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KFF Health News' 'What the Health?': Bird Flu Lands as the Next Public Health Challenge
KFF Health News' 'What the Health?'

Bird Flu Lands as the Next Public Health Challenge

Episode 347

The Host

Julie Rovner
KFF Health News
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.

Public health officials are watching with concern since a strain of bird flu spread to dairy cows in at least nine states, and to at least one dairy worker. But in the wake of covid-19, many farmers are loath to let in health authorities for testing.

Meanwhile, another large health company — the Catholic hospital chain Ascension — has been targeted by a cyberattack, leading to serious problems at some facilities.

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


Rachel Cohrs Zhang
Stat News
Alice Miranda Ollstein

Among the takeaways from this week’s episode:

  • Stumbles in the early response to bird flu bear an uncomfortable resemblance to the early days of covid, including the troubles protecting workers who could be exposed to the disease. Notably, the Department of Agriculture benefited from millions in covid relief funds designed to strengthen disease surveillance.
  • Congress is working to extend coverage of telehealth care; the question is, how to pay for it? Lawmakers appear to have settled on a two-year agreement, though more on the extension — including how much it will cost — remains unknown.
  • Speaking of telehealth, a new report shows about 20% of medication abortions are supervised via telehealth care. State-level restrictions are forcing those in need of abortion care to turn to options farther from home.
  • And new reporting on Medicaid illuminates the number of people falling through the cracks of the government health system for low-income and disabled Americans — including how insurance companies benefit from individuals’ confusion over whether they have Medicaid coverage at all.

Also this week, Rovner interviews Atul Grover of the Association of American Medical Colleges about its recent analysis showing that graduating medical students are avoiding training in states with abortion bans and major restrictions.

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

Julie Rovner: NPR’s “Why Writing by Hand Beats Typing for Thinking and Learning,” by Jonathan Lambert.  

Alice Miranda Ollstein: Time’s “‘I Don’t Have Faith in Doctors Anymore.’ Women Say They Were Pressured Into Long-Term Birth Control,” by Alana Semuels.  

Rachel Cohrs Zhang: Stat’s “After Decades Fighting Big Tobacco, Cliff Douglas Now Leads a Foundation Funded by His Former Adversaries,” by Nicholas Florko.  

Sandhya Raman: The Baltimore Banner’s “People With Severe Mental Illness Are Stuck in Jail. Montgomery County Is the Epicenter of the Problem,” by Ben Conarck.  

Also mentioned on this week’s podcast:

[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 the status quo. Find us at 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, May 16, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go.

We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: And we welcome back to the podcast following her sabbatical, Sandhya Raman of CQ Roll Call.

Sandhya Raman: Hi, everyone.

Rovner: Later in this episode we’ll have my interview with Atul Grover of the Association of American Medical Colleges. He’s the co-author of the analysis we talked about on last week’s episode about how graduating medical students are avoiding applying for residencies in states with abortion bans or severe restrictions. But first this week’s news.

Well, I have been trying to avoid it, but I guess we finally have to talk about bird flu, which I think we really need to start calling “cow flu.” I just hope we don’t have to call it the next pandemic. Seriously, scientists say they’ve never seen the H5N1 virus spread quite like this before, including to at least one farmworker, who luckily had a very mild case. And public health officials are, if not actively freaking out, at least expressing very serious concern.

On the one hand, the federal government is providing livestock farmers tens of thousands of dollars each to beef up their protective measures — yes, I did that on purpose — and test for the avian flu virus in their cows, which seems to be spreading rapidly. On the other hand, many farmers are resisting efforts to allow health officials to test their herds, and this is exactly the kind of thing at the federal level that touches off those intra-agency rivalries between FDA [Food and Drug Administration] and USDA [United States Department of Agriculture] and the CDC [Centers for Disease Control and Prevention].

Is this going to be the first test of how weak our public health sector has become in the wake of covid? And how worried should we be both about the bird flu and about the ability of government to do anything about it? Rachel, you wrote about this this week.

