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.

Health care might not have been the biggest issue in the campaign, but the return of Donald Trump to the presidency is likely to have a seismic impact on health policy over the next four years. 

Changes to the Affordable Care Act, Medicaid, and the nation’s public health infrastructure are likely on the agenda. But how far Trump goes will depend largely on who staffs key health policy roles and on whether Democrats take a majority in the U.S. House, where several races remain uncalled. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, and Alice Miranda Ollstein of Politico.

Panelists

Rachel Cohrs Zhang Stat News @rachelcohrs Read Rachel's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories.

Among the takeaways from this week’s episode:

• As of Friday morning, it remained unclear which party will control the House next year. A Democratic-controlled House would offer a check against Republican policy changes and some control of key government oversight committees. A Republican House would give the party full control of Congress and the presidency. Either way, the party in control will have a slim majority.
• Majorities of voters in eight states voted to protect abortion rights — though the ballot measures passed in only seven states. (More than half of voters in Florida voted for the abortion rights measure, but the state requires at least 60% support for ballot measures to pass.)
• Robert F. Kennedy Jr. — now a key voice in the Trump transition team — is telegraphing big plans for health policy. Who ends up in Trump’s Cabinet will make a difference, as the president-elect is seemingly outsourcing much of his health policy planning in favor of focusing on issues such as the economy, immigration, and trade.
• And conservative appointees throughout the judicial system are likely to remain friendly to Trump administration causes, which could open the door to more challenges to federal policies. Several important legal challenges are already winding through the courts.

Also this week, Rovner interviews KFF Health News’ Jackie Fortiér, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month” feature, about a 2-year old who had an expensive run-in with a rattlesnake. Do you have a medical bill that is exorbitant, baffling, infuriating, or all of the above? Tell us about it!

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

Julie Rovner: KFF Health News’ “Dentists Are Pulling ‘Healthy’ and Treatable Teeth to Profit From Implants, Experts Warn,” by Brett Kelman and Anna Werner of CBS News. 

Alice Miranda Ollstein: Politico’s “The Election’s Stakes for Global Health,” by Carmen Paun. 

Rachel Cohrs Zhang: KFF Health News’ “As Nuns Disappear, Many Catholic Hospitals Look More Like Megacorporations,” by Samantha Liss. 

Also mentioned in this week’s podcast:

• The New York Times’ “R.F.K. Jr. Lays Out Possible Public Health Changes Under Trump,” by Remy Tumin.
• KFF Health News’ “Toddler’s Backyard Snakebite Bills Totaled More Than a Quarter Million Dollars,” by Jackie Fortiér.

[Correction: During this episode, the discussion about a toddler’s medical bills after a rattlesnake bite misstated the total amount billed. The total amount was $297,461 — not $279,461.]

click to open the transcript Transcript: Trump 2.0

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

Julie Rovner: 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 Friday, November 8th, at 10 a.m. As always, and particularly this week, news happens fast, and things might have changed by the time you hear this. So, here we go. 

Today, we are joined via videoconference by Rachel Cohrs Zhang of Stat News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: And Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hi, Julie. 

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Jackie Fortiér, who reported and wrote the latest “Bill of the Month” about a very lucky 2-year-old who suffered a very expensive rattlesnake bite. But first, this week’s news. So, I want to start with some broad themes on what Donald Trump 2.0, a Republican-majority Senate, and maybe a Republican-majority House, too, will mean for health care. 

Next week, we’ll talk more about the lame-duck Congress and the Affordable Care Act open enrollment, which started already. But this week I want to take a bit longer view. First, what difference will it make if the House flips to Democratic control, even by only a vote or two, compared to the trifecta of Republicans in charge of the House, the Senate, and the presidency? 

Ollstein: I mean, a Democratic House would really be the only check on what Republicans would be able to do, and so it would limit the scope of their ambition on health care and everything else. I think that it will have a big effect on things like appropriations, where we’ve seen efforts to, for instance, put a bunch of policy riders in appropriations bills to do all kinds of things, quote-unquote “culture war” actions on abortion and trans rights and other things, but also other health policy priorities across the board, and so I think appropriations is a big area that would be influenced. And, also, I think, I’m sure we’re going to talk a lot about the Obamacare subsidy fight coming up next year, and I think that’s another area where control of the House will have a major influence. 

