“Dedicated to the Future of Health Care in the Tri-State Area,” the sign declares. “May 11, 1981.”

More recent placards posted at the facility’s entryways are ominous, however. “Closed,” they say. “No Trespassing.”

The Keokuk hospital, which served rural areas of Iowa, Illinois, and Missouri, closed in October 2022. But new owners plan to reopen the hospital with the help of a new federal payment system. The Rural Emergency Hospital program guarantees hospitals extra cash if they provide emergency and outpatient services but end inpatient care.

“We’ve been without a hospital for over a year — and I don’t think anybody in Keokuk or the surrounding areas will be picky in any way, shape, or form,” said Kathie Mahoney, mayor of the town of about 9,800 people. She said residents would prefer to have a full-service hospital with inpatient beds, even though those types of beds had been used sparingly in recent years.

The revival of the Keokuk hospital would mark a small victory in the nationwide struggle to save rural hospitals, which continue to close due to staffing shortages, low reimbursement rates, and declining patient numbers. The new federal program, which went into effect in January 2023, is meant to stem the closures. But there have been growing pains, said George Pink, deputy director of the North Carolina Rural Health Research Program, which tracks hospital closures and conversions.

Just 18 of the more than 1,700 eligible rural hospitals nationwide have applied for and won the new designation. Many hospitals are reluctant to give up inpatient services entirely, and some are concerned about how other payment streams could be affected, rural health leaders say. The new designation’s unclear definition of “rural” has also caused confusion.

“We are still in an era of rural hospital closures,” Pink said. Nine hospitals closed in 2023, and that number could rise in 2024, he said. An influx of federal relief funds during the pandemic kept struggling hospitals afloat, but now that money is largely gone.

The Rural Emergency Hospital program is the first new federal payment model for hospitals since 1997. Dora Hughes, acting chief medical officer of the Centers for Medicare & Medicaid Services, said the new model’s criteria are outlined by statute and “hospitals should consider specific circumstances before making the decision to apply.”

The federal agency is providing outreach to rural communities and welcomes feedback, Hughes wrote in an email to KFF Health News.

Now, rural health leaders and federal lawmakers are working quickly to tweak the new program to attract more applicants, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association.

Currently, facilities that convert to rural emergency hospitals receive a 5% increase in Medicare payments, plus an average annual payment of about $3.2 million, in exchange for giving up their expensive inpatient beds and focusing solely on emergency and outpatient care. Rural hospitals with no more than 50 beds, like Keokuk’s, that closed after the law was signed on Dec. 27, 2020, are eligible to apply for the program and reopen with emergency and outpatient services.

More than 100 rural hospitals nationwide have inquired about converting, said Janice Walters, interim executive director for the Rural Health Redesign Center, which has a federal grant to provide technical assistance to hospitals that want to apply.

But only about a quarter of those inquiries are likely to become a rural emergency hospital, and persuading more troubled hospitals to make the leap would require regulators to make changes, Walters said.

Her advice? “Give them 10 beds to just take care of their community.”

In a journal article published last year, general surgeon Sara Schaefer worried about the unintended consequences of getting rid of rural inpatient beds. Schaefer, who spent six months of medical school at a small rural Idaho hospital, said she saw firsthand how difficult it was for the hospital to transfer patients to bigger facilities, which were often too full to take them.

“There has to be a better way,” said Schaefer, who is also a research fellow at the Center for Healthcare Outcomes & Policy at the University of Michigan.

The rural health association’s Cochran-McClain said lawmakers are considering changes that could allow the hospitals to:

• Keep overnight beds for patients who need moderate levels of care, such as those with pneumonia or in need of physical therapy after surgery.
• Allow participation in a federal drug discount program called 340B, which provides hospitals with extra revenue.
• Keep inpatient psychiatric or rehabilitation units open.
• Clarify eligibility, including which facilities qualify under the definition of “rural” and whether the hospitals that closed before the 2020 date in the law can apply.

Updates to the law could affect communities nationwide. In Fort Scott, Kansas, where the hospital closed in late 2018, Mayor Matthew Wells said the community wants the eligibility date pushed back. U.S. Sen. Jerry Moran (R-Kan.) introduced a bill in December that, if passed, would push eligibility back to 2015.

“This is a matter of life and death to my community,” Wells said. “I see a clear path, but the federal regulations in particular make that path nearly impossible.”

In Holly Springs, Mississippi, hospital chief executive Kenneth Williams said he doesn’t understand the federal definition of “rural.” His hospital, Alliance Healthcare Hospital, was one of the first to win the new Rural Emergency Hospital designation in early 2023. He laid off staff and shut down his inpatient beds. Then, CMS officials called to tell him they had made a mistake.

“And I said, ‘Wait a minute,’” Williams said. The hospital, which is about an hour south of Memphis, Tennessee, doesn’t meet the current criteria of rural, they told him. Williams, an internal medicine doctor, bought the hospital in 1999 and has been trying to keep it running since.

Federal regulators are now asking Williams to convert the facility into another type of Medicare payment model, such as the sole community hospital with inpatient beds that it was before. Williams said that would be difficult: “What kind of transition can I make, especially with reduced services?”

In Keokuk, the hospital fits the current requirements. Insight Health Group, the Michigan company that bought the shuttered facility last March, plans to apply for the new federal designation as soon as it obtains state permits under new Iowa regulations tailored to rural emergency hospitals. It would be the first such hospital in the state.

Like many other rural hospitals struggling to survive, Keokuk’s shuttered several key departments years ago, including its birthing and inpatient psychiatric units. In 2021, the last full year it was open, the hospital averaged fewer than three inpatients per night, according to data posted by the Iowa Hospital Association.

More than half of the three-story building would remain mothballed if the facility reopened under the new designation, but the emergency department could serve patients again as soon as late summer, said Atif Bawahab, Insight’s chief strategy officer.

Bruce Mackie has worked 32 years at the hospital, including 10 years as director of plant operations. The new owners kept him on to watch over the building. Beds, high-tech scanners, and lab equipment remain, but most of the clocks have stopped. “It’s spooky,” he said.

Even if the services are more limited than before, Mackie said, “everybody wants the hospital to reopen. This city needs an ER.”

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“We’re going to fight for much better health care than Obamacare. Obamacare is a catastrophe,” Trump said at a campaign stop in Iowa on Jan. 6.

The perplexing revival of one of Trump’s most politically damaging crusades comes at a time when the Obama-era health law is even more popular and widely used than it was in 2017, when Trump and congressional Republicans proved unable to pass their own plan to replace it. That failed effort was a big part of why Republicans lost control of the House of Representatives in the 2018 midterms.

Despite repeated promises, Trump never presented his own Obamacare replacement. And much of what Trump’s administration actually accomplished in health care has been reversed by the Biden administration.

Still, Trump secured some significant policy changes that remain in place today, including efforts to bring more transparency to prices charged by hospitals and paid by health insurers.

Trying to predict Trump’s priorities in a second term is even more difficult given that he frequently changes his positions on issues, sometimes multiple times.

The Trump campaign did not respond to a request for comment.

Perhaps Trump’s biggest achievement is something he rarely talks about on the campaign trail. His administration’s “Operation Warp Speed” managed to create, test, and bring to market a covid-19 vaccine in less than a year, far faster than even the most optimistic predictions.

Many of Trump’s supporters, though, don’t support — and some even vehemently oppose — covid vaccines.

Here is a recap of Trump’s health care record:

Public Health

Trump’s pandemic response dominates his overall record on health care.

More than 400,000 Americans died from covid over Trump’s last year in office. His travel bans and other efforts to prevent the global spread of the virus were ineffective, his administration was slower than other countries’ governments to develop a diagnostic test, and he publicly clashed with his own government’s health officials over the response.

Ahead of the 2020 election, Trump resumed large rallies and other public campaign events that many public health experts regarded as reckless in the face of a highly contagious, deadly virus. He personally flouted public health guidance after contracting covid himself and ending up hospitalized.

At the same time, despite what many saw as a politicization of public health by the White House, Trump signed a massive covid relief bill (after first threatening to veto it). He also presided over some of the largest boosts for the National Institutes of Health’s budget since the turn of the century. And the mRNA-based vaccines Operation Warp Speed helped develop were an astounding scientific breakthrough credited with helping save millions of lives while laying the groundwork for future shots to fight other diseases including cancer.

Abortion

Trump’s biggest contribution to abortion policy was indirect: He appointed three Supreme Court justices, who were instrumental in overturning the constitutional right to an abortion.

During his 2024 campaign, Trump has been all over the place on the red-hot issue. Since the Supreme Court overturned Roe v. Wade in 2022, Trump has bemoaned the issue as politically bad for Republicans; criticized one of his rivals, Florida Gov. Ron DeSantis, for signing a six-week abortion ban; and vowed to broker a compromise with “both sides” on abortion, promising that “for the first time in 52 years, you’ll have an issue that we can put behind us.”

He has so far avoided spelling out how he’d do that, or whether he’d support a national abortion ban after any number of weeks.

More recently, however, Trump appears to have mended fences over his criticism of Florida’s six-week ban and more with key abortion opponents, whose support helped him get elected in 2016 — and whom he repaid with a long list of policy changes during his presidency.

Among the anti-abortion actions taken by the Trump administration were a reinstatement of the “Mexico City Policy” that bars giving federal funds to international organizations that support abortion rights; a regulation to bar Planned Parenthood and other organizations that provide abortions from the federal family planning program, Title X; regulatory changes designed to make it easier for health care providers and employers to decline to participate in activities that violate their religious and moral beliefs; and other changes that made it harder for NIH scientists to conduct research using fetal tissue from elective abortions.

All of those policies have since been overturned by the Biden administration.

Health Insurance

Unlike Trump’s policies on reproductive health, many of his administration’s moves related to health insurance still stand.

For example, in 2020, Trump signed into law the No Surprises Act, a bipartisan measure aimed at protecting patients from unexpected medical bills stemming from payment disputes between health care providers and insurers. The bill was included in the $900 billion covid relief package he opposed before signing, though Trump had expressed support for ending surprise medical bills.

His administration also pushed — over the vehement objections of health industry officials — price transparency regulations that require hospitals to post prices and insurers to provide estimated costs for procedures. Those requirements also remain in place, although hospitals in particular have been slow to comply.

Medicaid

While first-time candidate Trump vowed not to cut popular entitlement programs like Medicare, Medicaid, and Social Security, his administration did not stick to that promise. The Affordable Care Act repeal legislation Trump supported in 2017 would have imposed major cuts to Medicaid, and his Department of Health and Human Services later encouraged states to require Medicaid recipients to prove they work in order to receive health insurance.

Drug Prices

One of the issues the Trump administration was most active on was reducing the price of prescription drugs for consumers — a top priority for both Democratic and Republican voters. But many of those proposals were blocked by the courts.

One Trump-era plan that never took effect would have pegged the price of some expensive drugs covered by Medicare to prices in other countries. Another would have required drug companies to include prices in their television advertisements.

A regulation allowing states to import cheaper drugs from Canada did take effect, in November 2020. However, it took until January 2024 for the FDA, under Trump’s successor, to approve the first importation plan, from Florida. Canada has said it won’t allow exports that risk causing drug shortages in that country, leaving unclear whether the policy is workable.

Trump also signed into law measures allowing pharmacists to disclose to patients when the cash price of a drug is lower than the cost using their insurance. Previously pharmacists could be barred from doing so under their contracts with insurers and pharmacy benefit managers.

