[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 from 吃瓜不打烊 and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 吃瓜不打烊, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

Today, we are joined via video conference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with 吃瓜不打烊’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies 鈥� the ones that expired Jan. 1.  

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.  

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are very nearly 鈥� in the words of longtime Congress watcher  鈥� a [majority] in name only, which I guess is pronounced “MINO.” Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise fairly routine labor bill. Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the House’s Democrats to pass the bill and send it to the Senate. But it seems that the bipartisan efforts in the Senate to get a deal are losing steam. What’s the latest you guys are hearing? 

Ollstein: Yeah, so it wasn’t a good sign when the person who has sort of come out as a leader of these bipartisan negotiations, Ohio Sen. Bernie Moreno, at first came out very strong and said, We’re in the end zone. We’re very close to a deal. We’re going to have bill text. And that was several days ago, and now they’re saying that maybe they’ll have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and, from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before. There is not agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it should treat abortion. 

And so the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a nonstarter for most, if not all, Democrats. So I don’t know where we go from here. 

Rovner: Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They seem to [be] making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can come up with a bill that can get 60 votes in the Senate and a majority in the much more conservative House? That is a pretty narrow needle to thread. I don’t think abortion is going to be a huge issue in Labor, HHS, because that’s where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the House [is] probably not so excited about putting all of that money back. I’m just wondering if there really is a deal to be had, or if we’re going to see for the, you know, however many year[s] in a row, another continuing resolution, at least for the Department of Health and Human Services. 

Ollstein: Well, you’re hearing a lot more optimism from lawmakers about the spending bill than you are about a[n] Obamacare subsidy deal or any of the other things that they’re fighting about. And I would say, on the spending, I think the much bigger fights are going to be outside the health care space. I think they’re going to be about immigration, with everything we’re seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts. On health, yes, I think you’ve seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it impacts their districts and their voters too. So that makes sense. 

Kenen: We’ve also seen the Congress vote for spending that the administration hasn’t been spent. So Congress has just voted on a series of things about science funding and other health-related issues, including global health. But it remains to be seen whether this administration takes appropriations as law or suggestion. 

Rovner: So while the effort to revive the additional ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago. Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital outpatient payments, and continued funding for community health centers. Could that finally become law? That thing that they said, Oh, we’ll pass it first thing next year, meaning 2025. 

Edney: I think it’s certainly looking more likely than the subsidies that we’ve been talking about. But I do think we’ve been here before several times, not just at the end of last year 鈥� but, like with these PBM reforms, I feel like they have certainly gotten to a point where it’s like, This is happening. It’s gonna happen. And, I mean, it’s been years, though, that we’ve been talking about pharmacy benefit manager reforms in the space of drug pricing. So basically, you know, from when [President Donald] Trump won. And so, you know, I say this with, like, a huge amount of caution: Maybe. 

Rovner: Yeah, we will, but we’ll believe it when 鈥� we get to the signing ceremony. 

Ollstein: Exactly. 

Rovner: Well, back to the Affordable Care Act, for which enrollment in most states end today. We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies. Sign-ups on the federal marketplace are down about 1.5 million from the end of last year’s enrollment period, and that’s before most people have to pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans. I’m wondering if these early numbers 鈥� which are actually stronger than many predicted, with fewer people actually dropping coverage 鈥� reflect people who signed up hoping that Congress might actually renew the subsidies this month. Since we kept saying that was possible. 

Ollstein: I would bet that most people are not following the minutiae of what’s happening on Capitol Hill and have no idea the mess we’re in, and why, and who’s responsible. I would love to be wrong about that. I would love for everyone to be super informed. Hopefully they listen to this podcast. But you know, I think that a lot of people just sign up year after year and aren’t sure of what’s going on until they’re hit with the giant bill.  

Rovner: Yeah. 

Ollstein: One thing I will point out about the emerging numbers is it does show, at least early indications, that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans, that’s really working. You’re seeing enrollment up in some of those states, and so I wonder if that’ll encourage any others to get on board as well. 

Kenen: But 鈥� I think what Julie said is it’s 鈥� the follow-up is less than expected. But for the reasons Julie just said is that you haven’t gotten your bill yet. So either you haven’t been paying attention, or you’re an optimist and think there’ll be a solution. So, and people might even pay their first bill thinking that there’ll be a solution next month, or that we’re close. I mean, I would think there’d be drop-off soon, but there might be a steeper cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because they’re not as bad as some people forecast doesn’t say that this is going to be a robust coverage year. 

Edney: And I think, I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up, are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out in other aspects? I think will be .. of the economy of jobs, like, where does that lead us? I think will be something to watch out for too. 

Rovner: And by the way, in case you’re wondering why health insurance is so expensive, we got the , and total health expenditures grew by 7.2% from the previous year to $5.3 trillion, or 18% of the nation’s GDP [gross domestic product], up from 17.7% the year before. Remember, these are the numbers for 2024, not 2025, but it makes it pretty hard for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because we’re spending more on health care. It’s not really that complicated, right? 

Kenen: This 17%-18% of GDP has been pretty consistent, which doesn’t mean it’s good; it just means it’s been around that level for many, many, many years. Despite all the talk about how it’s unsustainable, it’s been sustained, with pain, but sustained. $5.7 trillion, even if you’ve been doing this a long time 鈥� 

Rovner: It’s $5.3 trillion. 

Kenen: $5.3 trillion. It’s a mind-boggling number. It’s a lot of dollars! So the ACA made insurance more 鈥� the out-of-pocket cost of insurance for millions of Americans, 20-ish million 鈥� but the underlying burden we’ve not solved the 鈥� to use the word of the moment, the “affordability” crisis in health care is still with us and arguably getting worse. But like, I think we’re sort of numb. These numbers are just so insane, and yet you say it’s unsustainable, but 鈥� I think it was Uwe’s line, right? 