Rovner: Oversight, too, right? I mean, even if they only have a one- or two-seat majority, Democrats would then control the committees, which is a big deal. 

Cohrs Zhang: Right. The oversight and also just like the structure of oversight committees. I know there’s a select committee on China, that it was unclear if that was going to continue if the House remained in Democratic control, and, obviously, subpoena power. 

Rovner: You mean if the House switched to Democratic control? 

Cohrs Zhang: Yeah, if the House switched to Democratic control, that the future of that was unclear, and then, obviously, subpoena power, those fun things. So I think certainly the control of the committees in general, but also the structure of how things work and what the hearings would be focused on. 

Rovner: We’ve seen the Republican majority — the little, the teeny-tiny Republican majority they’ve had this Congress. Not very effective, because they haven’t been able to get everybody on the same page. Two questions. If they keep their majority, it’s likely to continue to be teeny-tiny, and if the Democrats get it, theirs is likely to be teeny-tiny. Whoever controls the House is likely to control it by, at most, three or four votes. Would Democrats with a very small majority be any more successful in getting anything done than Republicans with their very small majority? 

Cohrs Zhang: It wouldn’t be as much about getting things done as stopping things from getting done, almost. I think, clearly, we see, I think, with a Republican trifecta, the opportunity, again, like Democrats used in 2022, for a reconciliation bill that includes taxes and, like Alice was talking about, the ACA. So I think that would just take that off of the table, but if Republicans do hold the House, then I think that just opens up a really broad range of policy on a lot of different issues, including reform of public health agencies and just some other targets that Republicans have been waiting for amid this era of Democratic control of Congress. 

Rovner: Or at least partial Democratic control of Congress. Also, what is this election a mandate for? As we’ll get into later, voters were often completely contradictory. In eight of 10 states with abortion ballot measures, majorities voted to enshrine abortion rights. Yet, in many of those same states, majorities also voted not just for Trump, but for validly anti-abortion Republicans for Senate and other offices. In five swing states, majorities voted for Trump, but also, apparently, for Democratic senators. This doesn’t feel like a populace clamoring for a repeal of the ACA and a federal abortion ban. This feels like a populace that isn’t quite sure what it wants. 

Ollstein: So, a few things. One, we know from polling, including from KFF’s polling, that the top issues people were voting on were not abortion. They were not health care issues. Those ranked lower down on the priority list. And so I think when you look at the large support for Trump and for several other downballot Republicans, I don’t think you can say that it’s a mandate on health care. I think it’s a mandate on other issues. 

Also, in terms of the split with the ballot measure results, people should not be surprised. We’ve seen this ever since the beginning of this wave in Dobbs. The very first state to vote, in Kansas, they reelected a very anti-abortion attorney general on the same ballot where they voted in favor of abortion rights. In Kentucky, which was one of the ones that came after that, people reelected [Sen.] Rand Paul, who’s very anti-abortion. At the same time, they voted in favor of abortion rights on the ballot measure. This has been a pretty consistent trend, and so it seemed to take a lot of people by surprise this year, but I’m not really sure why. 

Rovner: Because they don’t listen to “What the Health?,” because we’ve been talking about it ever since. 

Ollstein: I guess so. And there’s been some very interesting introspection in the abortion rights community and grappling with the question of whether ballot measures created — one source of mine called it a “permission structure” for people to feel OK voting for Republicans because they felt: Oh, well, I took care of the threat to abortion by voting on the ballot initiative. Now I can focus on other things when I go to pick a president or pick a senator. 

Rovner: Rachel, what about other health issues? I mean, does anybody come out of this feeling like they’re emboldened and empowered to do something specific? 

Cohrs Zhang: Well, I think we’ve certainly seen Robert F. Kennedy Jr. really excited, and I think his pitch for the “Make America Healthy Again” agenda was a key part of the Trump campaign’s closing message leading into Election Day. It was a relatively recent development if you look at the whole arc of the campaign, but I think that the Trump campaign finally just seized on this message that did appeal more to his voters who were skeptical of Operation Warp Speed and just the development of the covid-19 vaccine, distrustful of public health institutions. And we’re seeing it all come to a head by empowering him. 

Potentially, again, we’ll see who gets what positions in the transition. He was promised things before that didn’t materialize in 2016. So, again, it’s early stages, but I think that RFK Jr., who has been a surrogate on TV, on podcasts, just really rallying his supporters for the Trump cause, I think he would feel empowered. He certainly has seemed like it. He’s been making promises about things that the Trump administration would do in the early days. And so I think this transition period will be really instrumental in determining how much that influence will actually transfer to policymaking power. 

