Any Hope to Avoid Govt. Shutdown in ’24? Health Care Reporters Assess the Chances

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Mark Masselli ( 00:05 ):
Most Americans think 2023 was better than the three years before, according to one poll. The nation's
improving healthcare situation probably has a lot to do with it. This was the year the majority of us could
really look at COVID in the rearview mirror. But what's on the horizon?

Nathaniel Weixel ( 00:21 ):
At this point, it looks like a compromise is a long ways off, both in terms of top - line numbers and just
policy. The House hasn't passed their funding bill for the Department of Health and Human Services yet.

Margaret Flinter ( 00:40 ):
Our guests are joining us from the nation's capital to break down, explain, and analyze the top
healthcare stories they're tracking.

Caitlin Owens ( 00:47 ):
Look at what my fellow panelists are talking about. Right? Nathaniel was talking about a transparency
bill that may or may not be able to get through the Senate. We're talking about the Republican primary,
where they're discussing transgender care. I mean, on one end, we have very polarizing issues that
there's no hope of bipartisan compromise on. And then on the other, we have examples of bipartisan
compromise, but they're not the wide - scale. It's not the Affordable Care Act repeal or replace, or
Medicare for All. These are very minor in the grand scheme of things.

Margaret Flinter ( 01:21 ):
This is Conversations on Health Care.

Mark Masselli ( 01:32 ):
Well, we've got a great guest list today, and we welcome them to Conversations on Health Care. They're
all distinguished journalists known for insights they bring to reporting. Joyce Frieden oversees MedPage,
today's coverage of Washington and health policy. Caitlin Owens is a senior policy reporter for Axios,
and Nathaniel Weixel is a healthcare policy reporter for The Hill.

Mark Masselli ( 01:55 ):
Nathaniel, let's start with you. I don't think this is a New Year's wish that you could have, but we do have
for the new year, two potential federal government shutdown deadlines in 2024, one in January that
includes money needed for the FDA and Veterans Affairs, and the other in February that covers other
funding for the US Department of Health and Human Services. I'm wondering, do you see any hopes for
a compromise between the Republicans and Democrats to get these bills passed?

Nathaniel Weixel ( 02:26 ):
I mean, at this point, it looks like a compromise is a long ways off, both in terms of top - line numbers and
just policy. The House hasn't passed their funding bill for the Department of Health and Human Services
yet. They keep trying, but it keeps getting either delayed or pulled because of disagreements among
moderate Republicans and conservative Republicans. You get disagreements about funding levels,
disagreements about abortion, disagreements about lots of unrelated issues that come into play. So it
seems like a compromise is a long ways off. I wouldn't say never, but it's going to be a rough couple of
weeks when we get back.

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Margaret Flinter ( 03:17 ):
Well, Nathaniel, a bipartisan group in the house did pass a significant healthcare package, the Lower
Costs, More Transparency Act, but its fate in the Senate, perhaps for the reasons you've just outlined, is
uncertain. What's in this bill and what are the points of contention?

Nathaniel Weixel ( 03:35 ):
Yeah, I mean, this bill passed pretty overwhelmingly in the House. Really, it's a transparency bill, I'd say,
is one of the big issues. And it makes it clear. The other issue, site mutual payments, it equalizes
payments on medical sites. That's the biggest point of contention among hospitals, is that it equalizes
payments on outpatient departments. So hospitals are clearly lobbying hard against it. They like some of
the other transparency requirements, but it divided Democrats in the House, because some Democrats
felt it didn't go far enough in terms of transparency. There wasn't enough information on private equity
ownership issues.

Nathaniel Weixel ( 04:17 ):
But as we said, it's a pretty bipartisan bill, so it could do well in the Senate. It sets the House up as a
strong negotiating point for when it does get to the Senate. It's not clear if all of those provisions will be
included in whatever the final version is. And they're looking likely as an add - on to a year - end bill come,
well, not the year end, but what would be a year - end bill on January 19th. So these provisions, whatever
they are, would likely be on that. And the House is in a good position to negotiate concessions from the
Senate, or just to make a Senate bill look closer to a House version. But I guess we'll see.

