A Colorful Cast Could Lead Key Health Agencies

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.

President-elect Donald Trump has continued naming out-of-the-box choices to lead key federal health agencies. Three of those picks — Marty Makary, who would lead the FDA; Jay Bhattacharya, who would head the National Institutes of Health; and Dave Weldon, chosen to administer the Centers for Disease Control and Prevention — have something notable in common: All have proposed major changes to the organizations they would oversee.

Meanwhile, the Supreme Court heard a case challenging Tennessee’s ban on transgender health care for minors, with the conservative justices seeming likely to support the state’s law.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Joanne Kenen of the Johns Hopkins University’s schools of public health and nursing and Politico, and Shefali Luthra of The 19th.

Panelists

Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen Read Joanne's stories. Shefali Luthra The 19th @shefalil Read Shefali's stories.

Among the takeaways from this week’s episode:

In recent weeks, Trump has named his picks to lead key federal health agencies, including the FDA, NIH, and CDC. His selections suggest big changes could be in store. For instance, Weldon — a former congressman and a practicing physician — has often advocated against scientific consensus, including on vaccines.
The Supreme Court this week heard arguments on Tennessee’s law barring transitional care for transgender minors, and from listening to the conservative majority’s remarks, it seems likely they will uphold the law — with implications for those living in the more than 20 states with similar measures on the books. Plus, in a separate case on vaping, the court sounded sympathetic to the FDA’s decisions to reject applications for flavored e-cigarettes that could put children at risk of addiction.
Meanwhile, the incoming Trump administration is poised to take custody of some health-related lawsuits it could very well drop, as well as some big policies it could end — but it remains to be seen what actions it chooses to take. Medicare drug negotiations, for example, are a Biden administration policy, though Trump and his pick for Health and Human Services secretary, Robert F. Kennedy Jr., have also advocated for cracking down on the drug industry.
In abortion news, a federal appeals court has cleared the way for Idaho to begin to enforce parts of its law making it a crime to help a minor obtain an abortion in another state. And officials in Texas and Georgia throttled state commissions studying maternal mortality after cases showed the states’ abortion bans were responsible for at least some women’s deaths.

Also this week, Rovner interviews KFF Health News’ Bram Sable-Smith, who reported and wrote the latest KFF Health News-Washington Post Well+Being “Bill of the Month” feature, about an emergency room bill for a visit that didn’t make it past the waiting room. If you have an outrageous or inscrutable medical bill you’d like to send us, you can do that here.

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

Julie Rovner: The New Yorker’s “The Texas OB-GYN Exodus,” by Stephania Taladrid.

Shefali Luthra: The Washington Post’s “Post Reports” podcast’s “A Trans Teen Takes Her Case to the Supreme Court,” by Casey Parks, Emma Talkoff, Ariel Plotnick, and Bishop Sand.

Joanne Kenen: ProPublica’s “For Decades, Calls for Reform to Idaho’s Troubled Coroner System Have Gone Unanswered,” by Audrey Dutton.

Sarah Karlin-Smith: Stat’s “What YouTube Health Is Doing To Combat Misinformation and Promote Evidence-Based Content,” by Nicholas St. Fleur.

Also mentioned in this week’s podcast:

KFF Health News’ “What the Health?”: Tennessee Seeks Medicaid Changes,” by Julie Rovner (featuring Marty Makary).
ProPublica’s “A Third Women Died Under Texas’ Abortion Ban. Doctors Are Avoiding D&Cs and Reaching for Riskier Miscarriage Treatments,” by Lizzie Presser and Kavitha Surana.
ProPublica’s “Georgia Dismissed All Members of Maternal Mortality Committee After ProPublica Obtained Internal Details of Two Deaths,” by Amy Yurkanin.
KXAN’s “Texas Maternal Mortality Committee To Skip Over Full Reviews in Years After Abortion Ban,” by Jala Washington.
The American Diabetes Association’s “Statement on Compounded Incretin Products.”

Click to open the transcript Transcript: A Colorful Cast Could Lead Key Health Agencies

[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 Thursday, Dec. 5, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. Today we are joined via video conference by Joanne Kenen of the Johns Hopkins School of Public Health and Politico Magazine.

Joanne Kenen: Hey, everybody.

Rovner: Shefali Luthra of The 19th.

Shefali Luthra: Hello.

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

Sarah Karlin-Smith: Hi, everybody.

Rovner: Later in this episode, we’ll have my “Bill of the Month” interview with my KFF Health News colleague Bram Sable-Smith. This month’s patient never actually saw a doctor and still got a big bill from the hospital ER. But first, this week’s and last week’s (since we were off) news. Since we last talked about the news, President-elect [Donald] Trump has named most of the rest of the people he wants to run the key agencies at HHS [the Department of Health and Human Services], under HHS Secretary-designate Robert F. Kennedy Jr. They include Johns Hopkins surgeon and medical author and provocateur Marty Makary to run the FDA, former Florida congressman and anti-abortion leader Dr. Dave Weldon to run the CDC [Centers for Disease Control and Prevention], author of the let-covid-rip-so-we-get-herd-immunity “[Great] Barrington Declaration” [co-]author and Stanford professor Jay Bhattacharya at NIH [the National Institutes of Health], and Fox News contributor and urgent care medical director Janette Nesheiwat as surgeon general. Is there anything these people have in common other than that they are all good on TV and appear regularly on Fox News?

Karlin-Smith: Well, they’re all, as you alluded to, what people have been calling lately, covid contrarians, who pushed a variety of controversial theories around what we should or shouldn’t have done to prevent people from getting covid or dying from covid. And then, how maybe they had different opinions than probably what turned out to be, what happened in terms of how bad the pandemic was actually going to be as … well, downplayed the severity of it.

Kenen: I think that’s less true of the surgeon general.

Rovner: Joanne?

Kenen: I think that from what I’ve read — I had not heard of the surgeon general nominee before — she seems to have been treating patients. She doesn’t have a completely conventional view of health care, but from the little I’ve read, she seemed to be more hands-on and recognizing …

Rovner: She’s the sister of a former Trump aide and the sister-in-law of another incoming Trump official.

Kenen: She’s connected to Trump World, but she was actually treating patients.

Rovner: Yes. She’s connected to Trump World, and I’m thinking that that seems to be what ties all these people together. They have very different views on a lot of things, but they all seem to be super loyal to Donald Trump. And that seems to be the most important thing in this sort of Cabinet and these sub-Cabinet picks, right?

Kenen: But it does remain to be seen how loyal he is to them. Right? When [Rick] Gates was gone, Trump didn’t try to defend him. We’re seeing that with a defense secretary right now. He’s already interviewing other people. So this dynamic, if we’ve learned one thing in the last — since 2016 — he’s very unpredictable.

Rovner: And loyalty goes one way. You’re right.

Kenen: Some people he’s very loyal to and is bringing back, despite histories and problems, and other people. … We just don’t know how the Senate’s going to react entirely, and we also just really do not know how Trump is going to react. Although these first two nominations that are in trouble, that are not health nominations, I’m not going to predict anything about nominees — or about confirmation, rather.

Rovner: Shefali?

Luthra: I was going to add also, I think one thing that is really illuminating then about how the only commonality amongst these various nominees is their connection to Trump and their regular appearances on Fox News, or what have you, is that’s also why it seems like it’s pretty hard to actually preview what policy will look like, because we have so many people with very different views, some with very little to zero experience running these giant institutions and bureaucracies.

Rovner: Most of them with very little to zero.

Luthra: Exactly. Yeah. And I think we just don’t really know, as a result, what would a Secretary Robert F. Kennedy Jr. actually do on a lot of the issues that come to HHS, a very, very large institution. And how much of those decisions would instead be farmed out to lower-profile appointees and day-to-day staffers who could come from organizations like the Heritage Institute, or places that we know are very influential in Republican politics but don’t get the same attention as the marquee nominees.

Rovner: The Heritage Foundation. But yes, they do have the Project …

Luthra: Oh, excuse me. Yes.

Rovner: … the Project 2025 list of potential appointees. I want to go a little deeper. Sarah, you’re our FDA expert. What are people at FDA saying, thinking, whispering about Marty Makary, who arguably is the most qualified of all of these people that have been nominated to anything at HHS?

Karlin-Smith: Yeah. I think there’s probably, especially in comparison to Robert F. Kennedy, a little bit of a sigh of relief in terms of thinking for the drug industry, which I follow very closely. The phrase I heard that I thought was most helpful is, he’s not going to be as “industry-friendly” as some of the past FDA commissioners. But, he’s not anti-industry in the same way I think people view RFK being — very antagonist to the drug industry. He has a mixed record, I think, in terms of how people view him. He’s very respected for some of the things he’s done in his career: hospital surgery checklists and stuff like that.

It seems like the thing that I think both potentially excited folks and worries folks is he says he’s focused very much on evidence-based medicine and following the science and data. The question is, when you start actually looking into some of his writing and work, he sometimes veers away from truly following the best quality evidence and data when it doesn’t support a position he seems to want to advocate for. So I think that’s the biggest concern is, does he really stick to pushing high-quality science when making health policy at FDA or not?

Rovner: And longtime listeners might remember that he’s actually been a guest on the podcast. We’ll link to that appearance in the show notes. I do want to talk about NIH for a moment. It’s been this big bipartisan darling in Congress for at least 30 years. Joanne, you were around when then-House Speaker Newt Gingrich first proposed doubling its budget. It was ignored during the first Trump administration, at least aside from Dr. Tony Fauci’s leadership on covid. But, it could be facing the biggest changes yet, at least if we’re to believe what some Republicans are saying, not to mention what RFK Jr. is saying, right? This could be a big turning point for the NIH?

Kenen: From what we know. Yes. He is … so am I pronouncing right? Bhattacharya?

Rovner: Yeah.

Kenen: He’s an MD, but his career … he has a medical degree, but his career has mostly been in health economics. He’s not a biomedical scientist. To the best of my knowledge, he’s never run anything all that big, certainly not as big as NIH. His covid-denial stuff. Nobody got it all right. Nobody, right? They called it novel coronavirus for a reason. No one had ever seen it before. But there’s degrees of wrong. And if he was not wrong about everything, he was certainly wrong about things that many people in public health take very strong issue with.

But, he’s not a biomedical scientist. He’s not a lab scientist. He’s not a researcher. He’s not a vaccine developer, which probably was one reason he didn’t get the job. He did get the job. But he isn’t a cancer researcher. He’s not any of those things. He comes from a different world with a pretty hostile view of the NIH, if not necessarily a hostile view of every scientist who works there. … So I think that the degree of change that he would try to implement would be more than the FDA. I think there’d be changes to the FDA, but I think we would recognize the FDA, and I’m not sure how dramatically he wants to change the NIH.