Rovner: Which is a perfect segue to my next big question, which is: How much does this all depend on who gets what jobs? Trump, obviously, can’t run all the agencies himself, and even his loyalists can get in trouble when they think they’re interpreting what he wants. How many times on the campaign trail did Trump directly contradict something Vice President-elect JD Vance said? For example, two of the names I’ve heard bandied about for HHS [Department of Health and Human Services] secretary are Bobby Jindal, a former HHS official under President George W. Bush and former Louisiana governor and kind of an old-school conservative at this point, and Florida Surgeon General Joseph Ladapo, whose name will be familiar to podcast listeners as a basically vaccine denier with an M.D. So, I mean, I assume a lot of this is going to be … Health has never been Trump’s sort of — 

Cohrs Zhang: Top priority? 

Rovner: Yeah. 

Cohrs Zhang: Yeah. 

Rovner: Yes, his highest personal priority, so, I mean, what difference does it make who ends up with these jobs? 

Cohrs Zhang: Oh, it makes all the difference, because I think this isn’t a top priority for Trump. He’s made it very clear that his top priorities are immigration and trade and economic issues. And so, in the advocacy space and also in the health industry space, there’s just a lot of focus on who is going to be in these key Cabinet roles, as well as further down in the bureaucracy, because that’s where the rubber is really going to meet the road, and they feel like they’re going to have a lot of room to do whatever they want, because this isn’t going to be a top focus of the Trump administration. And so you’re seeing a lot of anti-abortion groups really arguing that personnel is policy, and they want to see people who are aligned with them ideologically in these key roles pushing these policies. 

Rovner: I mean, it’s going to be interesting, and we’ll get to this in a few minutes, on when it comes to abortion, where Trump has said all these things about leaving abortion to the states, but it’s hard to imagine that, not anti-abortion activists in any of these jobs, don’t you think? 

Cohrs Zhang: I mean, it’s unclear, because the RFK Jr. wing, even though he’s sort of been all over the place on abortion and, at times, has advocated for national restrictions on abortion, but then backed away from it and sort of has been flip-flopping. But, like Trump, it does not seem to be his top priority. And so, in his world, skepticism of vaccines and Big Pharma is more of a priority, and so I think you’re not going to see a lot of abortion rights advocates in these roles, but you could see people who are sort of — 

Rovner: For whom it’s not their top priority, either. 

Cohrs Zhang: Exactly, exactly, who are much more focused on other areas. 

Rovner: So we also need to talk about how some of Trump’s bigger efforts could end up having an outsize impact on health policy. Deporting millions of immigrants could take a bite out of the health care workforce, for example. And purging the government of civil servants who are perceived to be disloyal could lead to a really big brain drain, particularly in health agencies where there’s a lot of expertise, like the NIH [National Institutes of Health] and the FDA [Food and Drug Administration] and the CDC [Centers for Disease Control and Prevention]. Rachel, that’s something you guys are looking at, right? 

Cohrs Zhang: Certainly. I think we’re looking at just how the agencies could look different. And, I mean, even, I think, the most traditional conservative, lowercase-C former Trump officials, we’ve seen Scott Gottlieb call for CDC reform, and I think that just the general sense is that the public health agencies are doing too much, they shouldn’t necessarily be weighing in on gun violence or even smoking cessation sometimes. And I think they’re just arguing for kind of a back-to-the-basics approach. And I think RFK Jr. certainly has threatened jobs at the FDA, especially in the food division. Civil servants do have legal protections, but there are plans to change those, and so I think we are going to see protracted legal fights over some of these executive orders. And, when they come, and I think it’s not going to be like a Day 1 thing, but it’s certainly going to be a very important theme that we’re going to be tracking, as to how the shape of these agencies change in this larger anti-bureaucratic movement. 

Rovner: And, once again, you have walked right into the next question, which is how courts are going to be pivotal here, because we already know from his first term that Trump likes to blow through regulatory and legal guardrails and is likely to do it even more now that he’s term-limited and, basically, has been given carte blanche by the Supreme Court. On the other hand, the Supreme Court overturning Chevron deference last year suggests it will be easier to use the courts to block government actions. The Democrats were all hand-wringing about how, Oh, my goodness, the government is not going to have a lot of power, because courts are going to now have to say, “Congress, you need to spell out everything you’re going to do.” So this could be one of the few sort of bright spots for the anti-Trump forces, right? 