Mark Masselli ( 05:01 ):
And Joyce, the presidential campaign season is underway. We'll kick into high gear very soon. I think
Iowa's four or five weeks out. You recently wrote about the Republican candidates who debated. And
they focused in on transgender care and fentanyl policy. I'm wondering if you could give our listeners an
overview of their positions, and what they're trying to achieve.

Joyce Frieden ( 05:24 ):
Sure, Mark. Yeah, the transgender care really was quite a divisive issue. The moderator very aggressively
confronted Chris Christie about his position that transgender surgery is a parental rights issue, that
parents should have a say in whether to allow this for their children. And she asked if he thought he was
out of step with the Republicans, and he stood his ground. He said, "No, I'm not. Republicans believe in
less government, not more. We're out there saying we should empower parents in education, and that
they should be able to teach kids what they believe in, and yet we want to take other parental rights
away."

Joyce Frieden ( 06:14 ):
He personally said he thought gender transition surgery is very dangerous, "But that's my opinion as a
parent," he said, "and I get to decide." Ron DeSantis, on the other hand, totally disagreed and said, "As a
parent, you don't have the right to abuse your kids." And he called it mutilation of minors. That earned
him a rebuke from the Endocrine Society, which said that what DeSantis said contradicted mainstream
medical practice. And then Nikki Haley chimed in, and she used this as an opportunity not only to talk
about what she had done in this area as a South Carolina governor, but also to say that biological boys
shouldn't be playing in girls' sports or use girls' bathrooms. And then Vivek Ramaswamy said that

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transgenderism is a mental health disorder, and these procedures shouldn't be done on minors. So they
all had slightly different opinions.

Joyce Frieden ( 07:23 ):
And then when they talked about fentanyl, similarly, they differed on the causes and the solutions.
DeSantis was focused on the drug cartels, and what to do about that. And he was emphasizing building a
wall across the Southern border. Whereas Nikki Haley was talking about China and the fact that fentanyl
was coming from there. And she said, "We need to end trade relations with China, and they immediately
will put a stop to it, because they need us." And Ramaswamy, again, focused on the mental health issue,
and said, "The mental health epidemic that's raging here is the cause of a lot of this problem." So again,
very different views on these topics.

Margaret Flinter ( 08:18 ):
Absolutely. And Caitlin, let me turn to you. You wrote a story with a provocative headline, I thought,
provocative, that said, "The era of major US health reform is over." And I call it provocative because a
Times Magazine poll found that over 70% of Americans feel failed by the healthcare system. Do you
think there's really no hope for policy change, especially with this percentage of the country unhappy
with things as they are now?

Caitlin Owens ( 08:48 ):
I think that's the case in the short term, short to medium term. Just look at what my fellow panelists are
talking about. Nathaniel was talking about a transparency bill that may or may not be able to get
through the Senate. We're talking about the Republican primary, where they're discussing transgender
care. I mean, on one end, we have very polarizing issues that there's no hope of bipartisan compromise
on. And then on the other, we have examples of bipartisan compromise, but it's not the Affordable Care
Act repeal or replace, or Medicare for All. These are very minor in the grand scheme of things, changes
to the system.

Caitlin Owens ( 09:30 ):
So the point of my piece was mostly that our political system is so gridlocked today that, to your point,
despite the challenges that the country faces with healthcare, despite voters' dissatisfaction with the
system, the political system does not allow for huge change right now. I think that that will eventually
change if and when voters become even more dissatisfied with the system. But for now, it's hard to see
bridges to big reforms, based on the gridlock in Washington.

