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[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, from ���ϳԹ��� News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? ��’m Julie Rovner, chief Washington correspondent for ���ϳԹ��� News. And, as always, ��’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, July 9, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. Today, we are joined via video conference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi, everybody. 

Rovner: And Victoria Knight of Bloomberg News. 

Victoria Knight: Hi, everyone. 

Rovner: Later in this episode, we’ll have my ���ϳԹ��� News “Bill of the Month” interview with Samantha Liss, about a woman who fought back against a series of insurance company prior authorization denials and won, but it wasn’t easy. But first, this week’s news. 

So we’re just a little more than halfway through the year; I thought this would be a good time to take measure of where we are in terms of healthcare politics. First, Affordable Care Act premiums. As we’ve been reporting, as data has come in, enrollment in ACA plans has dropped pretty precipitously in the wake of Congress letting the expanded covid-era subsidies lapse, with millions of people finding themselves unable to pay unsubsidized or less subsidized premiums. Now we’re starting to get a look at proposed premiums for next year, and we’re looking at more eye-popping increases. Insurers are saying they have no choice. Among other reasons for the increases, the healthiest people are the ones who are most likely to decide they don’t need or can afford to live without insurance, while the sicker people will hang on to it as long as they can, even if they have to go without other necessities. Is this the beginning of the insurance death spiral that everyone’s always been so worried about? 

Knight: Enhanced subsidies expired at the end of December 2025, and we knew we wouldn’t really start seeing the data till the summer. So we’re just now starting to see the effects, and we’re seeing, yeah … the data varies state by state, but we’re seeing a lot of people drop off, and we’re seeing premiums rise. And then that’s in addition to all of the Medicaid overhaul changes that Republicans also included in their big tax-and-spending bill last year. And so we’re starting to see those.The work requirements will go into effect in January, but some states are starting now, and they have to be in effect by next January. And so Medicaid is also a huge one, where people are starting to lose coverage as well. So I think Medicaid and then Affordable Care Act combined, we are going to see a lot more uninsured people, and I think that conversation is going to start entering the election conversation, potentially more than we’ve seen it as of now — which is really surprising, given that Democrats shut down the government last year over the ACA tax credits, and then really haven’t been talking about it as much. But I think we’re starting to see it trickle back in. 

Rovner: Yeah, and you know, Republicans say — and I don’t want to let this sort of go unsaid — that well, you know, one of the big reasons for the drop in enrollment is because there were all these phantom enrollees, people that insurance companies had enrolled, who didn’t even know they were covered, and the insurance companies were just collecting the premiums from the federal government. I’ve read too many stories about real people who said, Yeah, my insurance used to be $300 a month, and now it’s $1,100 a month, and I can’t afford it anymore. I mean, not to say there weren’t some phantom enrollees; there obviously were. We knew … that fraud is an issue, but this does feel bigger than just, Oh, we’ve gone after fraud, and so this should be the right size for the Affordable Care Act marketplace. 

Luthra: It’s very obvious that people have, in fact, lost insurance, like, people have said, “I have lost insurance, I have stopped paying for it because it is too expensive.” Voters have said this is a very big concern for them, because they are going without health insurance, and I mean, to your point, Julie. Yes, there is some level of fraud, of course, but also one of the data points for these phantom enrollees was people who enrolled and then didn’t use health insurance, and that’s actually very normal to not use your health insurance. I have gone many years, you know, you don’t use it some years, then you use it others, and that is what keeps the market healthy, that is why we have risk pools that work. So it seems like this is just an argument that doesn’t really stand scrutiny, and also just doesn’t really make much sense. 

Rovner: Yeah, I mean, the whole point of health insurance is, or insurance in general, is that you only use it when you need it, and that if you’re young and healthy, the people that we want to be insured, and a lot of the people who got insured when it got really cheap to get insurance with those enhanced subsidies, it’s like, Oh, I can afford, you know, $25 a month in case something happens. And then nothing happens, and so they don’t use it. Which is, again, not to say that there weren’t some phantom enrollees, we know this, but there were also, I suspect, a lot of people who had insurance and just didn’t need it during the course of the year. And that was, as you say, it was those premiums that helped pay for the sick people who actually did need to use their insurance over the course of the year. 

