Author: bkellaway

The Host

Congress has mostly stood by as the Trump administration — spurred by Elon Musk and his Department of Government Efficiency, named and created by President Donald Trump  — takes a chainsaw to a broad array of government programs. But now the courts are stepping in to slow or stop some efforts that critics claim are illegal, unconstitutional, or both.

Funding freezes and contract cancellations are already having a chilling effect on health programs, such as biomedical research grants for the National Institutes of Health, humanitarian and health aid provided overseas by the U.S. Agency for International Development, and federal funding owed to community health centers and other domestic agencies.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Shefali Luthra of The 19th, and Maya Goldman of Axios.

Among the takeaways from this week’s episode:

• Universities are reconsidering hiring and other forward-looking actions after the Trump administration imposed an abrupt, immediate cap on indirect costs, which help cover overhead and related expenses that aren’t included in federal research grants. A slowdown at research institutions could undermine the prospects for innovation generally — and the nation’s economy specifically, as the United States relies quite a bit on those jobs and the developments they produce.
• The Trump administration’s decision to apply the cap on indirect costs to not only future but also current federal grants specifically violates the terms of spending legislation passed by Congress. Meanwhile, the health impacts of the sudden shuttering of USAID are becoming clear, including concerns about how unprepared the nation could be for a health threat that emerges abroad.
• Congress still hasn’t approved a full funding package for this year, and Republicans don’t seem to be in a hurry to do more than extend the current extension — and pass a budget resolution to fund Trump’s priorities and defund his chosen targets.
• The House GOP budget resolution package released this week includes a call for $880 billion in spending cuts that is expected to hit Medicaid hard. House Republican leaders say they’re weighing imposing work requirements, but only a small percentage of Medicaid beneficiaries would be subject to that change, as most would be exempt due to disability or other reasons — or are already working. Cuts to Medicaid could have cascading consequences, including for the national problem of maternal mortality.

Also this week, Rovner interviews Mark McClellan — director of the Duke-Margolis Institute for Health Policy who led the FDA and the Centers for Medicare & Medicaid Services during the George W. Bush administration — about the impact of cutting funding to research universities. And Rovner reads the winner of the annual KFF Health News’ “health policy valentines” contest.

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

Julie Rovner: Axios’ “Nonprofit Hospital Draws Backlash for Super Bowl Ad,” by Maya Goldman. 

Shefali Luthra: Politico’s “‘Americans Can and Will Die From This’: USAID Worker Details Dangers, Chaos,” by Jonathan Martin. 

Maya Goldman: KFF Health News’ “Doctor Wanted: Small Town in Florida Offers Big Perks To Attract a Physician,” by Daniel Chang.

Jessie Hellmann: NPR’s “Trump’s Ban on Gender-Affirming Care for Young People Puts Hospitals in a Bind,” by Selena Simmons-Duffin. 

Also mentioned in this week’s podcast:

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

In Arkansas, state health officials announced a stunning statistic for 2023: The total number of abortions in the state, where some 1.5 million women live, was zero.

In South Dakota, too, official records show zero abortions that year.

And in Idaho, home to abortion battles that have recently made their way to the U.S. Supreme Court, the official number of recorded abortions was just five.

In nearly a dozen states with total or near-total abortion bans, government officials claimed that zero or very few abortions occurred in 2023, the first full year after the Supreme Court eliminated federal abortion rights.

Those statistics, the most recent available and published in government records, have been celebrated by anti-abortion activists. Medical professionals say such accounts are not only untrue but fundamentally dishonest.

“To say there are no abortions going on in South Dakota is ludicrous,” said Amy Kelley, an OB-GYN in Sioux Falls, South Dakota, citing female patients who have come to her hospital after taking abortion pills or to have medical procedures meant to prevent death or end nonviable pregnancies. “I can think of five off the top of my head that I dealt with,” she said, “and I have 15 partners.”