Veterans’ Health

Trump is credited by some advocates for overhauling Department of Veterans Affairs health care. However, while he did sign a major bill allowing veterans to obtain care outside VA facilities, White House officials also tried to scuttle passage of the spending needed to pay for the initiative.

Medical Freedom

Trump scored a big win for the libertarian wing of the Republican Party when he signed into law the “Right to Try Act,” intended to make it easier for patients with terminal diseases to access drugs or treatments not yet approved by the FDA.

But it is not clear how many patients have managed to obtain treatment using the law because it is aimed at the FDA, which has traditionally granted requests for “compassionate use” of not-yet-approved drugs anyway. The stumbling block, which the law does not address, is getting drug companies to release doses of medicines that are still being tested and may be in short supply.

Trump said in a Jan. 10 Fox News town hall that the law had “saved thousands and thousands” of lives. There’s no evidence for the claim.

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CHARLESTON, S.C. — Republican presidential hopeful Nikki Haley will learn how her campaign is resonating with voters after the Jan. 15 Iowa caucuses, the first presidential nominating contest of this election year.

Already, the former South Carolina governor — who became well known as one of the Affordable Care Act’s loudest critics during her tenure in office from 2011 to 2017 — has raised questions about what her presidency could mean for the nation’s health care policy.

“I would be very concerned,” said Sue Berkowitz, policy director and special counsel for the South Carolina Appleseed Legal Justice Center. “South Carolina is at the bottom of so many things in rankings in our country because of a number of the decisions she made while governor.”

While politicians from both parties rallied behind Haley when she urged lawmakers to remove the Confederate battle flag from statehouse grounds following the 2015 church shooting in this coastal city, her politics diverged sharply from those of her Democratic colleagues when it came to most health care issues.

Haley’s campaign did not respond to multiple requests for comment, but statements she’s made during recent debates offer clues about her health care positions.

She has criticized the Biden administration for high federal spending on covid relief and for the number of people on Medicaid, a program she has argued the federal government should give states more flexibility in funding and administering.

She has also emphasized the need to find consensus on banning abortions late in pregnancy. And on Jan. 10, during her heated sound-off with Florida Gov. Ron DeSantis in the final debate before the Iowa caucuses, she reiterated her critical stance on gender-affirming care.

“I have always said that boys need to go into boys’ bathrooms, girls need to go into girls’ bathrooms, that we shouldn’t have any gender transitions before the age of 18,” she said. “Just like we don’t have tattoos before the age of 18, we shouldn’t have gender transformation or puberty blockers.”

On the campaign trail, she’s addressed reforming Medicare and Social Security. But her tenure as governor, which overlapped with several tumultuous years of national health care reform, offers an even clearer picture of how a Haley presidency might look.

Former South Carolina Medicaid Director Anthony Keck pointed out that one of her early achievements as governor was fixing a $228 million Medicaid deficit.

“People forget what dire straits the Medicaid program was in when she came into office and how it took us a couple years to right the ship,” said Keck, now executive vice president for system innovation at Ballad Health in Tennessee.

Beyond that, Keck said Haley understood that the cost of health care was “growing faster than most people’s paychecks,” adding that affordability and access were “really important to her.”

As Haley eyes the White House, here’s a recap of her health care record as South Carolina governor, a post she left in 2017 after Trump appointed her as ambassador to the United Nations.

Affordable Care Act

In 2011, Haley convened an advisory committee to decide if South Carolina should build its own health insurance marketplace instead of participating in the federal one established under the Affordable Care Act.

But before the group gathered for its first meeting, Haley wrote in an email to her advisers that the “whole point of this commission should be to figure out how to opt out and how to avoid a federal takeover, NOT create a state exchange,” according to a report published by The Post and Courier.

When that email was made public, then-Sen. Tom Harkin (D-Iowa) requested a federal investigation to find out if Haley had predetermined the outcome of the committee. She was eventually cleared of any wrongdoing.

Throughout her time in office, Haley repeatedly advocated for the repeal and replacement of the ACA, but she has not given a definitive answer on the campaign trail about whether she’d try to repeal the law if elected president, The New York Times has reported.

Medicaid

In 2012, when the U.S. Supreme Court upheld the constitutionality of the ACA and made Medicaid expansion an option for every state, Haley declined to expand it in South Carolina. Christian Soura, one of her former cabinet members, estimated in 2019 that “several hundred” people in the Palmetto State had died because of the decision.

On the presidential campaign trail, Haley’s stance on Medicaid expansion has remained unchanged, even as people who live in nonexpansion states broadly support it, according to KFF polling.

South Carolina remains one of 10 states that have not expanded Medicaid eligibility under the ACA, leaving more than 90,000 residents in a health insurance coverage gap, according to a 2023 KFF report.

Even so, Medicaid enrollment and spending in South Carolina during Haley’s tenure grew substantially, drawing criticism from some conservatives.

In 2012, her administration chose to implement a federal program that automatically issued new Medicaid coverage to children from low-income families based on data from welfare assistance and the Supplemental Nutrition Assistance Program, formerly known as food stamps. A 2013 case study found that the Express Lane Eligibility initiative grew Medicaid enrollment in South Carolina by more than 92,000 children in less than a year and that the simplified process “resulted in large enrollment and retention improvements.”

Haley’s administration was also widely applauded for establishing a coalition of health insurers, hospitals, and health care providers to improve birth outcomes in a state where Medicaid pays for more than 60% of all deliveries. Infant and maternal death rates in South Carolina have long ranked among the worst in the nation.

Recent research suggests, however, that some of the policies Haley’s administration prioritized, such as a home visiting program and a campaign to prevent early elective deliveries, didn’t improve maternal or infant health outcomes.

Abortion

On the one-year anniversary of the U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization ruling, which allowed state legislatures to outlaw abortion, Haley called the decision a “victory for life and democracy.”

Her position aligned with a controversial bill she signed into state law in 2016 that banned the procedure in South Carolina 20 weeks after the probable date of fertilization — slightly past the midpoint of a woman’s pregnancy.

When she signed the law, it affected only hospitals because the state’s three outpatient abortion clinics already didn’t administer abortions after 15 weeks of gestation. The bill, which she championed, made exceptions for if the fetus were diagnosed with an “anomaly” and would die or if the mother’s life were threatened. But no exceptions were made for rape or incest.

During the recent debate in Iowa, Haley called herself “unapologetically pro-life.”

“Not because the Republican Party tells me to be, but because my husband is adopted, and I’ve got my two sweet children sitting in front of me, and I had trouble having both of them,” she said. “Our goal should be how do we save as many babies as possible and support as many moms as possible.”

On the campaign trail, Haley has tried to thread the needle between being pro-life and recognizing the difficulty of enacting a national abortion ban. She has spoken of finding areas that are winnable for Republicans, including increasing access to contraception and supporting adoption. That said, Haley indicated she would sign a national abortion ban as president if such a bill reached the Oval Office.

Certificate of Need

During her first term, Haley vetoed more than $1 million from the state budget that had been allocated to administer the health department’s long-standing “certificate of need” program. The program required hospitals and health care providers to apply for permission from the state before building new facilities or purchasing expensive equipment, with the goal of controlling health care costs and avoiding duplication of available health care services.

At the time, Haley called the rules “intensely political” and said they allowed “bureaucratic policymakers” to block health care providers from offering treatment. “We should allow the market to work rather than politics,” she said.

Nevertheless, the state Supreme Court ruled in 2014 that a budget veto wasn’t sufficient to eliminate the regulations.

The South Carolina Legislature ultimately repealed the state’s certificate of need rules last year.

During the Jan 10. debate, Haley said she would eliminate certificate of need across the country. The rules still exist in about two-thirds of states.

Rural Hospitals

During Haley’s second year in the governor’s office, the hospital where she was born in 1972 closed its doors. After a failed attempt to merge with other hospitals in the area, it became financially unfeasible for that hospital in the rural town of Bamberg to remain open.

In 2013, Haley announced her administration would reimburse rural hospitals across the state for all their uncompensated care costs, amounting to tens of millions of dollars over her time in office. The policy is still in effect.

Essentially, hospitals lose money when uninsured patients don’t pay their bills. Federal law offers some support. For example, it requires state Medicaid programs to make “disproportionate share” payments to hospitals that serve large numbers of low-income and uninsured people.

But programs like those don’t necessarily cover all of the losses.

Haley prompted the South Carolina Legislature to support rural hospitals by increasing their disproportionate share payments because, without an infusion of cash, several of them faced the same fate as Bamberg County Memorial Hospital.

“I certainly don’t think it’s a bailout,” Haley told The Post and Courier in 2014. “We’re allowing solid footing for these hospitals to make the changes that they need to make.”

But her plan wasn’t fail-safe. Two more rural hospitals closed during Haley’s tenure as governor.

Vaccine Mandates

As a member of the state House of Representatives in 2007, Haley co-sponsored a bill that would have made the vaccine for HPV, the virus that causes nearly all cases of cervical cancer, mandatory for girls entering seventh grade. It was ultimately killed by evangelical lobbyists, who have historically associated the HPV vaccine with encouraging underage sex, KFF Health News reported.

Several years later, Haley called her support of that bill a mistake.

In 2012, Haley vetoed a bill that would have provided free, voluntary HPV vaccines to seventh graders in South Carolina.

During the pandemic, Haley, whose sister-in-law died from covid, said she received a covid vaccine, though she has said she firmly opposes covid vaccine mandates.

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

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As this election year begins in earnest, making it harder for Congress to pass bills, lawmakers on Capitol Hill are still struggling to fund the government for the fiscal year that began last October. And many health priorities hang in the balance.

Meanwhile, the Supreme Court is again wading into the abortion debate, accepting a case out of Idaho that pits a federal law requiring emergency care, including for pregnant women, against the state’s strict abortion ban.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• In Washington, lawmakers have reportedly reached a deal that could pave the way for passing necessary government spending bills. But it is unlikely they will pass a full package before the current extensions end, leaving many federal health programs hanging. And ahead of next week’s Iowa caucuses, it bears asking what Republicans would do in health if the party reclaims the White House.
• The Supreme Court is again stepping into the fray over abortion rights, choosing to review the conflict between Idaho’s abortion ban and a federal law requiring emergency medical care. It is notable that justices did not have to take this case and, by swooping in now, are setting up another major abortion ruling before the 2024 election.
• The Biden administration announced it will scale back so-called conscience protections for health providers that the Trump administration sought to beef up. The back-and-forth over the policy — which was created during the George W. Bush administration — reinforces the importance of pressing presidential candidates about what they would do administratively on abortion policy, rather than asking what bills they might sign into law.
• News out of Florida this week: Newly introduced legislation there would, among other things, classify abortion as a felony and penalize those outside the state involved in the sale or distribution of abortion pills if they are “likely to be used in Florida” — a concerning example of a state effort to regulate access to abortion nationwide.
• And the FDA approved Florida’s request to import drugs from Canada, a change for which Republican Gov. Ron DeSantis is taking credit — though both President Joe Biden and former president Donald Trump could also claim some of that credit. But there are a lot of hurdles left before the state receives its first shipments, and due to the way the policy will be implemented, it may not save the state much money anyway.

“This Week in Health Misinformation” highlights Olympic gold medalist and medical crowdfunding beneficiary Mary Lou Retton, who said this week she could not afford health insurance before her headline-grabbing bout of pneumonia because her preexisting conditions made having insurance too expensive. But a decade into the existence of the Affordable Care Act, the fact is that patients can no longer be penalized on the insurance market for preexisting conditions — and, as the record 20 million Americans who enrolled in ACA coverage this year may attest, there are plenty of federal subsidies available to help afford insurance, too.

