these speeches in her first week as the candidate at the top of the ticket, saying, “I’m going to restore reproductive freedom.” And she kept saying that over and over. And I saw that that became a Rorschach test for a lot of people. And some people said, “Oh, that is code for she’s going to go beyond Roe v. Wade.”

I saw a lot of projection on that front. But when we got the campaign to confirm, they said, “No, she means Roe v. Wade.” So she’s endorsing the exact same policy that Biden was endorsing, which a lot of abortion rights groups say is not good enough. They point out that many people were denied abortions under Roe v. Wade. States could impose all these restrictions, they could have bans on abortions later in pregnancy, they could have restrictions throughout pregnancy, they put clinics out of business, etc. And so the hopes that she would really advocate for going beyond restoring Roe v. Wade have sort of fizzled. Although there’s also a divide between sort of the big mainstream groups and the smaller, scrappier, more sort-of-militant progressive groups.

Rovner: It’s kind of the mirror image of what’s going on on the anti-abortion side.

Ollstein: Absolutely, absolutely. You have hard-liners and then you have more politically pragmatic, “Let’s just get done what we can get done.” And a lot of this conversation is theoretical because the likelihood of a Congress willing to pass either restoring Roe v. Wade, or going further, is very slim. What the administration could do on the executive front is also curtailed by recent Supreme Court opinions on Chevron. So, some of this is theoretical. It’s not totally clear to me what Kamala Harris would do on abortion rights that Biden has not already done. And it seems that a lot of this race is pledging to stop Donald Trump from undoing those things and imposing restrictions.

Rovner: So it looks like another issue that Harris is appearing to be highlighting is medical debt, something she’s been working on as vice president. The federal government this week approved a novel program out of North Carolina that would raise Medicaid rates for hospitals that forgive patient medical debt, as well as automatically enroll eligible low-income patients in financial assistance programs.

Now, there was a study a couple of months back that showed that forgiving medical debt after it’s gone to collections doesn’t actually help people all that much. Their credit rating is still a mess, and they still can’t afford a lot of things. What does seem to help is preventing those debts in the first place. So is this project — which includes some of these things like enrolling people automatically in assistance programs — maybe the beginning of an effort to address this debt further upstream?

Weber: I think, theoretically, it’s the beginning of an effort, but if you read the fine print, none of the hospitals have signed on yet, from what I understand. So, when you’ve got the hospital association saying, “Oh, we’re working on it,” but no one signed on, I don’t know that you have a deal yet. I mean, that remains to be seen. Obviously, this is something that they’re really hoping to get done. But if you don’t have hospital buy-in — which is the major player here — and the hospitals in lobbyists-speak are saying things like, “We think the insurers and other parts of the health care system should be involved,” I’m just hesitant to comment on the longevity of this project before these people actually sign on the dotted line.

Rovner: And it’s important to remember that hospitals are supposed to be doing this anyway. Nonprofit hospitals, at least, are supposed to be doing this anyway. That’s one of the things that they keep their nonprofit status for. And yet we have seen, obviously, rather painfully, over particularly more in this last decade or so, that that’s just not happening. And people are ending up with these big bills, and they’re being sent to collections, and their credit ratings are being ruined, and makes it harder for them to find a place to live, or in some cases get a job. I mean, this spin-out from unpaid medical debt is not great, and affects many other parts of people’s lives.

OK, well meanwhile, President Biden, who is still president for another five and a half months, this week proposed a pretty sweeping overhaul of the Supreme Court, including term limits and enforceable ethics requirements. This obviously isn’t going to happen while he’s still in office, but it lays down a marker going forward for Democrats. I know President Biden was very resistant to calls for major Supreme Court change earlier in his term. I guess some of the scandals that we’ve been hearing about with some of these Supreme Court justices have perhaps made him soften a little bit towards doing something.