Mark Masselli ( 10:03 ):
Well, that's such a good observation. Nathaniel, we don't want to leave out former President Donald
Trump, though he didn't attend the debates, but he's leading in the polls, both in the Republican
primary and on the one - on - one with President Biden. But let's dive into his healthcare ideas. He wants
to repeal and replace the Affordable Care Act. He says it's too expensive, and yet we're seeing surveys
that show it's popular, and Americans want to keep it. He's against cuts to Medicare and Social Security,
and yet some of the Republican opponents support reductions. And he wants to institutionalize those
who are homeless situations. I'm wondering how these ideas are playing on Capitol Hill, in any sense of
what else he could roll out soon.

Nathaniel Weixel ( 10:56 ):

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I mean, anytime you try to talk about Donald Trump to Congressional Republicans, you're either going to
get praise for whatever his ideas are, or they haven't seen the tweet, or they haven't seen whatever the
latest policy proposal. So -

Mark Masselli ( 11:12 ):
Haven't read the full brief. That's right.

Nathaniel Weixel ( 11:14 ):
Right. So a lot of what he talks about, they don't want to address on Capitol Hill, maybe up until they're
forced to reckon with it, when or if he is back in the Oval Office, like repeal and replace. It didn't work
last time. Trump clearly hasn't given up on it. Republicans don't really want to talk about it, because as
you said, it's so popular. But they may have to, if he's back in and wins a trifecta in the House and
Senate, and he's in the White House and he says, "We're going to repeal and replace, and try again."
Then they're going to have to deal with it.

Nathaniel Weixel ( 11:56 ):
But as the last Trump presidency you saw, he talked a big game on a lot of things. He talked a big game
on pharma, about lowering prescription drug prices. Nothing really came of his policies. One was
blocked by a court. Biden has tried to repeal some others that weren't so popular. So Trump talks a lot.
It remains to be seen if what he says in terms of his hard healthcare policy will come to be.

Margaret Flinter ( 12:29 ):
Well, Caitlin, that's a good opportunity for us to also take a look at President Biden's agenda. I'll list just
a couple of them. His aides are looking at providing access to Obamacare coverage in those 10
remaining states that have not expanded Medicaid. And he's looking, I understand, at a renewed push
for a public option, which would create a government - run healthcare plan that could compete for
customers with private insurance companies. What does your reporting tell you about these ideas and
how they're being received?

Caitlin Owens ( 13:01 ):
From what we know so far of what President Biden will be running on, which we're still waiting for a lot
of detail and public confirmation, basically, it can be summed up as a "finish the job" agenda, all of these
things finishing or filling the coverage gap with Medicaid expansion, making enhanced Affordable Care
Act subsidies permanent, potentially a public option, potentially expanding the Medicare drug pricing
negotiations law. All of this stuff, none of it are new ideas that Biden has not talked about before, at
least so far, from what we're seeing. It's agenda items that he was not able to accomplish in his first
term, or that he was on a temporary basis. For example, the subsidies. Right now, he's talking about
making those permanent.

Caitlin Owens ( 13:54 ):
And so I think in some respects, "finish the job" agenda, as we were talking about earlier, it's not an
entirely new healthcare plan. It's not Medicare for All. But as defenders and supporters of Biden will
point out, if Biden is able to do these policies, that will go a long way towards achieving Democrats' goal
of universal coverage, which has been a decades - long goal. And we're just at the point where some