For some data scientists, these statistics also suggest a troubling trend: the potential politicization of vital statistics.

“It’s so clinically dishonest,” said Ushma Upadhyay, a public health scientist at the University of California-San Francisco, who co-chairs WeCount, an academic research effort that has kept a tally of the number of abortions nationwide since April 2022.

The zeroing out is statistically unlikely, Upadhyay said, and also runs counter to the reality that pregnancy “comes with many risks and in many cases emergency abortion care will be needed.”

“We know they are sometimes necessary to save the pregnant person’s life,” she said, “so I do hope there are abortions occurring in South Dakota.”

State officials reported a sharp decline in the official number of abortions after the Supreme Court overturned Roe v. Wade in June 2022.

• Arkansas reported zero abortions in 2023, compared with 1,621 in 2022.
• Texas reported 60 in 2023, after reporting 50,783 abortions in the state in 2021.
• Idaho reported five in 2023 compared with 1,553 in 2021.
• South Dakota, which had severely restricted abortions years ahead of the Dobbs ruling, reported zero in 2023 compared with 192 abortions in 2021.

Anti-abortion politicians and activists have cited these statistics to bolster their claims that their decades-long crusade to end abortion is a success.

“Undoubtedly, many Arkansas pregnant mothers were spared from the lifelong regrets and physical complications abortion can cause and babies are alive today in Arkansas,” Rose Mimms, executive director of Arkansas Right to Life, said in a press statement. “That’s a win-win for them and our state.”

A spokesperson for the Arkansas Department of Health, Ashley Whitlow, said in an email that the department “is not able to track abortions that take place out of the state or outside of a healthcare facility.” State officials, she said, collect data from “in-state providers and facilities for the Induced Abortion data reports as required by Arkansas law.”

WeCount’s tallies of observed telehealth abortions do not appear in the official state numbers. For instance, from April to June 2024 it counted an average of 240 telehealth abortions a month in Arkansas.

Groups that oppose abortion rights acknowledge that state surveillance reports do not tell the full story of abortion care occurring in their states. Mimms, of Arkansas Right to Life, said she would not expect abortions to be reported in the state, since the procedure is illegal except to prevent a patient’s death.

“Women are still seeking out abortions in Arkansas, whether it’s illegally or going out of state for illegal abortion,” Mimms told KFF Health News. “We’re not naive.”

The South Dakota Department of Health “compiles information it receives from health care organizations around the state and reports it accordingly,” Tia Kafka, its marketing and outreach director, said in an email responding to questions about the statistics. Kafka declined to comment on specific questions about abortions being performed in the state or characterizations that South Dakota’s report is flawed.

Kim Floren, who serves as director of the Justice Empowerment Network, which provides funds and practical support to help South Dakota patients receive abortion care, expressed disbelief in the state’s official figures.

“In 2023, we served over 500 patients,” she said. “Most of them were from South Dakota.”

“For better or worse, government data is the official record,” said Ishan Mehta, director for media and democracy at Common Cause, the nonpartisan public interest group. “You are not just reporting data. You are feeding into an ecosystem that is going to have much larger ramifications.”

When there is a mismatch in the data reported by state governments and credible researchers, including WeCount and the Guttmacher Institute, a reproductive health research group that supports abortion rights, state researchers need to dig deeper, Mehta said.

“This is going to create a historical record for archivists and researchers and people who are going to look at the decades-long trend and try to understand how big public policy changes affected maternal health care,” Mehta said. And now, the recordkeepers “don’t seem to be fully thinking through the ramifications of their actions.”

A Culture of Fear

Abortion rights supporters agree that there has been a steep drop in the number of abortions in every state that enacted laws criminalizing abortion. In states with total bans, 63 clinics have stopped providing abortions. And doctors and medical providers face criminal charges for providing or assisting in abortion care in at least a dozen states.

Practitioners find themselves working in a culture of confusion and fear, which could contribute to a hesitancy to report abortions — despite some state efforts to make clear when abortion is allowed.