Ollstein: I mean, this has kind of bubbled up for a while, and you’ve slowly seen more members of Congress endorsing these kinds of reforms. Biden has, he’s famously an institutionalist. He was resistant to calling for the end of the Senate filibuster. He was resistant to some of these big reforms. He sort of convened committees to study the issue and sort of kick it down the road a bit. But I think in the context of some of this was starting to be announced when he was attempting to save his own presidential candidacy and was shoring up support from progressives on that front. But there is not a Congress, and there is not likely to be a Congress, willing to pass these reforms. And so I think the shift in conversation is still important. And I think some of these reforms that were once considered crazy, fringe ideas are now being taken more seriously by top-level folks. Still, obviously a long way to go. But like you said, all of the scandals around ethics at the Supreme Court have really highlighted and brought this to the fore.

Karlin-Smith: It does seem notable to me that even though he did sort of tease this a little bit as he was still trying to save his campaign, he really didn’t lean into it until he was in this lame-duck period. And that gives you that sense of, it felt politically dangerous a bit to go this far, and gives you a sense of where we are on it. And that he has not brought up what I think some people on the left would like Democrats to think about, which is adding more justices to the Supreme Court, which could be something that I think might have a bigger impact. And there is some justification for that given that the expansion of the circuit court system and so forth over the years. So I think those are two big markers for me that give a sense of, there’s progress in this area, but for people that really want to see major reform, we’re a long way off from that.

Rovner: Yeah. It bears noting that the way that the term-limit proposal is structured, every president would get two appointments, because it would be 18 years and they would be staggered. So you wouldn’t have sort of the odd situation we’re in now, where Democrats have been in the presidency, in the nominating form, for more years than Republicans, and yet there’s now a 6 to 3, basically Republican-appointed majority, on the court. But as Alice says, I don’t think anybody thinks this is going to happen. Somewhat like medical debt, this is going to be a political talking point for this fall.

So, in Republican political news, the head of the Heritage Foundation’s Project 2025 resigned this week, as top staff at the Trump campaign tried to distance their candidate from some of the really-out-there proposals in the 900-page blueprint for the next Republican administration. But while the policy part of Project 2025 may or may not be winding down, we’ve heard differing ideas about the personnel part of the project. The presidential personnel database, which is arguably even more important, remains up and running. Trump has said he wants to remove civil service protections from tens of thousands of federal workers and replace them with people loyal to him and his agenda. And Project 2025 is presumably going to have those people ready, and waiting, and vetted. Sarah, just as an example, what could this mean in an agency like the FDA [Food and Drug Administration]?

Karlin-Smith: The FDA has a pretty small amount of political appointees and so forth, but it could kind of impact tenure of people higher up in senior positions and their ability to stay in them. And even if it doesn’t impact, even if the Trump administration didn’t necessarily go after them directly, I have heard reports from people that suggest it might initiate a series of people leaving, and then trickle-down effect there. And it really makes career positions a lot less secure, in part because it could give a lot of ammunition to basically move people around to jobs they don’t want to be in, or don’t like.

Rovner: Yeah, I mean we saw this during the Trump administration, just with the Trump administration picked up the Bureau of Land Management, moved it to Colorado, and a lot of people quit their jobs. There was, I think a piece of the Ag[riculture] Department that they moved to Kansas City. And civil servants — we’re not talking about these top political appointees — civil servants have wives and spouses, and kids in school, and it’s hard for them to just sort of up and say, “I’m going to move to another part of the country,” without really very much warning.

Weber: If anybody’s wondering, they should probably pick up Michael Lewis’ The Fifth Risk. I would highly recommend it as a very interesting book that gets at what happens if you eliminate career federal employees that you have no idea how important their job is because they operate in the background. So, it’s really helpful background. I just wanted to also add, I think we have to read aloud what the Trump campaign said about Project 2025, which is reports of Project 2025’s demise would be greatly welcomed and serve as notice to anyone or any group trying to misrepresent their influence of President Trump in his campaign: it will not end well with you. Which I found to be just a particularly savvy bit of marketing. Because I mean, the president, former President Trump, has made it very clear that he’s not going to give positions on things that he thinks could cost him votes, which is what I think this statement is from. That doesn’t necessarily mean he’s not going to take Project 2025’s guidebook by letter and key. I find this messaging moment to be very interesting.