Cohrs Zhang: I did, yes. It is kind of wild to see a lot of these patterns play out yet again, as if we’ve learned nothing. We still have a lot of challenges between coordinating with state and local health officials and federal agencies like CDC. We’re still seeing authorities that are exactly the same between USDA and FDA. USDA actually got $300 million from covid relief bills to try to increase their surveillance for these kind of diseases that spread among animals, but people are worried it could all potentially jump to humans.

So I think there was a lot of hope that maybe we would learn some lessons and learn to respond better, but I think we have seen some hiccups and just these jurisdictional issues that have just continued to happen because Congress didn’t really address some of these larger authorities in any meaningful way.

Rovner: I think the thing that worries me the most is looking at the dairy farmers who don’t want to let inspectors onto their farms. That strikes me as something that could seriously hamper efforts to know how widely and how fast this is spreading.

Cohrs Zhang: It could. And USDA does have more authority than they have had in other foodborne disease outbreaks like E. coli or salmonella to get on these farms, according to the experts that I’ve talked to. But we do see sometimes federal agencies don’t always want to use their full statutory authority because then it creates conflict. And obviously USDA has this dual mission of both ensuring food safety and promoting agriculture. And I think that comes into conflict sometimes and USDA just hasn’t been willing to enforce anything mandatory on farms yet. They’ve been kind of trying to use the carrot instead of the stick approach so far. So we’ll see how that goes and how much information they’re able to obtain with the measures they’ve used so far.

Rovner: Alice, you want to add something.

Ollstein: Yeah, I mean, like Rachel said, it’s sort of Groundhog Day for some of the bigger missteps of covid: inadequate testing, inadequate PPE [personal protective equipment]. But it’s also like a scary repeat of some of the specifics of covid, which really hit agricultural workers really hard. And a lot of that wasn’t known at the time, but we know it now. And a lot of workers in these agricultural, meatpacking, and other sectors, were just really devastated and forced to keep working during the outbreak.

This sector in particular has been resistant to public health enforcement and we’re just seeing that repeat once again with a potentially more deadly virus should it make the jump to humans.

Rovner: Basically, from what they can tell, this virus is in a lot of milk. It seems that pasteurization can kill it, but is this maybe what will get people to stop drinking raw milk, which isn’t that safe anyway? And if you need to know why you shouldn’t drink raw milk, I will link to a highly informative and entertaining story by Rachel’s colleague Nick Florko about how easy it is to buy raw milk and how dangerous it can be. This is one of those things where the public looks at the public health and goes, “Yeah, nah.”

Ollstein: Right, yeah. I think, at least anecdotally, the raw milk seller that Nick bought from indicated that business is good for him, business is booming. A lot of the people that maybe weren’t so concerned about covid aren’t so concerned about bird flu, and I think that will continue to drink that. Again, we haven’t seen a lot of data about how exactly that works with bird flu fragments or virus fragments: whether it’s showing up in raw milk?; what happens when people drink it? There’s so many questions we have right now because I think the FDA has been focused on pasteurized milk because that’s what most people drink. But certainly in terms of concern with transitions into humans, I think that’s an area to watch.

Raman: One of the things that struck me was that one of the benefits from what the USDA and HHS [Department of Health and Human Services] were doing was the benefit for workers to get a swab test and do an interview so they can study more and gauge the situation.

If $75 is enough to incentivize people to take off work, to maybe have to do transportation, to do those other things. And if they’ll be able to get some of the data, just as Rachel was saying, to just kind of continue gauging the situation. So I think that’ll be interesting to see.

Because even with when we had covid, there were so many incentives that we did just for vaccines that we hoped would be successful for different populations and money and prizes and all sorts of things that didn’t necessarily move the needle.

Rovner: Although some did. And nice pun there.

All right, well, moving on to less potentially-end-of-the-world health news, Congress is grappling with whether and how to extend coverage of telehealth and, if so, how to pay for it. Telehealth, of course, was practically the only way to get nonemergency health care throughout most of the pandemic, and both patients and providers got used to it and even, dare I say, came to like it. But as a Politico story succinctly put it this week, telehealth “has the potential to reduce expenses but also lead to more visits, driving up costs.”

Rachel, you’ve been watching this also this week. Where are we on these competing telehealth bills?