For instance, South Dakota Department of Health Secretary Melissa Magstadt released a video to clarify when an abortion is legal under the state’s strict ban.

The procedure is legal in South Dakota only when a pregnant woman is facing death. Magstadt said doctors should use “reasonable medical judgment” and “document their thought process.”

Any doctor convicted of performing an unlawful abortion faces up to two years in prison.

In the place of reliable statistics, academic researchers at WeCount use symbols like dashes to indicate they can’t accurately capture the reality on the ground.

“We try to make an effort to make clear that it’s not zero. That’s the approach these departments of health should take,” said WeCount’s Upadhyay, adding that health departments “should acknowledge that abortions are happening in their states but they can’t count them because they have created a culture of fear, a fear of lawsuits, having licenses revoked.”

“Maybe that’s what they should say,” she said, “instead of putting a zero in their reports.”

Mixed Mandates for Abortion Data

For decades, dozens of states have required abortion providers to collect detailed demographic information on the women who have abortions, including race, age, city, and county — and, in some cases, marital status and the reason for ending the pregnancy.

Researchers who compile data on abortion say there can be sound public health reasons for monitoring the statistics surrounding medical care, namely to evaluate the impact of policy changes. That has become particularly important in the wake of the Supreme Court’s 2022 Dobbs decision, which ended the federal right to an abortion and opened the door to laws in Republican-led states restricting and sometimes outlawing abortion care.

Isaac Maddow-Zimet, a Guttmacher data scientist, said data collection has been used by abortion opponents to overburden clinics with paperwork and force patients to answer intrusive questions. “It’s part of a pretty long history of those tools being used to stigmatize abortion,” he said.

In South Dakota, clinic staff members were required to report the weight of the contents of the uterus, including the woman’s blood, a requirement that had no medical purpose and had the effect of exaggerating the weight of pregnancy tissue, said Floren, who worked at a clinic that provided abortion care before the state’s ban.

“If it was a procedural abortion, you had to weigh everything that came out and write that down on the report,” Floren said.

The Centers for Disease Control and Prevention does not mandate abortion reporting, and some Democratic-led states, including California, do not require clinics or health care providers to collect data. Each year, the CDC requests abortion data from the central health agencies for every state, the District of Columbia, and New York City, and these states and jurisdictions voluntarily report aggregated data for inclusion in the CDC’s annual “Abortion Surveillance” report.

In states that mandate public abortion tracking, hospitals, clinics, and physicians report the number of abortions to state health departments in what are typically called “induced termination of pregnancy” reports, or ITOPs.

Before Dobbs, such reports recorded procedural and medication abortions. But following the elimination of federal abortion rights, clinics shuttered in states with criminal abortion bans. More patients began accessing abortion medication through online organizations, including Aid Access, that do not fall under mandatory state reporting laws.

At least six states have enacted what are called “shield laws” to protect providers who send pills to patients in states with abortion bans. That includes New York, where Linda Prine, a family physician employed by Aid Access, prescribes and sends abortion pills to patients across the country.

Asked about states reporting zero or very few abortions in 2023, Prine said she was certain those statistics were wrong. Texas, for example, reported 50,783 abortions in the state in 2021. Now the state reports on average five a month. WeCount reported an average of 2,800 telehealth abortions a month in Texas from April to June 2024.

“In 2023, Aid Access absolutely mailed pills to all three states in question — South Dakota, Arkansas, and Texas,” Prine said.

Texas Attorney General Ken Paxton filed a lawsuit in January against a New York-based physician, Maggie Carpenter, co-founder of the Abortion Coalition for Telemedicine, for prescribing abortion pills to a Texas patient in violation of Texas’ near-total abortion ban. It’s the first legal challenge to New York’s shield law and threatens to derail access to medication abortion.