Roubein: Then, in talking about, as you mentioned, is insurance sort of in a spiral, , I believe it was this week, about the employer-based health insurance system. And they talked to some small-business owners who said just how expensive it is, and one of them was sort of making the decision between do I lay off employees or do I get rid of health insurance? So, like, these are just very, very real decisions that people are making, as business owners, are making: Can I cover these kind of rising prices or not? 

Rovner: And you literally anticipated my next question, which was to bring up the Stat story, which is a whole series looking at the impact of rising health insurance costs on small businesses. But it raises the broader question of: Is the era of employer-provided insurance nearing its breaking point? And what happens if employers really do start dropping insurance en masse? I mean, this, you know, obviously the first tension point comes with small business, for whom this is a bigger outlay of money compared to, you know, how much they bring in and how much they pay their workers than it is for larger companies. But this has always been the concern that at some point businesses are just going to say we can’t do this anymore. This can’t be what Republicans want, because one presumes the next step after that is, oh, you know, things like “Medicare for All” that presumably they hate a lot more. 

Luthra: Well, that’s what’s so interesting, right, is there’s so much chatter right now about this insurgent DSA [Democratic Socialists of America], yet again seems like something we have, in fact, seen happen in the past. And part of that message is Medicare for All, and what that means is maybe a little bit squishy. We don’t fully know, we never quite fully know, but it does seem like there’s a lot of interest in broadly making health insurance and healthcare more affordable. And there’s a lot of energy on the left and on this growing more progressive movement to use government as a vehicle for health insurance, and I mean, if you have fewer employers providing health insurance, then that does strengthen the case that someone should step in. 

I think ��’m still not fully sure if we can say when or what a breaking point looks like, because employers have been talking about this for so long. I mean, as long as a lot of us have been covering healthcare, there’s been talk about employer healthcare expenditures getting unsustainable, and yet here we are still in this system. The inertia continues. And the other thing that I keep thinking about is what about public sector workers, right, unions who have negotiated for these benefits that they are not going to give up, and those are often very good health insurance plans. It’s just so complicated because our system is so fragmented to get us toward having health insurance for people. 

Rovner: Yeah, this is like my fourth time going around with: Are employers going to stop providing health insurance? Well, meanwhile, to continue the theme of this week, which is everything old is new again, we have the return of death panels and Medicare catastrophic health insurance. First, death panels. Back in 2009, during the debate over the Affordable Care Act, there was a bipartisan provision that would have paid doctors to have end-of-life conversations with Medicare patients — things like: Do you want to be kept alive on a ventilator? Republicans called them “death panels,” and the ensuing controversy nearly sank the entire bill. In the end, the provision was jettisoned as more trouble than it was worth. Fast-forward to last month, and lo and behold, the Trump administration is proposing to regularize end-of-life conversations, including by possibly penalizing hospitals that don’t record a patient’s end-of-life wishes in their electronic medical records. Now, dare I say, this was considered by most bioethicists and other experts to be a good idea back in 2009 and a good idea now in terms of good patient care. But what happened to make Republicans do such an about-face, other than it’s no longer part of a bigger bill that they hate. As my fellow health reporter friend Jonathan Cohn put it: Some of us would like our summer of 2009 back, please. 

Luthra: I mean, part of it is like political convenience, right? This is something that most people know is, in fact, a good thing. I mean, I think when you explain it to a consumer, also in the correct and not misleading terms, yes, people would like the doctors to know what they would want if they had a medical emergency or catastrophe. That is good policy. But the death panel discourse was somewhat cynical — I think that’s noncontroversial to say — that this was a targeted political attack to try and bring down the Affordable Care Act. And so, of course, when you are divorced from those politics, this is just something that is practical when you think about the actual implementation of health insurance and provision of care. 