Rovner: It was, it was a famous Uwe Reinhardt line. 

Kenen: No, it’s sustainable, if we’re sustaining it at a high 鈥� in economically 鈥� zany price.  

Rovner: Right. 

Kenen: And, like, the other thing is, like, where is the money? Right? Everybody in health care says they don’t have any money, so I can’t figure out who has the $5 trillion. 

Rovner: Yeah, well, it’s not 鈥� it does not seem to be the insurance companies as much as it is, you know, if you look at these numbers 鈥� and I’ll post a link to them 鈥� you know, it’s hospitals and drug companies and doctors and all of those who are part of the health care industrial complex, as I like to call it. 

Kenen: All of them say they don’t have enough.  

Rovner: Right. All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate health committee chairman and ardent anti-abortion senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about the reputed dangers of the abortion pill, mifepristone. Alice, like me, you watched yesterday’s hearing. What was your takeaway? 

Ollstein: So, you know, in a sense, this was a show hearing. There wasn’t a bill under consideration. They didn’t have anyone from the administration to grill. And so this is just sort of your typical each side tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside 鈥� they’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill. Their bigger goal is outlawing all abortion, but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting. And so they’re frustrated that, you know, both [Robert F.] Kennedy [Jr.] and [Marty] Makary have promised some sort of review or action on the abortion pill, and they say, We want to see it. Why haven’t you done it yet? And so I think that pressure is only going to mount, and this hearing was part of that. 

Rovner: I was fascinated by the Louisiana attorney general saying, basically, the quiet part out loud, which is that we banned abortion, but because of these abortion pills, abortions are still going up in our state. That was the first time I think I’d heard an official say that. I mean that, if you wonder why they’re going after the abortion pill, that’s why 鈥� because they struck down Roe [v. Wade] and assumed that the number of abortions would go down, and it really has not, has it? 

Ollstein: That’s right. And so not only are people increasingly using pills to terminate pregnancies, but they’re increasingly getting them via telemedicine. And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal. You know, a lot of people just really prefer the telemedicine option, whether because it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons. So the right 鈥� you know, again, including senators like Cassidy, but also these activist groups 鈥� they’re saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And they’re pretty open about saying that.  

Rovner: Well, rather convenient timing from the , which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single time, except once, and that once was during the first Trump administration. Alice, is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications? There were, how many, like 100, more than 100 peer-reviewed studies that basically show this, plus the experience of many millions of women in the United States and around the world. 

Ollstein: Well, just like I’m skeptical that there’s any compromise that can be found on the Obamacare subsidies, there’s just no compromise here. You know, you have the groups that are making these arguments about the pills’ safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it can’t be health care if it’s designed to end a life, and that kind of rhetoric. And so the focus on the rate of complication 鈥� I mean, I’m not saying they’re not genuinely concerned. They may be, but, you know, this is one of many tactics they’re using to try to curb access to the pills. So it’s just one argument in their arsenal. It’s not their, like, primary driving, overriding goal is, is the safety which, like you said, has been well established with many, many peer-reviewed studies over the last several years. 

搁辞惫苍别谤:听So, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein: It was one pot of money they’re fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last summer, those are still in place. And so that’s an order of magnitude more than this pot of Title X family planning money that they just got back. So that aside, I’ve seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and it’s a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a patient, you can then submit for reimbursement. And so if the clinic’s not there, it’s not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.  

Rovner: Yeah. The wheels of the courts, as we have seen, have moved very slowly. 

OK, we’re going to take a quick break. We will be right back. 

So while abortion gets most of the headlines, it’s not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that a majority of justices would strike down the laws, which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue in recent weeks. The House passed a bill in December, sponsored by now former Republican congresswoman Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide. And the Department of Health and Human Services issued proposed regulations just before Christmas that wouldn’t go quite that far, but would have roughly the same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid funding, and would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote, “does not meet professionally recognized standards of health care,” and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports team exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors? That’s what this would do. 

Edney: Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that we’re even talking about. And so those who are against it have done an effective job of making that the issue. And so there 鈥� who support gender-affirming care, who have looked into it, would see that a lot of this is hormone treatment, things like that, to drugs 鈥�  

Rovner: Puberty blockers! 

Edney: 鈥� they’re taking 鈥� exactly 鈥� and so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think, too, talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them. So I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like that that’s kind of winning the day. 

Kenen: I think, like, from the beginning, because, like, five or six years ago was the first time I wrote about this. The playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now they’re talking about it in protecting children’s health. And, as Anna said, they’re using words like mutilation. Puberty blockers are not mutilation. Puberty blockers are a medication that delays the onset of puberty, and it is not irreversible. It’s like a brake. You take your foot off the brake, and puberty starts. There’s some controversy about what age and how long, and there’s some possible bone damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now 鈥� most of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids, cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body. So you know, I think it’s really important to repeat 鈥� the point that Anna made, you know, 12-year-olds are not getting major surgery. Very few minors are, and when they are, it’s closer 鈥� they may be under 18, it’s rare. But if you’re under 18, you’re closer to 18, it’s later in teens. And it’s not like you walk into an operating room and say, you know, do this to me. There’s years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania, in particular. This is something that people don’t understand and get very upset about, and the inflammatory language, it’s not creating understanding. 

Rovner: We’ll see how this one plays out. Finally, this week, things at the Department of Health and Human Services continues to be chaotic. In the latest round of “we’re cutting you off because you don’t agree with us,” the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees canceling their funding immediately. It’s not entirely clear how many grants or how much money was involved, but it appeared to be something in the neighborhood of $2 billion 鈥� that’s around a fifth of SAMHSA’s entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then, Wednesday night, after a furious backlash from Capitol Hill and just about every mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts. Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?  