Cohrs Zhang: Well, potentially, but we’ve also seen courts that are dominated by very conservative appointees treat different clients’ arguments differently. So, yes, in theory, curtailing administrative power cuts both ways and would curtail the administrative power of conservatives, but you’ve seen courts not always be consistent in how they apply these principles. And so I think it’s very possible that a Trump administration could get more deference from federal courts than the Biden administration has on some of these rulemaking efforts. 

Rovner: With or without Chevron. 

Cohrs Zhang: We’ve definitely seen that in the past. And folks I’ve talked to insist that, overall, this is a win for them because they do believe in less regulation, and so their ability to create new regulations being limited is not the blow to them that it is to progressives. 

Rovner: Yes. Well, courts will certainly be active in the next four years, as they would have been no matter who won. All right. Well, let’s dig down just a little bit deeper. Alice, I think I’m counting right, there were 11 abortion ballot questions in — 

Ollstein: Ten. 

Rovner: — 10 states on Tuesday. 

Ollstein: Oh, yes, yes. 

Rovner: Yeah, but there was — 

Ollstein: Eleven in 10 states, yes. 

Rovner: Right, 11 in 10 states, because there were two in Nebraska. What happened to them? And how soon might some of them take effect? 

Ollstein: Yeah, so here’s the breakdown. So, on seven of them, states either voted to restore abortion access, protect existing abortion access, or expand abortion access. So seven of the 10 went in favor of the abortion rights movement. Three did not, including, you mentioned, Nebraska, where there were two competing initiatives on the ballot, which many predicted would be confusing to voters. And, in that state, the more restrictive option prevailed. 

In Florida — I saw a lot of misleading reporting on Florida. I saw stories that said, Voters reject the abortion rights amendment in Florida. Let’s be clear. Fifty-seven percent of voters voted in favor of that, so I don’t think you can say voters reject. But the state has long, for decades, required a 60% supermajority to pass ballot initiatives, so it did fall short, even though an overwhelming majority voted in favor. And in South Dakota, one of the most conservative states to ever take up this issue, a majority of voters did, in fact, reject the proposed abortion rights measure that would have restored some access in the state. So, it was a mixed bag. 

Rovner: It’s funny. People talk about South Dakota as being so conservative. I covered the South Dakota abortion referendum in 2006 and 2008. There were two, and they both lost. Those were efforts to restrict abortion, probably, at that point, illegally. Would have gone to this, I mean, they were trying to set up a Supreme Court challenge. But it was surprising, both in 2006 and 2008, that that lost. So, obviously, South Dakota has turned even more red since the mid-aughts. I mean, most of these that passed, though, are just, as you said, reassuring states where it was already legal. I mean, there were only, what, two where it actually overturned a ban. 

Ollstein: Yes, Arizona, where it overturned a 15-week ban, and Missouri, where it overturned a near-total ban. And I saw that the abortion rights groups in Missouri have already moved aggressively to file a lawsuit challenging the state’s ban, pointing to the newly passed measure, and not just challenging the state’s overall ban on abortion, but challenging a lot of narrower policies in terms of regulations on abortion. So I think they’re moving to argue in court that these restrictions can’t stand under the new ban, so we’ll see what happens there. 

Rovner: So nothing happens immediately? 

Ollstein: Yeah. I think that’s important for folks to realize. These ballot measures passed, but then you either have to go to court to get the actual state laws changed or the state legislature can act to say: OK, the voters, this is the will of the people. We need to repeal the things that are currently on the books. 

Rovner: Meanwhile, I feel like it bears repeating that, even though Trump has said repeatedly during the campaign that he wants to leave abortion to the states and that he wouldn’t sign a nationwide ban, which probably couldn’t pass Congress in its current form even if Republicans have both Houses, he could actually do things that would make abortion effectively unavailable in much of the country. Remind us what a couple of those things are. 

Ollstein: Oh, I mean, there’s a lot that can happen both through the administrative side and through courts. There are several pending cases in court that could really curtail access nationwide. At the administrative level, you have FDA regulation of abortion pills. Abortion pills are used in more than two-thirds of all abortions in the U.S., and so there are expected to be efforts both to reimpose the pre-pandemic restrictions on how people can access the pills or challenge their decades-old approval and really cut off access entirely. There are also efforts to use the Comstock Act to restrict mail delivery of both abortion pills and any medication or instruments that could potentially be used for abortion. And so folks should understand that these things would impact people everywhere, including in states that just voted in favor of these ballot initiatives. 