Cohrs Zhang: Well, we have some news this morning. The [House Committee on] Energy and Commerce Health Subcommittee is planning to mark up their telehealth bill. And the underlying bill will be a permanent extension of some of these Medicare telehealth flexibilities that matter a lot to seniors. But they’re planning to amend it today, so that they’re proposing a two-year extension, which does fall more in line with what the Ways and Means Committee, which is kind of the counterpart that makes policy on health care, marked up …

Rovner: Yes, they shared jurisdiction over Medicare.

Cohrs Zhang: … unanimously passed. They shared, yes, but it is surprising and remarkable for them to come to an agreement this quickly on a two-year extension. Again, I think industry would’ve loved to see a little bit more certainty on this for what these authorities are going to look like, but I think it is just expensive. Again, when these bills pass out of committee, then we’ll actually get formal cost estimates for them, which will be helpful in informing what our end-of-the-year December package is going to look like on health care. But we are seeing some alignment now in the House on a two-year telehealth extension for some of these very impactful measures for Medicare patients.

Rovner: Congress potentially getting things done months before they actually have to! Dare we hope?

Meanwhile, bridging this week’s topics between telehealth and abortion, which we will get to next, a new report from the family planning group WeCount! finds that not only are medication abortions more than half of all abortions being performed these days, but telehealth medication abortions now make up 20% of all medication abortions.

Some of this increase obviously is the pandemic relaxation of in-person medication abortion rules by the FDA, as well as shield laws that attempt to protect providers in states where abortion is still legal, who prescribe the pills for patients in states where abortion is banned.

Still, I imagine this is making anti-abortion activists really, really frustrated because it is certainly compromising their ability to really stop abortions in these states with bans, right?

Ollstein: Well, I think for a while we’ve seen anti-abortion activists really targeting the two main routes for people who live in states with bans to still have an abortion. One is ordering pills and the other is traveling out of state. And so they are exploring different policies to cut off both. Obviously both are very hard to police, both logistically and legally. There’s been a lot of debate about how this would be enforced. You see Louisiana moving to make abortion pills a controlled substance and police it that way. These pills are used for more than just abortions, so there’s some health care implications to going down that route. They’re used in miscarriage management, they’re used for other things as well in health care. And then of course, the enforcement question. Short of going through everyone’s mail, which has obvious constitutional problems, how would you ever know? These pills are sent to people’s homes in discreet packaging.

What we’ve seen so far with anti-abortion laws and their enforcement is that just the chilling effect alone and the fear is often enough to deter people from using different methods. And so that could be the goal. But actually cutting off people from telehealth abortions that, like you said, like the report said, have become very, very widely used, seems challenging.

Raman: And I would say that that really underscores the importance of the case we’d heard this year from the Supreme Court, and that we will get a decision coming up about the regulation of medication abortions. And how the court lands on that could have a huge impact on the next steps for all of these. So it’s in flux regardless of what’s happening here.

Cohrs Zhang: I want to emphasize, too, that mail-order abortion pills have been sort of held up as this silver bullet for getting around bans. And for a lot of people, that seems to be the case. But I really hear from providers and from patients that this is not a solution for everyone. A lot of people don’t have internet access or don’t know how to navigate different websites to find a reliable source for the pills. Or they’re too scared to do so, scared by the threat of law enforcement or scared that they could purchase some sort of counterfeit that isn’t effective or harms them.

Some people, even when they’re eligible for a medication abortion, prefer surgical or procedural because with a medication you take it and then you have to wait a few weeks to find out if it worked. And so some people would rather go into the clinic, make sure it’s done, have that peace of mind and security.

Also, these pills are delivered to people’s homes. Some people, because of a domestic violence situation or because they’re a minor who’s still at home with their parents, they can’t have anything sent to their homes. There’s a lot of reasons why this isn’t a solution for everyone, that I’ve been hearing about, but it is a solution, it seems, for a lot of people.

Rovner: In other abortion news this week, Democrats in the Missouri state Senate this week broke the record for the longest filibuster in history in an effort to block anti-abortion forces from making it harder for voters to amend the state constitution.

Alice, this feels pretty familiar, like it’s just about what happened in Ohio, right? And I guess the filibuster is over, but so far they’ve managed to be successful. What’s happening in Missouri?