Edney: That is a great question. I really don’t know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly, like there was a miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS. 

Rovner: I didn’t count, but I got dozens of emails yesterday.  

Edney: Yeah. 

Rovner: My entire email box was overflowing with people basically freaking out about these cuts to SAMHSA. Joanne, you wanted to say something? 

Kenen: I think that one of the shifts over 鈥� I’m not exactly sure how many years 鈥� 7, 8, 9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue. It’s not that everybody thinks that. It’s not that every lawmaker thinks that, but we have really turned this into, we have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the “deaths of despair.” Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is, you know, you’ve had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes 鈥� some of the “Opioid Belts” are very conservative states, and Republican governors, you know, really saying we’ve had progress. Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their telephones, they were bombarded.  

Rovner: Yeah. Well, meanwhile, several hundred workers have reportedly been reinstated at the National Institute of Occupational Safety and Health 鈥� that’s a subagency of CDC [the Centers for Disease Control and Prevention]. Except that those RIF [reduction in force] cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work? And in news from the National Institutes of Health, Director Jay Bhattacharya told a podcaster last week that the DEI-related [diversity, equity, and inclusion] grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard Pazdur said at the J.P. Morgan [Healthcare] Conference in San Francisco this week that the firewall between the political appointees at the agency and its career drug reviewers has been, quote, “breached.” How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots? 

Ollstein: Not to mention all of this back and forth and chaos and starting and stopping is costing more, is costing taxpayers more. Overall spending is up. After all of the DOGE [Department of Government Efficiency] and RIFs and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it hasn’t even saved the government any money, either. 

Kenen: Like, you know, the game we played when we were kids, remember, “Red Light-Green Light,” you know, you’d run in one direction, you run back. And if you were 8 years old, it would end with someone crying. And that’s sort of the way we’re running the government these days [laughs]. The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You can’t even keep track. You don’t even know what email to use if you’re trying to keep in touch with them anymore. The churn, with what logic? It’s, as Alice said, just more expensive, but it’s, it’s also just 鈥� like you can’t get your job done. Even if you want a smaller government, which many of conservatives and Trump people do, you still want certain functions fulfilled. But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring. I mean, the American public is not against research, and the American public is not against keeping people alive. You know, the inconsistency is pretty mind-boggling. 

Edney: Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is it kind of seems like the message as anybody can do this part, because it’s all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different, like you said, everyone wants research, but I, Joanne, but I do think they only want certain kinds of research in this case. So it’s been interesting to watch how many leaders in these agencies that are going away and not being replaced. 

Rovner: And all the institutional memory that’s walking out the door. I mean, more people 鈥� and to Alice’s point about how this hasn’t saved money 鈥� more people have taken early retirement than have been actually, you know, RIF’d or fired or let go. I mean, they’ve just 鈥� a lot of people have basically, including a lot of leaders of many of these agencies, said, We just don’t want to be here under these circumstances. Bye. Assuming at some point this government does want to use the Department of Health and Human Services to get things done, there might not be the personnel around to actually effectuate it. But we will continue to watch that space. 

OK, that’s this week’s news. Now we will play my “Bill of the Month” interview with Elisabeth Rosenthal, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at KFF Health News and originator of our “Bill of the Month” series, which in its nearly eight years has analyzed nearly $7 million in dubious, infuriating, or inflated medical charges. Libby also wrote the latest “Bill of the Month,” which we’ll talk about in a minute. Libby, welcome back to the podcast. 

Elisabeth Rosenthal: Thanks for having me back. 

Rovner: So before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated are you that eight years on, it’s as relevant as it was when we began? 

Rosenthal: We were worried it wouldn’t last a year, and here we are, eight years later, still finding plenty to write about. I mean, we’ve had some wins. I think we helped contribute to the No Surprises Act being passed. There are states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic, it’s the same cost. The country’s starting to address drug prices. But, you know, we seem to be the billing police, and that’s not good. We’ve gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls, they’re like, Oh, that was a mistake or Yeah, we’re going to write that off. And I’m like, You’re not writing that off; that shouldn’t have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system that has left, as we know, you know, 100 million adult Americans with medical debt. So we will keep going until it’s solved, I hope. 

Rovner: Well, getting on to this month’s patient, he gives new meaning to the phrase “It must have been something I ate.” Tell us what it was and how he ended up in the emergency room. 

Rosenthal: Well, Maxwell [Kruzic] loves eating spicy foods, but he’s never had a problem with it. And suddenly, one night, he had just excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right? So they were all like, ready to go to the operating room. And then the scan came back, and it was like, whoops, his appendix is normal. And then, oh, could he have kidney stones? And it’s like no sign of that either. And finally, he thought, or someone asked, Well, what did you eat last night? And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million [Scoville heat units], which is, like, through the roof, and it was a reaction to the chili peppers. I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff. 

Rovner: So in the end, he was OK. And the story here isn’t even really about what kind of care he got, or how much it cost. The $8,000 the hospital charged for his few hours in the ER doesn’t seem all that out of line compared to some of the bills we’ve seen. What was most notable in this case was the fact that the bill didn’t actually come until two years later. How much was he asked to pay two years after the hot pepper incident? 

Rosenthal: Well, he was asked to pay a little over $2,000, which was his coinsurance for the emergency room visit. And as he said, you know, $8,000 鈥� now we go, well, that’s not bad. I mean, all they did, actually, was do a couple of scans and give him some IV fluids. But in this day and age, you’re like, wow, he got away 鈥� you know, from a “Bill of a Month” perspective, he got away cheap, right? 

Rovner: But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later? 