Rovner: One thing we know is that RFK Jr. has said he wants to — I believe that his phrase is “take a pause from studying infectious disease and focus on chronic disease.” That would be obviously a really big change at the NIH, which clearly spends a lot of time, money, and effort doing both. There’s an awful lot of chronic disease research. It’s not like the government is lacking in it, it’s just that we haven’t quite broken the code on a lot of chronic diseases. And there are those who say that NIH is ripe for some overhaul. So, could this end up being a good thing?

Karlin-Smith: I think there’s one important thing to consider here, which is NIH’s function is to do things that corporations are not financially incentivized and motivated to do. And that includes a lot of basic research that then gets applied to a variety of different diseases. And sometimes when you start doing the research, we don’t always have this sense of exactly where it’s going to be applicable to, but it is very important. And I think especially the way the Trump administration is talking with the Department of Government and Efficiency and stuff like that … I think those people seem to get really hyper-focused on this research without understanding that it’s hard to conceptualize the connection that it’s important. And then, in terms of infectious disease, the thing that is worrying to me is that I know there’s probably a lot of RFK statements come from his anti-vaccine stance.

But we also have other products for infectious diseases, like antibiotics. There’s a huge antibiotic-resistance crisis. This has been getting worse, and there hasn’t been a lot of new antibiotic development lately. And part of that is because the drug industry has backed out of that space. They don’t see it as a financially viable part of the market. So that’s an area where we need government more, say, than … obviously we need NIH investing in cancer research, but private industry is also very interested in that, in doing work there. They see that as more financially viable. So I think if they do make choices that switch things up, there could potentially be consequences, that maybe they’re not necessarily thinking about right now.

Rovner: And my favorite example is that the GLP-1 weight loss drugs that we’ll talk about in a little while were developed from a study on Gila monster venom. You can laugh about that stuff, but that was a pretty darn big breakthrough from something that looked absurd when it was first being studied.

Kenen: Right. What Sarah’s saying is the really, really basic science, the cellular, really the starting points, much of which will fail, right? Testing hypotheses, trying things. By definition, some of it’s going to fail. But, drug companies don’t do that. They build on that. They then take this basic science and then try to develop the drugs with varying success, that either work or don’t work, or get approved or don’t, but they don’t do this really primal science. That’s done by government, that’s done with government support. And the NIH also supports basic science in many, many universities and labs around the country. So, yeah. It’s got huge ripple effects.

Rovner: Before we move on to other news, I do want to mention the CDC, because I feel like really people have not. Dave Weldon is kind of a name out of right field for this position, was not one of the people that we were expecting to hear. He is a vaccine skeptic who’s never really been involved in public health. In Congress, he was on the Energy and Commerce health subcommittee, where I covered him, but he spent a lot of his time on anti-abortion causes. What do we think that, that trying to put him at CDC will mean?

Luthra: It’s interesting, because at least from the abortion standpoint, CDC isn’t one of the institutions that people have been really looking at. There was a lot of attention on FDA, on DOJ [the Department of Justice], on CMS [the Centers for Medicare & Medicaid Services] even. But, CDC feels like a wild card. But they are very influential. They help us understand a lot of public health issues. They are really useful in terms of measuring things like prevalence of abortion, the public health implications of certain policies, pregnancy-related mortality, etc. And I think it’s worth keeping an eye on whether the head of CDC, being someone who opposes abortion, whether that shifts the direction in which research could head, or if it doesn’t have an impact either way. But, we could be talking about, for instance, a lot of states are trying to not use their maternal mortality review committees to look at the implications of abortion bans.

Rovner: And we’ll talk about that, too.

Luthra: Exactly. And I mean, I think there’s real questions to be asked about whether we see that direction away from scientific inquiry and public health impact and measurement on a national level as well. And if so, what that would mean.

Rovner: Yeah. Well, there is plenty of other news this week. Besides the incoming Trump administration, the Supreme Court heard two health-related cases this week — the first two of the term that began in October. One was a case challenging a Tennessee law, which is one of many around the country — I believe there’s 24 others — that bans gender-affirming care for minors. Shefali, a story about this is your extra credit this week. Why don’t you tell us about the case and your story?

Luthra: Absolutely. So the case involves this law from Tennessee that bans gender-affirming care for minors. It bans puberty blockers, hormone therapy, surgical treatments, etc. And so, an important context is that it is very, very difficult for minors already to get these kinds of treatments. They usually have a lot of screening. There is a lot of serious conversations amongst families, amongst doctors, figuring out is this the right thing for them? The Tennessee law is a blanket ban. It allows these kinds of treatments for cisgender minors who want to affirm their gender, but it does not allow them for trans minors. An example is if you are a young, cis boy and you are experiencing puberty early, you could take puberty blockers to delay puberty. But you can’t have that if you are young and trans and are trying to delay puberty, so that you have some more time and can eventually age into the correct gender identity for you.

And so this law is one of two dozen around the country. And Tennessee’s law is being challenged in court by some families in Tennessee and also by the federal government. The federal government is arguing that this constitutes sex discrimination, because if you match the gender of the treatment you want, you can get it. But if you don’t, you cannot. And the idea is that this is a sex-based line, and it should be subject to higher scrutiny than it has been. We saw a lot of skepticism from the conservative majority, so it seems pretty likely that Tennessee’s law will stand, although things could change. But that is sort of the consensus right now.

And the extra credit I picked is something that I think is really important. It’s a podcast from The Washington Post, an interview with Casey Parks, who has been covering this case from the perspective of the plaintiffs in Tennessee, these families, and, in particular, these minors who have shown a lot of courage to take this case to court. The headline of the podcast is “A Trans Teen Takes Her Case to the Supreme Court.” And I really like this, because I think it’s so easy for us to look at this in terms of big questions about constitutions, big questions about science and medicine. But, at its core, we are talking about people’s lives and the decisions they make as a family. And I really admire and appreciate journalism that holds those voices at the center, as this Post piece does.

Rovner: Yeah. It’s really good. And just a reminder, we’ll probably see a decision in this case sometime in 2025. The other case that the justices heard this week, where they reportedly seemed more sympathetic to the federal government’s case, concerned vaping and the FDA’s process for approving, or in this case not approving, flavored vapes. Sarah, how big a deal is this case? And what might the outcome mean?

Karlin-Smith: I think the case could potentially be a pretty big deal because it could have ramifications beyond the tobacco space and FDA’s regulation of e-cigarettes and even potentially beyond the FDA, because it centers around — basically the vaping companies are arguing that FDA went against guidance it developed. And FDA disagrees about the interpretation of the guidance but also argues this is non-binding guidance. So it’s there to help companies develop products, but they don’t necessarily have to be held to this. And the concern is, depending on how the court rules around these guidances, that it can make agencies hesitant to issue guidance and do things through guidance.

And that could be pretty problematic in terms of efficiency of government and also really to the supports various parties that work with agencies like FDA need, because actually in a lot of cases, companies that are regulated by FDA like guidance, because it helps them know what they need to shoot for to get a food product, a drug, a medical device, or whatever through the agency. And without that, they might either be stuck with rulemaking, which takes a long time, or just without that advice at all. So I think, particularly also after the Supreme Court’s other rulings last year around Loper Bright [Enterprises v. Raimondo] in deference to agencies and stuff, there’s been a sense that guidance would become more popular. I think it would be concerning if agencies felt hamstrung in terms of issuing guidance.

Rovner: Yeah. I think there’s going to be so much to watch in terms of agencies and regulations and getting rid of regulations and putting out new regulations. And I think this is going to be a big year for people who like to watch the administrative state and what had happened and how it works. One thing that I feel like has not gotten as much attention as it probably deserves, as long as we’re on the subject of lawsuits. With the changing of administrations is how much policy could be shifted just by the incoming Justice Department dropping cases, or defenses of cases, involving some key health issues.

There’s Braidwood, which we have talked about before. That’s the case, challenging the constitutionality of the U.S. Preventive Services Task Force. There’s the abortion pill case in Texas, which is still alive, even though the Supreme Court denied standing to the original plaintiffs. It’s now been basically taken over by three states. There’s the EMTALA cases, the Emergency Medical Treatment and Active Labor Act case, where the Biden administration’s interpretation of the emergency room law requiring abortions in medical emergencies is at odds with some states’ bans. And there are a whole raft of lawsuits challenging Medicare’s drug negotiation structure. Any clue on what happens to any of these? I think it’s safe to assume that the incoming administration will change the administration’s position in some, if not all, of them.

Luthra: I think that’s probably right, that we will not see the Trump administration, for instance, defending the abortion pill or the Biden administration’s interpretation of EMTALA. One thing that I’m keeping an eye out for and have been talking to folks about, is whether we might see different advocacy groups try and step in and take over the suit on their behalf of … for instance, the ACLU has said that’s something that’s very much on the table, at least in the abortion cases. So it very much could try and keep some of these legal challenges alive. With something like EMTALA it might get a little trickier, though. If the Trump administration changes how it interprets the law to not protect abortion, then that case very well could go away. I think there’s a lot of wait-and-see, but this is one of those areas where, even without a new law or massive new policy, the simple change in president could have really meaningful implications for health access.

Rovner: Sarah, what do we think about any of the cases challenging the Medicare drug negotiation? Have we heard anything about the Trump administration and Medicare drug negotiations?

Karlin-Smith: I think that’s one that’s really hard call, because Trump has changed his tune a lot in terms of how he’s thought about going after the drug industry and the prices they charge, and so forth. And again, you have RFK, that I think is particularly sort of anti- what he would describe as the Big Pharma industry, the big companies, not necessarily maybe smaller, biotech players. So I could see them in some ways having some interest in continuing to defend the law. Although does it get challenging because maybe they don’t want to be seen as defending a Biden-Democratic law? There’s also, I think in general, traditional Republicans, if you will, in the U.S. have not opposed the government doing drug price negotiation, like the IRA [Inflation Reduction Act] does. They’ve tended to prefer leaving it to private plans. But, I think Trump and his health picks are a little bit a-traditional in that regard.

Rovner: That’s a very nice phrase. Well, in other news about things that could end up in court, the Biden administration, just before Thanksgiving, left a lovely little gift for the Trump administration: a reinterpretation of Medicare rules that could let the program cover those buzzy and effective weight loss drugs like Wegovy and ZepBound for obesity as well as diabetes. Sarah, why is this a big deal? And what do you think the Trump administration’s going to do after the comment period ends — which of course will be after the Trump administration takes over? We do know that potential incoming CMS Administrator Mehmet Oz has been a paid endorser of these drugs, while his possible boss, RFK Jr., doesn’t like them.