Rovner: I just didn’t want to let it go unnoticed that this was something that the Republicans used for great political gain back in 2009 reappearing 16 years later as “noncontroversial.” We’ll see if it stays that way. And going back even further in time, a group of Senate Democrats, led by Finance Committee Ranking Member Ron Wyden, have introduced a bill to cap annual out-of-pocket costs to patients on Medicare at $5,000 per year. What, you say? How can Medicare be basically the only insurance policy in America with no cap on what patients can be required to pay for long hospital stays or expensive outpatient care? Well, let me tell you a story of the first big bill I covered back in the late 1980s. It was called the Medicare Catastrophic Coverage Act. It did create an out-of-pocket cap for Medicare, but it was financed by a surtax on wealthier Medicare beneficiaries themselves, and after a not-always-truthful campaign, not unlike the one over death panels, Congress actually repealed the law about 18 months after it passed, in 1989. So, after almost 40 years, will Congress finally put Medicare in line with just about every other health insurance policy on the planet? Or will they stumble, as usual, about how to pay for it? Because it would be expensive to put a cap on what patients could be asked to pay for Medicare. 

Knight: We’re starting to see Democrats really trying to release a lot of proposals now, particularly around healthcare, trying to contrast themselves with Republicans, and being like, look what they did, they let enhanced ACA subsidies expire, they did this Medicaid overhaul, everyone is dropping coverage. Here’s our solution: Republicans took your coverage away, we want to give you coverage, we want to help you reduce costs for your healthcare. And so I think we’re seeing that Sen. Ron Wyden, ranking member of the Finance Committee — if the Senate somehow becomes a Democratic majority, then he would be Finance chair, most likely. He has been putting out a lot of proposals around healthcare, trying to show what he would do if he does gain a gavel in the next Congress. I think the Senate is less likely that it’s going to turn Democratic. I think we’ll probably have a split Congress, if I have to guess, and perhaps the House goes Democratic. So, I think the long and short of it is, I think this proposal is unlikely to go much of anywhere for a while, but it is something that I think we could see have some more traction potentially in a few years if there is another Democratic trifecta or something like that. I think Democrats want to build more on a lot of proposals they put together in the Inflation Reduction Act, capping cost in Medicare, capping cost of drugs, things like that. This would build on that. 

Rovner: Yeah, and keeping with our themes, this is sort of a Let’s make a case for this year’s midterms that we’re the party of health. Rachel, you wanted to add something. 

Roubein: I agree with what Victoria was saying. It’s messaging [indecipherable] ahead of the midterms. It’s, I mean, it’s definitely an interesting, long-standing, as you noted, issue, Julie, but I mean, generally both parties view seniors, older adults as really important voting blocs, and we tend to see various proposals around Medicare around these times, or even accusations from both parties. I think it was in 2023 Republicans and Democrats were accusing each other of cutting Medicare. It’s kind of a tradition of, like, “Mediscare,” as you will. 

Rovner: Yes, actually, and after the Affordable Care Act passed, the Republicans regained control of Congress, talking about not so much the rest of the Affordable Care Act, but the Medicare cuts in the Affordable Care Act, which, of course, were made to pay for a lot of the other things in the Affordable Care Act. 

Well, next up, hospitals in the crosshairs. Now, this is one of those occasional moments in health policy when policymakers in Washington in both parties dare to criticize hospitals, which are powerful political voices, because not only is there one in every congressional district, they are also usually major employers, as well as taking care of sick people. But for decades now, Democrats and Republicans have asked whether nonprofit hospitals, in particular, are providing enough community benefit to earn their right not to pay taxes. Before leaving for the July 4 recess, the House Ways and Means Committee approved a bill that requires a lot more transparency from hospitals about how they justify their tax-exempt status. A related issue has to do with a program that’s nerdily referred to as 340B. It requires drugmakers to sell to nonprofit hospitals and community health clinics at deep discounts. Then those hospitals can turn around and bill insurers, and sometimes patients, full prices for those drugs and keep the difference to help pay for otherwise uncompensated care. Drugmakers hate it, of course, saying it’s being abused. Hospitals say it’s critical to their ability to provide care, and now the administration and Congress are both trying to reform it. So, this House Ways and Means bill addresses both issues. Victoria, you covered it. What would the bill do? 