Also this week, Rovner interviews American Medical Association President Jesse Ehrenfeld, whose focus is helping the nation’s physicians navigate a rapidly changing health care system.

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

Julie Rovner: CNN’s “Bottled Water Contains Thousands of Nanoplastics So Small They Can Invade the Body’s Cells, Study Says,” by Sandee LaMotte. Also, ScienceAlert’s “It Turns Out Paper Straws Might Pose a Serious Problem Too,” by Carly Cassella. Also, The Washington Post’s “How Plastic Hides in Supposedly Eco-Friendly Laundry Products,” by Michael J. Coren.

Tami Luhby: KFF Health News’ “Most People Dropped in Medicaid ‘Unwinding’ Never Tried to Renew Coverage, Utah Finds,” by Phil Galewitz.

Alice Miranda Ollstein: Stat’s “Texas Taxpayers Wanted to Help the Poor Get Health Care. Instead They’re Funding a Medical School at a Wealthy University,” by Rachel Cohrs.

Sarah Karlin-Smith: The New York Times’ “The F.D.A. Warned an Asthma Drug Could Induce Despair. Many Were Never Told,” by Christina Jewett and Benjamin Mueller.

KFF Health News’ ‘What the Health?’Episode Title: 329Episode Number: All About the (Government) FundingPublished: Jan. 11, 2024

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

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, Jan. 11, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this, so here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: And Tami Luhby of CNN.

Tami Luhby: Good morning.

Rovner: Later in this episode, we’ll have my interview with Jesse Ehrenfeld, this year’s president of the American Medical Association. It’s a bumpy time to be a doctor, and the AMA is more relevant than it’s been for quite a few years. But first, this week’s news. So we heard over the weekend that House and Senate negotiators reached a deal on top-line spending ceilings for defense and non-defense discretionary spending.

Actually, they were kind of the top lines, I believe, that they agreed to last summer, and then the House Republicans tried to change. That is all well and good, and it is definitely a prerequisite for passing full-year appropriations bills, but that’s not going to happen between now and Jan. 19, when the first of two temporary spending bills expires. So what do we expect to happen?

Ollstein: I was up on the Hill yesterday, and it’s a very “what they’re saying vs. what they’re doing” situation. They’re talking a lot about, “We got this top line. We’re moving forward. People are somewhat warming to the idea of another short-term CR [continuing resolution] to give them a little breathing room to get this done.” But then Republicans who were pissed about the entire process voted down an unrelated rule on an unrelated bill just to say, “We’re mad.” So that’s obviously not a good sign for getting big things done quickly in the next few weeks.

An issue I’m tracking is also conservatives who are disgruntled about the level of spending being higher than they wanted, saying, “Well, if we’re going to agree to this, we might as well get some policy wins out of it.” And they’re digging in harder on some of these anti-abortion provisions, other culture war things. I think the health care ones are being somewhat overshadowed right now by the immigration border stuff, but the health care things are still in the mix, for sure.

Rovner: Yeah. The CR that expires first also includes continuing authorizations for a bunch of health programs like community health centers and a delay of a bunch of scheduled Medicare payment cuts. Tami, you’re following WIC [Women, Infants, and Children nutrition program], I know, and food stamps. Do we have any idea what the fate is going to be of these things that will also expire when that first CR expires? Do we expect they’ll continue until Congress decides what to do?

Luhby: Well, actually things are looking a little better for WIC participants in terms of a shutdown, not necessarily in terms of full-year funding. But if the government had shut down in October, the USDA warned that it actually only had a few days left of money to provide for WIC. But if the government does shut down next week, then the USDA has told me that SNAP participants, food stamp participants, and WIC participants can expect to continue to get their benefits for food stamps January and February and for WIC January, February, March.

But separate from that, one of the issues that WIC participants have — and WIC, by the way, is the program that provides funding for pregnant women, new moms, infants, and young children to buy groceries. The WIC program is underfunded because there’s actually a big growth in enrollment. And so, even though the Senate provided some more money in their initial bill, they actually need more than a billion dollars more to continue the program at the current participation levels.

And a lot of folks are warning that if Congress doesn’t provide more money, there could actually be waiting lists for the first time in decades. So it’s a big issue that’s continuing because, as we know, the Republicans are not looking to add more money to nutrition assistance.

Rovner: Jumping ahead, it’s a little bit to the abortion debate. This is the argument that if you’re basically going to force women to have babies, you’re going to need to help support them if the women otherwise would’ve had an abortion because they couldn’t afford it. I think where we are with WIC, I think, is sort of the leading edge of this.

Luhby: And WIC is actually very important to that because it also provides breastfeeding assistance and guidance as well as other supports for new moms.

Rovner: So there were things, though, that didn’t even make it into the CR. One of them is the 3.4% cut in Medicare doctor pay. That took effect Jan. 1. Doctors I know would like to get that rolled back. There’s other things that are hoping to catch a ride on whatever the next vehicle is, right?

Karlin-Smith: I mean, one thing I had been watching is PBM [pharmacy benefit manager] reform. There seemed like there was some bipartisan and bicameral momentum to try and tack that on to the next big moving package. And one positive thing for that is that it does offer some amount of savings that then could be applied to other areas like spending, including potentially helping maybe with some of the Medicare cuts. So that’s something in the mix to look for.

Rovner: Yeah. Something that actually is proceeding on a separate track, right? We don’t expect that to be folded into the appropriations — unless we do. My impression was that was proceeding on its own, at least for the moment.

Karlin-Smith: I think it was proceeding on its own, but there’s been talk of could they fold it into any deal that struck to fund the government, because I think the likelihood that it really does fully clear both the House and Senate on their own is small.

Rovner: Yes, it is an election year. It is harder for Congress to get anything done. Speaking of which, on the campaign trail, the Iowa caucus is next week. Boy, that sort of snuck up on us. Former President [Donald] Trump still seems very likely to win, and he’s once again vowing to undo the Affordable Care Act, which, by the way, hit an all-time enrollment record of 20 million this week. And open enrollment isn’t even quite over. Tami, do we know what Trump would do instead? That seems to be the part. He doesn’t ever say.

Luhby: No. It’s pretty much the same plan that he probably has from 2016 and 2017, which we never really fully learned about. So, no, it’s just going to be replaced with a “better plan” because, in his view, Obamacare is failing, and as we know, [Florida Gov.] Ron DeSantis also jumped on the same bandwagon, saying that he would actually also come up with a better plan, but he needs a few months to think about it.

Rovner: Because it’s always been right about to happen, of course.

Luhby: Well, as you may have heard, health care is complicated.

Rovner: And we’ll see something in two weeks.

Luhby: Right. Along with his block grant proposal for Medicaid that he mentioned at last night’s CNN debate.

Rovner: Yes. I was sort of taken by the comments of how they would fix health care in that debate, because Nikki Haley says, “We can fix it with tort reform and transparency.”

Luhby: Transparency. Yes.

Rovner: Right. Which are nice things, and as we say, almost every week, Congress is working on those things, but they are not going to solve what ails the health care system. All right, let us turn to abortion. Remember last week when I said we were still waiting to hear from the Supreme Court on the emergency petition from Idaho regarding the conflict between its state abortion ban and the federal Emergency Medical Treatment & Active Labor Act, EMTALA?

Well, on Friday, the court not only took the case, it overturned the stay of Idaho’s ban. So, at least for now, doctors cannot even provide abortions in medical emergencies unless the woman is at immediate risk of death. Alice, I assume that gives us a hint of where the court might be going with this case, and I imagine also that similar case out of Texas.

Ollstein: Yeah. So again, with the Supreme Court, you kind of have to read the tea leaves and make educated guesses. They’re obviously very secretive. But people who are following this case closely that I’ve spoken to, they think that both the stay of the lower-court ruling and the fact that they took this case at all is the sign that they’re really gunning for ruling on the side of the state abortion restrictions. Because this is really about the state-federal clash. When state abortion bans run into federal protections for patients in emergency circumstances, and which will prevail in that circumstance. So they didn’t have to take this case. The thinking was there is eventually going to be a circuit split on this issue between the 9th Circuit and the 5th Circuit. But the 9th Circuit hasn’t had a chance to rule yet. And so they could have waited, let this play out, allowed the 9th Circuit to hear the case and issue a decision, that would’ve probably punted this case until after the election. So it’s really interesting that they instead wanted to swoop in, allow Idaho to leapfrog the 9th Circuit, and also insert themselves into this really politically volatile case, and now they’re poised to issue a ruling right before the 2024 election that could have major implications for the whole country.

Rovner: They’re going to hear the mifepristone case before this summer too, right?

Ollstein: Absolutely. And so even people who had sort of assumed on the mifepristone case like, “Oh, the Supreme Court’s going to kind of punt. They’re going to dismiss on standing.” Now, because of how aggressive they’re being in this other case, I have experts telling me, “Well, now I’m not so sure about the mifepristone case. Maybe they don’t care about optics as much as they used to.”

Rovner: Well, also, I think this is this Supreme Court’s theme, of “let states do whatever they want.” Even though federal law is supposed to trump state law, they seem to be reversing that in a rather aggressive fashion.

Ollstein: Yes. A big theme is definitely skepticism of federal rulemaking power. This falls under that same category as well.

Rovner: Well, speaking of federal rulemaking power, those who follow abortion policy in D.C. know that every time an administration changes parties, the so-called Mexico City policy that bans funding to international groups that support abortion rights gets either canceled or restored, depending on which party is in power. Well, now we have another policy that seems to be flip-flopping every time an administration changes. It was a rule first issued at the end of the George W. Bush administration. The so-called conscience rule made it easier for medical professionals and others in health care to decline to provide care that violates their religious or moral beliefs. So not just abortion but transgender care, in some cases, just treating people with AIDS. The Obama administration scaled back the Bush rule, and then the Trump administration broadened it. Then it got blocked by the courts, and now the Biden administration has formally rolled back the Trump changes that never really took effect. Alice, where are we with this?

Ollstein: Like you said, this is a back-and-forth, and I think this is why a lot of the questions being asked of candidates on the campaign trail right now, related to abortion, are the wrong questions. They keep getting asked about what kind of bills they would sign. That’s not the question. The question is what would they do administratively, which they could do so much. They could undo this. They could reverse all kinds of things. I follow the Title X stuff. I follow the Mexico City policy on restrictions on international spending on reproductive health. There’s just so much, obviously — FDA regulation of abortion pills — but these are the things we should be focused [on], not a bill that Congress has shown itself unable to pass even with one-party control of Congress.

Rovner: Nikki Haley keeps correctly saying there aren’t 60 votes for anything in the Senate related to abortion.

Ollstein: Right. But then, she also is saying that to mean a future Republican president couldn’t really do much, and that part is not true. They could do a lot.

Rovner: Exactly. Well, moving on, it’s January, and state legislatures are coming back into session. And we’re seeing some pretty eye-popping bills introduced in Florida, where abortion rights supporters just secured enough signatures to get a referendum protecting abortion rights on the 2024 ballot. Republican state Rep. David Borrero introduced a bill that would not only ban abortion, it would classify it as a third-degree felony with penalties of up to 10 years in prison. It also seeks to reach anyone outside the state who makes, sells, or mails abortion pills if they are, quote, “likely to be used in Florida.” The bill also defines personhood as beginning at the moment of fertilization, which would, among other things, make most birth control illegal and give fetuses constitutional rights. Alice, this bill is obviously not likely to pass, but legislators are playing the long game here by trying to make these things look sort of not out of the ordinary, right?