Karlin-Smith: Right. So here again, we have another conflict where Oz has been very public in support of these products, and also to a point where people have raised whether he really has financial conflicts of interest from some of his past work, or sponsorships from Novo Nordisk. And then you have RFK, who basically argues if you need to lose weight, you should diet and exercise and drugs are not the right way to go, and he kind of very critical of the medicines. So again, I think this is a little bit of a toss-up, because traditionally you might expect a Republican administration to be less interested in doing this, particularly given the cost to the government. CMS is estimating, because it would also would impact both Medicare and Medicaid, it would cost about $40 billion over 10 years, which CMS is pointing out: That’s a very small fraction of the trillion-dollar-plus health spending over that time.

Rovner: And it could be less if Medicare negotiates the price. I guess the first one that’s eligible for negotiation is Wegovy?

Karlin-Smith: Right. So in 2027, that drug will be up for price negotiation. It’s unclear. CMS declined to say when they gave that $40 billion number, whether they factored that in or not. So it’s possible that’s there. So it’s going to be interesting, because whether Congress or anybody else wants to challenge this and feel like, you know, CMS is usurping their authority, because for a long time the idea had been you really needed a law to change this. And CMS is reinterpreting it saying, Well, actually, the 2003 law that bars Medicare paying for weight loss drugs isn’t really applicable here, because these are anti-obesity medications. Obesity has, since 2003, the science has evolved. We have a better understanding of all the other bodily functions and disease that obesity can cause and create, and it’s really considered a disease in its own right. This isn’t about cosmetic weight loss drugs, as I think people were thinking about in 2003.

Rovner: In 2003? Right. Also, we didn’t have these drugs in 2003. One of the reasons that that was there in 2003 is that the only weight loss drugs that there were, were mostly proved to be either ineffective or dangerous.

Karlin-Smith: Right. So, yeah. The landscape has changed and actually the drug industry has been pushing this narrative as well. So it’ll be interesting to see how that impacts whether this gets finalized and who challenges it. Again, because I think RFK is particularly … has his antenna set to anything where he feels like there’s undue industry influence here. But I think even a lot of Republicans in Congress have been interested in figuring out how to expand access to these drugs. And in some ways, doing it via rulemaking might be easier for them, because it’s kind of harder for Congress to do something that costs a lot of money. So maybe doing it through the rulemaking process takes a little bit of the burden off of them feeling like they’re the ones adding to the spending.

Kenen: And probably some of them are taking it, right? Or their family members, right? There’s several hundred people in Congress, many of whom probably have diabetes or obesity problems as an illness.

Rovner: Meanwhile, one way that people who don’t have coverage — and most people don’t have coverage for these drugs — one way that people are getting them is by buying lower-cost, compounded versions of them, which are available, because there’s a shortage … and there’s a debate about whether there’s a shortage. But I noted that this week the American Diabetes Association announced new guidance for patients and physicians against the use of compounded forms of these drugs, which are technically unapproved versions, quote, “due to uncertainty about their content safety, quality and effectiveness.” Now, is this going to have any effect, Sarah? I know there’s a continuing legal battle about the continuing availability of these compounded copies. I’m just wondering what the American Diabetes Association, which is pretty influential, what effect they’ll have, particularly on some of the doctors who’ve been prescribing these as a workaround for people who want these drugs but can’t afford the real deal?

Karlin-Smith: I think that’s a tricky question, because you have to weigh the trade-offs, particularly if you’re dealing with somebody who is actually Type 2 diabetic, versus somebody who is obese or trying to prevent the health problem down the road and maybe isn’t actually experienced it. Is it better to have a compounded drug that comes with a little higher safety risk, than maybe a normal FDA-approved drug? Or is it better to just not take the drug altogether, or not be able to afford the drug? And I think that’s the difficult position. I even, actually, reread that ADA statement about four or five times last night, because they sort of come out against it, but not entirely, because I think they understand the complicated dynamics. But, they probably want, maybe they want their position on the record in terms of when FDA or other agencies make policy decisions here moving forward.

Rovner: Well, we will continue to follow this. I want to turn back to abortion. The big news this week was an abortion-trafficking law out of Idaho, which had been stayed by a lower court, but will now be allowed to go into effect, at least in part, thanks to a decision by the 9th Circuit Court of Appeals. Shefali, what would this law do and why is it so important?

Luthra: This law targets minors essentially by going after people who are not parents, who would bring minors out of Idaho to get an abortion, to get one in another state, because Idaho has an abortion ban. And I think something you and I have talked about before, Julie, is this is obviously not the first law that has gone after minors’ ability to travel out of state for abortions. There’s a history of this even before Dobbs. But, it is the first such law to have been passed after Roe was overturned. And it’s really important for a couple of reasons, one of which is that there is a lot of concern from abortion opponents about the ways in which people can continue to access care, even when abortion is banned in their states. And one of those ways is through travel. They are very excited about ways to find ways to curtail travel, to deter people from doing it, to cut off avenues of support.

The other thing that I think is really important for us to keep note is that, when we see restrictions on abortion and we see restrictions on marginalized forms of health care in general, we very often see laws that go after minors first. They see if those will stand muster, if those will be politically viable. And then if they are, they might go bigger and go after people of other ages as well, including general population. And so, it’s worth keeping an eye on what happens with this Idaho law if it can stay in effect. And also if it actually has an impact, if it does deter people from leaving the state for abortions. Because also, it’s tricky to enforce. How do you actually stop someone and figure out that they are in fact traveling out of state for an abortion specifically, as opposed to simply going on a nice road trip? But, what we see from this law could be very helpful in understanding what paths the anti-abortion movement might take in trying to restrict travel.

Rovner: Yeah. Well, meanwhile in Texas — because this is always about Texas, where ProPublica this week chronicled the death of yet another pregnant woman who failed to get standard care for pregnancy complications — the state’s considering joining Louisiana in declaring the abortion pills mifepristone and misoprostol controlled substances. But, as they’ve already discovered in Louisiana, which did this first, these drugs are also used for emergency miscarriage care. And there have been cases where women have basically bled out waiting for the medications in hospitals. At some point, are lawmakers going to start listening to the doctors? Obviously in Texas, this is just a proposed law. It is not a law yet, but the legislature will come back into session in 2025.

Luthra: It’s a good question, because many doctors have been very clear about the harms that various anti-abortion bills and laws have created. And so far the response in states like Texas that have these very restrictive laws, has been to often demonize the doctors and to say they are the ones who don’t understand the laws, that the exceptions to them are quite clear. And that if you’re following the law correctly, there should be no harm to people who are not getting abortions, even though we know in reality this simply isn’t true.

With the Texas bill, in particular, I think it’s still a bit early to see what the state will actually go for. There is a lot of interest in the legislature and in the anti-abortion community in Texas, in trying to get some new restrictions passed this year. But, they aren’t confident about which approach they will take and whether something like this Louisiana bill is actually a model they want to follow. So I think we really all just have to pay a lot of attention to Texas in the coming year, to see what they do next to try and build on their total abortion ban.

Rovner: So while we’re on the subject of ProPublica and women dying from pregnancy complications, in Georgia the public health commissioner fired the entire state maternal mortality committee, after someone shared internal documents with the reporter, detailing the cases of two women whose deaths were determined to be a result of the state’s abortion ban. And in Texas, that state’s maternal mortality committee has decided to just skip reviewing cases from 2022 and 2023, which were the first full years after that state’s ban took effect in September of 2021 — remember, before Roe was overturned. Shefali, you referred to this earlier. Is anybody buying the reasoning that this is because they don’t have enough staff to keep up and it would be better to look at more recent cases?

Luthra: No one seems to really be accepting that reasoning, because it just does not pass any smell test. It is very obvious that you are skipping the two years in which the abortion bans immediately had an effect. There just isn’t really a good explanation, especially when you look in the broader context in which anti-abortion lawmakers around the country, such as in Georgia, are operating. People don’t want to have to engage with the harms that these laws have created. And if you have data, you may have to engage with it. But, if you don’t, you can try and pretend it doesn’t exist. It seems like this is pretty obvious.

Rovner: We should take a step back and explain what these committees do.

Luthra: What they do is they track the cases of maternal mortality, of pregnancy-related death that occur in the state. And they figure out what went wrong and why, because we know that very often when people die because of pregnancy, it is preventable. And so, we have public health committees that are devoted to figuring out what happened, who are the people most affected, because we have very unequal pregnancy-related outcomes in this country. And then they use that to try and figure out better health care systems going forward. What can we change to improve our pregnancy-related outcomes, where we really lag compared to other wealthy countries? And if you skip these years, not only do you ignore, or deny the chance to understand what abortion bans have done, but you also, at large, are compromising this long-term public health effort to improve our outcomes for people who get pregnant in this country.

Rovner: Which is something that both sides of the debate agree on. Joanne, you want to add something?

Kenen: Yeah. I think it’s important to understand, too, that building on what she just said is, we’re looking at maternal mortality, we’re looking at the entire year after birth. We’re not just talking about someone … I didn’t know that a few years ago. I thought it was like things that went wrong around the time of giving birth. It’s a full year. All sorts of things go wrong, including a high homicide rate. Many, many states have actually expanded Medicaid for the postpartum, even states that haven’t taken the ACA [Affordable Care Act] expansion. Something like 40 states. Shefali might know the exact number. I believe it’s 40 states now have expanded Medicaid coverage for the first year of postpartum.

And if you’re doing things to try to save women’s lives — or people’s lives, women, children, families — you should want to know if what you’re doing is working. Right? Are you making gains? Are you doing the right things? There’s some very conservative governors who have embraced this drive to improve maternal mortality, but you can’t do it in the dark. And there are flaws with these things. Some states we’re not looking at all causes. That’s a related, separate story. But, it’s not just the abortion deaths. It’s anything that takes the life that could be preventable. And as we’ve noted … most of it is preventable.

Rovner: All right. Well, that is as much news as we can cover this week. Now, we will play my bill of the month interview with Bram Sable-Smith and then we’ll come back and do our extra credits. I am pleased to welcome back to the podcast my KFF Health News colleague Bram Sable-Smith, who reported and wrote the latest KFF Health News “Bill of the Month.” Bram, welcome back.

Bram Sable-Smith: Thanks for having me again.

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

Sable-Smith: This is one that really hit me as the father of a toddler. Our patient this month is Ryan Wettstein. She was 3 at the time that she went to the emergency room last December in Peoria, Illinois, where she lives. Her mom, Maggi, put her down for sleep last December and she kept crying and crying and crying. And nothing seemed to help. She’d been having some trouble with UTIs and yeast infections when she was going through potty training. So her mom, at 10:30 that night, was like, “Fine. We’ll go to the ER,” and she took her to the ER. They checked in. It wasn’t busy at all. She got a nasal swab test for covid and flu. Then they waited. And while they were waiting there in the waiting room, Maggi saw Ryan playing in the play area and she said, “She seems fine. I’m just going to take her home. No point in sticking around and waiting for a big bill just to see a doctor.”