Still, some state officials in states with abortion bans have sought to choke off the supply of medication that induces abortion. In May, Arkansas Attorney General Tim Griffin wrote cease and desist letters to Aid Access in the Netherlands and Choices Women’s Medical Center in New York City, stating that “abortion pills may not legally be shipped to Arkansas” and accusing the medical organizations of potentially “false, deceptive, and unconscionable trade practices” that carry up to $10,000 per violation.

Good-government groups like Common Cause say that the dangers of officials relying on misleading statistics are myriad, including a disintegration of public trust as well as ill-informed legislation.

These concerns have been heightened by misinformation surrounding health care, including an entrenched and vocal anti-vaccine movement and the objections of some conservative politicians to mandates related to covid-19, including masks, physical distancing, and school and business closures.

“If the state is not going to put in a little more than the bare minimum to just find out if their data is accurate or not,” Mehta said, “we are in a very dangerous place.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

California Gov. Gavin Newsom and state legislators in Sacramento seem to agree: Prescription drug prices are too high. But lawmakers and the second-term governor are at odds over what to do about it, and a recent proposal could trigger one of the biggest health care battles in Sacramento this year.

A California bill awaiting its first hearing would subject drug industry intermediaries known as pharmacy benefit managers, or PBMs, to licensing by the state Department of Insurance. And it would require them to pass along 100% of the rebates they get from drug companies to the health plans and insurers that hire them to oversee prescription drug benefits.

But the proposal, which would impose some of the toughest PBM regulations in the nation, faces at least one major hurdle: Newsom. He vetoed a similar measure last year, unconvinced it would lower consumer costs. He signaled his intent to offer an alternative but has yet to reveal it.

Any fight over PBM reform promises to be a pricey one. Interest groups on both sides spent at least $7 million combined lobbying California lawmakers and the Newsom administration on health care last year, according to records filed with the secretary of state.

“This bill directly threatens the profitability of PBMs going forward,” said Ge Bai, a health policy professor at Johns Hopkins University who has tracked similar bills in other states. “These bills are really the result of an interindustry dog fight, and these are ridiculously fierce fights because PBMs control revenue for pharmacies, as well as for manufacturers.”

The country’s top three PBMs —CVS Caremark, affiliated with Aetna; UnitedHealth Group’s Optum Rx; and Express Scripts, owned by Cigna — control roughly 80% of prescriptions in the United States, according to the Federal Trade Commission. In theory, they leverage their buying power to extract steep discounts from drug manufacturers and pass savings along to insurance companies and employers who provide health coverage.

But as prescription drug prices continue to spiral and federal efforts to control them stall, state lawmakers are focusing on PBMs, which help insurers decide which drugs their plans cover and how much patients will pay out-of-pocket to get them. However, they have been stymied by the drug industry’s secretive ecosystem of rebates, reimbursements, and obscure fees, thwarting efforts to lower drug costs.

In addition to California, PBM proposals have been introduced this legislative session in Arkansas, Iowa, and at least 20 other states as of Feb. 10, according to the National Academy for State Health Policy. All 50 states and Washington, D.C., have some sort of PBM regulation on the books.

And although President Donald Trump has criticized PBMs and vowed to “knock out the middleman,” his recent actions undoing moves to lower prescription drug prices have left some health care experts skeptical that meaningful reform will come from Washington, D.C.

Meanwhile, state data shows California health plan drug costs have grown by more than 50% since 2017. California insurers spent 11% more on pharmaceuticals in 2023 than in 2022, with specialty and brand-name drugs driving the increase.

Both Newsom and bill author Sen. Scott Wiener (D-San Francisco) have said PBMs play a role in high drug prices. While Wiener wants to ban some of their practices outright, Newsom has so far taken a more measured approach, calling for more disclosure and pointing to his plan for the state to manufacture its own generic drugs, which has yet to get off the ground.