Rovner: The people who wrote Project 2025 are people who are currently loyal to President Trump. Many of them are former Trump appointees, or people who worked for Trump. Basically what this is is a much more sophisticated preparation for if he gets back into office than he had in 2016 when he famously said he didn’t think he was going to win. And it took them months, and in some cases years, to actually get people into the administration.

Ollstein: Yeah, it’s become this interesting double-edged sword. Because like you said, when he was elected in 2016, they were clearly unprepared. And when they attempted to do all of these rule changes at federal agencies, a lot of them got blocked in court. They weren’t really ready for prime time. And so this was an attempt to have all of the groundwork laid, so that they could have this sort of blitz to remake federal law as soon as they entered office and have the loyal personnel ready to execute it. But it’s now backfiring politically, and Trump has always sort of been sensitive to portrayal of any group or person being the ideas generator and not himself. I’m thinking of “No puppet” from … if people remember that.

So any sort of portrayal of him as the mouthpiece or the puppet of some other group has always really sort of triggered him. And so you see him lashing out now and saying, “I have nothing to do with this group.” Even though, like you said, this group has lots and lots and lots of ties to him. And the repeated disavowals show that this is a sensitive point for them. But like Lauren said, there’s no sign this is stopping or severing ties to them in the future.

Rovner: And of course, Trump rather famously wants to preserve his ability to say different things to different audiences at different times. Sometimes he contradicts himself in the same paragraph. In fact, frequently he contradicts himself in the same paragraph. He’s thinking aloud, that’s sort of his thing. So he can pretend to be all things to all people. And having things written down, like Project 2025, sort of hamper his ability to do that. I think we all agree that the fact that this guy stepped down does not mean that this is not going to be what’s very much the plan for the administration, assuming he gets back into office.

Well, speaking of former President Trump, on Wednesday he took the stage at the National Association of Black Journalists conference in Chicago. And let us say, it was not very pretty. On abortion, he repeated his false claim that Democrats support abortion in the ninth month and even after birth. That’s murder, people. And he tried to make it clear that the issue is now successfully back to the states to decide, which is what he said he wanted. But Alice, you have a story this week about how anti-abortion forces in several different states are working hard to keep voters from getting to express their views on abortion-related ballot questions. So, what’s sort of the rundown here?

Ollstein: We’ve seen the states that are working to put this on the ballot. They’ve already overcome several waves of lawsuits and attempts by state legislatures to pass new rules, making the ballot initiative process more difficult. And so now we’re nearing the deadline, and we’re seeing a new blitz of efforts, both from Republican state officials and outside anti-abortion groups, to keep these off the ballot, or sort of put a thumb on the scale in terms of inserting wording that is favorable to the anti-abortion side. Inserting cost estimates saying, “Oh, if this passes, it’ll cost the state so much in litigation.” That’s happening in Florida.

And so I think the next few weeks, the certification deadlines, a lot of them are in late August so the next few weeks will be really crucial to see if these will or will not get on the ballot. In certain states, they could also have ripple effects on other political races by spurring higher turnout potentially. You see Democrats hoping that’s the case. But we’re seeing things are not yet settled in a lot of really major states — Arizona, Missouri, Montana, South Dakota, Florida — so wanting to keep a close eye on these fights. Obviously, all of the ones that have happened so far over the past two years have been victories for the pro-abortion-rights side. And knowing that, and anticipating that will continue, you see anti-abortion forces really mobilizing to make sure these votes don’t happen in the first place.

Weber: And as you pointed out, I mean, this is obviously important because this is a turnout election, especially now with the new Harris-Trump dynamic. And so all of these battles that are down-ticket have so much more emphasis now with what we’re looking at, especially as new poll results show this election could be pretty tight. We’ll still see. Obviously, there’s still a lot of adjustment to be done. But I think these battles that Alice reported on are so critical, because they have so much more reverberation than even just the abortion reverberation, but in the possible turnout that could drive other factors.