Rovner: So they leave. You assume, no harm, no foul, and then the bill comes.

Sable-Smith: And then the bill comes. Isn’t that what always happens? So even though they did not see the doctor, even though they did not get past the waiting room, they still got a bill for about $300. And that was for that one nasal swab test for covid and flu. The hospital charged actually $445. Her insurance had negotiated a discount, but because they were still in their deductible, even there at the end of the year, they were on the hook for all of the rest. And that was about $300.

Rovner: And these are the kinds of swabs, kind of tests that you can buy at the drugstore now, right?

Sable-Smith: Yeah. I think you can get an at-home covid and flu test from Walgreens for like $30, or something like that. You can get a little bit of a laboratory test from Walgreens again, still in the $100-$150 range. So this is significantly more than that. And it’s what you expect when you’re getting something done in the ER.

Rovner: So what happened with the bill?

Sable-Smith: Well, she was shocked by it. Maggi, the mom, called it mind-blowing. She said, “We didn’t even get past the waiting room. We didn’t see a doctor. How am I on the hook for $300?” She called the hospital. The representative on the line said, “That does sound high. Let me check this out for you. Don’t pay this.” But then, she got a letter in the mail that said, “Actually, yeah. That’s the right charge and it’s supported by documentation.” She reached out to us, we investigated it, and she was just on the hook for it. So at the end of the day, she’s on the hook for the $300, even though they didn’t leave the waiting room, even though they didn’t see the doctor. And it’s really just these healthy ER mark-ups that are pretty famous for hospitals and their emergency rooms.

Rovner: But, it’s also a triage fee. Right? She didn’t see the doctor, but she did see a health professional, presumably, who did the test and determined that she wasn’t in immediate, crisis danger?

Sable-Smith: She did get triaged. If you look through the medical records, she did get triaged. And the triage showed the symptoms that she had a fever or she had a history of fever at the time. And so, “OK. Let’s give her this nasal swab test.” What she was actually billed for, though, was just that one test. It’s a joint covid-influenza A and B test. So the actual thing that she’s paying for is just that one test. And so, in some ways, you could think actually she got off lucky. “Bill of the Month” has received bills from people who went to the ER, and even though they also left before seeing a doctor, they got charged a facility fee, or they got charged for that ER visit. So Maggi didn’t have to pay for that, just for the test. So, in some ways, this $300 bill was getting off easy.

Rovner: And she did have to pay it, right?

Sable-Smith: And she did have to pay it.

Rovner: So how do you avoid having the same thing happen to you?

Sable-Smith: Well, if you have something like this, going to an urgent care, or primary care doctor, or a pediatrician, you’re going to incur less of a fee. At the time, 10:30 at night, none of the urgent care clinics in their area were open. This was the only facility that she could go to, so her options were limited. But she’s not going to make a habit out of going to the ER again. She’s now going to think twice. It’s like, “Oh, if my daughter needs something, yeah, we’ll go to the urgent care. Yeah, we’ll set up something with the pediatrician.” But she’s not going to make a habit of going back to the ER. And just one more tip for listeners is that, if you are leaving the emergency room, Maggi ended up leaving —there was no one at the desk at the time, so she didn’t say she was leaving. But, if you go to the desk and you report that you’re leaving and say, “Hey, we’re getting out of here. It’s not worth it for us,” there’s a chance you could potentially avoid some fees that way.

Rovner: Bottom line, don’t go to the emergency room unless you really, really have to.

Sable-Smith: Sounds about right.

Rovner: Bram Sable-Smith, thank you so much.

Sable-Smith: Always a pleasure.

Rovner: OK. We are back. Now it’s time for our extra-credit segment. That’s wherer we each recommend a 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. Shefali, you’ve already done yours. Joanne, why don’t you go next?

Kenen: There’s a piece in ProPublica by Audrey Dutton: “For Decades, Calls for Reform to Idaho’s Troubled Coroner System Have Gone Unanswered.” This literally goes back to the 1950s. Idaho has … This is not abortion-related. We were just talking about Idaho in another context. They have a really bad coroner system. They’re undertrained, under-resourced. They have to drive hours to get an autopsy. They don’t have money. And for years and years and years, the state tiptoes up to investing in it and reforming it. And then they actually don’t want to — I think the story used the word, “don’t want to spend money on death.” So in addition to literally making it easier to get away with murder, which is part of the problem, it’s also part of our public health system.

And this particular article looked, in particular, at infant deaths. What was the cause of the infant death? A family needs to know that, both emotionally, and also if there’s something that, if they want to have more children or their risk factors. So the story really focused on what if you can’t get answers about why your baby died? And why it’s taken Idaho 70 years of not fixing this. And, although the article didn’t go into it there, the coroner system is also a sentinel data point for a lot of other — it differs a little bit state to state — but it does help us get some understanding on suicide and drug use and other diseases that crop up. And it’s part of how we learn what our threats and challenges are. And Idaho — it’s a shocking story.

Rovner: Sarah?

Karlin-Smith: I took a look at a Stat Q&A from Nicholas St. Fleur, with Garth Graham, who is YouTube’s global head of health care and public health, which I think is just interesting [“What YouTube Health Is Doing To Combat Misinformation and Promote Evidence-Based Content”]. Just that, that YouTube has somebody in charge of thinking about health care and public health. And it goes through all the different ways YouTube is trying to ensure people are directed to accurate health information and not to misinformation. I’d be interested to see what they do to study how this works. Some of the things I was curious about, one of the things they do is they try and label information when it’s coming from accredited health facilities, or licensed doctors and stuff.

And so that just piqued my interest, because we know that, well, there are oftentimes places we can trust. But, when you, say, put somebody like RFK, who is anti-vaccine, as the HHS secretary, people are worried about that changing communication coming out from the government. And if you automatically put a stamp on the government’s information, because of who that is, how that impacts things. But, I just thought it was a cool Q&A to see YouTube trying to take some responsibility to make sure people are getting directed to accurate information on their website.

Rovner: I thought it was a super interesting interview. My extra credit this week is from The New Yorker. It’s called “The Texas OB-GYN Exodus,” by Stephania Taladrid. And it’s a subject I’ve been all over, which is how abortion bans are driving away doctors who care for pregnant women, which is resulting in pretty much the opposite of what anti-abortion groups say they want. This piece focuses on the Rio Grande Valley, one of the poorest parts of the state, with the least access to health care of all kinds, and how it managed to stand up a program to bring OB-GYNs to the region and to start a training program for residents who were willing to practice there, only to see it all crumble in the face of doctors not being allowed to practice what they consider evidence-based medicine.

The story quotes a report from the consulting firm Manatt Health that found that more than three-quarters of Texas OB-GYNs surveyed in the wake of the state’s abortion ban, quote, “said [that] they could no longer treat patients in accordance with evidence-based medicine. Twenty-one percent said [that] they were either considering leaving the state or already planning to do so; 13% had decided to retire early.” It’s a pretty convincing indictment of what’s going on and well worth your time to read.

OK. That is this week’s 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 again this week to our temporary production team, Taylor Cook and Lonnie Ro, as well as our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me less and less on X, @jrovner, and increasingly at Bluesky @julierovner.bluesky.social. Shefali, where are you hanging these days?

Luthra: I am pretty much off X. But, you can find me on Bluesky at shefali.bluesky.social.

Rovner: Sarah?

Karlin-Smith: I am a little bit on X and at Bluesky — @SarahKarlin or @sarahkarlin-smith.

Rovner: Joanne?

Kenen: I’ve got a Bluesky account, but I think I’m just joannekenen. It might be joannekenen1, I forgot. I do a little bit on Threads, but not too much. There it’s joannekenen1.

Rovner: You could be found somewhere.

Kenen: Right.