In vetoing Wiener’s 2024 bill, which passed in a near-unanimous bipartisan vote, Newsom said he was unconvinced that licensing PBMs would improve affordability for patients and instead directed his administration to “propose a legislative approach” to gather more data from PBMs. In a statement, Newsom spokesperson Elana Ross noted that “Big Pharma backed the vetoed bill” and said the Democratic governor, in partnership with the legislature, will take action to address PBMs this year. She declined to elaborate.

In his January budget proposal, Newsom said his administration was “exploring approaches to increase transparency” in the entire drug supply chain, not just PBMs.

Industry representatives say they’re being unfairly targeted with transparency laws and regulations and blame pharmaceutical companies for setting high drug prices.

“The PBM is taking the risk on price variation, and it allows the client to have certainty on what they’re going to be paying,” said Bill Head, an assistant vice president of state affairs for the Pharmaceutical Care Management Association, which represents PBMs. “We’re hired because it works. It saves money at the end of the day.”

He said PBMs pass on more than 95% of the rebates they receive from drugmakers — a number health policy researchers say is hard to verify.

Consumer advocates say drugmakers simply raise their prices to maintain profits and PBMs charge insurers far more for many medicines than pharmacies are paid to actually dispense them, a practice known as spread pricing.

A January report by the Federal Trade Commission found the three biggest PBMs appeared to steer the most profitable prescriptions away from competitors and to their affiliated pharmacies, which they reimbursed at markups exceeding 1,000% for some drugs, including some used to treat cancer, multiple sclerosis, and serious lung conditions. Over a six-year period, the analysis found, those PBMs and their affiliated pharmacies made roughly $8.7 billion in additional revenue by marking up prices on a sample of 51 specialty drugs.

Wiener’s latest bill, SB 41, would ban such markups, as well as spread pricing, and bar PBMs from receiving performance bonuses based on drug rebates. Similar provisions were stripped out of last year’s bill in the final days before its passage.

“These are practices that only PBMs are engaging in and they’re causing harm, reducing consumer choice, increasing drug costs, and it’s time to address them,” Wiener said. “I’m not going to let that idea just evaporate because of one veto.”

Clint Hopkins, who has co-owned Pucci’s Pharmacy in Sacramento since 2016, said he often deals with complaints from frustrated patients who don’t understand drug pricing schemes and restrictions set by pharmacy benefit managers.

He’s had to turn away customers whose drugs can cost him hundreds of dollars in losses each time they’re filled and says spread pricing is helping drive independent pharmacies out of business.

“I’m not asking to be paid more. I am asking to be paid fairly — at cost or above.”

Under current law, California requires PBMs to disclose some information about drug rebates, and other information, to its clients. That data is often labeled as proprietary to the companies, leaving an incomplete picture of the supply chain, said Maureen Hensley-Quinn, a senior program director at the National Academy for State Health Policy.

PBM representatives say pharmacies, insurers, and other actors in the supply chain should have to disclose information about their profits and practices, too.

“You want to look under the hood?” Head said. “We’re open to that, but let’s look under everybody’s hood.”

Bai said lawmakers are likely going after PBMs because insurers are one portion of the supply chain that they have the power to regulate. But she warned such legislation could cost consumers more if drugmakers and pharmacies remain unchecked. A better approach, Bai suggested, would be to bar PBMs entirely from managing benefits for generic drugs, one of their biggest revenue sources.

“In health care, there’s no saint and there’s no villain. Everybody’s trying to make money,” Bai said. “These fights will bring no benefit to patients unless we go to the root.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

Prices for brand-name drugs in the U.S. are three times what the same drugs cost in other countries. And in a recent KFF survey, 3 in 10 adults reported not taking their medicine as prescribed at some point in the past year because of costs.

“An Arm and a Leg” is collecting stories from listeners about what they’ve done to get the drugs they need when facing sticker shock. 

If you’ve ever faced difficult choices in order to afford your medicine, “An Arm and a Leg” would love to hear about it. If you’re interested in contributing, you can learn more and submit your stories using this form.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

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To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.