Ollstein: Yeah, the pill one, I think, is more the one to watch there. I’m curious if other states try to do that as well. Obviously, that runs into legal concerns about regulating interstate commerce, et cetera. But I think that we’ve seen these sort of nation attempts to restrict the movement of both people and medications across state lines, since that is a huge way that people are managing to terminate pregnancies despite bans right now. And so I think there’s only going to be more and more activity in that area to try to close off those remaining outlets for people. But yes, on the personhood front, that’s something that states have been attempting to do for a long time now, obviously more recently. And I think there’s sort of a strategy of, “Let’s just put it in everything we can. Let’s throw it in everything we can. Let’s throw it in bills. Let’s throw it in amicus briefs.” And the hope is to eventually force this issue in court and to get a court to rule on whether the 14th Amendment covers fetuses, basically. Will that happen and when remains to be seen, but there’s definitely an effort to sort of seed it in the landscape.

Rovner: Sarah, this obviously — not so much the personhood part, although maybe that too — but trying to ban the movement of medication is something that clearly impacts the FDA. They seem to have been pretty quiet about this, but there’s an awful lot that seems to be sort of threatening the basic core procedures of what the FDA does. Are you hearing anybody whispering about this? Is there concern?

Karlin-Smith: I think the mifepristone case at the Supreme Court is a concern for people who watch FDA’s power and regulation, not just because of abortion but because it is seen as depending on how the court decides that case is something that really could touch on all of its regulatory authority as well. Certainly, this provision that Florida is trying to put in is really something where they seem like they’re effectively trying to regulate the abortion pill throughout the entire country and regulate manufacturers. So that would be concerning, again, if that somehow came to pass and was not struck down by courts, as Alice mentioned, for interstate commerce regulation, which is not some power that is usually given to the states, but so, in general, the abortion pill controversy makes anybody who’s impacted by the FDA regulation nervous.

Rovner: Well, meanwhile, the Federal Trade Commission has entered the chat. This week, it barred a tech company from selling data on people’s visits to medical centers and other health facilities. This was not affecting abortion. They were actually just trying to help people figure out where people are and help them sort of get through their medical undertakings. But this seems like kind of a big deal enforcing privacy post-Dobbs. It’s the first one of these I’ve seen. Have you seen any of these, Alice?

Ollstein: I’m in the same camp as you. Yeah. This is sort of the first I’ve seen of this. But as has been the trend over the last couple of years, it’s a very “throw things against the wall and see what sticks” kind of environment, and so you can’t dismiss the outliers because the outliers can very quickly become the norm.

Rovner: This obviously was not a company that was trying to get women’s menstrual data and figure out whether they’re pregnant and whether they’re going to have an abortion. But there is a lot of concern that because there’s so much medical data floating out now in the metaverse, shall we say, that it would not be that hard to do that. And I guess the FTC is trying to plant a flag and say, “Mm-mm, don’t even try.” Although I’m sure people will …

Ollstein: Again, circling back to our previous theme, like, who a presidential administration installs at places like the FTC that you might not think that has anything to do with health care and abortion, but it certainly does. It certainly can. Same with DOJ, Labor Department. A lot of these things touch on reproductive health in ways that aren’t always obvious.

Rovner: That’s right. Well, turning to prescription drug news, the FDA has approved Florida’s request to import cheaper drugs from Canada. But, Tami, you wrote about this. This comes with a long list of caveats, right? It’s not like they just opened the borders and said, “OK, buy what you want.”

Luhby: No, and Florida has also put forth a fairly restricted proposal. It’s only going to be for people in their public payer program, people like inmates and people who are cared for by the county health systems and, later, Medicaid. And it’s also a pretty small list of drugs, drugs for HIV/AIDS and mental illness, and certain ones. But no, there’s a lot of hurdles before the state can actually start importing drugs. There’s going to likely be a lawsuit by PhRMA. They came out pretty strongly against it. They don’t want this, and Canada doesn’t necessarily want this. They said this in 2020 when the Trump administration first indicated that they were going to move in this direction, and then Health Canada on Friday put out a pretty strong statement saying they are clear in its position. “Bulk importation will not provide an effective solution to the problem of high drug prices in the U.S.” So there’s a long path before Florida will be able to actually see this and an even longer path before its general residents will see it. People may think, “Oh, I can go up to CVS now and order my Canadian version of the drug, which will be much cheaper.” And that’s not at all the case.

Rovner: Sarah, this has been going on for more than 20 years — I think I covered it first time in 1998 — because it’s really popular among Republicans and Democrats because it sounds so good. “We’ll just buy cheaper drugs from other countries where they have the same drugs, and they sell them for less money because they have price controls.” But Canada can’t even supply Florida, much less the rest of the country, right?

Karlin-Smith: Right. I think people, sometimes you look at Canada on a map geographically. It’s a very large area, but the population compared to the U.S. is much smaller. So the supply chain that’s feeding Canada is very different. And then you get into why HHS and FDA has usually pushed back against this idea is because they’re concerned about securing the supply-chain safety and making sure people are actually getting what they … think they’re getting and know how to use the drug. And what’s basically happened under starting the Trump administration and then Biden’s kind of continued it is they came up with a pathway to sort of make importation potentially possible. But they put in so many hoops that these states will have to go through and so many processes in place to ensure the safety of it that by the time Florida does all of this, and again, as Tami mentioned, FDA hasn’t cleared any specific drugs for Florida to import yet; each drug product still is going to have to go through a bunch of steps to get that OK. So by the time they do all of that, it doesn’t look like it’s going to save very much money. Florida’s estimating maybe not quite $200 million for the first year and about the same the second year. If you look at just their Medicaid spending in a year on outpatient drugs, it’s like $1.-something billion. So you can see how tiny a savings that is.

Rovner: Yes. This is one of those things that’s not been partisan. It’s always been sort of the FDA wanting to protect the integrity of the supply chain, whether it’s controlled by Democrats or Republicans versus Democrats and Republicans who would like to find a way to help their constituents get cheaper drugs.

Luhby: One thing also to note that’s going to be interesting, because there’ve been so many people involved in this, we saw Ron DeSantis say yesterday at the debate that he took credit for pushing the federal government and beating the federal government, I think he said, to be allowed to import drugs. But this is also going to be a talking point that Trump and Biden will also be able to say on the campaign. So basically, everyone is probably going to try to take credit for this.

Rovner: Right. Everybody’s going to take credit for something that’s probably only going to happen in a very small way, if it happens at all.

Luhby: If it all happens at all.

Rovner: That’s right. Well, also this week, drug maker Eli Lilly said it is setting up its own telehealth service to help patients access not only its soon-to-be blockbuster weight loss drug Zepbound but also other diabetes and migraine drugs, basically cutting out the doctor or at least cutting out the patient’s regular doctor, if they have one. Sarah, this feels to me like a really big sea change. Is the FDA going to let this happen? Is the AMA going to let this happen?

Karlin-Smith: It’s really interesting. I think the first headline of it makes it seem a little bit more extreme or maybe novel than once you actually look into the details because Lilly’s …

Rovner: Kind of like drug importation.

Karlin-Smith: Right. Although I think more patients maybe will actually be served by this program. But, basically, Eli Lilly is setting up a website that will then connect patients to outside telehealth companies that have the ability to prescribe the drug. Again, these telehealth companies are supposedly prescribing all different drugs, not just Eli Lilly products. The doctor’s supposed to make sure you actually qualify for the product, and so forth. And then Lilly also seems to have developed partnerships with a couple online pharmacy companies that could then directly mail you the product. So Eli Lilly is sort of helping facilitate these connections for patients. But I think probably to avoid various scrutinies by the federal government, they’ve tried to disconnect themselves a few steps, but certainly make the process of getting a drug and their drug easier for patients. Also helping ease the process of getting any copay support or coupons the company offers. So they seem to be kind of taking advantage of a trend that we’ve seen in other areas, with ADHD, like male sexual health products, and so forth, of people wanting to do this through telehealth. And so they’re trying to, I think, get at least a cut of it or at least help steer their product there. But there’s definitely going to be questions, I think, around how you handle advertising and other things for the government to look at.

Rovner: Yeah, it’s definitely a space that, now, we’re going to have to start watching as well as everything else. All right. Well, now it is time for “This Week in Health Misinformation,” which is going to Olympic gold medalist gymnast Mary Lou Retton. Retton, who is now in her mid-50s, contracted a rare form of pneumonia, ended up in the hospital for a month, and became the subject of a crowdfunding effort launched by her daughter because she didn’t have health insurance. Retton, who has been very closed-mouthed about her illness and what happened to the half a million dollars the crowdfunding campaign raised, as is her right, did do an interview this week with the “Today” show on NBC in which she said she couldn’t afford health insurance because her preexisting conditions made it too expensive. For the record, if you’re uninsured, you can still sign up for an Affordable Care Act Plan in most states, and you can’t be charged more due to preexisting conditions. And there are still extra subsidies that we talked about earlier that were implemented during covid that makes insurance even more affordable. Why is it that people don’t know this yet?

Ollstein: Well, as we saw with record-breaking enrollment, a lot of people do know it, but the people who don’t are still loud.

Rovner: We’re 10 years into the ACA!

Ollstein: Yes. It’s funny. I mean, living in D.C. and doing this work, I always try to think about what of all of our reporting actually breaks through around the country. And it’s always interesting to see what does and what doesn’t.

Rovner: I used to stomp around the NPR newsroom when the ACA was just getting up and running, saying, “It is not my job to do the administration’s publicity. It’s really not my job.” But …

Luhby: Yeah.

Rovner: … they are still working on it.

Luhby: It also may be selective ignorance, because I’m sure if she actually asked anyone about health insurance or called any agent or insurer and said, “Well, I have this preexisting condition,” they may have said, “Well, on the ACA, it doesn’t matter anymore.”

Rovner: Yes. And that if she said she didn’t have the money after her divorce, it’s like those are the people who are eligible for big subsidies. All right. Well, that is this week’s news. Now, we will play my interview with AMA President Jesse Ehrenfeld, and then we will come back and do our extra credits.

I am pleased to welcome to the podcast, in person here in our D.C. studio, Dr. Jesse Ehrenfeld, president of the American Medical Association. Dr. Ehrenfeld is an anesthesiologist, medical school professor, researcher on medical information technology, and director of a statewide health philanthropy in Wisconsin, among other activities. He’s an Afghanistan combat veteran twice over, as well as the first openly gay president of the AMA and a national advocate for LGBTQ+ rights. Dr. Ehrenfeld, thank you so much for coming in. You are a very busy person.

Jesse Ehrenfeld: Well, thanks for having me. It’s great to talk to you today.

Rovner: So I want to start on Capitol Hill, since we’re here in D.C.

Ehrenfeld: Sure.

Rovner: And Congress is coming back and working on a budget, or so we hear.

Ehrenfeld: We hope they’re working.

Rovner: I know physicians are facing, again, a cut in Medicare pay, but that’s not the only AMA priority here in Washington at the moment, right?

Ehrenfeld: Well, it’s a big one for us. And, you know, it’s really painful that you turn the clock back, Jan. 1, and 3.37% Medicare cut to physician payments. It’s unconscionable. And so we’re optimistic that we can get a fix, hopefully retroactive, as the omnibus consolidation work goes forward, short of this Jan. 19 deadline coming up. But we can’t have it. Physicians continue to struggle. My parents lost their own primary care physician because of a challenge with their primary care doctor not being able to take Medicare anymore. And what we’re seeing is more and more doctors just stopping seeing new Medicare patients, or opting out of the program entirely. So, every other provider under Medicare is actually fighting for how many increase they’re getting while doctors are getting cut. So we’re hopeful that we can solve this, but it really is something that’s just urgent for us as an association.