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

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<h1>KFF Health News' 'What the Health?': A Colorful Cast Could Lead Key Health Agencies</h1>
<div>		<time class="posted-on" datetime="2024-12-05T14:00:00-08:00">
			December 5, 2024		</time>
		</div>
<h3>		The Host	</h3>															Julie Rovner	KFF Health News						<a href="https://twitter.com/jrovner">				@jrovner			</a>										<a href="https://kffhealthnews.org/news/author/julie-rovner/"> 				Read Julie's stories.			</a>								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.				President-elect Donald Trump has continued naming out-of-the-box choices to lead key federal health agencies. Three of those picks — Marty Makary, who would lead the FDA; Jay Bhattacharya, who would head the National Institutes of Health; and Dave Weldon, chosen to administer the Centers for Disease Control and Prevention — have something notable in common: All have proposed major changes to the organizations they would oversee. Meanwhile, the Supreme Court heard a case challenging Tennessee’s ban on transgender health care for minors, with the conservative justices seeming likely to support the state’s law.This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Joanne Kenen of the Johns Hopkins University’s schools of public health and nursing and Politico, and Shefali Luthra of The 19th.		<h3>		Panelists	</h3>															Sarah Karlin-Smith	Pink Sheet						<a href="https://twitter.com/SarahKarlin">				@SarahKarlin			</a>										<a href="https://pink.pharmaintelligence.informa.com/authors/sarah-karlin"> 				Read Sarah's stories.			</a>																							Joanne Kenen	Johns Hopkins University and Politico						<a href="https://twitter.com/JoanneKenen">				@JoanneKenen			</a>										<a href="https://publichealth.jhu.edu/faculty/4294/joanne-l-kenen"> 				Read Joanne's stories.			</a>																							Shefali Luthra	The 19th						<a href="https://twitter.com/shefalil">				@shefalil			</a>										<a href="https://19thnews.org/author/shefali-luthra/"> 				Read Shefali's stories.			</a>												Among the takeaways from this week’s episode:<ul><li>In recent weeks, Trump has named his picks to lead key federal health agencies, including the FDA, NIH, and CDC. His selections suggest big changes could be in store. For instance, Weldon — a former congressman and a practicing physician — has often advocated against scientific consensus, including on vaccines.</li><li>The Supreme Court this week heard arguments on Tennessee’s law barring transitional care for transgender minors, and from listening to the conservative majority’s remarks, it seems likely they will uphold the law — with implications for those living in the more than 20 states with similar measures on the books. Plus, in a separate case on vaping, the court sounded sympathetic to the FDA’s decisions to reject applications for flavored e-cigarettes that could put children at risk of addiction.</li><li>Meanwhile, the incoming Trump administration is poised to take custody of some health-related lawsuits it could very well drop, as well as some big policies it could end — but it remains to be seen what actions it chooses to take. Medicare drug negotiations, for example, are a Biden administration policy, though Trump and his pick for Health and Human Services secretary, Robert F. Kennedy Jr., have also advocated for cracking down on the drug industry.</li><li>In abortion news, a federal appeals court has cleared the way for Idaho to begin to enforce parts of its law making it a crime to help a minor obtain an abortion in another state. And officials in Texas and Georgia throttled state commissions studying maternal mortality after cases showed the states’ abortion bans were responsible for at least some women’s deaths.</li></ul>Also this week, Rovner interviews KFF Health News’ Bram Sable-Smith, who reported and wrote the latest KFF Health News-Washington Post Well+Being “<a href="https://kffhealthnews.org/news/article/surprise-bill-toddler-445-dollars-swab-covid-test-november-bill-of-the-month/">Bill of the Month</a>” feature, about an emergency room bill for a visit that didn’t make it past the waiting room. If you have an outrageous or inscrutable medical bill you’d like to send us, <a href="https://kffhealthnews.org/send-us-your-medical-bills/">you can do that here</a>.Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too: Julie Rovner: The New Yorker’s “<a href="https://www.newyorker.com/magazine/2024/12/02/the-texas-ob-gyn-exodus?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_Free_112524&utm_campaign=aud-dev&utm_medium=email&utm_term=tny_daily_digest&bxid=5f0f53ad034ed008a84d1a83&cndid=61650171&hasha=a493323304f23a0c4c4f39f3162f5fff&hashb=3e8b3bbbb59f60e56a395fd777bc75059bdcc746&hashc=329fd06ffd8af71d9deb8d385652a6275cd12996c45b58703465eac35abbc1ec&esrc=register-page&mbid=CRMNYR012019">The Texas OB-GYN Exodus</a>,” by Stephania Taladrid.  Shefali Luthra: The Washington Post’s “Post Reports” podcast’s “<a href="https://www.washingtonpost.com/podcasts/post-reports/a-trans-teen-takes-her-case-to-the-supreme-court/">A Trans Teen Takes Her Case to the Supreme Court</a>,” by Casey Parks, Emma Talkoff, Ariel Plotnick, and Bishop Sand.  Joanne Kenen: ProPublica’s “<a href="https://www.propublica.org/article/idaho-coroner-law-failed-reform">For Decades, Calls for Reform to Idaho’s Troubled Coroner System Have Gone Unanswered</a>,” by Audrey Dutton.  Sarah Karlin-Smith: Stat’s “<a href="https://www.statnews.com/2024/11/29/youtube-health-director-garth-graham-on-misinformation-free-speech-trusted-advice/">What YouTube Health Is Doing To Combat Misinformation and Promote Evidence-Based Content</a>,” by Nicholas St. Fleur.  Also mentioned in this week’s podcast:<ul><li>KFF Health News’ “<a href="https://kffhealthnews.org/news/podcast-khn-what-the-health-tennessee-seeks-medicaid-changes-september-19-2019/">What the Health?”: Tennessee Seeks Medicaid Changes</a>,” by Julie Rovner (featuring Marty Makary).</li><li>ProPublica’s “<a href="https://www.propublica.org/article/porsha-ngumezi-miscarriage-death-texas-abortion-ban">A Third Women Died Under Texas’ Abortion Ban. Doctors Are Avoiding D&Cs and Reaching for Riskier Miscarriage Treatments</a>,” by Lizzie Presser and Kavitha Surana.</li><li>ProPublica’s “<a href="https://www.propublica.org/article/georgia-dismisses-maternal-mortality-committee-amber-thurman-candi-miller">Georgia Dismissed All Members of Maternal Mortality Committee After ProPublica Obtained Internal Details of Two Deaths</a>,” by Amy Yurkanin.</li><li>KXAN’s “<a href="https://www.kxan.com/news/texas/texas-maternal-mortality-committee-to-skip-over-full-reviews-in-years-after-abortion-ban/">Texas Maternal Mortality Committee To Skip Over Full Reviews in Years After Abortion Ban</a>,” by Jala Washington.</li><li>The American Diabetes Association’s “<a href="https://diabetes.org/newsroom/press-releases/american-diabetes-association-announces-statement-compounded-incretin">Statement on Compounded Incretin Products</a>.”</li></ul>																	Click to open the transcript																				Transcript: A Colorful Cast Could Lead Key Health Agencies																[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 Thursday, Dec. 5, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. Today we are joined via video conference by Joanne Kenen of the Johns Hopkins School of Public Health and Politico Magazine. Joanne Kenen: Hey, everybody. Rovner: Shefali Luthra of The 19th. Shefali Luthra: Hello. Rovner: And Sarah Karlin-Smith of the Pink Sheet. Sarah Karlin-Smith: Hi, everybody. Rovner: Later in this episode, we’ll have my “Bill of the Month” interview with my KFF Health News colleague Bram Sable-Smith. This month’s patient never actually saw a doctor and still got a big bill from the hospital ER. But first, this week’s and last week’s (since we were off) news. Since we last talked about the news, President-elect [Donald] Trump has named most of the rest of the people he wants to run the key agencies at HHS [the Department of Health and Human Services], under HHS Secretary-designate Robert F. Kennedy Jr. They include Johns Hopkins surgeon and medical author and provocateur Marty Makary to run the FDA, former Florida congressman and anti-abortion leader Dr. Dave Weldon to run the CDC [Centers for Disease Control and Prevention], author of the let-covid-rip-so-we-get-herd-immunity “[Great] Barrington Declaration” [co-]author and Stanford professor Jay Bhattacharya at NIH [the National Institutes of Health], and Fox News contributor and urgent care medical director Janette Nesheiwat as surgeon general. Is there anything these people have in common other than that they are all good on TV and appear regularly on Fox News? Karlin-Smith: Well, they’re all, as you alluded to, what people have been calling lately, covid contrarians, who pushed a variety of controversial theories around what we should or shouldn’t have done to prevent people from getting covid or dying from covid. And then, how maybe they had different opinions than probably what turned out to be, what happened in terms of how bad the pandemic was actually going to be as … well, downplayed the severity of it. Kenen: I think that’s less true of the surgeon general. Rovner: Joanne? Kenen: I think that from what I’ve read — I had not heard of the surgeon general nominee before — she seems to have been treating patients. She doesn’t have a completely conventional view of health care, but from the little I’ve read, she seemed to be more hands-on and recognizing … Rovner: She’s the sister of a former Trump aide and the sister-in-law of another incoming Trump official. Kenen: She’s connected to Trump World, but she was actually treating patients. Rovner: Yes. She’s connected to Trump World, and I’m thinking that that seems to be what ties all these people together. They have very different views on a lot of things, but they all seem to be super loyal to Donald Trump. And that seems to be the most important thing in this sort of Cabinet and these sub-Cabinet picks, right? Kenen: But it does remain to be seen how loyal he is to them. Right? When [Rick] Gates was gone, Trump didn’t try to defend him. We’re seeing that with a defense secretary right now. He’s already interviewing other people. So this dynamic, if we’ve learned one thing in the last — since 2016 — he’s very unpredictable. Rovner: And loyalty goes one way. You’re right. Kenen: Some people he’s very loyal to and is bringing back, despite histories and problems, and other people. … We just don’t know how the Senate’s going to react entirely, and we also just really do not know how Trump is going to react. Although these first two nominations that are in trouble, that are not health nominations, I’m not going to predict anything about nominees — or about confirmation, rather. Rovner: Shefali? Luthra: I was going to add also, I think one thing that is really illuminating then about how the only commonality amongst these various nominees is their connection to Trump and their regular appearances on Fox News, or what have you, is that’s also why it seems like it’s pretty hard to actually preview what policy will look like, because we have so many people with very different views, some with very little to zero experience running these giant institutions and bureaucracies. Rovner: Most of them with very little to zero. Luthra: Exactly. Yeah. And I think we just don’t really know, as a result, what would a Secretary Robert F. Kennedy Jr. actually do on a lot of the issues that come to HHS, a very, very large institution. And how much of those decisions would instead be farmed out to lower-profile appointees and day-to-day staffers who could come from organizations like the Heritage Institute, or places that we know are very influential in Republican politics but don’t get the same attention as the marquee nominees. Rovner: The Heritage Foundation. But yes, they do have the Project … Luthra: Oh, excuse me. Yes. Rovner: … the Project 2025 list of potential appointees. I want to go a little deeper. Sarah, you’re our FDA expert. What are people at FDA saying, thinking, whispering about Marty Makary, who arguably is the most qualified of all of these people that have been nominated to anything at HHS? Karlin-Smith: Yeah. I think there’s probably, especially in comparison to Robert F. Kennedy, a little bit of a sigh of relief in terms of thinking for the drug industry, which I follow very closely. The phrase I heard that I thought was most helpful is, he’s not going to be as “industry-friendly” as some of the past FDA commissioners. But, he’s not anti-industry in the same way I think people view RFK being — very antagonist to the drug industry. He has a mixed record, I think, in terms of how people view him. He’s very respected for some of the things he’s done in his career: hospital surgery checklists and stuff like that. It seems like the thing that I think both potentially excited folks and worries folks is he says he’s focused very much on evidence-based medicine and following the science and data. The question is, when you start actually looking into some of his writing and work, he sometimes veers away from truly following the best quality evidence and data when it doesn’t support a position he seems to want to advocate for. So I think that’s the biggest concern is, does he really stick to pushing high-quality science when making health policy at FDA or not? Rovner: And longtime listeners might remember that he’s actually been a guest on the podcast. We’ll link to that appearance in the show notes. I do want to talk about NIH for a moment. It’s been this big bipartisan darling in Congress for at least 30 years. Joanne, you were around when then-House Speaker Newt Gingrich first proposed doubling its budget. It was ignored during the first Trump administration, at least aside from Dr. Tony Fauci’s leadership on covid. But, it could