Rovner: In some of these very swingy states, too. Well, one final interesting piece of news on the reproductive health front this week. A patient in Kansas is suing the University of Kansas Health System for denying her an emergency abortion in 2022 in violation of the federal EMTALA law, the Emergency Medical Treatment and Active Labor Act. This appears to be the first such lawsuit of its type, and the patient is seeking not just financial compensation — her water broke early and she ended up having to go to another state — but she wants the hospital to admit that it violated both federal and Kansas law so that this doesn’t happen to anybody else. Do we expect to see more of these kinds of actions? And somebody remind us what EMTALA does and doesn’t do, and how the fight over this is still live because Supreme Court decide the case out of Idaho anyway.

Ollstein: Yeah. So we have seen some other patients sue over being turned away from hospitals. But what I think is really interesting is that the Biden administration pledged really aggressive enforcement of EMTALA. But yet you’re not seeing this lawsuit come from the administration, you’re seeing it come from a patient, an outside advocacy group. So I think that’s really notable. Maybe the Biden administration is doing more behind the scenes that we don’t know about. I’ve tried to ask them and they have not said. Like you said, the Supreme Court punted on this issue of the intersection between federal patient protections under EMTALA and state abortion bans and where to draw the line. And which one takes precedence when they’re in conflict, or whether they’re in conflict, is also up for debate.

So we could see more of this, but we’ve also seen over the past two years that a lot of patients don’t want to put themselves out there like this and become a public figure in the face of a lawsuit for very understandable reasons in this really painful moment. And so I think that’s why you see groups wanting the administration to do more on the front end to prevent this from happening, rather than patients having to take this on after it happens to them in a devastating way.

Rovner: I have also talked to people in the administration who have suggested to me that they are in fact doing more on this. Although Alice, as you say, we haven’t really seen it publicly. But I mean, I had somebody approach me to make it known that this is something that they are extremely concerned about. There is some reporting out this week from my former colleague, Joan Biskupic, who covers the Supreme Court for CNN, about speculation about that Idaho case was exactly correct. They took the case and they didn’t decide it. They sent it back to the lower court, because they had split 3-3-3. That the liberals wanted to dismiss the case entirely. The three hard-line conservatives wanted to find that Idaho did not have to provide abortions in emergency cases unless the life, rather than both the life and the health, were threatened. And that Chief Justice [John] Roberts and Justice [Brett] Kavanaugh and [Justice] Amy Coney Barrett were concerned and were stuck in the middle.

And the deal that they struck was to put back the stay that had kept the Iowa law from taking effect, but send it back to the lower court, which, of course, is what they ended up doing. So, as we said at the time, this case continues to go on. There is still not sort of a judicial decision about the situations in which hospitals have to provide emergency abortions for people in these cases that are health-threatening, and/or life-threatening, but not imminently life-threatening, which is what we’ve been seeing. So this is obviously something that’s going to continue.

All right, moving on. Medicare and Medicaid turned 59 this week, making the program almost old enough to qualify for benefits. And as of today, we are exactly a month away from the first 10 negotiated drug prices being officially unveiled. Sarah, what are you hearing about how this is going? I think there was another court case this week that pharma lost. So I mean, this is definitely going forward, right?

Karlin-Smith: Right. Novo Nordisk joined the slew of losses for the industry here. There are appeals, but I don’t think anybody is expecting anything to change the dynamic leading up to the announcements around this first set of drugs. The thing to remember is, and a number of the pharma companies that have drugs impacted have been speaking about the dynamics on their financial earnings calls, which just sort of are happening around now for this quarter of the year, and have kind of made some suggestions that have gone headlines like, “Oh, it’s not so bad, it’s fine.” But there’s sort of these caveats that, like, “We still hate the law!” And it’s still problematic. And I think it’s important to kind of understand the dynamics here. So one thing is this first set of drugs that’s going for negotiations are older drugs, just based on the way the law was written. The things around the money, and how long they have to be on the market. When you start a program like this, the first drugs are going to be older. So they’ve been on the market longer than drugs that’ll come up as part of the program in the past. A lot of them have competition, brand competition, are actually in some ways competitors to each other. So there’s a sense that Medicare Part D private plans are already getting pretty significant discounts through that private process.