Rosenthal: That’s the problem, like, and Maxwell 鈥� he’s a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept thinking, I must owe something. And he checked and he checked and he checked and it kept saying zero. He actually called his insurer and to make sure that was right. And they said, No, no, no, it’s right. You owe zero. And then, you know, after like, six months, he thought, I guess I owe zero. But then he didn’t think about it, and then almost two years later, this bill arrives in the mail, and he’s like, What?! And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at “Bill of the Month,” and in many cases, it’s legal, because of what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like, Yeah, you know, someone was away on vacation, and someone left their job, and we couldn’t 鈥� you know, the hospital billed them correctly. And the hospital said, No, we didn’t. And they were just kind of doing the usual back-end negotiations to figure out what a service is worth. And when they finally agreed two years later what should be paid, that’s when they sent Maxwell the bill. And the problem is, whether it’s legal really depends on your insurance contracts, and whether they allow this kind of late billing. I do not know to this day if Maxwell’s did, because as soon as I called the insurer and the hospital, they were like, Never mind. He doesn’t owe anything. And you know, as he said, he’s a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said, Whoops, I forgot to bill for something, they would be like, Forget it! you know. So I do think this is something that needs to be addressed at a policy level, as we so often discover on “Bill of the Month.” 

Rovner: So what should you do if you get one of these ghost bills? I should say I’m still negotiating bills from a surgery that I had six months ago. So I guess I should count myself lucky. 

Rosenthal: Well, I think you should check with your insurer and check with the hospital. I think more with your insurer 鈥� if the contract says this is legal to bill. It’s unclear to me, in this case, whether it was. The hospital was very much like, Oh, we made a mistake; because it took so long, we actually couldn’t bill Maxwell. So I think in his case, it probably was in the contract that this was too late to bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude. Well, doesn’t hurt to try, you know, maybe they’ll pay it. And people are afraid of bills, right? They pay them.  

Rovner: I know the feeling. 

Rosenthal: Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations, essentially, on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say, Well, we won’t pay this. 

Rovner: And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least modified them? 

Rosenthal: He said he will never eat scorpion peppers again. 

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

Rovner: OK, we’re back, and now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will post the links in our show notes on your phone or other mobile device. Anna, why don’t you start us off this week? 

Edney: Sure. So my extra credit is from MedPage Today: “.” I appreciated this article because it answered some questions that I had, too, after the sweeping change to the childhood vaccine schedule. There was just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will parents be confused? Will pediatricians 鈥� how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA Perspectives that lays out, essentially, to clinicians, you know, that they should not fear malpractice .. issues if they’re going to talk about the old schedule and not adhere to the newer schedule. And so it lays out some of those issues. And I thought that was really helpful. 

Rovner: Yeah, this was a big question that I had, too. Alice, why don’t you go next? 

Ollstein: Yeah, so I have a piece from ProPublica. It’s called “.” So this is about how there’s been this huge push on the right to end public water fluoridation that has succeeded in a couple places and could spread more. And the proponents of doing that say that it’s fine because there are all these other sources of fluoride. You can get a treatment at the dentist, you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who arepushing for ending fluoridated public drinking water are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus all of the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged neurological impacts. But it also, that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what that’s going to do to the nation’s teeth? 

Rovner: Yeah, it’s like vaccines. The more you talk it down, the less people want to do it. Joanne. 

Kenen: This is a piece by Dhruv Khullar in The New Yorker called “,” and it was really great, because there’s certain things I think that we who 鈥� like, I don’t know how all of you watch it 鈥� but like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED [emergency department] have, you know, homelessness problems and can’t afford food and all that. But Dhruv talked about how it sort of brought that home to him, how our social safety net, the holes in it, end up in our EDs. And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient a day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER scene. It’s just a very thoughtful piece about why we all love that TV show. And it’s not just because of Noah Wyle. 

Rovner: Although that helps. My extra credit this week is from The New York Times. It’s called “,” by Maxine Joselow. And while it’s not about HHS, it most definitely is about health. It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost to human health when setting clean air rules for ozone and fine particulate matter, quoting the story: “That would most likely lower costs for companies while resulting in dirtier air.” This is just another reminder that the federal government is charged with ensuring the help of Americans from a broad array of agencies, aside from HHS 鈥� or in this case, not so much.  

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X , or on Bluesky . Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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

[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.]鈥� 

Emmarie Huetteman: Hello and welcome to “What the Health?” from 吃瓜不打烊 and WAMU. I’m Emmarie Huetteman, a senior editor for 吃瓜不打烊, filling in for host Julie Rovner this week. I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 13, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go. 

Today, we’re joined via video conference by Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning. 

Huetteman: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Huetteman: And Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Huetteman: Later in this episode, we’ll have Julie’s interview with 吃瓜不打烊’ Julie Appleby, who wrote our latest “Bill of the Month” story about a doctor who became the patient after a car accident sent her to the hospital and $64,000 into debt. But first, this week’s news. 

The longest federal government shutdown in history is over. Late Wednesday, six House Democrats joined most Republicans in approving legislation that funds the government through January. That vote came after a handful of Senate Democrats broke ranks with their party last weekend and brokered a deal to end the shutdown. Although the Trump administration was still fighting earlier this week not to fully fund food stamps, the White House has said those benefits would be fully restored within hours of the shutdown’s end. That said, food banks and other safety-net programs have warned the shutdown’s consequences could linger, especially for those who were forced to redirect rent money, dip into savings, and make other sacrifices to feed their families. Notably, despite Democrats’ demands, the deal does not include an extension of the expanded tax credits that help people afford Affordable Care Act plans. That means those enhanced subsidies are still slated to expire at the end of the year. Sandhya, you were on Capitol Hill last night. What was included in the deal? And now that the shutdown’s over, can we expect a vote on extending the tax credits? 