be facing the biggest changes yet, at least if we’re to believe what some Republicans are saying, not to mention what RFK Jr. is saying, right? This could be a big turning point for the NIH? Kenen: From what we know. Yes. He is … so am I pronouncing right? Bhattacharya? Rovner: Yeah. Kenen: He’s an MD, but his career … he has a medical degree, but his career has mostly been in health economics. He’s not a biomedical scientist. To the best of my knowledge, he’s never run anything all that big, certainly not as big as NIH. His covid-denial stuff. Nobody got it all right. Nobody, right? They called it novel coronavirus for a reason. No one had ever seen it before. But there’s degrees of wrong. And if he was not wrong about everything, he was certainly wrong about things that many people in public health take very strong issue with. But, he’s not a biomedical scientist. He’s not a lab scientist. He’s not a researcher. He’s not a vaccine developer, which probably was one reason he didn’t get the job. He did get the job. But he isn’t a cancer researcher. He’s not any of those things. He comes from a different world with a pretty hostile view of the NIH, if not necessarily a hostile view of every scientist who works there. … So I think that the degree of change that he would try to implement would be more than the FDA. I think there’d be changes to the FDA, but I think we would recognize the FDA, and I’m not sure how dramatically he wants to change the NIH. Rovner: One thing we know is that RFK Jr. has said he wants to — I believe that his phrase is “take a pause from studying infectious disease and focus on chronic disease.” That would be obviously a really big change at the NIH, which clearly spends a lot of time, money, and effort doing both. There’s an awful lot of chronic disease research. It’s not like the government is lacking in it, it’s just that we haven’t quite broken the code on a lot of chronic diseases. And there are those who say that NIH is ripe for some overhaul. So, could this end up being a good thing? Karlin-Smith: I think there’s one important thing to consider here, which is NIH’s function is to do things that corporations are not financially incentivized and motivated to do. And that includes a lot of basic research that then gets applied to a variety of different diseases. And sometimes when you start doing the research, we don’t always have this sense of exactly where it’s going to be applicable to, but it is very important. And I think especially the way the Trump administration is talking with the Department of Government and Efficiency and stuff like that … I think those people seem to get really hyper-focused on this research without understanding that it’s hard to conceptualize the connection that it’s important. And then, in terms of infectious disease, the thing that is worrying to me is that I know there’s probably a lot of RFK statements come from his anti-vaccine stance. But we also have other products for infectious diseases, like antibiotics. There’s a huge antibiotic-resistance crisis. This has been getting worse, and there hasn’t been a lot of new antibiotic development lately. And part of that is because the drug industry has backed out of that space. They don’t see it as a financially viable part of the market. So that’s an area where we need government more, say, than … obviously we need NIH investing in cancer research, but private industry is also very interested in that, in doing work there. They see that as more financially viable. So I think if they do make choices that switch things up, there could potentially be consequences, that maybe they’re not necessarily thinking about right now. Rovner: And my favorite example is that the GLP-1 weight loss drugs that we’ll talk about in a little while were developed from a study on Gila monster venom. You can laugh about that stuff, but that was a pretty darn big breakthrough from something that looked absurd when it was first being studied. Kenen: Right. What Sarah’s saying is the really, really basic science, the cellular, really the starting points, much of which will fail, right? Testing hypotheses, trying things. By definition, some of it’s going to fail. But, drug companies don’t do that. They build on that. They then take this basic science and then try to develop the drugs with varying success, that either work or don’t work, or get approved or don’t, but they don’t do this really primal science. That’s done by government, that’s done with government support. And the NIH also supports basic science in many, many universities and labs around the country. So, yeah. It’s got huge ripple effects. Rovner: Before we move on to other news, I do want to mention the CDC, because I feel like really people have not. Dave Weldon is kind of a name out of right field for this position, was not one of the people that we were expecting to hear. He is a vaccine skeptic who’s never really been involved in public health. In Congress, he was on the Energy and Commerce health subcommittee, where I covered him, but he spent a lot of his time on anti-abortion causes. What do we think that, that trying to put him at CDC will mean? Luthra: It’s interesting, because at least from the abortion standpoint, CDC isn’t one of the institutions that people have been really looking at. There was a lot of attention on FDA, on DOJ [the Department of Justice], on CMS [the Centers for Medicare & Medicaid Services] even. But, CDC feels like a wild card. But they are very influential. They help us understand a lot of public health issues. They are really useful in terms of measuring things like prevalence of abortion, the public health implications of certain policies, pregnancy-related mortality, etc. And I think it’s worth keeping an eye on whether the head of CDC, being someone who opposes abortion, whether that shifts the direction in which research could head, or if it doesn’t have an impact either way. But, we could be talking about, for instance, a lot of states are trying to not use their maternal mortality review committees to look at the implications of abortion bans. Rovner: And we’ll talk about that, too. Luthra: Exactly. And I mean, I think there’s real questions to be asked about whether we see that direction away from scientific inquiry and public health impact and measurement on a national level as well. And if so, what that would mean. Rovner: Yeah. Well, there is plenty of other news this week. Besides the incoming Trump administration, the Supreme Court heard two health-related cases this week — the first two of the term that began in October. One was a case challenging a Tennessee law, which is one of many around the country — I believe there’s 24 others — that bans gender-affirming care for minors. Shefali, a story about this is your extra credit this week. Why don’t you tell us about the case and your story? Luthra: Absolutely. So the case involves this law from Tennessee that bans gender-affirming care for minors. It bans puberty blockers, hormone therapy, surgical treatments, etc. And so, an important context is that it is very, very difficult for minors already to get these kinds of treatments. They usually have a lot of screening. There is a lot of serious conversations amongst families, amongst doctors, figuring out is this the right thing for them? The Tennessee law is a blanket ban. It allows these kinds of treatments for cisgender minors who want to affirm their gender, but it does not allow them for trans minors. An example is if you are a young, cis boy and you are experiencing puberty early, you could take puberty blockers to delay puberty. But you can’t have that if you are young and trans and are trying to delay puberty, so that you have some more time and can eventually age into the correct gender identity for you. And so this law is one of two dozen around the country. And Tennessee’s law is being challenged in court by some families in Tennessee and also by the federal government. The federal government is arguing that this constitutes sex discrimination, because if you match the gender of the treatment you want, you can get it. But if you don’t, you cannot. And the idea is that this is a sex-based line, and it should be subject to higher scrutiny than it has been. We saw a lot of skepticism from the conservative majority, so it seems pretty likely that Tennessee’s law will stand, although things could change. But that is sort of the consensus right now. And the extra credit I picked is something that I think is really important. It’s a podcast from The Washington Post, an interview with Casey Parks, who has been covering this case from the perspective of the plaintiffs in Tennessee, these families, and, in particular, these minors who have shown a lot of courage to take this case to court. The headline of the podcast is “<a href="https://www.washingtonpost.com/podcasts/post-reports/a-trans-teen-takes-her-case-to-the-supreme-court/">A Trans Teen Takes Her Case to the Supreme Court</a>.” And I really like this, because I think it’s so easy for us to look at this in terms of big questions about constitutions, big questions about science and medicine. But, at its core, we are talking about people’s lives and the decisions they make as a family. And I really admire and appreciate journalism that holds those voices at the center, as this Post piece does. Rovner: Yeah. It’s really good. And just a reminder, we’ll probably see a decision in this case sometime in 2025. The other case that the justices heard this week, where they reportedly seemed more sympathetic to the federal government’s case, concerned vaping and the FDA’s process for approving, or in this case not approving, flavored vapes. Sarah, how big a deal is this case? And what might the outcome mean? Karlin-Smith: I think the case could potentially be a pretty big deal because it could have ramifications beyond the tobacco space and FDA’s regulation of e-cigarettes and even potentially beyond the FDA, because it centers around — basically the vaping companies are arguing that FDA went against guidance it developed. And FDA disagrees about the interpretation of the guidance but also argues this is non-binding guidance. So it’s there to help companies develop products, but they don’t necessarily have to be held to this. And the concern is, depending on how the court rules around these guidances, that it can make agencies hesitant to issue guidance and do things through guidance. And that could be pretty problematic in terms of efficiency of government and also really to the supports various parties that work with agencies like FDA need, because actually in a lot of cases, companies that are regulated by FDA like guidance, because it helps them know what they need to shoot for to get a food product, a drug, a medical device, or whatever through the agency. And without that, they might either be stuck with rulemaking, which takes a long time, or just without that advice at all. So I think, particularly also after the Supreme Court’s other rulings last year around Loper Bright [Enterprises v. Raimondo] in deference to agencies and stuff, there’s been a sense that guidance would become more popular. I think it would be concerning if agencies felt hamstrung in terms of issuing guidance. Rovner: Yeah. I think there’s going to be so much to watch in terms of agencies and regulations and getting rid of regulations and putting out new regulations. And I think this is going to be a big year for people who like to watch the administrative state and what had happened and how it works. One thing that I feel like has not gotten as much attention as it probably deserves, as long as we’re on the subject of lawsuits. With the changing of administrations is how much policy could be shifted just by the incoming Justice Department dropping cases, or defenses of cases, involving some key health issues. There’s Braidwood, which we have talked about before. That’s the case, challenging the constitutionality of the U.S. Preventive Services Task Force. There’s the abortion pill case in Texas, which is still alive, even though the Supreme Court denied standing to the original plaintiffs. It’s now been basically taken over by three states. There’s the EMTALA cases, the Emergency Medical Treatment and Active Labor Act case, where the Biden administration’s interpretation of the emergency room law requiring abortions in medical emergencies is at odds with some states’ bans. And there are a whole raft of lawsuits challenging Medicare’s drug negotiation structure. Any clue on what happens to any of these? I think it’s safe to assume that the incoming administration will change the administration’s position in some, if not all, of them. Luthra: I think that’s probably right, that we will not see the Trump administration, for instance, defending the abortion pill or the Biden administration’s interpretation of EMTALA. One thing that I’m keeping an eye out for and have been talking to folks about, is whether we might see different advocacy groups try and step in and take over the suit on their behalf of … for instance, the ACLU has said that’s something that’s very much on the table, at least in the abortion cases. So it very much could try and keep some of these legal challenges alive. With something like EMTALA it might get a little trickier, though. If the Trump administration changes how it interprets the law to not protect abortion, then that case very well could go away. I think there’s a lot of wait-and-see, but this is one of those areas where, even without a new law or massive new policy, the simple change in president could have really meaningful implications for health access. Rovner: Sarah, what do we think about any of the cases challenging the Medicare drug negotiation? Have we heard anything about the Trump administration and Medicare drug negotiations? Karlin-Smith: I think that’s one that’s really hard call, because Trump has changed his tune a lot in terms of how he’s thought about