So I think there’s not a ton of optimism in some ways that the government can do much better. And it’s going to be very hard to figure out whether they did or didn’t. Again, because so much of this is not transparent, right? We don’t actually know. Every Part D plan is going to have different discounts. And even one of the things that’s said is could we look at what other countries are paying compared to what the government gets. Well, even when many of these country systems negotiate discounts, we have a sense they’re getting better discounts than the U.S., but we don’t actually know what they are. So lack of transparency makes it hard.

So, it’s going to be a little bit of, I think, like this thing where the headlines are going to be a bit confusing for people to parse. That doesn’t mean that there may not be savings for taxpayers. There may not be savings for some consumers when they get their copay. But I think we’re going to have to wait and see later on as this law progresses what happens when drugs actually get thrown into the mix earlier on in their life cycle, and when we get what are known as Medicare Part B drugs, which are the drugs that you get at a doctor’s office administered to you, like say, an expensive chemotherapy or something. With those drugs, there really is no negotiation system going on now in the private sector, the government just pays a set formula that people say inflates the cost of drugs.

So, it’s going to be interesting to watch. Democrats are certainly going to highlight this. There’s some thought process they’ll actually try and time the government announcements to the Democratic [National] Convention. But I think it’s going to be really hard for people initially to make clear claims as to whether this is a success or a failure. And certainly industry is going to keep going after the law, particularly on the idea that just even this threat of government negotiation down the line impacts the amount of money and investment that goes into new innovation and treatments for people down the road.

Rovner: Well, I mean, obviously this was sort of a big deal for the administration. So one would think that they would want to have a chance. And of course, I think the first is the Friday before Labor Day. So it’s not the biggest news week in general. So yeah, I wouldn’t be surprised if they tried to do something a little bit beforehand.

OK, that is the news for this week. Now we will play my Bill of the Month interview with Elisabeth Rosenthal, and then we will come back and do our extra credits.

I am so pleased to welcome back to the podcast my KFF Health News colleague, Elisabeth Rosenthal, who reported and wrote the latest KFF Health News-NPR Bill of the Month. Libby, of course, is the person who launched this entire project in the first place more than six years ago. Libby, welcome back to “What the Health?”

Elisabeth Rosenthal: Thanks for having me again.

Rovner: So, tell us about this month’s patient. Who she is, where she’s from, and what kind of medical care she got.

Rosenthal: Well, her name is Caitlyn Mai, and she’s this wonderful woman from Oklahoma who, basically she needed a cochlear implant, because she’s had single-sided deafness since an infection when she was 12. And people will go like, “Single-sided deafness, what’s the big deal? She has one hearing ear.” But she couldn’t locate where things were, she couldn’t have conversations because she didn’t know who was talking. So actually, over time it’s become a real impediment in school and in work life. She got approved to have a cochlear implant. She was so excited, because it really would change her life. And she gets the implant: It’s magic. She can suddenly find her phone if it’s lost when it rings. And she’s so excited, except then she gets a bill for $139,000.

Rovner: Yeah. So let’s go back a second. As you have advised us so many, many times, she did all of her homework before the surgery …

Rosenthal: Totally.

Rovner: … checking to make sure she had the paperwork for the prior authorization from her insurance company, and checking to make sure that the hospital and all of the doctors were in-network. And as you say, the bill came! So what happened here?

Rosenthal: Well, the problem is we say, “Oh, the patient’s not responsible, there’s prior authorization,” blah, blah, blah, but there’s no problem in trying. You generate a bill, you send it to a patient, it scares the pants off of them. She said she had to leave work she was so upset. And my first piece of advice, which I would never give people in any other part of their lives is, “Don’t pay the bill.” You get a bill, it says you owe $139,000. Of course, she couldn’t pay it. And I believe it also said, “Hey, if you don’t have $139,000, you can pay it off with $19,000-a-month payments.”