Ollstein: So Missouri Democrats, with their filibuster that lasted for days, managed to stop a vote for now on a measure that would’ve made ballot measures harder to pass, including the abortion rights ballot measure that’s expected this fall. It’s not over yet. They sort of kicked it back to committee, but there’s only basically a day left in the legislature session, and so stay tuned over the next day to see what happens.

But what Democrats are trying to do is prevent what happened in Ohio, which is setting up a summer special election on a provision that would make all ballot measures harder to pass in the future. In Ohio, they did hold that summer vote, and voters defeated it and then went on to pass an abortion rights measure. And so even if Republicans push this through, it can still be scuttled later. But there, Democrats are trying to nip it in the bud to make sure that doesn’t happen in the first place.

Rovner: I thought that was very well explained. Thank you very much.

And speaking of misleading ballot measures, next door in Nebraska — and I did have to look at a map to make sure that Nebraska and Missouri do have a border, they do — anti-abortion forces are pushing a ballot measure they’re advertising as enshrining abortion rights in the state constitution, but which would actually enshrine the state’s current 12-week ban.

We’re seeing more and more of this: anti-abortion forces trying to sort of confuse voters about what it is that they’re voting on.

Raman: I mean, I think that that has been something that we have been seeing a little bit more of this. They’ve been trying different tactics to see — the same metaphor of throwing spaghetti at the wall and seeing what sticks. So with Nebraska right now, the proposal is to ban abortions after the first trimester, except in the trio of cases: medical emergencies, rape, incest.

And so that’s definitely different than a lot of the other ballot measures that we’ve seen in the last few years in that it’s being kind of pitched as a little bit of a middle ground and it has the backing of the different anti-abortion groups. But at the same time, it would allow state legislature to put additional bans on top of that. This is just kind of like the mark in the constitution and it would already keep in place the bans that you have in place.

So it’s a little bit more difficult to comprehend, especially if you’re just kind of walking in and checking a box, since there’s more nuance to it than some of the other measures. And I think that a lot of that is definitely more happening in states like that and others.

Rovner: I feel like we’re learning a lot more about ballot measures and how they work. And while we’re in the Great Plains, there’s a wild story out of South Dakota this week about an actual scam related to signatures on petitions for abortion ballot measures. Somebody tease this one apart.

Ollstein: So in South Dakota, they’ve already submitted signatures to put an abortion rights measure on the November ballot. The state is, as happens in most states, going through those signatures to verify it. What’s different than most states is that the state released the names of some of the people who signed the petition, and that enabled these anti-abortion groups to look up all those people and start calling them, and to try to convince them to withdraw their signatures to deny this from going forward.

What happened is that, in doing so, these groups are accused of misrepresenting themselves and impersonating government officials in the way they said, “Hey, we’re the ballot integrity committee of the something, something, something.” And they said it in a way that made it sound like they were with the secretary of state’s office. So the secretary of state put out a press release condemning this and referring it to law enforcement.

The group has admitted to doing this and said it’s done nothing wrong, that technically it didn’t say anything untrue. Of course there’s lying versus misleading versus this versus that. It’s a bit complicated here.

So regardless, I am skeptical that enough people will bother to go through the process of withdrawing their signature to make a difference. It’s a lot more work to withdraw your signature than to sign in the first place. You have to go in person or mail something in. And so I am curious to see if, one, whether this is illegal, and two, whether it makes a difference on the ground.

Rovner: Well, at some point, I think by the end of the summer we’ll be able to make a comprehensive list of where there are going to be ballot measures and what they’re going to be. In the meantime, we shall keep watching.

Let’s move on to another continuing story: health system cyberhacks. This week’s victim is Ascension, a large Catholic system with hospitals in 19 states. And the hack, to quote the AP, “forced some of its 140 hospitals to divert ambulances, caused patients to postpone medical tests, and blocked online access to patient records.”

You would think in the wake of the Change Healthcare hack, big systems like Ascension would’ve taken steps to lock things down more, or is that just me?

