Reporters’ Roundtable: High Cost of Health Care

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Mark Masselli (00:04)
Americans have more economic anxiety about healthcare costs than anything else. According to a KFF poll,
we're talking to reporters in Washington and across the country covering that issue and others.

Nada Hassanein (00:18)
The drops in coverage. we actually won't know the extent, until people, you know, have paid their first
premiums, but ranging from anywhere from 833,000 to 1.2 million according to preliminary snapshots of
enrollment numbers. But states have been tracking like where communities are seeing the most drops. So, for
example, the Pennsylvania Health Insurance Exchange Authority in recent weeks told me that rural counties
we're seeing the bigger drops in enrollment.

Margaret Flinter (00:46)
Joining our reporters roundtable are Nada Hassanein, who covers health issues for Stateline, Michael McAuliff,
who writes about politics and policy for Modern Healthcare, and Sandhya Raman, who focuses on health policy
news for Bloomberg Law.

Michael McAuliff (01:01)
One of the Democrats running, and they have these jungle primaries out there. So, it gets a little bit complicated,
is a doctor. and I'll be really curious to see how well he does versus the sort of moderate Republican and the
other regular Democrats running and that, I think that'll give us a good window into how the voters feel about it,
if not necessarily what- you know, the party bosses.

Margaret (01:23)
This is Conversations on Health Care.

Mark (01:36)
Well, welcome to all of you to Conversations on Health Care.

Michael (01:41)
Well, thanks for having me.

Mark (01:42)
Yeah, absolutely.

Nada (01:42)
Thanks for having us.

Sandhya (01:43)
Thank you for having us.

Mark (01:43)
Absolutely. We're looking forward to really a robust discussion, on national and state health policy issue.
Michael, let's start with you. President Trump is focused- really focused his healthcare message right now on
affordability. I think we all see the healthcare spending in the US rose over 7% annually between 2022 and
2024. What is the president proposing and could it work?

Michael (2:11)
Well, his big pitch, was his great healthcare plan, and it, it seems to primarily be focused on drug prices. And it
doesn't seem like it has really broad implications for most people because if you are, have an employer
sponsored plan, which most of us do, then you're not going to TrumpRx, which is this new portal to take
advantage of what are essentially coupons that are available there. And it's really not clear how much, that will
work or, or impact a lot of people. So, I, I don't think folks are, are, you know, seeing their premiums go up in
their paychecks or, or if they're on the ACA, seeing how much more they have to pay, feeling like the TrumpRx
or this idea of savings accounts, self-savings accounts is really going to do much for them. I mean, 'cause there's
like, I think the savings accounts would be about 1500 bucks for, for one person. you know, how much
healthcare these days will you buy for $1,500?

Margaret (03:09)
Well, Sandhya, you, closely cover the Department of Health and Human Services, and so as we talk, we're
awaiting the president's proposed budget for the next fiscal year. It does seem to me like it's only been a
nanosecond since we finished the last one. but is the feeling that he's going to try, and chop away at HHS
budgets and do you think Congress will go along if there's further cost cutting or further funding costs? Or
further funding, I should say?

Sandhya (03:35)
I think what we can expect is just to kind of follow the pattern of what we've seen in the past. I mean, every
president uses their budget request as kind of a wish list. No one's gonna get everything they want on that wish
list, but it is kind of, you know, setting the tone for what they hope Congress will do. So, I think what we can
kind of expect is that, for him to propose decreases, across HHS I think I would especially look for places like
NIH and CDC to have proposed smaller amounts. and within that, you know, proposing to cut some programs
that don't align with the president's priorities. Things we've seen in the past are, you know, programs related to
DEI or, you know, some of this HIV programming. so, we look for that. the other part of it is kind of looking at
some of the policy proposals that are also included within that budget request. So again, I would look for things
that are MAHA aligned or, you know, promoting the administration for Healthy America that the administration
kind of wants to reshuffle around in HHS, you know, what that entails. You know, we've seen a much bigger
push on, you know, nutrition and, and eating and, and that compared to some of the other MAHA priorities. So,
I would look for that. and then I think I'll also along the lines of what Michael said, you know, just, some of the
drug pricing proposals, things like most favored nations kind of emphasized within that, budget proposal.