Knight: Yeah, it’s really interesting. I think Congress is kind of a hamster wheel always, with which healthcare entity they want to go after. And so, last Congress, it was pharmacy benefit managers, which is the third-party group that moves between drugmakers and pharmacies and helps with dispensing drugs. They went after them. They hit PBMs really hard in the government appropriations bill that was passed earlier this year, and so now PBMs are kind of off the target, and I think hospitals may be next. But hospitals are really, really hard to go after. But we’re starting to see a lot more movement in this Congress on hospitals, and so this bill, it’s basically a new reporting requirement. It would require nonprofit hospitals to, yeah, justify their tax-exempt status by giving a lot of data to the government, and so that would be how much charity care they’re providing compared to their financial assistance policy. So, how much did they say they’re going to help people? How much are they actually helping people? Also, their community benefit, and a lot, just a lot more financial data as well. And there’s kind of like a tiered system within the bill, so bigger hospitals that make more money, they would have additional reporting requirements, and that includes on the 340B drug discount program. And so, what are they paying for the drugs? What are they giving them to patients for? That kind of information. Hospitals were very not happy with this. It was advanced out of Ways and Means, but on a partisan basis. So we’ll see if it has any more movement. ��’m doubtful I would make it to a further place on the House floor or something, but you never know. We’ll see. 

Rovner: I know there’s efforts in Senate and the Finance Committee, and in the HELP [Health, Education, Labor, and Pensions] Committee to looking at 340B. Sen. [Bill] Cassidy’s been looking at it too, although you know it’s the fight between two behemoths, the drug industry and the hospital industry, and as long as Congress has been grappling with this, they have not been able to come up with a useful compromise that works for everybody, which is why I think they keep grappling with it. 

Knight: Yeah, Energy and Commerce members just released a new bill this week on it. It’s really seeing a lot more action, and the program really has, the 340B drug discount program has really increased the usage over time if you look at the stats. So it makes sense that maybe Congress will step in, but it’s really difficult to find a solution. Drugmakers and hospitals are both OK with it, and so yeah, it will continue. 

Rovner: As we like to say, the status quo likes to status quo. All right, we’re going to take a quick break. We will be right back.  

So, July 4 marked the one-year anniversary of the signing of that big Republican budget bill, and with that, the one-year ban on Medicaid funding for Planned Parenthood expired. You may or may not recall that in order to get the provision into the budget bill in the first place, past the Senate parliamentarian, the ban had to be only for a single year. That means Planned Parenthood clinics around most of the country can once again bill Medicaid for non-abortion services like birth control and cancer screenings and STI testing. And anti-abortion activists are big mad. Shefali, did Congress not extend the ban because it didn’t want to, or because it couldn’t? And what might this mean for the impending midterms? We haven’t seen a lot of reproductive health in this sort of go-round either. 

Luthra: I mean, I think when we look back to a year ago, there’s a reason that originally abortion opponents wanted this to be a 10-year defunding. That was not possible due to the parliamentarian’s interpretation of what could be kept in the reconciliation bill. So we had this one-year program instead. And even at the time, I talked to abortion opponents, whom I reconnected with again just now, and there was never really a very strong belief that this would be politically viable to renew months before a midterm election, because Republicans have a very slim majority, as we’ve discussed many times on this podcast, and defunding Planned Parenthood is unpopular. KFF has done great polling that shows that this is very unpopular, and so it’s just a very, very big ask to get Republicans, especially those in vulnerable seats, those that went blue in the presidential election, to vote to defund Planned Parenthood once more. I think what is really interesting is you are continuing to see Republicans get a lot of pressure from abortion opponents to take this up again, and so far there hasn’t really been much movement. I think it highlights how difficult it has been for the anti-abortion movement to get really concrete victories in the first two years of a Republican trifecta. This was their biggest win, and it’s over. And they have something to show for it, right? Maybe around two dozen Planned Parenthood clinics shut down between last July and this July. But if that’s the biggest thing you get in the first Republican administration and congressional majorities since the overturn of Roe v. Wade, that’s probably not what they had hoped for, or what they would have expected coming into this. 

Rovner: Yeah, and as we have discussed, anti-abortion activists are also big mad that the Trump administration has not reversed the FDA’s loosening of regulations on the abortion pill mifepristone that allows it to be sold via telehealth over state lines. A new law taking effect in Iowa this week bars Iowa residents from getting medication abortion from Iowa providers via telehealth. But, like other states with even stricter abortion bans, that law doesn’t really touch telehealth providers in other states with shield laws from prescribing and sending those same medications to Iowa residents. That’s what the anti-abortion forces really, really, really want, right? 