Rovner: Exactly. All right. Well, I want to turn to coverage, and I’m including this as a giant category that includes Medicare, Medicaid, and the Affordable Care Act. Trump, of course, said repeatedly on the campaign trail that he wouldn’t cut Medicare, but that’s not really Republican health policy doctrine. I mean, Rachel, we don’t expect Medicare to just sort of float on untouched for the next four years. Right? 

Cohrs Zhang: Well, I mean, I don’t know that we’re going to see I think what people think of when they think of Medicare cuts, like raising the eligibility age, some of those really unpopular policies. I mean, under a Republican administration, we certainly could see more people moving into Medicare Advantage plans. I think that dynamic, which the group’s already been growing, of people who are enrolled in Medicare Advantage plans instead of a traditional Medicare plan. So we could see the growth of those private plans, which, again, lawmakers have raised some concerns about, just quality and access for people who are in those plans. 

We also could see some tweaks to the drug pricing policies that Democrats passed in 2022. From what my sources are saying, that even if there is a Republican trifecta, it’s unlikely that we’ll see a wholesale repeal of Medicare drug price negotiation, just because it would be really expensive. They’d have to find some other way to pay for that, which is not necessarily something that they would want to do. But there are some tweaks that the pharma industry has been asking for around the edges. And so I think there is a significant chance that we could see some changes to that program. So I think there are just — I don’t know that we’ll see quote-unquote “cuts” to the Medicare program, but there can certainly be changes and people getting funneled into different plans. And I think it will be a really interesting dynamic to watch, especially in the MA space. 

Rovner: Yeah. And, of course, not only has Trump failed to include Medicaid in the programs that he has promised to protect, but Medicaid was a major target in his first term. So, Alice, I guess we’re expecting action on the Medicaid front, right? 

Ollstein: That’s right. I mean, it’s just a question of, if you take massive programs of Medicare and Social Security off the table, as they’re purporting to do, I mean, really, what’s left? 

Rovner: Oh, that program that covers 80 million Americans? 

Ollstein: Exactly. Exactly. And so, again, there’s just a lot of things they could do. Depending if they win control of the House, there’s a lot they could do through Congress, but there’s also a lot they could do through waivers and rulemaking. And I think we really should be watching what happens on the expansion population, because that is where conservatives really oppose the level of spending currently. 

Rovner: Meaning, the additional subsidies for states to expanded Medicaid under the ACA? 

Ollstein: Exactly. 

Rovner: That expansion population. 

Ollstein: Exactly. There are a lot of conservatives who believe that that happened at the expense of the so-called traditional Medicaid population of pregnant women, low-income parents, et cetera, et cetera, et cetera, people with disabilities. And so a lot of conservatives are critical of the subsidized expansion of coverage to able-bodied childless adults, and so I would be really watching to see what happens there. 

Rovner: We also know, as you mentioned, Alice, that the expanded subsidies for the Affordable Care Act, not the Medicaid subsidies, expanded subsidies for people expire at the end of next year. Is it safe to say that those are toast under a Republican Congress and President Trump? 

Cohrs Zhang: I would say that it’s a little more complicated than that, just because a lot of these subsidies actually are benefiting states that have not expanded Medicaid, so they’re mostly Republicans who are politically benefiting from these subsidies and would politically feel the blowback if they were to expire and premiums would spike for their constituents. But I think they’re — I could see even a middle ground where they’re certainly not going to be renewed at their current levels, but there could be some scaling back who might be eligible for them. You could have some sort of guardrails around fraud, which I know is something that some Republicans in Trump’s orbit have raised. We certainly could see a scenario in which they just choose to not renew them entirely. But I think there is a possible middle ground here if the Republicans from these states like Florida really do stand up and realize the potential political blowback for them. 

Ollstein: Yeah. I also think there could be some horse trading. I mean, especially if Democrats manage to flip the House. There are a lot of other things Republicans really want. Extending tax cuts is one of them, and so I think there could be some horse trading to allow, like Rachel said, some of the subsidies to continue in exchange for something else. 