Mark (05:05)
Well, Michael, let's pick up on Sandhya's MAHA focus, there's reporting that the Make America healthy, again,
efforts are unpopular when it comes to changing vaccines, but it appears that the MAHA interest in healthier
more natural food seems to be attracting wide support. it seems that the White House believes this part of
Maha's winning issue. What, what, what are you seeing out there?

Michael (05:31)
Well, it's interesting. You have this primary in Texas today where, I think it's the agriculture commissioner, I, I
don't remember exactly what the name, what the title is, but the man, Sid Miller, who's had the job for like four
terms is like, he's running aggressively as a MAHA guy. Yeah. And his opponent is running aggressively as a
MAHA guy, and the Democrat is running aggressively as a MAHA guy. So, they're all very, very much
interested in all this. And, and it's sort of gotten a little bit complicated lately with this glyphosate executive
order that the president put out because Kennedy, and most of the folks in the MAHA are really worried about
pesticides and the impacts on people health. So, you know, there's this, there's this tension in there between the
sort of MAGA and the MAHA that's going on right now, but the, the MAHA stuff is, is pretty broadly
supported, even if on the left people don't really trust it.

Margaret (06:20)
Well, it's hard to argue against healthy food and good diets for everybody. So, it's, it's good to have something
we can rally, around. And I'm sure they're feeling a little bit of that too. But Nada I'd like to ask you, about
something that you've, written about policy decisions, have real life consequences and nowhere is that more
true, maybe, than in healthcare. Can you share with us what you learned about breast cancer survival rates in the
Medicaid expansion states?

Nada (06:50)
Yeah, sure. so, you know, study, by researchers from Howard University, and others looked at survival rates,
from about 1.6 million women, ages 40 to 64, who were diagnosed with breast cancer between 2006 and 2021.
And they compared survival rates among women living in states that expanded Medicaid eligibility under the
Affordable Care Act, with rates in states that did not expand Medicaid. And what they found was that women
with breast cancer living in states that expanded Medicaid eligibility were less likely to die from the disease. and
the researchers found that to be true, no matter the disease stage, race or ethnicity, neighborhood income.
women in expansion states whose cancer had spread to other organs, the most advanced stage of disease, saw
the most significant decline in deaths. but they did see variability. So Hispanic women saw the largest gains, and
black women and lower income women saw smaller gains, which is concerning, you know, given black women
have higher breast cancer death rates compared to white women, although fewer cases, they're often diagnosed
at a later stage. And so, the lead author told me his team is surmising that black women with breast cancer
benefited less in this study according to the study, from Medicaid expansion, simply because they're
disproportionately located in the south, which where there are seven of the non-expansion states.

Mark (08:16)
Nada, let's just stay with you for a moment on really the enhanced Obamacare subsidies, which expired at the
end of the year. What has Stateline reported about how states are reacting to insurance premium price hikes?

Nada (08:30)
Yeah, so, you know, the drops in coverage, we actually won't know the extent, until people, you know, have
paid their first premiums. but ranging from anywhere from 833,000 to 1.2 million according to preliminary
snapshots of enrollment numbers. But states have been tracking like where communities are seeing the most
drops. So, for example, the Pennsylvania Health Insurance Exchange Authority in recent weeks told me that
rural counties we're seeing the bigger drops in enrollment. other states, you know, have said, you know, their
hearing enrollees were holding out, for whether Congress would extend the subsidies. my colleague, Shalina
Ani also reported on how, 10, at least 10 Democratic leaning states, or actually using their own money to help
people buy Obamacare health plans, by at least partially replacing the federal tax credits that expired. and some
of that state assistance is being offered through programs that existed before the federal subsidies expired. you
know, but nonetheless, it, it, it is, it is an effort to grapple with this, with, you know, with the hikes. it's also
possible we might see more states wanting to offer a new public option as affordability continues to waiver.
Nevada actually became the latest state, the third state after Colorado and Washington to offer a new public
option to its state run exchange. And these are public private partnerships that are a sort of alternative to private
insurance coverage.