Rovner: I thought we took care of this in 2015. I feel like it’s Groundhog Day. I covered it every year from about 2003 to about 2015, and then we solved it briefly.

Ehrenfeld: We solved one problem and replaced it with another, unfortunately. And the doomed SGR did die in 2015 — the unsustainable “sustainable growth rate” problem — that did lead to those year-end patches. And, unfortunately now, though, because of budget neutrality rules and other — we’ll call them “features” — of the program, we’re in the situation again. We do have optimism, though, that we might get some standing inflationary updates. There was the introduction of a bill last session. And we hope that that can be something that does move forward once we get through this time-sensitive issue to deal with the 3.37% cut.

Rovner: So I feel like the physician shortage is kind of like climate change. People have been warning about it for decades, and suddenly it’s here.

Ehrenfeld: It’s here.

Rovner: With people having to wait weeks or sometimes months to see a doctor. Obviously, like with climate change, it’s going to take a while to get out of the hole that we have dug. I know we’ve seen the establishment of several new medical schools, both allopathic and osteopathic, in the past decade. How soon might we be able to see some relief, and what more will it take beyond training more doctors?

Ehrenfeld: Well, we’re opening more medical schools, but we’re not actually training more doctors. And that’s the problem. We haven’t expanded GME [Graduate Medical Education] residency programs. And unfortunately, because, as you know, GME funding through the federal government is tied to a fixed cap, set in the 1990s by Medicare, we’ve opened all these new schools and the students don’t have a place to go to train. So that’s a problem that we need to solve. We’ve had a little tiny, tiny increase these past few years, a couple of hundred spots here and there. We need thousands more training spots open. We need the GME dollars to come from Medicare. We also need to solve some of the issues around how we get international medical graduates here and ready to practice in the U.S. Twenty-five percent of practicing physicians in the U.S. were trained abroad. Most people don’t know that. We already have a huge international workforce, but we do silly things, like we’ll let an international doctor train their residency here, and then we make them go away for two years to their home country before they can come back. There are H-1B visa waiver bills that are circulating around the Conrad 30 extension. We need to do those things as well. Unfortunately, as you’re aware, immigration reform is a challenging issue here in Washington. But there are commonsense solutions that have bipartisan support. And we’re hopeful that we can get some workforce pressure reductions, not just by expanding GME for U.S.-trained individuals, but also those international graduates.

Rovner: Yeah, I feel like people forget that immigration is about more than just people coming across the southern border. There are a lot of skilled-worker issues in the immigration debate.

Ehrenfeld: In lots of industries, health care, technology, other places as well.

Rovner: I know the rise — or should I say the “re-rise” — of prior authorization requirements from insurance companies is something that contributes to physician burnout and the physician shortage by driving doctors out of practice, just from frustration. The Biden administration has a new regulation to limit prior authorization in the pipeline. Assuming that that regulation is finalized soon, how close will that come to fully addressing the problem for your members?

Ehrenfeld: You know, we hope it’ll move the needle a little bit, but we need wholesale reform, and we need to do more than Medicare Advantage plans. Unfortunately, I hear every week from colleagues who are just at their wits’ end, and it’s frustrating. I see it with my own parents. I’m an anesthesiologist. I have a habit now, I ask my patients: “So how long did it take your surgery to get scheduled?” Eh, it’s a couple weeks or a month. I said, “And how long did it take for your insurance company to approve the procedure?” And it’s months. And often what they tell me is they approved it, and then they denied it after they approved it. And they have to go through all of this rigmarole that just doesn’t make sense.

Rovner: You think that Congress is going to need to step in at some point, or is this something that can be worked out?

Ehrenfeld: I think we’re going to have to have regulatory relief from Congress, and we’re pushing for that through our grassroots network. Certainly, we try to bring all the third-party payers together. We have a set of principles that, theoretically, third-party payers have agreed to, and yet they ignore them, and they continue to just harass patients, really to improve their bottom line, but not doing what’s in their best interests.

Rovner: So I want to talk a little bit about physician autonomy. Since the overturn of Roe v. Wade, we’ve seen an increasing level of what I call legislators practicing medicine. Now we have the Supreme Court …

Ehrenfeld: It’s OK if they have an MD.

Rovner: [laughs] That’s true. Now we have the Supreme Court — none of whom have an MD as far as I know — about to decide whether doctors facing women with pregnancy emergencies should obey state abortion bans, the federal EMTALA law, or their medical ethics, all of which may conflict. What’s the AMA doing to help doctors navigate these very choppy and changing legal waters?

Ehrenfeld: “Choppy” is a good word for it. It’s confusing. And since the decision, the Dobbs decision, came out, we have been working with all of our state and federation partners to try to help physicians navigate this. And I can tell you, it’s unbelievable that now physicians are having to call their attorneys, the hospital legal counsel to figure out what they can and can’t do. And obviously, this is not a picture that is a picture that supports women’s health. So we are optimistic that we might get a positive ruling with this EMTALA decision on the Supreme Court. But, obviously, there’s a long way that we need to go to make sure that we can maintain access for reproductive care.

Rovner: You’re younger than I am, but when I was growing up and covering this, the AMA didn’t want to talk about abortion because it was controversial. And now, certainly in the last five or 10 years, the AMA has come out. Do you think that’s something that has dawned on the rest of the members of the AMA that this is not necessarily about abortion, this is about the ability to practice medicine?

Ehrenfeld: Well, you know, look, if you look at some of these socially charged restrictive laws, whether it’s in transgender health or abortion access, or other items, we take the same foundational approach, which is that physicians and patients ought to be making their health care decisions without legislative interference.

Rovner: So it’s not just abortion and reproductive health where lawmakers are trying to dictate medical practice but also care for transgender kids and adults and even treatment for covid and other infectious diseases. How big a priority is this for the AMA, and what are you doing to fight the sort of “pushing against” scientific discourse?

Ehrenfeld: Well, we will always stand up for science. And it’s so important that as an association we do that. Our foundation in 1847 was to get rid of quackery and snake oil salesmen in medicine. And yet here we are trying to do some of those same things with misinformation, disinformation. And obviously, even if you look at the attack on PrEP, preexposure prophylaxis for HIV prevention — you know, an important part of the Affordable Care Act, right? Making it basically zero out-of-pocket cost for many Americans — those things are just unconscionable. We have treatments. We know that they work. We ought to make sure that patients and their physicians can have access to them.

Rovner: What about doctors who are pushing things that you know to be not helpful?

Ehrenfeld: We call them out, and we would encourage others to call them out. If somebody is trying to sell something that’s inappropriate or do something that doesn’t follow the evidence, we need to call it for what it is, which is inappropriate.

Rovner: It’s not just legislators who want to practice medicine these days. We also have the rise of artificial intelligence, which I know promises both huge advances …

Ehrenfeld: I’m real, by the way.

Rovner: [both laugh] Yes, I can attest that you’re real. At least you seem real. But, obviously, our artificial intelligence can portend huge advances and also other issues, not all of which are good. How is the AMA trying to push the AMA more towards the former, the good things, and less towards the latter, the unintended consequences?

Ehrenfeld: Well, we’re really excited about it. I’m excited about it. I have an informatics background. So, you know, I believe that there is so much power that these technologies and tools can bring, but we need to make sure that the technology is an asset, not a burden. And we have all lived through the painful rollout of electronic health records where that just was not the case. So we did survey — we do routine surveys, data that’s a nationally representative sample — in August of this year, it’s on our website. An equal number of physicians are excited about AI as they are terrified about AI, anxious, concerned, right? And we need to make sure that we have the right regulatory framework. We’re very appreciative of the ONC [Office of the National Coordinator for Health Information Technology] rule that came out, out of HHS [the Department of Health and Human Services], at the end of last year. Certainly, the Biden administration’s, whole of government’s approach we think is important, but that is no substitution for regulation. And we need to make sure that we have appropriate regulation. The FDA doesn’t have the framework that they need. The system set up in the ’60s and ’70s for drugs and biologics and devices hasn’t held up. So we know that there have to be changes. We just need to make sure that those changes only let safe and effective algorithms, AI tools, AI-powered products come to the marketplace.

Rovner: Dr. Ehrenfeld, that’s all the time we have. Thank you so much for joining us.

Ehrenfeld: Oh, thanks for having me. It’s been a treat.

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Tami, why don’t you go first this week?

Luhby: OK. Well, my extra credit is titled “Most People Dropped in Medicaid ‘Unwinding’ Never Tried to Renew Coverage, Utah Finds,” by KFF Health News’ Phil Galewitz. And as many of our podcast listeners know, states are reviewing the eligibility of their residents in Medicaid and terminating the coverage of those they deem ineligible. Roughly 14.4 million people have been disenrolled. And the big question is, what has happened to them? Did they return to Medicaid? Did they find coverage elsewhere, or did they become uninsured? And that’s the question that many actually Medicaid directors have been unable to answer.

So Phil’s story looks at a first-of-its-kind study conducted in October by Utah’s Medicaid agency. And in Utah, 94% of those disenrolled were dropped for procedural reasons, such as not returning their paperwork, rather than being deemed ineligible. And the study found that 57% of respondents did not attempt to renew their Medicaid coverage. Thirty-nine percent shifted to employer plans, and 15% signed up for Affordable Care Act coverage. So they remained insured, but 30% became uninsured. The story also shows that many Medicaid enrollees said that they had trouble reapplying for Medicaid coverage. They didn’t get the documents. They didn’t have the necessary paperwork. They couldn’t get their questions answered. And these are all things that we’ve heard about anecdotally, but the Utah study and Phil’s story actually put some numbers to it. And interestingly, Utah officials also confirmed that the U.S. Department of Health and Human Services is conducting two audits of the state’s Medicaid unwinding. So we’ll see what happens and what we find out from Utah may inform us about what’s happening in the rest of the country.

Rovner: Yes, we have noted before that HHS has been very close-mouthed about how it is trying to get states to maintain coverage for these people who are, if not eligible for Medicaid anymore, eligible for something else. Alice, you have kind of a related story, so why don’t you go next?

Ollstein: Yeah, I have something from our own Rachel Cohrs at Stat. It’s called “Texas Taxpayers Wanted to Help the Poor Get Health Care. Instead They’re Funding a Medical School at a Wealthy University.” It’s a great accountability story about how taxpayers were convinced to put up tens of millions of dollars that they thought was going to provide care for very poor people in the area around Austin, Texas. And instead, basically, none of that money is going to … directly to provide that care to people. And instead, it’s gone to build fancy buildings at this medical school, and overhead, and recruiting faculty. And the school and hospital insist that all of this trickles down eventually to patients. But it’s not what taxpayers feel they were promised. And so they’re getting upset about that.

Rovner: It is a very nice medical school. Sarah.