going after the drug industry and the prices they charge, and so forth. And again, you have RFK, that I think is particularly sort of anti- what he would describe as the Big Pharma industry, the big companies, not necessarily maybe smaller, biotech players. So I could see them in some ways having some interest in continuing to defend the law. Although does it get challenging because maybe they don’t want to be seen as defending a Biden-Democratic law? There’s also, I think in general, traditional Republicans, if you will, in the U.S. have not opposed the government doing drug price negotiation, like the IRA [Inflation Reduction Act] does. They’ve tended to prefer leaving it to private plans. But, I think Trump and his health picks are a little bit a-traditional in that regard. Rovner: That’s a very nice phrase. Well, in other news about things that could end up in court, the Biden administration, just before Thanksgiving, left a lovely little gift for the Trump administration: a reinterpretation of Medicare rules that could let the program cover those buzzy and effective weight loss drugs like Wegovy and ZepBound for obesity as well as diabetes. Sarah, why is this a big deal? And what do you think the Trump administration’s going to do after the comment period ends — which of course will be after the Trump administration takes over? We do know that potential incoming CMS Administrator Mehmet Oz has been a paid endorser of these drugs, while his possible boss, RFK Jr., doesn’t like them. Karlin-Smith: Right. So here again, we have another conflict where Oz has been very public in support of these products, and also to a point where people have raised whether he really has financial conflicts of interest from some of his past work, or sponsorships from Novo Nordisk. And then you have RFK, who basically argues if you need to lose weight, you should diet and exercise and drugs are not the right way to go, and he kind of very critical of the medicines. So again, I think this is a little bit of a toss-up, because traditionally you might expect a Republican administration to be less interested in doing this, particularly given the cost to the government. CMS is estimating, because it would also would impact both Medicare and Medicaid, it would cost about $40 billion over 10 years, which CMS is pointing out: That’s a very small fraction of the trillion-dollar-plus health spending over that time. Rovner: And it could be less if Medicare negotiates the price. I guess the first one that’s eligible for negotiation is Wegovy? Karlin-Smith: Right. So in 2027, that drug will be up for price negotiation. It’s unclear. CMS declined to say when they gave that $40 billion number, whether they factored that in or not. So it’s possible that’s there. So it’s going to be interesting, because whether Congress or anybody else wants to challenge this and feel like, you know, CMS is usurping their authority, because for a long time the idea had been you really needed a law to change this. And CMS is reinterpreting it saying, Well, actually, the 2003 law that bars Medicare paying for weight loss drugs isn’t really applicable here, because these are anti-obesity medications. Obesity has, since 2003, the science has evolved. We have a better understanding of all the other bodily functions and disease that obesity can cause and create, and it’s really considered a disease in its own right. This isn’t about cosmetic weight loss drugs, as I think people were thinking about in 2003. Rovner: In 2003? Right. Also, we didn’t have these drugs in 2003. One of the reasons that that was there in 2003 is that the only weight loss drugs that there were, were mostly proved to be either ineffective or dangerous. Karlin-Smith: Right. So, yeah. The landscape has changed and actually the drug industry has been pushing this narrative as well. So it’ll be interesting to see how that impacts whether this gets finalized and who challenges it. Again, because I think RFK is particularly … has his antenna set to anything where he feels like there’s undue industry influence here. But I think even a lot of Republicans in Congress have been interested in figuring out how to expand access to these drugs. And in some ways, doing it via rulemaking might be easier for them, because it’s kind of harder for Congress to do something that costs a lot of money. So maybe doing it through the rulemaking process takes a little bit of the burden off of them feeling like they’re the ones adding to the spending. Kenen: And probably some of them are taking it, right? Or their family members, right? There’s several hundred people in Congress, many of whom probably have diabetes or obesity problems as an illness. Rovner: Meanwhile, one way that people who don’t have coverage — and most people don’t have coverage for these drugs — one way that people are getting them is by buying lower-cost, compounded versions of them, which are available, because there’s a shortage … and there’s a debate about whether there’s a shortage. But I noted that this week the American Diabetes Association announced new guidance for patients and physicians against the use of compounded forms of these drugs, which are technically unapproved versions, quote, “due to uncertainty about their content safety, quality and effectiveness.” Now, is this going to have any effect, Sarah? I know there’s a continuing legal battle about the continuing availability of these compounded copies. I’m just wondering what the American Diabetes Association, which is pretty influential, what effect they’ll have, particularly on some of the doctors who’ve been prescribing these as a workaround for people who want these drugs but can’t afford the real deal? Karlin-Smith: I think that’s a tricky question, because you have to weigh the trade-offs, particularly if you’re dealing with somebody who is actually Type 2 diabetic, versus somebody who is obese or trying to prevent the health problem down the road and maybe isn’t actually experienced it. Is it better to have a compounded drug that comes with a little higher safety risk, than maybe a normal FDA-approved drug? Or is it better to just not take the drug altogether, or not be able to afford the drug? And I think that’s the difficult position. I even, actually, reread that ADA statement about four or five times last night, because they sort of come out against it, but not entirely, because I think they understand the complicated dynamics. But, they probably want, maybe they want their position on the record in terms of when FDA or other agencies make policy decisions here moving forward. Rovner: Well, we will continue to follow this. I want to turn back to abortion. The big news this week was an abortion-trafficking law out of Idaho, which had been stayed by a lower court, but will now be allowed to go into effect, at least in part, thanks to a decision by the 9th Circuit Court of Appeals. Shefali, what would this law do and why is it so important? Luthra: This law targets minors essentially by going after people who are not parents, who would bring minors out of Idaho to get an abortion, to get one in another state, because Idaho has an abortion ban. And I think something you and I have talked about before, Julie, is this is obviously not the first law that has gone after minors’ ability to travel out of state for abortions. There’s a history of this even before Dobbs. But, it is the first such law to have been passed after Roe was overturned. And it’s really important for a couple of reasons, one of which is that there is a lot of concern from abortion opponents about the ways in which people can continue to access care, even when abortion is banned in their states. And one of those ways is through travel. They are very excited about ways to find ways to curtail travel, to deter people from doing it, to cut off avenues of support. The other thing that I think is really important for us to keep note is that, when we see restrictions on abortion and we see restrictions on marginalized forms of health care in general, we very often see laws that go after minors first. They see if those will stand muster, if those will be politically viable. And then if they are, they might go bigger and go after people of other ages as well, including general population. And so, it’s worth keeping an eye on what happens with this Idaho law if it can stay in effect. And also if it actually has an impact, if it does deter people from leaving the state for abortions. Because also, it’s tricky to enforce. How do you actually stop someone and figure out that they are in fact traveling out of state for an abortion specifically, as opposed to simply going on a nice road trip? But, what we see from this law could be very helpful in understanding what paths the anti-abortion movement might take in trying to restrict travel. Rovner: Yeah. Well, meanwhile in Texas — because this is always about Texas, where ProPublica this week chronicled the death of yet another pregnant woman who failed to get standard care for pregnancy complications — the state’s considering joining Louisiana in declaring the abortion pills mifepristone and misoprostol controlled substances. But, as they’ve already discovered in Louisiana, which did this first, these drugs are also used for emergency miscarriage care. And there have been cases where women have basically bled out waiting for the medications in hospitals. At some point, are lawmakers going to start listening to the doctors? Obviously in Texas, this is just a proposed law. It is not a law yet, but the legislature will come back into session in 2025. Luthra: It’s a good question, because many doctors have been very clear about the harms that various anti-abortion bills and laws have created. And so far the response in states like Texas that have these very restrictive laws, has been to often demonize the doctors and to say they are the ones who don’t understand the laws, that the exceptions to them are quite clear. And that if you’re following the law correctly, there should be no harm to people who are not getting abortions, even though we know in reality this simply isn’t true. With the Texas bill, in particular, I think it’s still a bit early to see what the state will actually go for. There is a lot of interest in the legislature and in the anti-abortion community in Texas, in trying to get some new restrictions passed this year. But, they aren’t confident about which approach they will take and whether something like this Louisiana bill is actually a model they want to follow. So I think we really all just have to pay a lot of attention to Texas in the coming year, to see what they do next to try and build on their total abortion ban. Rovner: So while we’re on the subject of ProPublica and women dying from pregnancy complications, in Georgia the public health commissioner fired the entire state maternal mortality committee, after someone shared internal documents with the reporter, detailing the cases of two women whose deaths were determined to be a result of the state’s abortion ban. And in Texas, that state’s maternal mortality committee has decided to just skip reviewing cases from 2022 and 2023, which were the first full years after that state’s ban took effect in September of 2021 — remember, before Roe was overturned. Shefali, you referred to this earlier. Is anybody buying the reasoning that this is because they don’t have enough staff to keep up and it would be better to look at more recent cases? Luthra: No one seems to really be accepting that reasoning, because it just does not pass any smell test. It is very obvious that you are skipping the two years in which the abortion bans immediately had an effect. There just isn’t really a good explanation, especially when you look in the broader context in which anti-abortion lawmakers around the country, such as in Georgia, are operating. People don’t want to have to engage with the harms that these laws have created. And if you have data, you may have to engage with it. But, if you don’t, you can try and pretend it doesn’t exist. It seems like this is pretty obvious. Rovner: We should take a step back and explain what these committees do. Luthra: What they do is they track the cases of maternal mortality, of pregnancy-related death that occur in the state. And they figure out what went wrong and why, because we know that very often when people die because of pregnancy, it is preventable. And so, we have public health committees that are devoted to figuring out what happened, who are the people most affected, because we have very unequal pregnancy-related outcomes in this country. And then they use that to try and figure out better health care systems going forward. What can we change to improve our pregnancy-related outcomes, where we really lag compared to other wealthy countries? And if you skip these years, not only do you ignore, or deny the chance to understand what abortion bans have done, but you also, at large, are compromising this long-term public health effort to improve our outcomes for people who get pregnant in this country. Rovner: Which is something that both sides of the debate agree on. Joanne, you want to add something? Kenen: Yeah. I think it’s important to understand, too, that building on what she just said is, we’re looking at maternal mortality, we’re looking at the entire year after birth. We’re not just talking about someone … I didn’t know that a few years ago. I thought it was like things that went wrong around the time of giving birth. It’s a full year. All sorts of things go wrong, including a high homicide rate. Many, many states have actually expanded Medicaid for the postpartum, even states that haven’t taken the ACA [Affordable Care Act] expansion. Something like 40 states. Shefali might know the exact number. I believe it’s 40 states now have expanded Medicaid coverage for the first year of postpartum. And if you’re doing things to try to save women’s lives — or people’s