Luthra: Yeah, and it’s just, it’s legally very difficult for them to come up with a framework that will prevent that interstate telehealth, unless the federal government intervenes, and since they aren’t getting much movement from the administration, that is why they are putting so much emphasis on federal courts. And we have so many legal challenges to mifepristone in the works. We had one that very briefly interrupted telehealth earlier this year. That case is still ongoing. It’s possible that it yields some sort of policy implications before the midterm elections, though we’ll see. But this is just a very difficult situation to stop interstate telehealth, unless you have someone with authority beyond state governments — and really that is federal courts, and that’s the federal government. 

Roubein: You can imagine this is going to come up when there’s a new Food and Drug Administration commissioner named. This is something that Sen. Josh Hawley, Sen. Bill Cassidy, they will be asking about this and pushing on this because they were very upset with how former FDA Commissioner Marty Makary handled this. 

Rovner: By basically continuing to put it off, although to some extent we don’t know whether that was Makary’s doing or it came from higher up at HHS [Department of Health and Human Services]. ��’m interested, apparently there’s going to be a confirmation hearing for attorney general nominee Todd Blanche next week, and I think some are going to ask him, because one outlet that the anti-abortion movement sees is getting the Justice Department to settle the lawsuit filed in Louisiana, challenging the FDA’s sort of down-regulating, if you will, of mifepristone. So they’re saying that the Justice Department should simply settle that lawsuit. Would that actually overrule FDA? ��’m still a little bit vague on how that might work. 

Luthra: That feels legally tricky, because there are other parties in the suit as well. The manufacturers have stepped in, and so there’s a real possibility that even if the Justice Department moved to settle, I mean, I don’t think we can say that this doesn’t necessarily end the case or end mifepristone’s availability through telehealth. And realistically it just seems that you need something stronger and perhaps through a different avenue. And, again, I think it’s really important for us to underscore that this is all pretty unpopular policy, and the Trump administration knows it is unpopular, and they probably would not want abortion and abortion restrictions to be in the national spotlight heading into a midterm election where they are already looking vulnerable. 

Rovner: Yeah, well, I’ll be interested to watch the attorney general confirmation hearings, which is not something I would normally say. While we’re on the subject of reproductive health, in general, in the fallout from last week’s narrower-than-expected Supreme Court decision upholding birthright citizenship, some Trump officials are now floating the idea of banning noncitizens from visiting the U.S. while pregnant to prevent them from giving birth to U.S. citizens. How would that work? 

Luthra: Just seems kind of difficult to implement, maybe more the kind of thing that you talk about on Fox News than the thing that you actually have a firm policy plan to put in place already. People are not given visas to come here solely for giving birth. Already people largely do not travel very late in pregnancy, because it is not a good idea. I think there’s something to be said for the fact that people will be looking in conservative spaces at ways to try and restrict immigrants from being here, find new pathways to prevent people from giving birth here, especially when they are immigrants. We had a hearing in Texas earlier this week where they were looking at surrogacy, and part of the argument there that conservatives are making is they believe that surrogates in the U.S. are being hired by people abroad to give birth to babies that will have U.S. citizenship. Again, this is all, like, very complicated, but I think what it shows is that the birthright citizenship issue is not going away, and that conservatives are looking for some kind of new strategy to weaken that protection that is very clearly spelled out in the Constitution. And we will see where that takes us. 

Rovner: Yeah, and to be clear, I mean, just like with fraud, there is birth tourism. There are, you know, particularly, I think there’s a lot of people from China going to the Northern Marianas, which is kind of halfway across the Pacific and a U.S. territory, to give birth. I think someone said there were more Chinese residents giving birth in Northern Marianas than there were residents of the Northern Marianas. So, I mean, there are problems, but that’s, as you point out, that’s already illegal. That’s not something that Congress would need to act to make illegal. Birth tourism is not a thing, but if you are born in the United States, then, said the Supreme Court, at least a small majority of the Supreme Court, you are a citizen, at least for now. 