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modifications here and there can really shrink the remaining population that does not have access to
affordable health insurance.
Mark Masselli ( 14:30 ):
I wonder if I could ask -
Margaret Flinter ( 14:31 ):
"Finish the job" agenda is a good - sounding phrase.
Mark Masselli ( 14:34 ):
I'm wondering how the three of you view where healthcare stands in the priority list for Americans at
this point. Is it 1, 2, 3, 4? Where do you see it on the list, Caitlin? Or -
Nathaniel Weixel ( 14:49 ):
Healthcare is a big issue among a lot of people. I don't know. KFF has done a lot of polling on this, and
you've seen that the cost of healthcare is generally number two, behind concerns about inflation. But if
you want to go into the specifics and talk about insurance coverage or things like that, it might be a little
lower down. But people care about how much they're paying for healthcare.
Caitlin Owens ( 15:22 ):
Well, and something that I've thought about and I haven't seen it teased out, that doesn't mean it
doesn't exist, but yeah, inflation is number one. Healthcare concerns are under that, according to recent
polling that I think we've all seen. But with inflation, I mean, obviously, healthcare costs are part of that.
And so I think that just from other reporting I've seen that, as cost of housing, other everyday living
items go up. I mean, just the chunk, there's less and less money in the family budget, and healthcare
costs were already expensive for families. So to me, it feels hard to completely extract healthcare
spending just from the concerns about inflation in general.
Joyce Frieden ( 16:03 ):
Well, and I think, too, the premiums are going up, and people are noticing it as a bigger bite out of their
paycheck than they previously were.
Margaret Flinter ( 16:11 ):
Absolutely.
Mark Masselli ( 16:13 ):
Those are great observation. Joyce, the administration recently announced it had the authority to march
in and break the patents of drugs developed using taxpayer money if the administration considers them
to be too expensive. And I'm wondering if you could explain how this would work, and what the drug
makers are saying.
Joyce Frieden ( 16:34 ):
Sure. Well, this happened a few weeks ago, and it has to do with a provision of an old law called the
Bayh... That's B - A - Y - H after Birch Bayh... - Dole Act of 1980. And that gave the government the authority

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under certain circumstances to take control of a drug patent and license it to another company if the
drug was developed with government support. And so the Biden administration wants to use this idea
as leverage when drug companies try to put too high a price on a drug. And so it issued a draft
framework for how they were going to use these rights. And according to that guidance, the march - in
actions will have to meet certain criteria, such as the drug being required for public use, and that the
regulatory requirements weren't satisfied by the contractor or the licensees. And on a related note,
they're really harping on this fair pricing issue, and they said last week that they were making fair pricing
a standard part of contract negotiations for medical products that were developed with federal
government support.

Joyce Frieden ( 17:50 ):
So they've done this so far in four contracts for Project NextGen, which is a $5 billion project from the
government to develop the next generation of COVID - 19 vaccines and treatments. And the contracts
state that if the products commercialize, its lowest price in the United States will be equal to or less than
its retail price in comparable global markets. Obviously, pharmaceutical companies are not happy with
march - in rights. A spokeswoman for them, Sarah Ryan, said that if the government is allowed to take
away patent protections at any time, there isn't any incentive for biopharmaceutical companies to
collaborate with the government.

Mark Masselli ( 18:37 ):
Joyce, remind me about the 10 drugs that they're negotiating. How is that proceeding?

Joyce Frieden ( 18:46 ):
Yeah, they've issued the list of the 10 drugs that they're negotiating. And my understanding is that it's
now they're currently undergoing a review of those drugs, and I think we'll know more next year.

Margaret Flinter ( 19:03 ):
Remarkable it's going back that far to that old law, as they take advantage of it. Thanks for that little
piece of history. And Nathaniel, let's turn to artificial intelligence, as the conversation often does these
days. You reported that AI can help combat health misinformation, according to the leader of the White
House Cancer Research Initiative. Tell us about this.

Nathaniel Weixel ( 19:24 ):
Yeah, so as she said, when asked about the role of AI or what could help combat disinformation, she
said, "This could be a surprising answer. But AI, so long as the AI systems are developed with the
appropriate safeguards to make sure that they take into account the inherent systems of how
disinformation is spread right now, and what the accurate information is." But it is surprising, that you
think AI can really be used to spread disinformation rather than being set up with appropriate
safeguards to help stop it.

Mark Masselli ( 20:11 ):
Well, it's got all those concerns about hallucinations and other things that are part and parcel of the
opportunity that AI could present to us, but certainly will be an area that we will be keeping an eye on.
And I know the three of you will.

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Mark Masselli ( 20:26 ):
Joyce, I want to move to something you've written about called something that doesn't roll off the
tongue easily, the Trusted Exchange Network and Common Agreement, and the news on that front. And
I'm wondering if you could explain that concept to our listeners, and what it might mean for the average
American.