Cohrs Zhang: We’re still using fax machines, Julie. What are your expectations here? So cyberattacks have been a theoretical concern of health systems for a long time. I mean, back in 2019, 2020, Congress was kind of sliding provisions into spending bills to help support health systems in upgrading their systems. But again, we’re just seeing the scale. And I think these stories that came out this week really illustrate the human impact of these cyberattacks. And people are waiting longer in an ambulance to get to the hospital.

I mean, that’s a really serious issue. And I’m hoping that health systems will start taking this seriously. But I think it’s just exposing yet another risk that the failure to upgrade these systems isn’t just an inconvenience for people actually using the system. It isn’t just a disservice to all kind of the power of health care data and patients’ information that they could be leveraging better. But it’s also a real medical concern with these attacks. So I am optimistic. We’ll see. Sometimes it takes these sort of events to force change.

Rovner: Well, just before we started to tape this morning, I saw a story out of Tennessee about one of the hospitals that’s being affected. And apparently it is. I believe the word “chaos” was used in the headline and the lead. I mean, these are really serious things. It’s not just what’s going on in the back room, it’s what’s going on with patient care.

In maybe the most depressing hacking story ever, in Connecticut criminals are hacking and stealing the value of people’s electronic food stamp debit card. The Stamford Advocate wrote about one older couple whose card has been now hacked five times and who are out nearly $1,400 they can’t get back because the state can only reimburse people for two hacks. I remember when electronic funds transfers were going to make our lives so much easier. They do seem to be making lives so much easier for criminals.

Finally this week, more on the mess that is the Medicaid unwinding, from two of my colleagues. One story by Daniel Chang is about how people with disabilities, who shouldn’t really have been impacted by the unwinding anyway, are losing critical home care services in all of the administrative confusion. This seems a lot like the cases of eligible children losing coverage because their parents were deemed to have too-high income, even though children have different eligibility criteria.

I know the Biden administration has been trying to soft-pedal its pushes to some of these states. Rachel, you were talking about the USDA trying not to push too hard, but it does seem like in Medicaid a lot of eligible people are falling between the cracks.

Raman: Yeah, I mean states, as we’ve seen, have been really trying to see how fast that they can go to kind of reverify this huge batch of folks because it will be a cost saver for them to have fewer folks on the rolls. But as you’re saying, that a lot of people are falling through the cracks, especially when it’s unintentionally getting pulled from the program like your colleague’s story. And people with a lot of chronic disabilities already qualify for Medicaid, don’t need to be reverified each time because they’re continually qualified for it. And so there are some cases that have been filed already by the National Health Law Program in Colorado, and [Washington,] D.C., and Texas. And so we’ll kind of see as time goes on, how those go and if there’s any changes made to stop that.

Rovner: Also on the Medicaid beat, my colleague Phil Galewitz has a story that’s kind of the opposite. According to a study in the policy journal Health Affairs, a third of those enrolled in Medicaid in 2022, didn’t even know it. That’s 26 million people. And 3 million people actually thought they were uninsured when they in fact had Medicaid. That not only meant lots of people who didn’t get needed health services because they thought they couldn’t afford them because they thought they didn’t have insurance, but also managed-care companies who got paid for these enrollees who never got any care, and conveniently never bothered to inform them that they were covered. Rachel, you had a comment about this?

Cohrs Zhang: I did, yes. One part I really liked about this story is how Phil highlighted that it’s in insurance companies’ best interests for these people not to know that they can get health care services. Because a lot of Medicaid, they’re getting a payment for each member, capitated payments. And so if people aren’t using it, then the insurance companies are making more money. And so I think there has been some more, I think, political conversation about the incentives that capitated payments create especially in the Medicaid population. And so I think that was certainly just a disservice. I mean, these people have been done a disservice by someone. And I think that it’s a really interesting question of who should have been reaching them. And we’ll just, I guess, never know how much care they could have gotten and how their lives could be different had they known.

Rovner: It’s funny, we’ve known for a long time when they do the uninsured statistics that people don’t always know what kind of insurance they have. And they’ll say when they started asking a follow-up question, the Census Bureau started asking a follow-up question about insurance, suddenly the number of uninsured went down. This is the first time I’ve seen a study like this though, where people actually had insurance but didn’t know it. And it’s really interesting. And you’re right, it has real policy ramifications.