Margaret (09:56)
Well, Michael, the Trump administration continues to draw attention to what it calls Medicaid fraud in the
States. I wonder if you could, tell us what's the latest on that front? Are we seeing that across the board? Does it
appear to be targeted to the expansion states? Tell us about that.

Michael (10:13)
Well, it, it appears to be targeted towards blue states, really. And, and Minnesota is the sort of big example right
now. I believe the state just, sued to block the administration from halting about 240 or $250 million worth of
payments to the Medicaid program. And, we actually had a reporter, Bridget Early at an event today with Dr.
Oz. So, she asked him about that and, and he said, yeah, you know, there's, there's, Minnesota is not clear on
what their standards are. They haven't been clear on, on what they're doing to stop fraud. And, you know, on, to
be fair, they've, I think, reclaimed around $80 million in 300 different fraud cases. So, you know, you have to,
you know, decide how much you believe which side. But Dr. Oz said, you know, it's just the bad guys are
making it worse for the good guys and the guardrails are not strong enough, and we're gonna do it here in
Minnesota, and we're gonna do it in these other states where we think it's a particular problem. So, I think you
will see more of that going forward. And, and as I said, so far, it's been more focused on blue states. I mean, if
you just do a quick Google search for Medicaid fraud, you'll see Texas pop up an awful lot right now. Maybe
you can say, well, Texas is popping up so much because they're fighting fraud, so well, but, you know,
Minnesota was fighting a lot of fraud too, so it gets very political, but I do think it's gonna keep on going, as we
go into the election season. And that's one way they can say that they're trying to cut costs.

Mark (11:41)
Sandhya, the administration's candidate, to be Surgeon General, has faced some very tough questions on Capitol
Hill. What are her chances, for Casey Means confirmation? it seems like it's in trouble, but they seem to rally
behind their candidates at the end of the day.

Sandhya (12:03)
I mean, I think you're right in that it is definitely one where the path isn't a hundred percent clear if they have the
votes. so, we, we have a two-step process. We need to advance through the Senate Health education, labor and
Pensions committee, where she testified a few days ago, and then through the full Senate. And I think the big
hurdle will really be the first vote, because without that, you can't get to the second vote. And there is, has been
some hesitation there. So, you have, you know, the leader of the committee, bill Cassidy, who's, you know, had
some, some back and forth, power play with, with RFK Junior at HHS, and he had a lot of questions for her on
vaccines and some of the recommendations on pediatric immunizations. And he did another round of questions,
and it's not a hundred percent clear if he was satisfied with all of those responses that he got. He's been a little
tightlipped about which way he's gonna go, but I think it will also rely on the fact that Senator Susan Collins and
Lisa Murkowski also had some kind of pointed questions where you can't really tell if, if they're going to be on
board. I mean, they question some things like, in in Means' book she talks a little bit about personal psychedelic
use and, you know, kind of how that would play as, the surgeon general kind of talking about that publicly. And

then, you know, just more of the vaccine, questions, from, from Senator Murkowski. So, I think depending on
how the different, you know, continued meetings go, we'll have a better idea on if she can get across the
committee level, but it's still unclear if, if she has the votes at this point.

Mark (13:48)
Remind me, are all three of those, senators Cassidy, Murkowski and, Collins up, for reelection this year?

Sandhya (13:58)
I'm not sure, on when all of them, but Bill Cassidy is the one that is in a pretty contested- you know, he was a
primary challenger…

Mark (14:05)
He voted for the- He voted for the president's impeachment, but I think Collins is up, right?

Sandhya (14:12)
Yes, yes, she is as well. I'm not sure when the next Alaska election is.