And this is a young woman, getting started in life, newly married. And I guess $19,000 a month wasn’t a viable alternative. So Caitlyn starts doing what many patients do, and we’ve seen this more and more in Bill of the Month: She calls the hospital, she calls the insurer. She’s like the referee. Like, the insurer says they didn’t do the billing codes right. She calls the hospital and says, “Oh, you didn’t give us an itemized bill. Can you generate one?” She calls the insurance, says they’re generating an itemized bill. They go back and forth, and back and forth. Then the itemized bill isn’t right, it contains the wrong codes. And in the meantime, for three months, or four months even, she’s getting these bills that say what you owe now: “prompt payment,” “discount,” and “overdue.” And many patients now are in the terrifying position of playing go-between between their provider and their insurance.

She actually said to the provider, “Send me an itemized bill. Send it to me and I will send it to the right person at the insurance company.” And she said to them, “Look, I’ve done all your work for you. Now just figure it out, you guys.” And, in the meantime, she wasn’t actually sent to collections, but threats were made and it was scary. And she spent endless amounts of time. She works for a nonprofit. She’s lucky, she has a job where she can play this kind of go-between role. But really it should be the provider and the insurer that work it out when you have preauth[orization]. There was no reason why any bills should be sent. And that’s one of my mantras. While you’re working this stuff out, don’t send patient bills, because they’re not responsible for this stuff.

Rovner: Well, that’s the whole point of Congress passing the No Surprises Act, that was supposed to take the patient out of the middle. Why is the patient still in the middle?

Rosenthal: Well, because the No Surprises Act did a lot of great things. It held the patient harmless. And this is actually not a surprise bill, it’s a slightly different issue. But even with the No Surprises Act and with surprise bills, it never said you can’t try. And that’s the problem. Americans are good bill-paying citizens. You send people a bill, and they think, “Wow, I guess I owe it.” So what should be added to the No Surprises Act — and I’m not supposed to use the word should — is you can’t send a bill until the insurer and the provider work it out. I know my mailbox is filled with medical bills that I know I don’t owe, right? But the mantra of the provider is, “Well, there’s no harm in trying. Let’s see if someone pays.”

Rovner: Eventually, she did get this worked out.

Rosenthal: She did get this worked out after hours of her time playing go-between, and many hours spent terrified that she would end up somehow having to foot this bill. Once again, the treatment is miraculous. The bills are not miraculous. I mean, they’re miraculous, but in a really different way. They’re horrifying.

Rovner: So what’s the takeaway here? I mean, we’ve given all the advice, “Don’t pay the first bill. Do your homework in advance.” Is there anything else that you can do to avoid getting six-figure bills for preauthorized surgery?

Rosenthal: Well, there is that “don’t pay your bill” advice, and “don’t be scared by the prompt payment discount,” which she had, too. But I think, unfortunately, you have to be the go-between often. And that’s a terrible position for Americans to be in, because it’s really an equity issue. You and I have jobs and knowledge where we can navigate between these two warring parties, essentially, being the peacemaker. And Caitlyn was lucky she had that kind of job. But many Americans don’t have 20 hours to spend on the phone to avoid a huge bill, and they end up in collections if it’s huge. Or if it’s a small bill — and I’ve done this, and I feel like I’m so angry when I do — if it’s a small bill, you’re like, “All right, fine. I’ll just pay it to get this over with.” Even though I know I don’t owe it.

So I do think there should be a policy that you can’t try to send bills to patients that they don’t owe. They know the patients don’t owe these bills. But like I said, there’s no harm in trying, and there’s no HHS [Department of Health and Human Services] police force out there saying, “You shouldn’t do this.” So, it should have been part of the act, but I think the health care system is endlessly agile in figuring out ways to get around laws that Congress has passed to rein in some of their more outrageous practices.

Rovner: As I like to say, full employment for health care reporters. Libby Rosenthal, thank you so much.

Rosenthal: Take care, Julie. Thanks.

Rovner: OK, we are back. 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. Sarah, why don’t you go first this week?

Karlin-Smith: Sure. I looked at a piece from Elisabeth Rosenthal, “Why Many Nonprofit (Wink, Wink) Hospitals Are Rolling in Money.” And we sort of alluded to this in the conversation around medical debt. But nonprofit hospitals are supposed to, as part of their nonprofit status, be providing certain sorts of commitments to how they serve patients and our greater society. And over the years, they have morphed from looking not much like nonprofits in many ways. And her lead sort of talks about the various for-profit businesses that they have acquired and lumped under their umbrella, and how that affects what they’re doing. And some of them do not even necessarily seem completely connected to health care.