All right, well that’s the news for this week. Before we get to our interview, Sandhya, you’ve been gone for the last couple of months on sabbatical. Tell us what you saw in Europe.

Raman: Yeah, so it’s good to be back. I was gone for six weeks mostly to France, improving my French to see how I could get better at that and hopefully use it in my reporting at some point. It was interesting because I was trying to tune out of the news a little bit and stay away from health care. And of course when you try to do that, it comes right back to you. So I would be in my French class and we’d do a practice, let’s read an article or learn a historical thing, and lo and behold, one of the examples was about abortion politics in France over the years.

It was interesting to have to explain to my classmates, “Yes, I’m very familiar with this topic, and how much do you want me to talk about how this is in my country? But let me make sure I know all of those words.” So it pops up even when you think you’re going to sneak away from it.

Rovner: Yes, and we’re very obviously U.S.-centric here, but when you go to another country you realize none of their health systems work that well either. So the frustration continues everywhere.

All right, that is the news for this week. Now we will play my interview with Atul Grover, then we will come back and do our extra credits.

I am so pleased to welcome to the podcast Dr. Atul Grover, executive director of the Association of American [Medical] Colleges’ Research and Action Institute. I bet you have a very long business card.

And I want to offer him a public apology for not having him on sooner. Atul is the co-author of the report we talked about on last week’s episode on how graduating medical students are less likely to apply for residency in states with abortion bans and restrictions. Welcome at last to “What the Health?”

Grover: Better late than never.

Rovner: So there seems to be some confusion, at least in social media land, about some of the numbers here. Tell us what your analysis found.

Grover: First, Julie, is there ever not confusion in social media land? The numbers basically bear out the same thing that we saw last year — making it a very short but real trend — which is that when we look at where new U.S. medical school graduates are applying for residencies, and they apply to any number of programs, what they’re doing, it appears, is selectively avoiding those states in which abortion is either completely banned or severely restricted. And that’s not just in reproductive health-heavy specialties like OB-GYN, but it seems to be across the board.

Rovner: Now, can you explain why all of the numbers seem to be going down? It’s not that the number of applicants are falling, it’s the number of applications.

Grover: There’s about 20,000 people that graduate from U.S. MD [medical degree] schools every year. There are another 15[,000] to 20,000 applicants for residency positions that are DO [doctor of osteopathic medicine] graduates domestically or international graduates. Could be U.S. citizens or foreign citizens.

But what we’ve tried to do for a number of years is encourage applicants to apply to a fewer number of residency programs because we found that they were out-applying, they were over-applying. Where we did some data analyses a couple of years back on diminishing returns where we said, “Look, once you apply to 15, 20, 30 programs, your likelihood of matching, I know you’re nervous, but the likelihood of matching is not going to go up. You’re going to do fine. You don’t need to apply to 60, 70, 80 programs.”

So the good news is we’re actually seeing those numbers come down by about, for U.S. medical grads, about 7% this year, which is really the first time that I can remember in the last 10 years that this has happened. So that is good news.

Rovner: And that was an explicit goal.

Grover: That was an explicit goal. We want to make this cheaper, easier, and more rational for applicants and for programs, as they have to screen people and figure out who really wants to come to their program.

So overall, we were really pleased to see that the average applicant, as they applied to programs, applied to a few less programs, which meant that in many cases they were maybe not applying to one or two states that the average applicant might’ve applied to last year. So on average, each state saw about a 10% decrease in the number of unique applicants. But that decrease was much higher when we looked at those states that had banned abortion or severely limited it.

Rovner: Eventually, all these residency positions fill though, right, because there are more applicants as you point out, more graduating medical students and incoming graduates from other countries than there are slots. So why should we care, if all of these programs are filling?

Grover: So, I think you should always care about the number of residency spots, and I know you have a long history here, as do I, in that that is the bottleneck where we have to deal with why we have physician shortages, or one of the reasons why across the board we just don’t train enough physicians.

We have increased the number of medical school spots. We have people that are graduating from DO schools, as I said, international graduates. More are applying every year than we have space for. Which means that, yes, right now every spot will fill, because if the alternative for somebody applying is, look, I either won’t get in and actually be able to train in my specialty of choice. Or, I may have to go to my third choice or 10th choice or 50th choice or 100th choice. I’d rather go to someplace than no place at all.