Raman: So part of that deal was that sometime in the middle of next month, the Senate is going to be able to vote on a health bill of Democrats’ choosing to extend the Affordable Care Act enhanced subsidies that are set to expire at the end of the year. There’s been a decent amount of talk already in both chambers about what a health care bill could look like, because it would need to be bipartisan to pass. There’s some multiple camps right now. 

I think in the Senate, Republicans are coalescing around putting money into flexible savings accounts instead of doing an extension of the credits as something that they would want to do instead. There are other Republicans that are still open to extending the credits with some reforms attached. The House, we figured out last night, was a little bit more fragmented. They’re less united in the way the House is around doing something with the flexible spending accounts. So a lot of them are still anti-extending the credits at all. They are working on a health package, but it remains to be seen what they want to do with that, given the short amount of time they have. But I think a lot of them are also looking for the same reforms that the Senate is on the Republican side, if they do sign on to extend them. 

Huetteman: Yeah, short is right. We’re already looking at that Dec. 31 deadline to extend the existing credits. And of course, we’re already in the open enrollment period at this point. People are already getting their plans for next year. Polls show that most Americans blamed Republicans for the shutdown. A tracking poll from my KFF colleagues out last week showed most Americans want Congress to extend the tax credits. Republicans are aware of this heading into the midterms next year, no? 

Raman: I think that’s definitely been a big factor when talking to folks, especially ones that I think have been more interested in extending the credits are set up for our competitive races next year. There has been talk at different times of doing a one-year extension. But that puts us pretty close to the midterms, which might not be in everyone’s best interest depending on how things shake out. So, I think it’s definitely in a lot of folks’ minds, just because it is a lot more popular than it has been in previous years. But there are a lot of the more conservative folks that just have been anti-ACA for so long, that they don’t want to extend something that was … The enhanced subsidies were started by Democrats during covid. They think it’s a covid-era thing that needs to be phased out. 

Huetteman: Yeah, and also notably, you might’ve noticed I said that they only funded the government through January. Does that mean we’re getting ready to do this again in a couple of months? 

Raman: There’s a chance. So part of the deal got done this week is that they did three of the 12 spending bills that they do every year to fund the government. But they usually do them in order of which ones are easiest to get done. So we still have to come to agreements on some of the bigger ones, including Labor, HHS [Health and Human Services]. Education is what funds most of the health activities, and that’s usually a tougher one. So, I think it depends on a few things. Are folks sticking to their word? Do they get that health care vote that they were promised? Do other things shake out that make people at odds with each other over the next bit? But we could possibly be in the same situation if we don’t make inroads on funding the government for a yearlong situation before then. 

Huetteman: Oh goodness. Well, it sounds like we’ll be back again having this conversation soon. Meanwhile, months after the president [Donald Trump] signed into law the One Big Beautiful Bill with big changes to Medicaid, new details are emerging about how the Trump administration is using the Medicaid program to promote its policy goals. My 吃瓜不打烊 colleague Phil Galewitz recently reported on how the Trump administration has ordered state Medicaid agencies to investigate the immigration status of certain enrollees 鈥� providing states with lists of names to re-verify 鈥� and effectively roping the health program into the president’s immigration crackdown. 

Also, NPR reports the Trump administration plans to dramatically restrict access to medical care for transgender youth. New proposals that could be released as soon as this month would block federal money from being spent on trans care. Policy experts say that would make it difficult, if not impossible, to access that care, in large part because government funding is a huge source of revenue, and losing it could force hospitals to end the programs entirely. Both of these programs are pretty striking: enlisting Medicaid to perform spot checks of immigration status, and also potentially blocking funding for trans care. Have we seen other presidential administrations use Medicaid like this? And since we’re talking about funding, is there a role for Congress here? 

Luthra: My understanding is that this approach, specifically with gender-affirming care and with immigration, doesn’t really have a precedent. And what I think is really important about these is these are decisions that will be litigated, challenged, argued in court. But, even if and as that happens, there’s a real chilling effect that I think is really important. Already, we know that a lot of immigrants are very afraid to sign up even for benefits they are entitled to, because they’re worried it could count against them. We already know that a lot of immigrants with health needs are skipping their health care because they are so worried about what happens if ICE [Immigration and Customs Enforcement] shows up at a hospital. This only threatens to add to that. On the vantage of gender-affirming care, already we have seen some major hospitals and health providers drop the offering, even in anticipation of this policy coming into effect. So I think what’s really important is to understand that no matter what happens, already, people’s health is really being affected, and people are suffering as a result. 

Raman: I think we’ve seen little sprinkles of some of these things that have happened in the past, but this is elevated at such a level that it’s different. Even in the first Trump administration, there were some things put in place with the public charge to crack down on what benefits immigrants could be entitled to. But I think, as with a lot of the things that we’re seeing, it’s really been amped up. I think one thing that Shefali was saying that made me think of was, we’ve already seen a lot of this chilling effect with a lot of things in abortion and reproductive care, where even if laws or regulations don’t go into effect, they’re being talked about or litigated. It already has that effect of people not wanting to show up or not knowing what’s available to them. So we have a little bit of that to look at as well. 

Huetteman: Yeah, absolutely. All right, well, we’re going to take a quick break. We’ll be right back with more health news. 

We’re back. In an Oval Office announcement last week, President Trump unveiled agreements with the pharmaceutical giants Eli Lilly and Novo Nordisk to offer some Americans lower prices on their weight loss drugs. Under the deals, the Trump administration says, most eligible patients on Medicare and Medicaid, or those who use the planned TrumpRx website, would pay a few hundred dollars a month for some of the most popular GLP-1 drugs. That’s compared to current price tags, which can be $1,000 or more. Anna, these are only some of the most recent deals between the Trump administration and drugmakers. What does this mean for Americans who take these weight loss drugs, and what do the companies get in exchange? 