Karlin-Smith: I looked at a New York Times story from Christina Jewett and Benjamin Mueller, “The F.D.A. Warned an Asthma Drug Could Induce Despair. Many Were Never Told,” and it’s about Singulair, a now generic asthma medicine. Over 20 years after it was first approved, FDA added what’s known as its strictest warning, a black box warning, warning of very serious mental health side effects, including suicidal thoughts. And The New York Times investigation seems to have found out that really these messages are not reaching doctors. They’re not reaching patients, or parents, and many young kids who are taking this medicine. And that has led to many ill effects, including some very young people who have died by suicide. And it’s a really good dive into the challenges that FDA faces and kind of translating their regulatory action into something that then gets communicated to a doctor, and then a doctor translates to a patient. In many ways, it’s not that surprising a story to me because I think it’s kind of well known that not a lot of people read drug labels and then certainly not on an individual level, but even on a doctor level. And I think a lot of the risk-benefit conversations that FDA envisions happen between doctors and patients before people take drugs don’t actually happen in the real world. I once actually had a doctor who told me, “This medicine has a box warning, but don’t worry about it.” Which I always find as a pretty funny story as a drug reporter. And it just also raises a lot of issues, this story, about how drugs are studied on children and what’s done to make sure that as a drug goes generic, the safety is still being monitored, and somebody is responsible again for ensuring people are aware of new safety updates. So it’s a really good dive. I think the thing I was most struck by, though, is I think the solutions perhaps here are not ones that would be very popular in the U.S., which is that by design, the FDA does not regulate the practice of medicine. And, in most cases, I don’t think Americans would want FDA pushing the boundaries much further to get at the safety hurdles this story maybe flags.

Rovner: Yeah. More along our theme of the federal government and its role in society. Well, my extra credit this week is actually a collection of stories. It’s sparked by the headline on this month’s issue of Consumer Reports, which is “How to Eat Less Plastic.” The first story is from CNN reporting on a study in the proceedings of the National Academy of Sciences called “Bottled Water Contains Thousands of Nanoplastics So Small They Can Invade the Body’s Cells, Study Says.” And it basically says that plastic sheds just like skin cells do. So anything you eat or drink that’s stored or wrapped in plastic is going to get into whatever it is you’re putting into your body. If that’s not enough to give you pause, my second story is from ScienceAlert, which is a website, called “It Turns Out Paper Straws Might Pose a Serious Problem Too.” And it’s about a study that found that many paper straws contain those forever chemicals we keep hearing about, called PFAS, which, of course, are also in many plastics. Finally, if that’s not enough plastic for you, here’s a story from The Washington Post called “How Plastic Hides in Supposedly Eco-Friendly Laundry Products.” Basically, those laundry sheets that can replace the use of all those plastic bottles that we keep seeing ads for? Apparently, even many of those sheets that claim to be, quote, “plastic-free” contains something called polyvinyl alcohol, which is, you guessed it, a plastic that’s been found in drinking water and breast milk. I think the message here is everything you do is probably bad for you in some way, so be humble and do the best you can.

OK, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our technical guru, Francis Ying, and our editor, my fellow happy Michigan Wolverine this week, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, or @julierovner at Bluesky and @julie.rovner at Threads. Sarah, where are you these days?

Karlin-Smith: I’m trying to be places, but then it’s hard to be at all of them. So mostly Twitter and Bluesky, @SarahKarlin or @sarahkarlin-smith.

Rovner: Tami?

Luhby: The best place to find me is cnn.com.

Rovner: There you go. Alice.

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

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

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Some background: Ehrenfeld is a Wisconsin anesthesiologist, researcher and medical school professor who also directs a health-care philanthropy in his state. He’s an Afghanistan combat veteran, the first openly gay president of the AMA and a national advocate for LGBTQ+ rights.

This transcript has been edited for clarity and brevity. You can hear the whole interview later today on “What the Health?”

Rovner: Congress is coming back and working on a budget, or so we hear. I know physicians are facing, again, a cut in Medicare pay, but that’s not the only AMA priority here in Washington at the moment, right? [Note: A 3.37 percent cut to Medicare physician payments took effect Jan. 1.]

Ehrenfeld: It’s unconscionable. And so we’re optimistic that we can get a fix, hopefully retroactive, as the omnibus consolidation work goes forward.

Physicians continue to struggle. My parents lost their own primary care physician because of a challenge with their primary care doctor not being able to take Medicare anymore. And what we’re seeing is more and more doctors just stopping seeing new Medicare patients, or opting out of the program entirely.

Rovner: Now we have the Supreme Court — none of whom have an M.D., as far as I know — about to decide whether doctors [treating] women with pregnancy emergencies should obey state abortion bans, the federal Emergency Medical Treatment and Active Labor Act, or their medical ethics, all of which may conflict. What’s the AMA doing to help doctors navigate these very choppy and changing legal waters?  

Ehrenfeld: Choppy is a good word for it. It’s confusing. And since the Dobbs decision, we have been working with all of our state and federation partners to try to help physicians navigate this. It’s unbelievable that now physicians are having to call their attorneys, the hospital legal counsel, to figure out what they can and can’t do. And, obviously, this is not a picture that supports women’s health. So we are optimistic that we might get a positive ruling with this EMTALA decision on the Supreme Court. But, obviously, there’s a long way that we need to go to make sure that we can maintain access for reproductive care.

Rovner: Do you think that’s something that has dawned on the rest of the members of the AMA that this is not necessarily about abortion, this is about the ability to practice medicine?  

Ehrenfeld: If you look at some of these socially charged restrictive laws, whether it’s in transgender health or abortion access, or other items, we take the same foundational approach, which is that physicians and patients ought to be making their health-care decisions without legislative interference. 

Rovner: It’s not just abortion and reproductive health where lawmakers are trying to dictate medical practice, but also care for transgender kids and adults and even treatment for covid and other infectious diseases. What are you doing to fight the sort of “pushing against” scientific discourse?  

Ehrenfeld: Our foundation in 1847 was to get rid of quackery and snake-oil salesmen in medicine. And yet here we are trying to do some of those same things with misinformation, disinformation. And obviously, even if you look at the attack on PrEP, preexposure prophylaxis for HIV prevention — making it basically zero out-of-pocket cost for many Americans — [not providing PrEP is] just unconscionable. We have treatments. We know that they work. We ought to make sure that patients and their physicians can have access to them.

Rovner: Artificial intelligence can portend huge advances and also other issues, not all of which are good. How is the AMA trying to push [medicine] more toward the former, the good things, and less toward the latter, the unintended consequences?  

Ehrenfeld: We need to make sure that we have appropriate regulation. The [Food and Drug Administration] doesn’t have the framework that they need.  We just need to make sure that those changes only let safe and effective algorithms, AI tools, AI-powered products come to the marketplace.

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“I was just trying to make a living,” said Brady, 56, a dealer and supervisor at Borgata in that New Jersey resort city. “You don’t think, you know, that you’re going to get sick at your job.”

Some casinos continue to allow indoor smoking even as the share of Americans who smoke fell from about 21% in 2005 to 12% in 2021 and smoking is banned in at least some public spaces in 35 states, the District of Columbia, and U.S. territories. Still, 13 of the 22 states and territories that allow casino gambling permit smoking in at least part of their facilities.

Brady is among the casino employees, anti-smoking advocates, and public health experts who argue it is long past time to snuff out casino exemptions from smoking bans, given the dangers of secondhand smoke. But they’ve faced stiff pushback from some gambling industry leaders, including in Missouri, Louisiana, Kentucky, and New Jersey, who argue that smoking bans drive gamblers away — especially in places where patrons can go instead to a casino in a nearby jurisdiction that allows them to light up.

The covid-19 pandemic renewed this fight and sharpened the arguments on both sides — on the dangers of particulate matter for the anti-smoking side and the vulnerability of revenues for the casino industry, even as the American Gaming Association reported record-breaking revenues in 2022 for in-person casino gambling beyond the growth of sports betting and online gambling.

Casinos were shut down for several months in spring 2020 as part of the nationwide effort to mitigate the spread of the coronavirus. Rules governing reopening, including masking and physical distancing requirements and bans on smoking, varied by state and, in some cases, by casino operator and community.

After suffering pandemic-era losses, some casino executives, and at least one union representing workers, leaned into a 2021 report commissioned by the Casino Association of New Jersey to combat efforts to ban or restrict smoking at their properties. Using data from 2019, the report suggests that as many as 2,500 Atlantic City casino workers could lose their jobs and tax revenue could fall by as much as $44 million in the first year if smoking is banned in New Jersey but not in neighboring Pennsylvania. Both states considered prohibitions on casino smoking in 2023; New Jersey lawmakers didn’t pass their bill and Pennsylvania’s remains in limbo.

Brian Christopher, a social media influencer specializing in casinos and gambling, said he has heard the arguments about lost business before — and is unconvinced. “People are not driving or flying to a casino to have a cigarette,” he said.

Still, officials in some places are persuaded by arguments about depressed tax revenue. Last spring, Shreveport, Louisiana, officials repealed a 2020 ban on smoking in casinos. Those pushing the repeal said local gambling taxes fell when gamblers left for nearby casinos where they could smoke. The new ordinance allows smoking on 75% of the casino floor.

And Churchill Downs Inc. announced in June it was moving a gambling facility planned for empty mall space in Owensboro, Kentucky, to a location outside the city limits. Though the company declined to comment for this article, the city’s mayor told the Messenger-Inquirer newspaper that a primary reason for the move was the city’s long-standing voter-approved smoking restrictions, which do not exempt casinos.

Kanika Cunningham, director of the St. Louis County Department of Public Health in Missouri, was part of an effort last year to end a casino loophole in her county’s 2011 indoor smoking ban. But after pushback from the gambling company Penn Entertainment, a compromise was reached allowing smoking on 50% of a casino’s floor.

“It’s a balance and one that we feel the marketplace should determine, particularly in such a competitive environment with other gaming facilities nearby and in neighboring states,” said Jeff Morris, Penn Entertainment’s vice president of public affairs and government relations.

Penn Entertainment employs “state of the art ventilation systems, extremely high ceilings,” and “adequate separation of smoking and non-smoking areas,” he wrote in an email to KFF Health News.

The problem, Cunningham said, is that secondhand smoke cannot be contained to a single location in a big room.

“There’s no safe amount, and trying to restrict it to a certain area isn’t going to work,” she said.

Filtration systems can remove much of the visible smoke, as well as the odor, from indoor spaces even when lots of people are smoking, creating the impression of clean air. But existing technology does not eliminate the dangerous particulates in cigarette smoke, according to a 2023 report from the American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE.

A study published in 2023 for the National Institutes of Health evaluated particulate matter at eight Las Vegas casinos that allowed smoking and one that did not. In casinos where smoking is allowed, particulate levels were significantly higher — even in areas designated as nonsmoking — than at the nonsmoking casino.

And in ventilated casinos where indoor smoking is allowed, one study showed, workers can have nicotine levels as much as 600% higher than employees exposed to smoking in other workplaces.

Secondhand smoke can cause coronary heart disease, stroke, lung cancer, and other diseases. Some studies have shown a link to breast cancer, although more research is needed, according to the National Cancer Institute.

The pandemic raised awareness of the dangers of airborne particulates, giving smoking bans fresh momentum, said Andrew Klebanow, co-founder of the independent industry consulting group C3 Gaming, which produced a report in 2022 largely refuting the economic risk of casinos going smoke-free.

Indeed, more than 1,000 U.S. casinos and other gambling properties now ban smoking, including more than 140 tribal casinos, according to Americans Nonsmokers’ Rights Foundation.

New Mexico’s tribal leaders collectively agreed to maintain smoking bans when pandemic restrictions were lifted, said Denis Floge, chief executive of Acoma Business Enterprises and Sky City Casino in North Acomita Village. Employee health has improved, he said, qualifying the casino for rebates on its insurance premium. Cleaning and replacement costs for carpets and equipment fell, he said, and the tribes “haven’t missed a beat” on revenues.