And just, again, it raises this issue of if you’re going to have this nonprofit status you should be fulfilling that other end of the commitment for not paying taxes. And if you don’t, perhaps we need to rethink that, if we are not getting the charity care and the other commitments to society, is health that we should get. And I wanted to flag, it was a Hollywood Reporter article [“New York’s Largest Hospital System Is Setting Its Sights on the Entertainment Business,”] that I had seen last week about Northwell [Health] Hospital getting into the movie and filmmaking business. And that just gives you a crazy example of what some of these nonprofit systems are doing. And I think it’s why it’s become so egregious and people have been making marks about it.

Rovner: Congress has been talking about the “nonprofit” health entities, particularly hospitals, since the 1990s. It goes along with drug prices, this sort of evergreen issue on Capitol Hill. Lauren, why don’t you go next?

Weber: Yeah. I have something from The Tributary called “Testimony: Florida Wrongly Cut People From Medicaid Due to ‘Computer Error,’ Bad Data.” It’s a story we’ve heard over and over again, but I will just note that highlighted in this story is the company Deloitte, who my former colleagues, who I love dearly at KFF News, Rachana Pradhan and Samantha Liss, had a great investigation on just, I think, a month ago? So, I think that you see these stories about people being removed from Medicaid rolls. And to be clear, this was in Florida, and I believe it was a bunch of moms who were removed the year after they gave birth. So, these are serious consequences for “computer errors.” And I mean, we have no idea the catastrophic impact these could have had. But I think it’s important to keep an eye on this, and I know Racha and Sam certainly have. And pretty wild stuff to see continued reporting on that.

Rovner: We’ve seen a continuing software programs that went in and thought that they would sort of efficiently look at household income, and to determine whether people were still eligible. And forgot that when they were programming it, that eligibility varies by income, depending on whether you’re a kid, or a pregnant woman, or a mom who’s just given birth. That those eligibility amounts are not the same, and that you can’t just go in and say, “You’re over a certain cutoff, you’re off.” So we’re continuing to see this in the continuing unwinding. Alice.

Ollstein: So, I have a really interesting piece from ProPublica about something I had never heard about. It’s called “A Lab Test That Experts Liken to a Witch Trial Is Helping Send Women to Prison for Murder.” So this is about a forensic practice that some states and counties use for determining whether a baby was stillborn, or that the mother ended the baby’s life after it was born alive. Sorry if this is graphic, folks, but it involves removing the lungs and seeing if they float or not. The reasoning being that that will help you determine if the baby was born alive and took a breath before it died, or if it was stillborn. But we’ve been learning about a lot of forensic “tests.” This is pseudoscience. It is really inaccurate. There are many ways that this could inaccurately convict someone of murder when, in fact, they suffered a stillbirth. So I think people think it’s scientific, it’s unbiased, but science is more complicated than that. So this was a really fascinating story.

Rovner: Yeah, this is something that’s been around for a good while. I became aware of it in, I think, the 2010s, when it was used to convict someone who, I believe her conviction was eventually overturned.

Well, my extra credit this week is from The Washington Post by Fenit Nirappil, and it’s called “Online Portals Deliver Scary Health News Before Doctors Can Weigh In.” It’s about a likely unintended impact of the transparency provisions of the 2016 [21st Century] Cures Act, requiring that patients be given access to test results as soon as they’re available, even before their doctors in many cases. Doctors are lobbying for a change in the regulations so they can at least have time to review the results first, so patients don’t open up a portal and find out that they have cancer. But the Biden administration, at least so far, says it’s the patient’s own information and that the patients have a right to it.

The story’s a really very nuanced look at how the solution to just about every problem in health policy inevitably creates problems of its own.

OK, that is our show. 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 technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner. Sarah?

Karlin-Smith: I’m @SarahKarlin.

Rovner: Lauren?

Weber: @LaurenWeberHP on X. “HP” is for health policy.

Rovner: Alice.

Weber: @AliceOllstein on X.

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

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