Joyce Frieden ( 20:48 ):
Sure. Yeah. We like to call it TEFCA, which is a little easier than Trusted Exchange Framework and
Common Agreement. In the very simplest terms, it's a network that the federal government is building
to make it easier for doctors' offices and hospitals to exchange patient information. So for example, it'll
make it easier if you're in DC, and there's a specialist in California that you want to advise on your case.
It will help that specialist get your electronic health record more easily. And what happened last
Tuesday, there were five health IT companies who had all met the technical criteria to become part of
the network. So they signed an agreement during a big ceremony at Health and Human Services
headquarters. And then the first transactions started a few hours later. Health and Human Services
Secretary Becerra said that, "I feel like we're watching the Big Bang occur in 2023." So he was saying it
was a really big deal.

Joyce Frieden ( 21:55 ):
One thing I should add that I've been interested in, what these companies don't have is a unique patient
identifier for each patient. A patient combination, numbers and letters, or some kind of ID that would
make it easier for the network to know that it was the correct patients whose information was being
exchanged. And the reason they don't have it, Congress has actually outlawed its use of an identifier,
and so it would take another act of Congress to allow for it. So I asked Micky Tripathi, who's the head of
the Office of the National Coordinator for Health IT about it, and he said that it'd be nice to have such an
identifier, but it wasn't absolutely necessary, and companies have figured out a way to work around it.

Margaret Flinter ( 22:47 ):
That's exactly right. Though on the ground in healthcare, we can say it's pretty complicated to make sure
that you have 100% perfection, which is the only acceptable way to do it. Caitlin, we know the Biden
administration has been very aggressive about going after corporate power, and you're reporting that
they're turning their eyes to healthcare consolidation. Certainly, we are seeing lots of pop - up references
to the issues of private equity and hospital ownership and health systems. But how big a problem does
the administration see this as, and how are they proposing to tackle it?

Caitlin Owens ( 23:24 ):
Well, let me just start by saying, when I started this year looking at my, I guess, healthcare bingo card, I
didn't have bipartisan attention on consolidation and anti - competitive business practices on it. So that's
been something a little surprising to me, just to look at where we were a year ago to where we are now.
So yes, the Biden administration is signaling that it's very serious about this. The FTC is looking into PBM
consolidation, which is pharmacy benefit managers, which are part of the drug supply chain. It's
signaling that it's going to be more strict about scrutinizing healthcare company mergers, which could
really affect hospital mergers. And then on the Hill, we're seeing this year, there's been almost every
major healthcare committee has had some kind of hearing on consolidation and anti - competitive
business practices that are a result of that consolidation, which is something we haven't seen in the
past.

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Caitlin Owens ( 24:23 ):
And I think that's really reflective of the fact of just how much more consolidated the industry has
become. I guess it's around half of the physicians are now owned by someone else, and 10% alone are
owned by Optum, which is a branch of UnitedHealthcare. So I think that as the system is getting more
and more consolidated, there's less opportunity for these companies to compete against each other for
pricing, which is the whole way that the US healthcare system is designed to control prices. So I think
that that's getting a lot more political scrutiny, just to bring it back full circle, because of that cost of
healthcare that Americans are so concerned about, and feeling so acutely.

Mark Masselli ( 25:09 ):
A final question to all three of you, and we won't ask you to make political predictions, but what do you
think the next 12 months look like in terms of health policy? Certainly, the upcoming Supreme Court
decision on abortion pill access is going to make news. What do you see out in your crystal ball as you
look over the next 12 months? Obviously, a national election coming up. So lots of transformation. And I
also know that going back and looking at everyone's predictions about the stock market and all sorts of
things last year, everybody got it wrong. But we're always fascinated with what might be. What's on
your minds?

Joyce Frieden ( 25:53 ):
Well, I'll start and say that you mentioned the Supreme Court decision. That's going to be really
interesting, because obviously, the question in front of them is whether the FDA acted within the law
when it approved Mifepristone, which is one of the two drugs taken in combination to achieve a
medication abortion.