Margaret (14:18)
Well, let me stay on vaccines for a minute, if not elections. Sandhya, I, understand that you're going to be
covering a CDC vaccine panel, a decision regarding what's referred to as COVID-19 injuries. I'm curious, what
exactly are they going to be voting on and what are the implications? And there's always been a process for
reporting vaccine related complications. but how, how is this different, do you think?

Sandhya (14:44)
So, I, I think this is really interesting because A, there's a lot that we don't know, and B, just because this is kind
of outside the jurisdiction of what we've seen from, this panel, known as ASIP in the past. So, what we know
from the notice that they've put out is they wanna look at COVID-19 vaccine injuries, long COVID, and just
how they make, different recommendations. We should know more with like a broader agenda closer to when
we have the meeting in March. But, one thing to consider is we possibly might not have that meeting altogether.
There's litigation trying to challenge whether or not that meeting can happen, and so there's a chance it gets
pushed more or canceled. but I think you're right, you know, the fact that vaccine injuries are not really
something that this panel looks at. They look at how vaccines should be used or not used to limit the spread of
communicable diseases. There are other panels within HHS that look at, you know, vaccine injuries, for, for
children or, you know, vaccine injuries related to other adverse events. And so, it's not guaranteed that they're
gonna vote on anything specific, the way the notice is written. It's, you know, they'll discuss it and possibly vote
on something, but if they do, it could, you know, open a whole new door to what sort of recommendations we
make. And what we've seen in the past is traditionally when they recommend something, CDC, you know, signs
off on it, and it, you know, becomes a full-fledged, recommendation. But, you know, we have another thorn in it
in that, you know, we have a new acting CDC director now, the head of the NIH Jay Patria is now the head of
the CDC in an acting capacity. And so, you know, it's unclear, is he gonna sign off in the same way? Is he gonna
push off, push back a little bit more? I think we have a lot of unknowns on what can happen. And so, it makes it
a little trickier to know what the implications will be without that. and knowing a little less about two of the new
members that were appointed just in the last week.

Mark (16:54)
And we have, we've had a number of conversations with, with leaders around long COVID. How much does
that, maybe to all of you, how much does that animate the health con- policy conversation down there? Is it
getting any traction or is there pretty much in the rear view mirror?

Michael (17:08)
I haven't heard people talking about it at all for, for quite a while now. I mean, by the time you get through, the
big, beautiful bill, the ACA and, and now there's a war, you know, long COVID is, is not long gone, but, but it's
not being talked about.

Margaret (17:25)
As is often the case except for the people who are impacted by experiencing it and, and the people who care for
them. Yeah. Well, mark, maybe I can, ask you, or I'm sorry, Nada, one issue we've been talking about, a lot out
here in, the front lines is the new rural health transformation program that's, going to be funding state initiatives,
and we're curious, $50 billion, $50 billion I might add. Yeah. What are you reporting on, regarding, this, big
initiative of the administration?

Nada (17:58)
Yeah, I mean, it is a big initiative. there are a few misnomers, around this program. so kind of trying to correct
some of, you know, misinformation out there around it, but some, some have been calling it the Rural Hospital
Fund. It really is not that. in fact, CMS has put limits on how much can be used for each approved purpose.
there's actually a 15% cap on how much of the award can go directly to providers. but there are other ways
states can support providers, and they proposed specific ways, including through recruitment efforts, training,
that kind of thing. but it's really not clear how much hospitals will effectively benefit or directly or indirectly
benefit from the funds. so, I'll be interested to see how states continue to sort of support the rural healthcare
landscape in that way. CMS isn't requiring public transparency around this. so, it's really important to kind of
track different states and, and, and what they're doing directly. you know, state agencies I've spoken with are
saying the money isn't enough to offset the Medicaid, the Medicaid cuts, over the next decade in the OB three.
that being said, I'm really interested in continuing to report on how states are looking to expand access to
clinicians. As we all know, part of what rural America suffers from is not only a lack of primary care providers,
but also a lack of specialists. whether that's, you know, cardiology, O-B-G-Y-N, so I'm looking to shed light on
how some states are actually using the funds to try to create regional care networks, or virtual ones that facilitate
access, to specialists for consultation in rural areas, kind of more seamlessly, profession, professional to
professional. another huge gap is maternal health, and this wildest infusion and money can't fix the system that
ultimately favors volume, you know, putting rural areas at a disadvantage. looking into how states
transformation programs are trying to maybe support, alternative birthing facilities like birth centers and
midwifery, which can help fill gaps, particularly for low risk pregnancies, as well as equipping training rural
EMS in maternal health emergencies. behavioral health was also an issue that came up a lot in states
applications, and in their project priorities. So, looking at that intersection, another important aspect is how
tribes are represented and not represented in the awards, how much money they received, or rather, which
specific initiatives were stipulated for and by them. because we know that American Indian, Alaska native and
native Hawaiian people have some really stark health disparities and a good number live in rural areas and tribes
or sovereign nations.