Some guests have grumbled about having to go outside to smoke, Floge said, but that’s about it. “We don’t have anybody who jumps up and down, or throws a fit and says, ‘I’m leaving and never coming back!’” he said.

Casino executives who oppose smoking restrictions overlook people who want to enjoy the “great food and the great entertainment, but won’t step foot in a casino because they get hit by a blast of smoke as soon as they step in,” said Pete Naccarelli, a Borgata dealer and one of three co-founders of the advocacy organization Casino Employees Against Smoking’s Effects.

He said they founded the group, which has chapters in New Jersey, Kansas, Pennsylvania, Rhode Island, and Virginia, after his casino put out ashtrays at 12:01 a.m. the day the pandemic-related smoking ban officially ended. Borgata did not answer requests for comment.

The industry-commissioned report on New Jersey suggests that while more nonsmokers might frequent casinos once smoking is banned, they probably would not make up for the revenue lost if smokers choose other venues or when smokers take breaks from gambling to light up.

But Brady, now cancer-free after chemotherapy and a full mastectomy, believes that if policymakers spent some time breathing the same air she and her co-workers do they’d act more quickly to ban smoking in casinos, rather than prioritize tax revenues. “Our lives are more important,” she said.

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Her commitment to becoming a maternal health care provider was sparked early on when she witnessed the discrimination and judgment leveled against her older sister, who became a mother as a teen. When the Supreme Court overturned Roe v. Wade in 2022, Peacock was already in her residency program in California, and her thoughts turned back to women like her sister.

“I knew that the people — my people, my community back home — was going to be affected in a dramatic way, because they’re in the South and because they’re Black,” she said.

But even though Peacock attended the Medical College of Georgia, she’s doing her obstetrics and gynecology residency at the University of California-San Francisco, where she has gotten comprehensive training in abortion care.

“I knew as a trainee that’s what I needed,” said Peacock, who plans to return to her home state after her residency.

Ever since the Supreme Court decision, California has worked to become a sanctuary for people from states where abortion is restricted. In doing so, it joins 14 other states, including Colorado, New Mexico, and Massachusetts. Now, it’s addressing the fraught issue of abortion training for medical residents, which most doctors believe is crucial to comprehensive OB-GYN training.

A law enacted in September makes it easier for out-of-state trainees to get up to 90 days of in-person training under the supervision of a California-licensed doctor. The law eliminated the requirement for a training license and also permitted training at programs such as Planned Parenthood that are affiliated with accredited medical schools.

“By allowing physician residents to come to California, where there are more opportunities for abortion training, and by allowing them to be reimbursed for this work, we’re sending a message that abortion care is health care and an essential part of physician training,” said Lisa Folberg, CEO of the California Academy of Family Physicians, which supported the bill.

The question of how to provide complete OB-GYN training promises to become more urgent as the effects of abortion bans on medical education become clear: 18 states restrict or ban abortion to the point of effectively stripping 20% of OB-GYN medical residents of the opportunity to get abortion training, according to the Ryan Residency Training Program in Abortion and Family Planning. That’s 1,354 residents this year out of 5,962 OB-GYN residents nationwide.

The restrictions in some cases aim to reach beyond state borders, spooking medical students and residents who fear hostility from anti-abortion groups and right-wing legislators.

One OB-GYN resident in a state with abortion restrictions, who asked to remain anonymous for fear of reprisals, said she’s keen on getting comprehensive abortion care training in California — but can’t.

“My program will not allow us to perform abortions in other states,” she said.

She said administrators worry that doing so would subject residents to litigation because the program is state-funded.

“That is how my program is interpreting the law,” she said. “They’re being very conservative in order to protect us.”

Pamela Merritt, executive director of Medical Students for Choice, pointed to a Kansas law that requires repayment of state medical school scholarships — with 15% interest — if residents perform abortions or work in clinics that perform them, except in cases of rape, incest, or a medical emergency.

Doctors point out that abortion training is not just about ending pregnancies. Peacock recalled a patient who started hemorrhaging badly shortly after a healthy delivery. Peacock and her team at UCSF performed a dilation and curettage — a procedure commonly used to terminate pregnancy.

“If we did not have that skill set, and the patient continued to bleed, it could have been life-taking,” said Peacock, chief OB-GYN resident at UCSF.

It’s not yet clear how many spots will be available in California to train out-of-state medical residents as demand ratchets up. “Many sites were already at their training maximums and are unable to expand opportunities to others,” said Michael Belmonte, a fellow with the American College of Obstetricians and Gynecologists.

Between June 2022, when Roe was overturned, and the end of June 2023, 125 out-of-state doctors did residencies in programs that use the Ryan Residency Training Program model, according to Kristin Simonson, director of programs and operations. Ryan helps OB-GYN residency programs integrate comprehensive abortion care training.

Even when opportunities to learn abortion care are available, those seeking training are proceeding with caution. “Residents arranging to travel for abortion training, like patients who travel for abortion care, are making arrangements quietly so they do not draw unwanted attention or repercussions,” said Janet Jacobson, medical director and senior vice president of clinical services at Planned Parenthood of Orange and San Bernardino Counties, which just trained its first resident from a state with an abortion ban.

Statistics on harassment and attacks against abortion providers or disruption of their work back up such concerns, even in states where abortions are allowed. From 2021 to 2022, for example, there were upticks in stalking of personnel, bomb threats, assault and battery, and obstruction, according to the latest data from the National Abortion Federation.

Jessica Mecklosky, a pediatric resident at UCSF, said she hopes to focus on adolescent medicine, including reproductive health, where she can offer young patients choices about their futures. Her medical school experience in Louisiana, she said, is a prime example of why abortion training in California and other states is so crucial.

She initially wanted to specialize in obstetrics and gynecology but switched to pediatrics, which also would involve reproductive health care. Although she knew Louisiana had abortion restrictions, she didn’t realize how much those restrictions would interfere with her ability to learn: There were just three abortion clinics in the entire state, and as she soon found out, none were available for her training.

“I was actually not going to be able to see any elective abortion procedures throughout medical school, because we don’t rotate through any abortion clinics,” she said. There was an opportunity for a day’s training in her third year, “but, unfortunately, Roe fell before I was able to do that.”

Through Medical Students for Choice, a group that provides stipends of up to $1,200, Mecklosky got an abortion care rotation at Montefiore Medical Center in New York during her summer break.

Mecklosky is torn about where she’ll land after her residency. She may return to Louisiana and advocate for legislative changes in reproductive health while attending to patients and making forays to other states to provide abortions.

She recounts an experience in New Orleans when the Dobbs v. Jackson Women’s Health Organization decision, which undid Roe, was imminent that is etched into her memory. “I had actually seen a few patients who were minors, were pregnant, and wanted to terminate their pregnancies,” she said, noting that they could not afford to travel for an abortion. “And I just remember having this sense of dread, just knowing that if we couldn’t get them into an appointment in the next 24 or 48 hours, it was possible that they would not be able to do it.”

Peacock, for her part, is adamant about returning to Georgia, where abortions are banned after six weeks. “I’m still going to provide abortions, whether that’s in Georgia or I need to fly to a different state and work in abortion clinics for a week out of the month,” she said. “It would definitely be a big part of my work.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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A nivel nacional, se ha registrado un marcado aumento en las visitas a salas de emergencia y hospitalizaciones por covid-19, influenza y el virus respiratorio sincitial, o VRS, a mediados de diciembre y parece estar ganando impulso.

Aquí hay algunas cosas que debes saber:

¿Qué está circulando ahora?

El virus de covid-19 sigue cambiando, y una versión reciente está ganando terreno en las estadísticas. Aunque apareció solo en septiembre, la variante conocida como JN.1, descendiente de ómicron, se está propagando rápidamente, representando entre el 39% y la mitad de los casos, según estadísticas previas a las vacaciones de los Centros para el Control y Prevención de Enfermedades (CDC).

Los datos de laboratorio indican que las vacunas actualizadas, las pruebas rápidas existentes y los tratamientos médicos para covid-19, son efectivos contra esta última variante.

Otra buena noticia es que “no parece representar riesgos adicionales para la salud pública más allá de los de otras variantes recientes”, según los CDC. Aun así, las nuevas hospitalizaciones por covid-19, que alcanzaron las 34,798 la semana que terminó el 30 de diciembre, están aumentando, aunque las tasas aún son sustancialmente más bajas que las de diciembre pasado.

Sin embargo, es temprano en la temporada. Los niveles del virus en aguas residuales, un indicador de cómo se están propagando las infecciones, son “muy altos”, superando los niveles vistos en esta época el año pasado.

Y no hay que olvidar que hay otros virus desagradables circulando. Más de 20,000 personas fueron hospitalizadas por influenza la semana que terminó el 30 de diciembre, y los CDC informan que el VRS sigue siendo elevado en muchas áreas.

“Hasta ahora, los números definitivamente van en una dirección no muy buena”, dijo Ziyad Al-Aly, jefe del servicio de investigación y desarrollo en el Sistema de Atención Médica de Veteranos de St. Louis y epidemiólogo clínico en la Universidad de Washington en St. Louis. “Es probable que veamos un gran aumento en enero ahora que todos han vuelto a casa después de las vacaciones”.

En comparación con el primer invierno de la pandemia, ahora las cosas están mejor. Muchas menos personas están muriendo o enfermándose gravemente, ya que las vacunas y las infecciones previas brindan cierta inmunidad y reducen la gravedad de la enfermedad.

Incluso en comparación con el invierno pasado, cuando ómicron estaba en aumento, la situación es mejor. Por ejemplo, las nuevas hospitalizaciones son cerca de un tercio de lo que eran alrededor de las vacaciones de 2022. Las muertes semanales disminuyeron ligeramente la última semana de diciembre a 839 y también están muy por debajo de los niveles de hace un año.

“La proporción de enfermedad leve a grave claramente ha cambiado”, dijo William Schaffner, profesor de medicina en la división de enfermedades infecciosas de la Escuela de Medicina de la Universidad de Vanderbilt en Nashville, Tennessee.

Aun así, la definición de “leve” es amplia, haciendo referencia a cualquier cosa que no sea lo suficientemente grave como para requerir hospitalización. Mientras que algunos pacientes pueden tener no más que un resfriado, otros que experimentan covid-19 “leve” pueden sentirse “miserables durante tres a cinco días”, dijo Schaffner.

¿Cómo afectará esto la vida cotidiana? “¿Me voy a enfermar mucho? ¿Tengo que volver a usar mascarilla?”. Es importante saber lo básico.

En primer lugar, es probable que los síntomas de las variantes actuales de covid-19 te resulten familiares, como secreción nasal, dolor de garganta, tos, fatiga, fiebre y dolores musculares. Así que si te sientes mal, quédate en casa, dijo Marcus Plescia, director médico de la Asociación de Funcionarios de Salud Estatales y Territoriales. “Puede marcar una gran diferencia”.

Desempolva esos kits de pruebas caseras de covid-19 en casa, verifica las fechas de caducidad extendidas en el sitio de la FDA y desecha aquellos que hayan expirado. Los tests se pueden comprar en la mayoría de las farmacias y, si aún no has pedido el tuyo, todavía hay kits de prueba gratuitos disponibles a través de un programa federal en covid.gov.

Realiza más de una prueba, especialmente si tus síntomas son leves. Los tests rápidos en casa pueden no detectar la infección por covid-19 en los primeros días, según la FDA, que recomienda usar “múltiples pruebas durante un cierto período de tiempo, como dos o tres días”.