All right. Finally, this week, two interesting stories about artificial intelligence in healthcare. First, Utah is in the midst of a pilot project allowing an AI chatbot to approve some prescription refills. Doctors, including the state’s medical board, are not thrilled with this. They’re worried about liability if something goes wrong, among other things. They’re also worried about a slippery slope. It’s just some relatively safe prescription drugs for now, but soon it will be all prescriptions, then lab tests, then who knows what? On the other hand, the makers of these tools say they’re exactly what’s needed to overcome the shortage of doctors and other health professionals. Let technology take over the routine stuff. Now, call me old-fashioned, but until customer service AI works a lot better than it does now, ��’m not sure ��’m ready for AI to be making my medical decisions, even my routine ones. 

Roubein: I mean, it’s definitely a controversial practice, as we’ve been seeing. I think doctors are sort of grappling with what is going to be the future here. 

Rovner: I mean, some of it can be helpful. We have sort of AI scribes now who can take notes, so that when you’re talking to your doctor, your doctor isn’t staring at a screen the entire time. I think everybody thinks that’s a good thing. But you know, then how accurate are the AI scribes? I know that just in voice transcription, it’s still not 100%. If you get a symptom or a drug wrong, that could be a bigger deal than when you’re doing a podcast transcript. 

Knight: There’s a great plot on The Pitt about this. 

Rovner: That’s right. I forgot. 

Knight: I know it’s super important, though. It was super important for the patient that the transcription was wrong. It was wrong. It said that they had a condition they did not have, so that could be really problematic. 

Luthra: I mean, one thing that I’ve sort of mulled over in other areas, as we see this push toward AI in certain areas, if it continues, is whether eventually we see some kind of divergence. I think there’s an open question, right? Do people actually want more things automated, or do they want more things done by a human? Do we see a world in which people pay a premium for things that are done by people, as opposed to AI, or vice versa? I mean, I think this is all just so early, but there’s a real possibility, at least it seems to me, that we see sort of different tiered offerings based on what’s perceived as better. And that raises questions also of who gets things that are maybe better versus who doesn’t, and what is better? I think there’s just so much that we don’t know, but there’s just a lot for us to sort of observe and interrogate as reporters. 

Rovner: I heard a story yesterday about robots climbing Mount Everest, and my only thought was: Why? It’s one thing if robots are doing things that are helpful, but it’s like, why would you need a robot to climb Mount Everest? Well, speaking of cautionary tales, a story from my ���ϳԹ��� News colleague Darius Tahir details how the launch of a pilot in six states to test an AI-powered prior authorization system for Medicare also hasn’t been smooth. Quoting from the story: “Patients, doctors, and other healthcare professionals who spoke with ���ϳԹ��� News say the effort has created confusion, errors, long wait times, and stress.” The opening anecdote of the story is about a patient who was asked to drive an extra 2½ hours literally just to fill out a piece of paper. Again, the goal here is a valid one. Medicare wants to make sure that frequently abused medical services are really necessary. That protects both patients and the taxpayers who pay the bills for Medicare. But the concern is that maybe these systems aren’t quite ready for prime time. I mean, I feel like that’s sort of the bigger thing here is that we’re launching this stuff before it’s ready, not that we’re wanting to use it. 

Roubein: I thought this was a really interesting story, because this is a program out of the CMS innovation center [Center for Medicare and Medicaid Innovation], which was created by the Affordable Care Act, and the CMS innovation center is wonky; it’s there to test Medicare experiments. You don’t really always hear a lot, just it doesn’t always make like a huge splash about what’s happening. But this one has. You’ve heard talk about this in Congress, and concerns about this, particularly within Washington state. And I thought this was a really good story, saying this happened so quickly, these are actually what’s happening, sort of on the ground, because the theory with these models is, if they work well, they can be expanded, they can become a permanent part of the Medicare program. In theory, these are tests. 

Rovner: Yeah, whenever we talk about the innovation center, I point out it’s just as valid to have tests that don’t work, because then you can see what doesn’t work and try something else. Yeah, and it’s possible that this will straighten itself out at some point. It is off to — as many of these AI tests are — it’s off to a bit of a rocky start. All right, that is this week’s news. Now, we’ll play my “Bill of the Month” interview with Samantha Liss, and then we will come back and do our extra credits.  