Edney: Yeah, I think for Americans who take these or are hoping to take these, I think, is probably where it really opens up. Because … Medicare was not covering these. Now that they’ve come to the table and made a deal, it might open it up to some Medicare beneficiaries. I don’t think you’re going to see everyone on Medicare who wants it be able to get it. I think it’ll be a little stricter on what BMI [body mass index] and comorbidities and things that they need to meet, but it will open access to some Americans. Medicaid, I think, it might not be as beneficial for people’s pocketbooks because they’re already paying extremely low out-of-pocket prices, and Medicaid already negotiates very low prices. That might not be the big change that it was hyped up to be. 

But on the Medicare side, certainly, the companies benefit from that, too, because that opens a new patient population to them. And through TrumpRx 鈥� that’s the other place where they made this deal for lowered prices on the GLP-1s 鈥� a lot of people have employer coverage that they might be trying to already get these drugs through, and then they’re not paying a whole lot out-of-pocket. But there are employer coverage plans that aren’t covering GLP-1s because they’re just so expensive. So it could be a place where some people might go to try to comparison shop and get their GLP-1s that they didn’t have access to before. 

Huetteman: I also noticed, in looking at the Trump administration’s fact sheet on this, that they were heralding that the companies had agreed to some extra American manufacturing. Let’s say concessions. Am I correct about that? Is this connected to tariffs by any chance? 

Edney: Yeah, I think that that’s been going on in conjunction with some of these deals. As you usually hear the companies say, And we’re opening a new factory in Virginia or somewhere. And certainly they’re trying to avoid the tariffs. As with a lot of these things, some of it, in some cases, they have been factories that the companies were already planning to open, and then they just pumped up for this purpose. I think for so many of this 鈥� and even for the prices, the lower prices that these companies are negotiating 鈥� we just haven’t seen the details that will matter on what the company’s got, and what the American people actually benefit from for all of this, and what these factories will mean or will be making. These are things that might not come online for several years. So you can say you’re building something, but will we see it once Trump is out of office? 

Huetteman: Exactly. And a lot of the framing has been: We’re helping Americans by bringing this work back to America, so that Americans can do the work, so that Americans can benefit from the drug prices. But it seems like there’s at best a lag on that sort of benefit. Right? 

Edney: Definitely. Definitely a lag on being able to bring some of that stuff online. I think with a lot of the Trump administration’s health policies 鈥� and I use that word loosely 鈥� it is that it is a lot of negotiation and handshakes. And so we don’t really know how solid those efforts will be in the years to come. 

Huetteman: Well, we can definitely keep an eye on that. In other news: Drama, drama, drama at the Food and Drug Administration. With a steady stream of controversial policy reversals, unexplained dismissals, and just plain unflattering stories, concerns are growing that mismanagement at the FDA is undermining the usually cautious agency’s credibility. In some of the latest developments, Stat reported the FDA’s top drug regulator resigned after being accused of using his position to punish a former associate. Stat also reported that dozens of scientists are considering leaving the already diminished FDA office that regulates vaccines, biologics, and the blood supply to get away from a toxic work environment. What are the ramifications of problems at the FDA? Is the internal drama interfering with business there? 

Edney: I think the pharmaceutical industry would say yes, definitely. They’re feeling like their applications for new drugs aren’t getting reviewed in time. They’re worried that they’re not going to be reviewed in time. And this starts with the administration letting go hundreds of workers in those offices, but also, is now … There’s just been such chaos at the top. You had Vinay Prasad, who is the head of vaccines and biologic drugs there, who has been let go and then brought back. And then now we have the head of the drug center, George Tidmarsh, who resigned under investigation for basically using his position to fulfill a vendetta against an old colleague who pushed him out of some companies. And so I think, certainly, there’s a lot of potential for disruption, as people are trying to avoid retaliation, avoid getting in the crosshairs of all of this. 

And recently, the FDA has now put Rick Pazdur, who was the head of their cancer center, in charge of the drug center to try to show some stability to encourage the pharmaceutical industry. Because he is someone who’s really pushed for innovation, pushed for trying to get drugs to the market faster. And he’s been at the FDA for, I think, 26 years. So, they’re trying to show some stability with that. But we’ll have to see how that goes because he’s also been highly criticized in the past by Prasad, and they’ll be working closely together at the head of those two centers. 

Huetteman: Well, finally, in reproductive health news, a federal judge ruled late last month that the FDA violated federal law by restricting access to mifepristone. While the government’s restrictions remain in place for the politically controversial medication, which is used to manage miscarriages as well as abortions, the judge did order the FDA to consider the relevant evidence in order to “provide a reasoned explanation for its restrictions.” And a major anti-abortion group, Susan B. Anthony Pro-Life America, announced plans for it and its super PAC [political action committee] to spend about $80 million in at least four states to support anti-abortion candidates in the midterm elections next year. Shefali, what does this say about how abortion opponents see this moment? What are they looking to gain in the midterms and beyond? 

Luthra: It’s so interesting to me to see how much anti-abortion groups are really 鈥� and, in particular, SBA 鈥� leaning into this moment. And they really see this as a reversal of last year’s election, where Trump certainly won. But we do know from polling that voters largely opposed abortion restrictions, supported abortion rights. I think some really useful context is to consider that the president, despite being backed by abortion opponents, has not really been the champion many of them would’ve hoped for. He hasn’t actually done very much on abortion, has not taken the very meaningful steps that you might’ve expected in a post-Dobbs landscape [Dobbs v. Jackson Women’s Health Organization] to remarkably restrict it, beyond the normal things any Republican president does. And so I think what we’re seeing here is an effort to reposition the anti-abortion movement beyond this presidential administration. Thinking ahead to what does it look like if there is a post-Trump GOP? 