Con los tres virus, aquellos más en riesgo incluyen a los pequeños, los adultos mayores, las embarazadas y aquellos con sistemas inmunes comprometidos o enfermedades subyacentes, como cáncer o problemas cardíacos. Pero incluso aquellos sin factores de alto riesgo también pueden verse afectados negativamente.

Aunque el uso de máscaras ha disminuido en la mayoría de los lugares, es posible que comiences a ver a más personas usándolas en espacios públicos, como tiendas, transporte público o lugares de entretenimiento.

Aunque es poco probable que haya un mandato federal de mascarillas, funcionarios de salud y hospitales en al menos cuatro estados: California, Illinois, Massachusetts y Nueva York, han vuelto a pedir a su personal y pacientes que las usen. Estos requisitos se implementan a través de directivas a nivel de condados.

Los datos de los CDC indican que, a nivel nacional, aproximadamente el 46.7% de los condados están experimentando tasas moderadas a altas de internaciones por covid-19.

“No vamos a ver mandatos generalizados de máscaras, ya que nuestra población no lo encontrará aceptable”, señaló Schaffner. “Dicho esto, a nivel individual, el uso de mascarillas es algo muy inteligente y razonable como una capa adicional de protección”.

Las N95, KN95 y KF94 son las que más protegen. Las de tela y papel no son tan efectivas.

Y, finalmente, si aún no te has vacunado contra covid-19 con una dosis actualizada o recibido una vacuna contra la gripe, no es tarde. También hay nuevas vacunas y anticuerpos monoclonales para proteger contra el VRS recomendados para ciertas poblaciones, que incluyen adultos mayores, embarazadas y niños pequeños.

En general, la gripe alcanza su pico a mediados del invierno y se extiende hasta la primavera. Covid-19, aunque no es técnicamente estacional, tiene tasas más altas en invierno, ya que las personas se agrupan en interiores.

“Si no has recibido las vacunas”, dijo Schaffner, “póntelas sin demora”.

¿No lo vamos a contraer todos? ¿Qué pasa con las reinfecciones?

Las personas que han evitado por completo covid-19 son la minoría.

Al mismo tiempo, las reinfecciones son comunes. El quince por ciento de los encuestados en una reciente encuesta de Yahoo News/YouGov dijo que habían tenido covid dos o tres veces. Una encuesta canadiense publicada en diciembre encontró que 1 de cada 5 residentes dijo que había contraído covid-19 más de una vez hasta junio pasado.

Además del inconveniente de estar enfermo y perder días de trabajo o escuela, continúa el debate sobre si las reinfecciones representan riesgos más pequeños o mayores para efectos de salud graves. No hay respuestas definitivas, aunque expertos siguen estudiando el tema.

Dos investigaciones sugieren que las reinfecciones pueden aumentar las posibilidades de que una persona desarrolle una enfermedad grave o incluso covid-19 prolongado, que se define de diversas maneras pero generalmente significa tener uno o más efectos que persisten durante un mes o más después de la infección.

El porcentaje preciso de casos, y los factores subyacentes, de covid-19 prolongado y por qué las personas lo desarrollan son algunas de las muchas preguntas sin respuesta sobre la afección. Sin embargo, hay un creciente consenso entre los investigadores de que la vacunación protégé.

Aun así, Al-Aly, del VA, dijo que un estudio del que fue coautor y que se publicó en noviembre de 2022 encontró que tener covid-19 más de una vez aumenta “un riesgo adicional de problemas en la fase aguda, ya sea hospitalización o incluso la muerte”, y hace que una persona tenga el doble de probabilidades de experimentar síntomas de covid prolongado.

La encuesta canadiense también encontró un mayor riesgo de covid prolongado entre aquellos que reportaron dos o más infecciones. Ambos estudios tienen sus limitaciones: la mayoría de las 6 millones de personas en la base de datos del VA eran hombres y mayores, y los datos estudiados provenían de los dos primeros años de la pandemia, por lo que algunos reflejaban enfermedades anteriores a la disponibilidad de vacunas. El sondeo canadiense, aunque más reciente, se basó en la auto información de infecciones y condiciones, que pueden no ser precisas.

Aun así, Al-Aly y otros expertos dicen que tomar medidas preventivas, como vacunarse y usar máscara en situaciones de mayor riesgo, puede ser una apuesta segura.

“Incluso si en una infección anterior te salvaste de covid prolongado”, dijo Al-Aly, “no significa que ocurra lo mismo cada vez”.

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

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Nationally, a sharp uptick in emergency room visits and hospitalizations for covid-19, influenza, and respiratory syncytial virus, or RSV, began in mid-December and appears to be gaining momentum.

Here are a few things to know this time around:

What’s Circulating Now?

The covid virus is continually changing, and a recent version is rapidly climbing the charts. Even though it appeared only in September, the variant known as JN.1, a descendant of omicron, is rapidly spreading, representing between 39% to half of the cases, according to pre-holiday stats from the Centers for Disease Control and Prevention.

Lab data indicates that the updated vaccines, as well as existing covid rapid tests and medical treatments, are effective with this latest iteration. More good news is that it “does not appear to pose additional risks to public health beyond that of other recent variants,” according to the CDC. Even so, new covid hospitalizations — 34,798 for the week that ended Dec. 30 — are trending upward, although rates are still substantially lower than last December’s tally. It’s early in the season, though. Levels of virus in wastewater — one indicator of how infections are spreading — are “very high,” exceeding the levels seen this time last year.

And don’t forget, other nasty bugs are going around. More than 20,000 people were hospitalized for influenza the week ending Dec. 30, and the CDC reports that RSV remains elevated in many areas.

“The numbers so far are definitely going in the not-so-good direction,” said Ziyad Al-Aly, the chief of the research and development service at the Veterans Affairs St. Louis Healthcare System and a clinical epidemiologist at Washington University in St. Louis. “We’re likely to see a big uptick in January now that everyone is back home from the holidays.”

But No Big Deal, Right?

Certainly, compared with the first covid winter, things are better now. Far fewer people are dying or becoming seriously ill, with vaccines and prior infections providing some immunity and reducing severity of illness. Even compared with last winter, when omicron was surging, the situation is better. New hospitalizations, for example, are about one-third of what they were around the 2022 holidays. Weekly deaths dropped slightly the last week of December to 839 and are also substantially below levels from a year ago.

“The ratio of mild disease to serious clearly has changed,” said William Schaffner, a professor of medicine in the division of infectious diseases at Vanderbilt University School of Medicine in Nashville, Tennessee.

Even so, the definition of “mild” is broad, basically referring to anything short of being sick enough to be hospitalized.

While some patients may have no more than the sniffles, others experiencing “mild” covid can be “miserable for three to five days,” Schaffner said.

How Will This Affect My Day-to-Day Life?

“Am I going to be really sick? Do I have to mask up again?” It is important to know the basics.

For starters, symptoms of the covid variants currently circulating will likely be familiar — such as a runny nose, sore throat, cough, fatigue, fever, and muscle aches.

So if you feel ill, stay home, said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. “It can make a big difference.”

Dust off those at-home covid test kits, check the extended expiration dates on the FDA website, and throw away the ones that have aged out. Tests can be bought at most pharmacies and, if you haven’t ordered yours yet, free test kits are still available through a federal program at covid.gov.

Test more than once, especially if your symptoms are mild. The at-home rapid tests may not detect covid infection in the first couple of days, according to the FDA, which recommends using “multiple tests over a certain time period, such as two to three days.”

With all three viruses, those most at risk include the very young, older adults, pregnant people, and those with compromised immune systems or underlying diseases, including cancer or heart problems. But those without high-risk factors can also be adversely affected.

While mask-wearing has dropped in most places, you may start to see more people wearing them in public spaces, including stores, public transit, or entertainment venues.

Although a federal mask mandate is unlikely, health officials and hospitals in at least four states — California, Illinois, Massachusetts, and New York — have again told staff and patients to don masks. Such requirements were loosened last year when the public health emergency officially ended.

Such policies are advanced through county-level directives. The CDC data indicates that, nationally, about 46.7% of counties are seeing moderate to high hospital admission rates of covid.

“We are not going to see widespread mask mandates as our population will not find that acceptable,” Schaffner noted. “That said, on an individual basis, mask-wearing is a very intelligent and reasonable thing to do as an additional layer of protection.”

The N95, KN95, and KF94 masks are the most protective. Cloth and paper are not as effective.

And, finally, if you haven’t yet been vaccinated with an updated covid vaccine or gotten a flu shot, it’s not too late. There are also new vaccines and monoclonal antibodies to protect against RSV recommended for certain populations, which include older adults, pregnant people, and young children.

Generally, flu peaks in midwinter and runs into spring. Covid, while not technically seasonal, has higher rates in winter as people crowd together indoors.

“If you haven’t received vaccines,” Schaffner said, “we urge you to get them and don’t linger.”

Aren’t We All Going to Get It? What About Repeat Infections?

People who have dodged covid entirely are in the minority.

At the same time, repeat infections are common. Fifteen percent of respondents to a recent Yahoo News/YouGov poll said they’d had covid two or three times. A Canadian survey released in December found 1 in 5 residents said they had gotten covid more than once as of last June.

Aside from the drag of being sick and missing work or school for days, debate continues over whether repeat infections pose smaller or larger risks of serious health effects. There are no definitive answers, although experts continue to study the issue.

Two research efforts suggest repeat infections may increase a person’s chances of developing serious illness or even long covid — which is defined various ways but generally means having one or more effects lingering for a month or more following infection. The precise percentage of cases — and underlying factors — of long covid and why people get it are among the many unanswered questions about the condition. However, there is a growing consensus among researchers that vaccination is protective.

Still, the VA’s Al-Aly said a study he co-authored that was published in November 2022 found that getting covid more than once raises an “additional risk of problems in the acute phase, be it hospitalization or even dying,” and makes a person two times as likely to experience long covid symptoms.

The Canadian survey also found a higher risk of long covid among those who self-reported two or more infections. Both studies have their limitations: Most of the 6 million in the VA database were male and older, and the data studied came from the first two years of the pandemic, so some of it reflected illnesses from before vaccines became available. The Canadian survey, although more recent, relied on self-reporting of infections and conditions, which may not be accurate.

Still, Al-Aly and other experts say taking preventive steps, such as getting vaccinated and wearing a mask in higher-risk situations, can hedge your bets.

“Even if in a prior infection you dodged the bullet of long covid,” Al-Aly said, “it doesn’t’ mean you will dodge the bullet every single time.”

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

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KFF Health News correspondent Daniel Chang discussed malfunctions of the LVAD Heart Mate 3, an FDA-approved mechanical heart pump, on Wisconsin Public Radio’s Ideas Network on Jan. 3.

• Click here to hear Chang on the Ideas Network’s “The Morning Show.”
• Read “Patients Facing Death Are Opting for a Lifesaving Heart Device — But at What Risk?” by Chang and Holly K. Hacker.

KFF Health News senior correspondent Aneri Pattani joined a roundtable panel to discuss the drug crisis and opioid settlement funds on NPR on Dec. 28. Pattani also discussed opioid settlement funds on CBS News’ “Eye on Health” on Dec. 15.

• Click here to hear Pattani on NPR.
• Click here to watch Pattani on “Eye on Health.”
• Read Pattani’s series, “Payback: Tracking the Opioid Cash Settlement.”

KFF Health News chief Washington correspondent Julie Rovner discussed how abortion bans fared in courts in Texas and New Orleans on NPR’s “All Things Considered” on Jan. 3.

• Click here to hear Rovner on NPR.

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

USE OUR CONTENT

This story can be republished for free (details).