Mark (20:48)
Nada, you have some interesting coverage about states requiring insurers to cover non-opioid pain medications.
What have the insurers been resistant to do? So why, why have they been resistant?

Nada (21:02)
Yeah, to be more specific, you know, this resistance, it's really a lack of parity when it comes to coverage of
non-opioid pain meds versus opioids. So, opioids in the US are really quite cheap. Opioids are abundant.
Opioids are also commonly available in generic forms. In contrast, a new to the market, non-addictive, you
know, non-opioid pain, prescription med, can be more expensive simply because it's newer to the market and
not available in the generic form. the FDA, for example, last year approved a new drug called Nerva, the brand
name, which is the first non-opioid pain relief medication in a new class of analgesic drugs, and that's about $15
per tablet. and so insurers or plans may instill higher copays for non-opioid prescription pain meds compared to
copays for opioids. insurers may also require step therapy, which is that fail first, you know, trying something
else first, something cheaper, or prior authorizations, all of which caused d delays in a patient getting the med.
One clinical pharmacist told me she daily has to appeal when filling prescriptions for non-opioid therapies.
Another clinical pharmacist told me insurance plans often, you know, avoid covering prescription strength, you
know, NSAIDs, non-steroidal, anti-inflammatories like ibuprofen because they'd rather people pay out of pocket
for the lower strength over the counter version.

Mark (22:29)
You know, maybe I can just, since we're talking about drugs, get a question in about three 40 B, what are you
hearing about legislation on that front, maybe to everyone?

Michael (22:38)
Well, I haven't heard a lot about legislation on that front, but there are still a lot of people talking about it more
sort of in the advocate sort of class than on Capitol Hill. but I know Bill Cassidy, the endangered Bill Cassidy,
certainly he's asking about, you know, what we can do to change the program there. There's a strong sense that,
some hospitals are abusing it and that perhaps it consider it contributes to hospitals growing too large, buying up
little clinics so that they can get into the 340B program, things like that. So there, there is a certain, emphasis on
Capitol Hill, amongst some, not, not too many of them, because a lot of 'em don't wanna hurt hospitals any more
than they feel like they may already have. But it's sort of a, a low boil beneath the surface, I would say.

Margaret (23:25)
Interesting. And thank you for keeping an eye on it. Michael, there are a relatively large number of physicians
who are running for the house, as Democrats we're really curious, how confident do you think the party is that
being a physician is maybe an advantage or a, winning point? Do you think that they will do well at the ballot
box as a group? Any comments on that?

Michael (23:49)
I don't know how the party as a whole feels, but I do know that there are a couple of hacks out there who have
formed precisely to promote not just doctors, but scientists, mathematicians, doctors and nurses that seem to be
the big, the big part, and I'm watching this California primary, I believe it's, California six where Dr. Amy Barra
used to be the, or still is the representative, but under redistricting, he's going to a different district. So you've
got a primary there where you have a member of Congress who's a Republican moderate, Kevin Kiley, who,
you know, he talks about supporting healthcare and things like that, but he voted for the big beautiful bill, and
he wanted to keep the a CA tax credits around, but he still voted against the three year extension, right? One of
the Democrats running, and they have these jungle primaries out there. So, it gets a little bit complicated, is a
doctor. and I'll be really curious to see how well he does versus the sort of moderate Republican and the other
regular Democrats running and that, I think that'll give us a good window into how the voters feel about it, if not
necessarily what, you know, the party bosses. I think the party bosses just want, you know, some good, good
looking candidate who can get out there and they, they'll take them an ex-Marine or a doctor or whatever they
can get their hands on.