I am pleased to welcome back to the podcast my colleague Samantha Liss, who reported and wrote the latest ���ϳԹ��� News “Bill of the Month.” Hi, Sam. 

Samantha Liss: Hi. 

Rovner: So, this month’s patient had the nerve to change Medicare Advantage plans. Those are the private plans that often cover more out-of-pocket costs than regular Medicare, but also limit choices, and as she found out the hard way, sometimes limit needed care. Tell us who she is, the ailment she’d had for two decades that needed treating. 

Liss: Yeah, thanks for having me. So I wrote this month about Margaret Hvatum. She lives outside St. Louis, and she is a part-time computer science professor. And she has a weakened immune system due to a rare condition known as primary immunodeficiency, and essentially it makes it difficult for her body to fight off infections. 

Rovner: So she’d been treating it successfully for a while, right? 

Liss: Yeah, she had. She relied on a drug known as Hizentra. 

Rovner: And Hizentra is what I would call a moderately expensive drug, not one of those that costs hundreds of thousands of dollars a month, which there are some that do, but this one was closer to $8,000 a month. And she had gotten prior authorization to take this drug from her previous Medicare Advantage plan, right? 

Liss: She did. That’s correct. 

Rovner: And it had been serving her well for some time? 

Liss: Yeah, she really liked it. It worked well for her. 

Rovner: And she was running marathons, as I noted. 

Liss: Yes, she … I think running, it’s safe to say running is an obsession for her. She … there’s not many races she hasn’t participated in. In fact, when she was vacationing over the summer, she sent me pictures from a marathon she completed in Norway. So it’s definitely what she loves to do in her spare time. 

Rovner: So a patient with a serious condition being successfully treated, she changes Medicare Advantage plans, and lo and behold, her new plan says, yeah, nope, we’re not going to approve your taking this drug anymore. Now, I thought Medicare Advantage plans had promised last year to stop using so much prior authorization and making patients and their doctors jump through bureaucratic hoops to get needed care. Why did she need to get prior authorization for this drug again? 

Liss: Yeah, that’s a really good question. I thought the same thing. Humana and many other Medicare Advantage plan insurers had made commitments that they were going to ease this burden of requiring prior authorization. And when I asked about Margaret’s case, they said … Humana told me that these commitments are for medical services only and do not apply to prescription medications, which surprised me, actually. 

Rovner: Yeah, it surprised me too. So, Humana, her new plan, denies her the drug, she misses her medication, promptly ends up in the hospital with an infection, which her new insurer declined to pay for, too, right? 

Liss: Right. 

Rovner: So, what ultimately happened with the bills, both for the drug and the resulting hospital stay? 

Liss: Yeah, so Humana reversed their initial denials, and I think, you know, one takeaway for us, for the readers and listeners here, is that patients should appeal prior authorizations because they often get their denials reversed. And, in fact, according to our colleagues at KFF, 81% of Medicare Advantage appeals were partially or fully overturned in 2024. 

Rovner: So is there a takeaway here, besides just making a fuss? I mean, according to your story, Margaret and her husband are considering moving to Norway because he’s a citizen and they can qualify for that country’s national health insurance. That feels a little bit extreme and not possible for many people. 

Liss: It does, doesn’t it? Yeah, you know, it can be an exhausting process, is what experts told me, because prior authorization too often puts the onus on patients and doctors, who also get frustrated, too. But you know, I think the real takeaway is: Appeal. 

Rovner: Don’t take no for a final answer. 

Liss: That’s right. 

Rovner: Samantha Liss, thank you very much. 

Liss: Thank you. 

Rovner: OK, we’re back. It’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will post the links in our show notes on your phone or other mobile device. Shefali, you chose first this week. Why don’t you go first? 