Rovner: Well, there’s so much more to cover. I think we’re going to stop there for this week. We will have more in the coming weeks. There will be no shortage of news. Now we will play my “Bill of the Month” interview with KFF Health News’ Jackie Fortiér, and then we’ll come back and do our extra credit. 

I am so pleased to welcome to the podcast my KFF Health News colleague Jackie Fortiér, who reported and wrote the latest KFF Health News “Bill of the Month.” 

Jackie, thanks for joining us. 

Jackie Fortiér: Thanks for having me. 

Rovner: So tell us about this month’s patient, who he is, what kind of medical care he needed. 

Fortiér: Yeah. Brigland Pfeffer had just turned 2 years old last April when he was bit by a small rattlesnake in his family’s backyard. They live in San Diego, and, like a lot of houses, their backyard is right next to rattlesnake habitat. Brigland Pfeffer was bit on his right hand between his thumb and his pointer finger while his parents were just a few feet away. His older brother saw that it was a rattlesnake, and his mom immediately called 911. EMTs took him to the nearest emergency room that had antivenom. But while he was in the ambulance he went into shock, and at the emergency room they couldn’t find a vein to start the antivenom. His blood pressure was dropping, so the ER doctor ended up drilling into his leg bone to get that starting dose of antivenom going. They stabilized Brigland and then transported him via another ambulance to Rady Children’s Hospital in San Diego, where he was in the pediatric intensive care unit for two days. He got more antivenom there, and then, after a couple days, he was sent home. 

Rovner: And, just to cut to the chase, he’s OK now, right? 

Fortiér: Yes. He is a rambunctious 2½-year-old. His hand has healed. You can’t even see where he was bit. But his mom tells me that he does have nerve damage in that hand and his right thumb isn’t as dexterous as his other fingers. And she said that he used to be right-handed but, since he was bit by the rattlesnake, he’s now left-handed. 

Rovner: Yeah. Well, he hasn’t been to kindergarten yet, so it should be OK, right? 

Fortiér: Yeah. Yeah. Exactly. 

Rovner: Now, sometimes, the bills we write about are fairly small and it’s the principle of the thing that’s the story. This is not one of those cases. This was a really, really big bill. How much was it? 

Fortiér: Yeah. The total bill for his care was [$297,461]. That includes two hospitals, two ambulance rides, and a couple of days in pediatric intensive care. Now, Brigland needed 30 vials of antivenom to save his life. So, out of that total bill, antivenom alone accounted for about 70%, or just about $213,000. 

Rovner: How did it break down? I assume that the family was not asked to pay six figures for their child’s medical care. 

Fortiér: The family’s health insurer covering Brigland negotiated down the antivenom charges by tens of thousands of dollars. And the cost was mostly covered by insurance. Brigland’s family did pay $7,200 of their plan’s out-of-pocket maximum. But insurance didn’t pay all the claims. His mother, Lindsay, got a letter saying that they owed a little over $11,000 for one of the ambulance rides that the insurance didn’t cover. And, as you know, the landmark No Surprises Act protects patients from many out-of-network bills and emergencies, but the law controversially exempted bills for ground ambulances, so his family may have to pay more than $18,000 for his care. 

Rovner: Yikes. But the big story here is how expensive that antivenom was. Why does it cost so much? You obviously don’t have time to comparison-shop when your 2-year-old’s just been bitten by a rattlesnake. 

Fortiér: And you can’t. I mean, there’s no way to know which emergency rooms have antivenom and which don’t. Antivenom is extremely expensive, for a couple of reasons. The first explanation is hospitals can and do mark up products as much as they want to balance overhead costs and to make money. At the first hospital where Brigland received the antivenom, they charged more than $9,574 per vial. The second hospital, they charged almost $3,700 less for exactly the same medication. 

The second reason antivenom is so expensive is the lack of competition. There’s only two companies cleared to sell snake antivenom in the U.S. For decades, CroFab was the only company. Then Anavip, which is what Brigland got, entered the market in about 2018. But its makers had to settle a patent infringement lawsuit with CroFab’s maker, so the makers of Anavip have to pay royalties until 2028. Anavip initially debuted at a retail price of about $1,200 per vial, but then the price later rose to cover the manufacturer’s millions of dollars in legal costs. So there’s a few complicated reasons why antivenom is so expensive. 