Mark (25:07)
Or a farmer. Well, you've covered, we've covered a lot of, items today, but maybe a question for all three of you.
What, what are emerging health public policy issues on the horizon that we've not discussed so far that you
have, a keen interest in?

Michael (25:23)
Well, I've been trying to look around for what hasn't happened this year. at some point, we'll, we'll do that story.
And the thing that I've heard a lot about is like, all right, what are we gonna do about doctors pay? Right? They
had a little stop gap, you know, in there, but it runs out at the end of the year, and you've got an election season
where no one really wants to spend money. So, a lot of lobbyists think there'll be some sort of, attempt to
address that in a lame duck session after the elections. And it was interesting when they did these, the, current
round of government funding, most of the healthcare priorities, they put a calendar year date on, so they end in
December rather than September 30th, which is the usual fiscal year on Capitol Hill. So, there's a lot of stuff,
there's more stuff that has to be extended. And so, there are, there is talk about like, “All right, what might we
want to attach in a lame duck?” And doctors pay was one of the things I've heard people talking about. Will that
happen? I don't know. Congress is very, very hard to predict lately.

Margaret (26:25)
I have no, no idea whether the issue is more or less, but that's all right. We'll leave that and I'll find out in the,
discussion, Nada or Sandhya?

Nada (26:34)
Yeah, yeah. I, I think, you know, Sandhya mentioned earlier about HIV, coverage and state assistance programs,
you know, funding has been really flat, you know, for, for, for quite a long time and states are looking to do, you
know, instill cost containment measures, interested to see how those really play out and how people are affected.
but also, health equity efforts, that have been sort of targeted by the federal administration or sort of canceled,
DEI initiatives across, you know, state nonprofit and university health systems. and how that'll really, you know,
affect, populations that, you know, experience health disparities, and seeing how, you know, these, these groups,
you know, try to find other funding streams to support those initiatives.

Mark (27:22)
And there's certainly an enormous amount of cuts coming out of NIH that focus those areas. So, we'll keep an
eye out.

Margaret (27:28)
and Drug assistance for HIV patients. Sandhya?

Sandhya (27:32)
Yeah, I think I'll be interested, just kind of see how the messaging changes in terms of priorities kind of more
broadly with this being a midterm election year. you know, we touched a little bit on this earlier before, but if
there are certain things we're starting to downplay, and kind of raise up just because of how, the political
appetite then for is different. So, you know, just are we changing the messaging on, on vaccines because of, you
know, how that is or is it shifting a lot more towards some of the other MAHA ideas? and just kind of how that,
plays out across different, you know, regulations and things, that'll be kind of interesting to watch.

Mark (28:15)
And do you think the air will be sucked out, around healthcare, around the war out there that, you know,
healthcare will take a, a backseat to all these issues?

Sandhya (28:25)
I don't know that healthcare is ever out of the hot seat. Even if they, we have a war going on, there's always
something.

Michael (28:32)
Well, there is a little silver lining to when there are other big issues. And that is like the staffers and the
stakeholders in healthcare can have conversations, you know, behind the scenes more easily. And, and then,
then when the spotlight is right on them, like it, it was with the ACA or with the big, beautiful bill. So, so when
the government was shut down, a lot of stuff actually moved forward, and a lot of sponsors got added to bills.
So, so, so maybe they can get that lame duck package together while everyone's, upset about the war.

Margaret (29:01)
Thank you Nada, Michael and Sandhya for joining us, and thank you to our audience for being here. Just a
reminder, be sure to subscribe to our videos on YouTube, find us on Facebook and X, and also share your
thoughts and comments about this program. Take care and be well.

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Margaret (29:21)
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