lives, women, children, families — you should want to know if what you’re doing is working. Right? Are you making gains? Are you doing the right things? There’s some very conservative governors who have embraced this drive to improve maternal mortality, but you can’t do it in the dark. And there are flaws with these things. Some states we’re not looking at all causes. That’s a related, separate story. But, it’s not just the abortion deaths. It’s anything that takes the life that could be preventable. And as we’ve noted … most of it is preventable. Rovner: All right. Well, that is as much news as we can cover this week. Now, we will play my bill of the month interview with Bram Sable-Smith and then we’ll come back and do our extra credits. I am pleased to welcome back to the podcast my KFF Health News colleague Bram Sable-Smith, who reported and wrote the latest KFF Health News “Bill of the Month.” Bram, welcome back. Bram Sable-Smith: Thanks for having me again. Rovner: So tell us about this month’s patient, who she is, what kind of medical care she needed. Sable-Smith: This is one that really hit me as the father of a toddler. Our patient this month is Ryan Wettstein. She was 3 at the time that she went to the emergency room last December in Peoria, Illinois, where she lives. Her mom, Maggi, put her down for sleep last December and she kept crying and crying and crying. And nothing seemed to help. She’d been having some trouble with UTIs and yeast infections when she was going through potty training. So her mom, at 10:30 that night, was like, “Fine. We’ll go to the ER,” and she took her to the ER. They checked in. It wasn’t busy at all. She got a nasal swab test for covid and flu. Then they waited. And while they were waiting there in the waiting room, Maggi saw Ryan playing in the play area and she said, “She seems fine. I’m just going to take her home. No point in sticking around and waiting for a big bill just to see a doctor.” Rovner: So they leave. You assume, no harm, no foul, and then the bill comes. Sable-Smith: And then the bill comes. Isn’t that what always happens? So even though they did not see the doctor, even though they did not get past the waiting room, they still got a bill for about $300. And that was for that one nasal swab test for covid and flu. The hospital charged actually $445. Her insurance had negotiated a discount, but because they were still in their deductible, even there at the end of the year, they were on the hook for all of the rest. And that was about $300. Rovner: And these are the kinds of swabs, kind of tests that you can buy at the drugstore now, right? Sable-Smith: Yeah. I think you can get an at-home covid and flu test from Walgreens for like $30, or something like that. You can get a little bit of a laboratory test from Walgreens  again, still in the $100-$150 range. So this is significantly more than that. And it’s what you expect when you’re getting something done in the ER. Rovner: So what happened with the bill? Sable-Smith: Well, she was shocked by it. Maggi, the mom, called it mind-blowing. She said, “We didn’t even get past the waiting room. We didn’t see a doctor. How am I on the hook for $300?” She called the hospital. The representative on the line said, “That does sound high. Let me check this out for you. Don’t pay this.” But then, she got a letter in the mail that said, “Actually, yeah. That’s the right charge and it’s supported by documentation.” She reached out to us, we investigated it, and she was just on the hook for it. So at the end of the day, she’s on the hook for the $300, even though they didn’t leave the waiting room, even though they didn’t see the doctor. And it’s really just these healthy ER mark-ups that are pretty famous for hospitals and their emergency rooms. Rovner: But, it’s also a triage fee. Right? She didn’t see the doctor, but she did see a health professional, presumably, who did the test and determined that she wasn’t in immediate, crisis danger? Sable-Smith: She did get triaged. If you look through the medical records, she did get triaged. And the triage showed the symptoms that she had a fever or she had a history of fever at the time. And so, “OK. Let’s give her this nasal swab test.” What she was actually billed for, though, was just that one test. It’s a joint covid-influenza A and B test. So the actual thing that she’s paying for is just that one test. And so, in some ways, you could think actually she got off lucky. “Bill of the Month” has received bills from people who went to the ER, and even though they also left before seeing a doctor, they got charged a facility fee, or they got charged for that ER visit. So Maggi didn’t have to pay for that, just for the test. So, in some ways, this $300 bill was getting off easy. Rovner: And she did have to pay it, right? Sable-Smith: And she did have to pay it. Rovner: So how do you avoid having the same thing happen to you? Sable-Smith: Well, if you have something like this, going to an urgent care, or primary care doctor, or a pediatrician, you’re going to incur less of a fee. At the time, 10:30 at night, none of the urgent care clinics in their area were open. This was the only facility that she could go to, so her options were limited. But she’s not going to make a habit out of going to the ER again. She’s now going to think twice. It’s like, “Oh, if my daughter needs something, yeah, we’ll go to the urgent care. Yeah, we’ll set up something with the pediatrician.” But she’s not going to make a habit of going back to the ER. And just one more tip for listeners is that, if you are leaving the emergency room, Maggi ended up leaving —there was no one at the desk at the time, so she didn’t say she was leaving. But, if you go to the desk and you report that you’re leaving and say, “Hey, we’re getting out of here. It’s not worth it for us,” there’s a chance you could potentially avoid some fees that way. Rovner: Bottom line, don’t go to the emergency room unless you really, really have to. Sable-Smith: Sounds about right. Rovner: Bram Sable-Smith, thank you so much. Sable-Smith: Always a pleasure. Rovner: OK. We are back. Now it’s time for our extra-credit segment. That’s wherer we each recommend a 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. Shefali, you’ve already done yours. Joanne, why don’t you go next? Kenen: There’s a piece in ProPublica by Audrey Dutton: “<a href="https://www.propublica.org/article/idaho-coroner-law-failed-reform">For Decades, Calls for Reform to Idaho’s Troubled Coroner System Have Gone Unanswered</a>.” This literally goes back to the 1950s. Idaho has … This is not abortion-related. We were just talking about Idaho in another context. They have a really bad coroner system. They’re undertrained, under-resourced. They have to drive hours to get an autopsy. They don’t have money. And for years and years and years, the state tiptoes up to investing in it and reforming it. And then they actually don’t want to — I think the story used the word, “don’t want to spend money on death.” So in addition to literally making it easier to get away with murder, which is part of the problem, it’s also part of our public health system. And this particular article looked, in particular, at infant deaths. What was the cause of the infant death? A family needs to know that, both emotionally, and also if there’s something that, if they want to have more children or their risk factors. So the story really focused on what if you can’t get answers about why your baby died? And why it’s taken Idaho 70 years of not fixing this. And, although the article didn’t go into it there, the coroner system is also a sentinel data point for a lot of other  — it differs a little bit state to state — but it does help us get some understanding on suicide and drug use and other diseases that crop up. And it’s part of how we learn what our threats and challenges are. And Idaho — it’s a shocking story. Rovner: Sarah? Karlin-Smith: I took a look at a Stat Q&A from Nicholas St. Fleur, with Garth Graham, who is YouTube’s global head of health care and public health, which I think is just interesting [“<a href="https://www.statnews.com/2024/11/29/youtube-health-director-garth-graham-on-misinformation-free-speech-trusted-advice/">What YouTube Health Is Doing To Combat Misinformation and Promote Evidence-Based Content</a>”]. Just that, that YouTube has somebody in charge of thinking about health care and public health. And it goes through all the different ways YouTube is trying to ensure people are directed to accurate health information and not to misinformation. I’d be interested to see what they do to study how this works. Some of the things I was curious about, one of the things they do is they try and label information when it’s coming from accredited health facilities, or licensed doctors and stuff. And so that just piqued my interest, because we know that, well, there are oftentimes places we can trust. But, when you, say, put somebody like RFK, who is anti-vaccine, as the HHS secretary, people are worried about that changing communication coming out from the government. And if you automatically put a stamp on the government’s information, because of who that is, how that impacts things. But, I just thought it was a cool Q&A to see YouTube trying to take some responsibility to make sure people are getting directed to accurate information on their website. Rovner: I thought it was a super interesting interview. My extra credit this week is from The New Yorker. It’s called “<a href="https://www.newyorker.com/magazine/2024/12/02/the-texas-ob-gyn-exodus?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_Free_112524&utm_campaign=aud-dev&utm_medium=email&utm_term=tny_daily_digest&bxid=5f0f53ad034ed008a84d1a83&cndid=61650171&hasha=a493323304f23a0c4c4f39f3162f5fff&hashb=3e8b3bbbb59f60e56a395fd777bc75059bdcc746&hashc=329fd06ffd8af71d9deb8d385652a6275cd12996c45b58703465eac35abbc1ec&esrc=register-page&mbid=CRMNYR012019">The Texas OB-GYN Exodus</a>,” by Stephania Taladrid. And it’s a subject I’ve been all over, which is how abortion bans are driving away doctors who care for pregnant women, which is resulting in pretty much the opposite of what anti-abortion groups say they want. This piece focuses on the Rio Grande Valley, one of the poorest parts of the state, with the least access to health care of all kinds, and how it managed to stand up a program to bring OB-GYNs to the region and to start a training program for residents who were willing to practice there, only to see it all crumble in the face of doctors not being allowed to practice what they consider evidence-based medicine. The story quotes a report from the consulting firm Manatt Health that found that more than three-quarters of Texas OB-GYNs surveyed in the wake of the state’s abortion ban, quote, “said [that] they could no longer treat patients in accordance with evidence-based medicine. Twenty-one percent said [that] they were either considering leaving the state or already planning to do so; 13% had decided to retire early.” It’s a pretty convincing indictment of what’s going on and well worth your time to read. OK. That is this week’s 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 again this week to our temporary production team, Taylor Cook and Lonnie Ro, as well as our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me less and less on X, <a href="https://twitter.com/jrovner">@jrovner</a>, and increasingly at Bluesky <a href="https://bsky.app/profile/julierovner.bsky.social">@julierovner</a>.bluesky.social. Shefali, where are you hanging these days? Luthra: I am pretty much off X. But, you can find me on Bluesky at <a href="mailto:@shefali.bsky.social%20https://bsky.app/profile/shefali.bsky.social">shefali.bluesky.social</a>. Rovner: Sarah? Karlin-Smith: I am a little bit on X and at Bluesky — <a href="https://twitter.com/sarahkarlin">@SarahKarlin</a> or <a href="https://bsky.app/profile/sarahkarlin-smith.bsky.social">@sarahkarlin-smith</a>. Rovner: Joanne? Kenen: I’ve got a Bluesky account, but I think I’m just joannekenen. It might be joannekenen1, I forgot. I do a little bit on Threads, but not too much. There it’s <a href="https://www.threads.net/@joannekenen1?igshid=MzRlODBiNWFlZA==">joannekenen1</a>. Rovner: You could be found somewhere. Kenen: Right. Rovner: We will be back in your feed next week. Until then, be healthy. 					<h3>		Credits	</h3>							Lonnie Ro	Audio producer															Taylor Cook	Audio producer															Emmarie Huetteman 	Editor 												To hear all our podcasts, <a href="https://kffhealthnews.org/news/tag/podcast/">click here</a>.And subscribe to KFF Health News’ “What the Health?” on <a href="https://open.spotify.com/show/32EdsB662C3oyIrqLMmBXI?si=TQhRjzzLTgWtK3crfbOFtA">Spotify</a>, <a href="https://podcasts.apple.com/us/podcast/what-the-health/id1253607372?mt=2">Apple Podcasts</a>, <a href="https://play.pocketcasts.com/web/podcasts/a379e280-3f57-0135-9028-63f4b61a9224">Pocket Casts</a>, or wherever you listen to podcasts.This article was produced by <a href="https://kffhealthnews.org/about-us">KFF Health News</a>, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at <a href="https://www.kff.org/about-us/">KFF</a> — the independent source for health policy research, polling, and journalism. <a href="https://kffhealthnews.org/about-us">KFF Health News</a> 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 <a href="https://www.kff.org/about-us/">KFF</a>.<h3>USE OUR CONTENT</h3>This story can be republished for free (<a href="https://californiahealthline.org/news/podcast/what-the-health-377-congress-chaos-budget-december-19-2024/view/republish/">details</a>).<a href="https://kffhealthnews.org/about-us">KFF Health News</a> 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 <a href="https://www.kff.org/about-us">KFF</a>.<a href="https://californiahealthline.org/morning-briefing/">Subscribe</a> to KFF Health News' free Morning Briefing.

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