Luthra: Sure. My story is from Stat. It is by Katie Palmer. The headline is “.” And Katie wrote about a secret-shopper study that was published in JAMA, looking at how easy it is to now get GLP-1 drugs and how little oversight there is from doctors. I think this kind of research is so interesting, because anyone who talks to anyone who has gotten GLP-1, or anyone who opens their social media, or sees ads on the internet, has probably figured out that it is very, very easy now to get a GLP-1 drug, even if you don’t medically qualify for them, typically. And that is really complicated, because these drugs have a lot of benefits, including many we don’t know about. However, they are also relatively new. There are a lot of things we don’t know about them still. They probably are not a good fit for everyone, but … 

Rovner: They have a lot of side effects. 

Luthra: Yes, and there’s a lot of societal pressure on people potentially to be a lot thinner in a world where GLP-1s are more ubiquitous. And I think all of that just really deserves interrogation, deserves scrutiny. It is completely changing our culture and our health as a society, and I really appreciate that this story just put some numbers and put some heft toward what people have probably observed. But now we can say, yeah, this is actually a thing and it deserves scrutiny. 

Rovner: Yeah, it definitely does. It was really good study. Victoria. 

Knight: I also have a Stat story for my extra credit. It is called “.” And ��’m always interested in lobbying and just the dynamics of power in Washington, and I thought this is a really good look at the alcohol industry, and how they wield power in Washington, kind of a peek behind the curtain. And it shows, it kind of begins the story with an anecdote about how a former staffer of the American Cancer Society felt bad for telling a reporter or kind of downplaying the risk of alcohol to cancer to a reporter back in the day, and then had to apologize to the reporter. And so it’s showing how lobbyists in the alcohol industry have influenced things like the American Cancer Society or other entities to not fully talk about the risk of alcohol related to cancer, or just generally the health risk of alcohol. So, this did a really good job of connecting the dots of who is connected to who in D.C. in the alcohol industry, and what lobbyist is married to this person, and just really interesting to show how the alcohol lobby is still trying to wield influence at a time when really a lot of Americans are not drinking as much as well. And so they’re trying to hold on to their power. Will that still be successful? I guess we’ll see. But yeah, it was great. 

Rovner: Yeah, it’s part of a series on the dangers of alcohol. It’s really, really interesting. Really well done. Rachel. 

Roubein: My extra credit this week is “” by Christina Jewett of The New York Times. I thought it was an interesting broad, sweeping look at tobacco policy under Trump, particularly looking at some of the cuts last year. And so Christina starts out the story by describing ads that we’ve all seen, I think, are all kind of part of the cultural moment of trying to stamp out tobacco use, such as one with, like, a man with a hole in his throat using a voice box to speak, that were powerful. Christina reports that the CDC’s 14-year ad campaign went dark last year, and that was several moves by the Trump administration. That change unraveled parts of the government’s anti-smoking initiative. She also writes about how the CDC’s Office on Smoking and Health, which managed that campaign and worked with states on smoking cessation measures, has been shut down for more than a year. She said in recent weeks CDC has given states small funding to air ads from the campaign’s archive, but there has been an impact where, in interviews with people who ran quit lines in several states, calls have plummeted, along with enrollment in programs that offered counseling, nicotine, gum, and patches. And some of this comes — as you know, Secretary Robert F. Kennedy Jr. talks about chronic disease a lot, but public health experts that I’ve spoken to in the past have pointed to kind of a contradiction here, where there is not much talk about trying to reduce the rates of smoking, which is a major cause of chronic disease. From the HHS’ response to Christina, they said that the CDC “remains committed to tobacco prevention control and continues to support this priority through outreach, education, and surveillance.” 

Rovner: Yeah, it was a really, really good piece. Well, my extra credit this week is from Tina Reed at Axios, and it’s called “.” It seems that the combination of peptide popularity and cryptocurrency payments are helping Chinese fentanyl manufacturers make more money at less risk from selling those loosely regulated peptides instead. Said one expert quoted in Tina’s story: “They departed from a trade in which they could be sanctioned or indicted by the U.S., and reappeared in a very lucrative scene that has widespread buy-in.” Um, yay, capitalism. Really, really interesting story. 

All right, that is this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had production help this week from Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts — as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X , or on Bluesky . Where are you guys hanging these days? Victoria. 

Knight: ��’m on X. 

Rovner: Shefali. 

Luthra: ��’m @shefali on . 

Rovner: Rachel. 

Roubein: on X; at Bluesky. 

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