So yes, everything is filling, but our look at the U.S. MD seniors was in part because we believe that they are the most competitive applicants, and in some ways the most desirable applicants. They have a 95% success in the match year after year. And so we thought they would be the most sensitive to look at in terms of, hey, I’ve got a little more choice here. Maybe I won’t apply to that state where I don’t feel like I can practice medicine freely for my patients.

And I think that’s a potential problem for a lot of these states and a lot of these programs is, if the people who might’ve been applying if the laws were different, who happened to be a better match for your program, for your specialty and your community, aren’t choosing to apply there, yes, you can fill it, but maybe not with the ideal candidate. And I think that’s going to affect patients and populations and local communities in the years to come.

Rovner: When we saw the beginning of this trend last year most of the talk was about a potential shortage of OB-GYNs going forward, since physicians often stay in practice where it is that they do their residency. But now, as you mentioned, we’re seeing a decrease in applications and specialties across the board. Why would that be?

Grover: So this is an informed opinion as to why people across specialties are choosing not to apply to residencies in these states. We didn’t ask the specific people who are matching this past year, “Why did you choose to apply or not to apply to this state?”

So what we know, though, from asking questions in other surveys is that about 70% of all health professions and health profession students believe that abortion should be legal at some point during a pregnancy. If you look at some specialties like adolescent medicine, that number goes up to 96%. So No. 1, I think it’s a potential violation of what people believe should be some freedom between doctors and patients as to allowing them to have the full range of reproductive health care.

No. 2, I think the potential penalties and the laws are often viewed as being incredibly punitive and somewhat unclear. And as much as doctors hate getting sued, we really don’t want to be indicted. I know some people are fine getting indicted. We really don’t want to be indicted. And that has implications because if we’re indicted, if we’re convicted of any kind of criminal offense, we could lose our license and not be able to care for patients. And we have a long investment in trying to do so.

The third thing that I think is relevant is certainly some of the specialties we’re looking at are heavily populated by women physicians, so OB-GYN, pediatrics. But again, across the board, it’s 50% women. So I think for the women themselves that happen to be applying, there is this issue of, think about their ages, 26, 27, 28 to the mid-30s, for the most part, and there are outliers on either end. But for the most part, they are of reproductive age, and I think they want to have control over their own lives and their own health care, and make sure that all services are available to them and their families if they need it. And I think even if it’s not relevant to you as an individual, it probably is relevant to your spouse or partner or somebody else in your family. And I think that makes a huge difference when people make these choices.

Rovner: So in the end, assuming these trends continue, I mean there really is concern for what the health professional community will look like in some of these states, right?

Grover: Yeah, and I think one of the things that I tried to look at last year in an editorial for JAMA was trying to overlay the states that have already significant challenges in recruiting and retaining physicians. They tend to be a lot of the heavily rural states, Southern states, parts of the Midwest. You overlay that on a map of the 14 states now that have basically banned abortion, and there’s a pretty close match.

So I think it’s critically important for state, local officials, legislatures, governors to think about their own potential impact of passing these laws on something that they may think is critically important, which is recruiting and retaining health professionals. And as you said, about half of people who train in a state will end up staying there to practice.

And for these pipeline programs, I know places like Mississippi and Alabama will really try and recruit individuals from underserved communities, get them through high school, get them into college, get them to stay in the state for med school, stay in the state for residency. They’re 80% likely to stay in those states. You lose them at any point along the way and they’re a lot less likely to come back.

So without even telling these states, I can’t tell you what’s good for you, but you should at least figure out how to collect the data at a local level to understand the implications of your policies on the health of everybody in a state, not just women of reproductive age.

Rovner: And I assume that we’ll be hearing more about this.

Grover: I would think so, yes.

Rovner: And asking more students about it.

Grover: Yes, we will. And we get to administer something called the Graduation Questionnaire every year for all these MD students. One of the questions we just added, and hopefully we’ll have some data, my colleagues will have that by probably August or so, is asking them specifically: What role did laws around some of these social issues have in your choice of where to do your residency? And again, there is some overlap here of states that have restricted reproductive rights, transgender care, and some other issues that are probably all kind of mixed in.