Rovner: Awesome. Just a great — a little microcosm of why health care is so expensive. Somebody is making money off of it, usually not the patient. What’s the takeaway here other than to try to make sure your 2-year-old doesn’t try to make friends with a venomous snake? 

Fortiér: Yes, being snake-aware is a good idea. I mean, this is really why you have health insurance, so make sure your coverage doesn’t lapse. One thing that really surprised me when I was reporting this story was the amount of antivenom that Brigland needed. He got 30 vials of antivenom. That sounds like a lot. But I talked to Michelle Ruha, who’s a toxicologist and an emergency room doctor in Arizona, and she told me that’s not unusual. She’s given 30 vials and more to numerous patients just this year. So there’s many more people who could be facing these enormous bills. Bottom line, if you or your family member gets bit by a rattlesnake, get to a hospital as quickly as you can. There is a saying: “Time is tissue.” A lot of people who get bit have amputations. Don’t put a tourniquet on it or ice. Just get to a hospital. And then, when the bills come, don’t pay the first bill, and try to negotiate them down. 

Rovner: And good luck. 

Fortiér: Yeah, and good luck. I mean, hopefully you have health insurance. And, if you don’t, you could be facing tens of thousands of dollars. 

Rovner: And, hopefully, the hospital you go to has the antivenom. 

Fortiér: Yes. Exactly. Usually, if they don’t have the antivenom, they will get antivenom sent from another facility or you get another ambulance ride to another hospital. When I talked to Dr. Ruha, she recommended going to a larger hospital if you can, because they’re more likely to have antivenom than a freestanding ER or urgent care. 

Rovner: All right. More than I ever want to know about rattlesnake bites. Jackie Fortiér, thank you so much. 

Fortiér: Thank you. 

Rovner: OK. We’re back. And now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. 

Rachel, why don’t you go first this week? 

Cohrs Zhang: Sure. My piece is in KFF Health News, by Samantha Liss. And the headline is, “As Nuns Disappear, Many Catholic Hospitals Look More Like Megacorporations.” And I think this is part of a larger series on Catholic health care in America by KFF Health News, which is an area of personal interest for me. And I think, as I’ve been reporting on systems in the past, I think there is just this stark transition from leadership by actual clergy, by nuns. And now I think you see more professional businesspeople, a lot of times not even medical professionals. They’re MBAs and accountants that are leading these organizations. 

And I think it’s important to note that trend and ask: What does Catholic health care really mean today? And I think, certainly, there are nuns who work at that, in the institutions, that do amazing work. And I think, when I’ve had the privilege to meet them, I mean, it’s just, they’re still certainly active in this space. But, in terms of decision-making at the top executive levels, both inside the hospitals but also in the structures that oversee them within the church, I think there’s just been this movement away from actually having nuns controlling health care. And I think there are really valid questions to ask about what that means for the systems as a whole. So I think— 

Rovner: It changes the mission. 

Cohrs Zhang: It does change the mission, yeah, and so I think this is a great way to quantify that effect. 

Rovner: Really good series. Really good story. Alice. 

Ollstein: Yeah, I chose a piece by my co-worker Carmen Paun about “The Election’s Stakes for Global Health.” I think a lot of these things really went under the radar and were not a major focus, but she really walks through what a Trump win means for things like WHO [World Health Organization] membership and the ongoing pandemic treaty negotiations that are happening there, programs for family planning around the world, programs for global health around the world. And so I just really recommend it, because this was not something that came up on the campaign trail very much and not something you’ve been hearing about in the wake of the election. But, obviously, it has major implications. 

Rovner: Oh yeah. Well, my story this week is from my colleague here at KFF Health News Brett Kelman and Anna Werner of CBS News, and it’s called “Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn.” And, I confess, I just had a tooth pulled to make way for an implant that I may or may not get now, and I’m left wondering if that was really necessary. And like all good stories involving profitable but questionably necessary care, yes, this one involves private equity investors. You should read it even if you have good teeth. 

OK. That is our show for this election 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 this week to our fill-in producer, editor Zach Dyer, as well as our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org. Or you can still find me for now at X. I’m @jrovner. 

Rachel, where are you? 

Cohrs Zhang: I’m on X, @rachelcohrs, and also on LinkedIn. 

Rovner: Alice? 

Ollstein: On X, @AliceOllstein, and on Bluesky, @alicemiranda. 

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

Credits

Zach Dyer Audio producer Emmarie Huetteman Editor

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.