How do you build out a movement that is a more staunch ally to the anti-abortion movement going forward? One other thing that I think is really noteworthy is: A lot of abortion opponents are looking at polling that says that voters who support abortion rights aren’t prioritizing it in the same way they might have a year ago. And they’re really hoping that things can revert to how they used to be. Or the voters who were these single-issue abortion voters were on their side, were supportive of restrictions, and then might be mobilized by these kinds of really seismic investments in elections. 

Huetteman: Yeah, absolutely. I’m thinking about now how there was such a reaction about a month ago 鈥� check me on the timing 鈥� when a generic version of the abortion pill was put out. What was the reaction like then, and what does that say about how they feel the Trump administration is reacting to their needs? 

Luthra: A lot of abortion opponents were really livid about this, and approving this generic was pretty standard. It was not that complicated of a process. This drug has been available for so long in other forms. But it underscored that a lot of people who oppose abortion feel like they’re really just waiting. The HHS and the FDA have promised this review of mifepristone that they say could ultimately lead to restrictions. But all it has really been has been a promise this review is ongoing, is coming. There will eventually be results, but there haven’t been any. So to be waiting for some kind of policy that people keep telling you is coming, and then at the same time, to see actually the FDA moving to make abortion medication more available 鈥� not less 鈥� is really frustrating for a lot of people who hope that this administration would be an ally to them. 

Huetteman: Absolutely. OK. That’s it for this week’s news. Now, we’ll have Julie’s interview with 吃瓜不打烊’ Julie Appleby. And then we’ll do our extra credits. 

Julie Rovner: I am pleased to welcome back to the podcast, 吃瓜不打烊’ other Julie, Julie Appleby, who reported and wrote the latest 吃瓜不打烊 “Bill of the Month.” Julie, welcome back. 

Julie Appleby: Thanks for having me. 

Rovner: So this month’s patient is actually a doctor, so she knows how the system works. But, as so often happens, she was in a car accident and ended up in an out-of-network hospital. Tell us who she is and what kind of care she needed. 

Appleby: OK. Her name is Lauren Hughes, and she was heading to see patients at a clinic about 20 miles from where she lives in Denver back in February when another driver T-boned her car, totaling it. She was taken by ambulance to the closest hospital, which turned out to be Platte Valley Hospital, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians there recommended immediate surgical repair because they wanted to wash out that wound on her knee. And also, she needed some screws in her ankle to hold it in place. 

Rovner: So then after the surgery and an overnight stay, she goes home, and then the bills start to come. How much did it end up costing? 

Appleby: Well, she was billed $63,976 by the hospital. 

Rovner: And the insurance company denied her claim. What was their argument? 

Appleby: Yeah, this is where it gets complicated, as many of these things often do. Her insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER. But it denied the surgery and the overnight stay charges from the hospital, which did happen to be out-of-network. Four days after her surgery, Anthem notified Hughes in a letter that after consulting clinical guidelines for her type of ankle repair, its reviewer determined that it wasn’t medically necessary for her to be fully admitted for an inpatient hospital stay. So, the note said that if she’d needed additional surgery or had other problems such as vomiting or fever, an inpatient stay might’ve been warranted. But they didn’t have that in this case. And generally, people don’t stay overnight in the hospital after broken ankle surgery. 

Rovner: Of course, she had no car and she 鈥� 

Appleby: Right? Her car was totaled. She had no way to get home. She had nobody to pick her up. And it turns out, there’s a couple more little quirks. So the surgery charges were denied because this quirk that under Anthem’s agreement with the hospital, all claims for services before and after a patient are approved or denied together. So, since the hospital stay was generally not required after the ankle surgery, the surgery charges itself were denied as well. Even though Anthem said they always felt that that was medically necessary 鈥� that she needed the ankle surgery 鈥� it all came down to this overnight hospital stay. 

Rovner: So, isn’t this exactly what the federal surprise billing law was supposed to eliminate 鈥� being in an accident, getting taken to an out-of-network hospital for emergency care? How did it not apply here? 

Appleby: Right. Well, that’s where it’s so interesting because initially, that’s what everybody thought: The No Surprises Act would cover it. And the No Surprises Act from 2022, it’s aimed at preventing these so-called surprise bills, which come when you go to an out-of-network hospital or provider. And in those cases, it limits your financial liability for emergency care to the exact same cost sharing as if you had been in an in-network hospital. 

So in this case, it applies to emergency care, and we saw that it did actually cover some of her emergency room charges, and that kind of thing. But generally though, emergency care is defined as treatment needed to stabilize a patient. So once she was stabilized before the surgery, she enters this post-stabilization situation. And if your provider determines that you can travel using nonmedical transport to an in-network facility, you might lose those No Surprises Act protections. Generally, you’re asked to sign some paperwork saying you want to stay at the out-of-network facility, and you want to continue treatment, and you waive your rights in that case. Hughes does not remember getting anything like that. And this case didn’t come down to the No Surprises Act. It was a question of medical necessity. Your insurer has broad power to determine medical necessity. And if they review a situation and determine that it’s not medically necessary, and you’re post-stabilization, that trumps any No Surprises Act protections. 

Rovner: So what eventually happened with this bill? 

Appleby: So what eventually happened was that the hospital resubmitted the charges as outpatient services. And that seemed to be the crux of the matter here. It was that inpatient overnight hospital stay. If she was kept [on] an observation status 鈥� which is a lower level of care, hospitals get paid a little bit less 鈥� that would’ve seemed to solve the problem. And that’s what happened here. Platte Valley resubmitted the bill, and her insurer paid about $21,000 of that bill. There was another $40,000 that was knocked off by an Anthem discount. And in the end, Hughes only owed a $250 copayment. 

Rovner: Wow. 

Appleby: Yeah. 