Rovner: Great. We’ll have you back to talk about it then.

Grover: Great. And I’m happy to come back and talk about market consolidation, about life expectancy, the quality of U.S. health, or anything else you want.

Rovner: Atul Grover, thank you so much.

Grover: Thanks for having me.

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 and in our show notes on your phone or other mobile device.

Sandhya, why don’t you go ahead and go first this week?

Raman: Great. So my story is from Ben Conarck at The Baltimore Banner, and it’s called “People With Severe Mental Illness Are Stuck in Jail. Montgomery County Is the Epicenter of the Problem.”

This is a really sad and impactful story about Montgomery County, Maryland, which is just outside of  D.C., and how they are leading to this problem in this state. And many people are on the wait list for beds and psychiatric facilities, but they’re serving pretty short sentences of 90 days or less, and just a lot of the issues there. And just the problems for criminal defendants waiting in facilities for months on end for treatment.

Rovner: And I would add, because I live there, Montgomery County, Maryland, is one of the wealthiest counties in the country, and it’s kind of embarrassing that there are people who are not where they should be because they don’t have enough beds. Alice.

Ollstein: I have a piece from Time magazine called “‘I Don’t Have Faith in Doctors Anymore.’ Women Say They Were Pressured Into Long-Term Birth Control.” And it’s about something that I’ve been hearing about from providers for a bit now, which is that IUDs are this very effective form of birth control. It’s a device implanted in the uterus, and it was supposed to be this amazing way to help people avoid unwanted pregnancies. But as with many things, it is being used coercively, according to this report.

Because a physician has to implant it and remove it, people say that, one, they were pressured into having one often right after giving birth when they were sort of not in a place to make that kind of big decision. And then people who were given one struggled to have someone remove it when they wanted that done in the future.

And so I think it’s a good reminder that these tools are not inherently good or inherently bad. They can be used unethically or ethically by providers.

Rovner: And all reproductive health care is fraught. Rachel?

Cohrs Zhang: Yes. So Nick has been on quite the tear this week. My colleague Nick Florko at Stat and I wanted to highlight a profile that he wrote. The headline is, “After Decades Fighting Big Tobacco, Cliff Douglas Now Leads a Foundation Funded by His Former Adversaries.”

And I think it just has so much nuance into just a figure who fought Big Tobacco to bring to light what they were doing over decades. And now he’s chosen to take over this organization that had, in the past, been entirely funded by a tobacco company. And so I think it’s this really interesting … what we see all the time in Washington, how people contort themselves to make that transition into the private sector, or what they choose to do with their careers after public service. This is a nontraditional public service, obviously, being an advocate in this way. But I think it will be a really interesting dynamic to watch to see how much he chooses to change the direction of the organization, how long that arrangement lasts, if he chooses to do that.

I learned a lot reading this profile, and I think it’s even more rare to see people sit down for lengthy interviews for an old-fashioned profile. So I really enjoyed the piece.

Rovner: Full disclosure, I’ve known Cliff Douglas since the 1980s when he was just a young advocate starting out on his antismoking career. It really is good piece. I also thought Nick did a really good job.

Well, my story this week is from the NPR Shots blog. It’s by Jonathan Lambert and it’s called “Why Writing by Hand Beats Typing for Thinking and Learning.” And it made me feel much better for often being the only person in a room taking notes by hand in a notebook when everyone else is on their laptop. In fact, I can type as fast as anyone, and I can definitely type faster than I can write in longhand, but I actually find I take better notes if I have to boil down what I’m listening to. And it turns out there’s science that bears that out. Now, if only we could get the schools to go back to teaching cursive, but that’s a whole different issue.

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. And happy birthday today to half of my weekly live audience: Aspen the corgi turns 4 today.

As always, you can email us your comments or questions. We’re at, or you can still find me at X or Twitter, whatever you want to call it, @jrovner. Sandhya, where are you?

Raman: @SandhyaWrites.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Rachel.

Cohrs Zhang: @rachelcohrs.

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


Francis Ying
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Emmarie Huetteman

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