Mark Masselli ( 26:14 ):
And approved it 23 years ago, right?

Joyce Frieden ( 26:17 ):
Right, exactly. But the thing is that if the court decides that, indeed, it wasn't approved legally, then it
just opens up this whole can of worms for any other drugs that the FDA approved. So it's much more
monumental even than just on the abortion front. So I think that's going to be very interesting. And a lot
of the stuff we talked about, more action to reign in pharmacy benefit management companies, I think
you're going to see. And the thing they talked about in the debate about trying harder to stop
importation of fentanyl and illicit drugs. And also, the AI, you mentioned artificial intelligence. The
health IT folks just last week released some regulations on how to make that more transparent. So
doctor's offices and hospitals will be trying to untangle that.

Mark Masselli ( 27:19 ):
Were those in addition to the president's executive order or part of -

Joyce Frieden ( 27:27 ):
Part and parcel.

Mark Masselli ( 27:28 ):
Part and parcel? Yeah. Great.

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Nathaniel Weixel ( 27:29 ):
I think Caitlin alluded to it earlier is that there's going to be a lot of nibbling around the edges in terms of
healthcare reform, too. There's going to be maybe some transparency, some targeting of PBMs, nothing
major. And then we're going to come into campaign season. But I think where things are going to be
interesting is you're going to look at the courts, you're going to look at the states. You're going to look at
abortion coming from the Supreme Court, abortion ballot measures in the states, clarity or not clarity on
state medical exemptions, as we just saw in Texas. I think that might be where the biggest health policy
issues are going to be next year.
Mark Masselli ( 28:12 ):
And those might be issues that roil the presidential election as well, I assume?
Nathaniel Weixel ( 28:20 ):
Especially if they come June, July, right in the middle of campaign season.
Mark Masselli ( 28:25 ):
That's right.
Margaret Flinter ( 28:26 ):
I'm betting that the abortion pill access is the one that will really capture the news, just given the impact
across every single state and the country, and really, the last remaining option for women. So we'll see
how that plays out, certainly.
Caitlin Owens ( 28:39 ):
And just one last thought. Democrats really think that abortion and healthcare and defending the
Affordable Care Act, that these are really strong issues for them. So even in the context of all of this, I
would expect to hear, especially as the campaign ramps up, I would expect a lot of healthcare talk going
into 2024. But as Nathaniel was saying, I mean, how things play out, a lot of it is up to the courts.
Margaret Flinter ( 29:02 ):
Any last comments from any of you as the year draws to a close?
Caitlin Owens ( 29:08 ):
Take a break now.
Margaret Flinter ( 29:11 ):
Absolutely.
Caitlin Owens ( 29:11 ):
You're probably going to be busy.
Margaret Flinter ( 29:13 ):
Absolutely. Well, certainly, in the world of community health centers, we're still hoping that things
advance in terms of protecting community health centers, the National Health Service Corps, Teaching

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Health Center Act, and many other things that we're keeping an eye on that affect certainly the lowest -
income, the most uninsured, and the most Medicaid people in the country. So we'll be keeping an eye
on that, and we may have more questions for you about those issues in the future as well.
Margaret Flinter ( 29:39 ):
But thank you all for joining us. We'll be reading and learning from your reporting in the year ahead. And
thank you to our audience for being with us. Be sure to go online to CHCRadio.com, sign up for our
updates, and share your thoughts and comments about this program. Happy holidays to all. Best wishes
for a terrific new year.
Mark Masselli ( 29:59 ):
Thank you all for joining us.
Nathaniel Weixel ( 30:02 ):
Thank you.
Joyce Frieden ( 30:02 ):
Thank you.
Margaret Flinter ( 30:02 ):
Thanks for the work you do.
Mark Masselli ( 30:04 ):
Yeah, absolutely. Very informative.
Margaret Flinter ( 30:11 ):
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