Rovner: Of course, you left out the part where we actually called and made it 鈥� 

Appleby: Well, there was that, too. And she was very savvy, as you mentioned. She also got her HR department at her employer involved. She wrote letters. She was not going to give up on this. That’s one of the advice that she gave is not to wait 鈥� not to delay too long if you get a notice of not medical necessity 鈥� but to quickly and aggressively question insurance denials once they’re received. Make sure you understand what’s going on. Try to get it escalated to the insurers and the hospital’s leadership. All of those things. And I think another takeaway for folks is 鈥� and this is harder because, look, you’re in the emergency room, you don’t know what’s going on 鈥� but it might be worth asking, Hey, am I post-stabilization? Am I being admitted as an inpatient? Am I being held for an observation stay? Is there some kind of difference with that in terms of my insurance coverage? And you could perhaps try to put this to the hospital billing department. But it’s even better if there’s a way you can call your insurer. But that’s not always realistic in these kinds of emergency situations. 

Rovner: Yeah, and just out of curiosity, if somebody totals my car and I end up [in] an ambulance needing surgery, I’m going to assume that the other driver’s insurance is going to pay my medical bills. Why didn’t that happen? 

Appleby: Well, in this case, the way it was explained to me is the other driver had the minimum coverage needed in the state of Colorado. And so it did pay nearly $5,000 toward some of these charges. But that’s about all it paid. 

Rovner: Wow. Well, now, obviously, as you said, Lauren Hughes is a doctor. Savvy about the way the system works, or doesn’t in this case. Even then, it took her months and called us to work this all out. How should somebody with less expertise handle a situation like this? Is there somebody they can turn to help, assuming that they’re not cognizant enough to start asking questions about their admission status while they’re still in the emergency room waiting for surgery? 

Appleby: Right. Again, that is so complicated. If you can, call your insurer and see what they have to say. And again, it may be after hours. It may be not possible. Perhaps see if you can chat with the hospital billing department. But again, some of this is going to be after the fact. And remember, the billing in this situation came down to how the hospital coded the billing. They coded it as an inpatient hospital stay, and that’s after the fact. And there’s not a lot you can do about it. But in the end, it was resubmitted as an outpatient service, and that made all the difference in this case. 

Rovner: Wow. Another complicated one. Or I guess you can just write to us. Julie Appleby, thank you very much. 

Appleby: Thanks for having me. 

Huetteman: All right, now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week that we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Anna, how about you go first this week? 

Edney: Sure. This story is from a few of my colleagues at Bloomberg. “.” And I thought this was an interesting story, not just because there is the possibility that the world’s most-used weed killer could be going away because it’s just folding under so many legal challenges related to cancer. But it’s also just a deep dive to look at this herbicide that has affected all of our lives and how it came to be, what’s going on with it now, why it’s not working. And also at this company, Bayer, that in the middle of these legal challenges, bought the company that owned Roundup. So I just think it’s an interesting look at the whole situation and something that we’ve probably all consumed before in certain ways, through just fruits and vegetables and different seeds and things. 

Huetteman: Definitely. Shefali, how about your story? 

Luthra: Sure. So I picked a four-part series by my colleague at The 19th, Orion Rummler. The headline for the piece I picked is “” I think this is a really smart package of stories because, as Orion notes, people who have “detransitioned” 鈥� transitioned and then transitioned back 鈥� are a really central part of the modern conservative movement’s efforts to target trans health and, in particular, trans health for young people. Saying, look at these people who transitioned and then came back and regretted it. But there hasn’t been a lot of journalism actually looking at people who navigate this experience beyond those who are these political tokens. So Orion does exactly that. He talked to people who have had the experience of transitioning and then detransitioning in some way. 

He notes that this is a pretty rare experience to have this journey with one’s gender, but that the people he interviewed, he profiled, said that they felt really frustrated with how the conversation has unfolded. In fact, their transitioning was an important part of their journey to discover their gender, and that they are deeply concerned that restrictions on trans health could be harmful to them and their loved ones as well. I think this is really valuable journalism, and I’m so excited that Orion did it, and I hope everyone reads it. 

Huetteman: That’s really interesting. Thank you for sharing that one. Sandhya, what do you have this week? 

Raman: So I pick, “,” and it’s by Nadine Yousif for the BBC. So this week, the Pan-American Health Organization, Canada is no longer measles-free. And so that means that the Americas region as a whole has lost its elimination status. I thought this was important because in the U.S., we’re at a 33-year high with measles. And Mexico has also seen a surge in cases. And just an interesting way to look at what’s happening a little broader than just the U.S. lens, as all these places are seeing fewer people vaccinated against measles. 

Huetteman: Thanks for sharing that story, Sandhya. My extra credit this week is a great scoop from my 吃瓜不打烊 colleague Amanda Seitz. The headline is, “Immigrants With Health Conditions May Be Denied Visas Under New Trump Administration Guidance.” Amanda got her hands on a State Department cable that expands the list of reasons that would make visa applicants ineligible to enter the country, including now age or the likelihood they might rely on government benefits. And it gives visa officers quite a bit of power to make those calls.  

Now immigrants, they’re already screened for communicable diseases and mental health problems. But the new guidance goes further and emphasizes that chronic diseases should be considered. And it calls on those visa officers to assess whether applicants can pay for their own medical care, noting that certain medical conditions can “require hundreds of thousands of dollars’ worth of care.” 

All right, that’s this week’s show. Thanks this week to our editor, Stephanie Stapleton, and our producer-engineers, Taylor Cook and Francis Ying. “What the Health?” is available on WAMU platforms, the NPR app, and wherever you get your podcasts. And, as always, on kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on . Where are you folks these days? Sandhya? 

Raman: I’m on  and on  @SandhyaWrites. 

Huetteman: Shefali? 

Luthra: I’m on Bluesky . 

Huetteman: And Anna? 

Edney:  or  @AnnaEdney. 

Huetteman: We’ll be back in your feed next week. Until then, be healthy.