As part of a media blitz aimed at women voters, Vice President Kamala Harris this week rolled out a plan for Medicare to provide in-home long-term care services. It’s popular, particularly for families struggling to care for both young children and older relatives, but its enormous expense has prevented similar plans from being implemented for decades.

Meanwhile, President Joe Biden called out former President Donald Trump by name for having “led the onslaught of lies” about the federal efforts to help people affected by hurricanes Helene and Milton. Even some Republican officials say the misinformation about hurricane relief efforts is threatening public health.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico.

Panelists

Among the takeaways from this week’s episode:

• Vice President Kamala Harris’ plan to expand Medicare to cover more long-term care is popular but not new, and in the past has proved prohibitively expensive.
• Former President Donald Trump has abandoned support for a drug price policy he pursued during his first term. The idea, which would lower drug prices in the U.S. to their levels in other industrialized countries, is vehemently opposed by the drug industry, raising the question of whether Trump is softening his hard line on the issue.
• Abortion continues to be the biggest health policy issue of 2024, as Republican candidates — in what seems to be a replay of 2022 — try to distance themselves from their support of abortion bans and other limits. Voters continue to favor reproductive rights, which creates a brand problem for the GOP. Trump’s going back and forth on his abortion positions is an exception to the tack other candidates have taken.
• The Supreme Court returned from its summer break and immediately declined to hear two abortion-related cases. One case pits Texas’ near-total abortion ban against a federal law that requires emergency abortions to be performed in certain cases. The other challenges a ruling earlier this year from the Alabama Supreme Court finding that embryos frozen for in vitro fertilization have the same legal rights as born humans.
• The 2024 KFF annual employer health benefits survey, released this week, showed a roughly 7% increase in premiums, with average family premiums now topping $25,000 per year. And that’s with most employers not covering two popular but expensive medical interventions: GLP-1 drugs for weight loss and IVF.

Also this week, excerpts from a KFF lunch with “Shark Tank” panelist and generic drug discounter Mark Cuban, who has been consulting with the Harris campaign about health care issues.

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

Julie Rovner: KFF Health News’ “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly.

Shefali Luthra: The 19th’s “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” by Mel Leonor Barclay.

Jessie Hellmann: The Assembly’s “Helene Left Some NC Elder-Care Homes Without Power,” by Carli Brosseau.

Joanne Kenen: The New York Times’ “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It,” by Kate Morgan.

Also mentioned on this week’s podcast:

• The New York Times’ “Biden Accuses Trump of ‘Outright Lies’ About Hurricane Response,” by Michael D. Shear.
• The Miami Herald’s “Florida Threatens To Prosecute TV Stations Over Abortion Ad. FCC Head Calls It ‘Dangerous,’” by Claire Healy and Ana Ceballos.
• KFF’s “2024 Employer Health Benefits Survey.”

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

Julie Rovner: Hello, and welcome back to “What the Health.” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, October 10th, 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 are joined via teleconference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Jesse Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: And Joanne Kenen of the Johns Hopkins Schools of Public Health and Nursing and Politico magazine. 

Joanne Kenen: Hi everybody. 

Rovner: Later in this episode, we’ll have some excerpts from the Newsmaker lunch we had here at KFF this week with Mark Cuban — “Shark Tank” star, part-owner of the Dallas Mavericks NBA team, and, for the purposes of our discussion, co-founder of the industry-disrupting pharmaceutical company Cost Plus Drugs. But first, this week’s news. 

We’re going to start this week with Vice President [Kamala] Harris, who’s been making the media rounds on women-focused podcasts and TV shows like “The View.” To go along with that, she’s released a proposal to expand Medicare to include home-based long-term care, to be paid for in part by expanding the number of drugs whose price Medicare can negotiate. Sounds simple and really popular. Why has no one else ever proposed something like that? she asks, knowing full well the answer. Joanne, tell us! 

Kenen: As the one full-fledged member of the sandwich generation here, who has lived the experience of being a family caregiver while raising children and working full time, long-term care is the unfulfillable, extremely expensive, but incredibly important missing link in our health care system. We do not have a system for long-term care, and people do not realize that. Many people think Medicare will, in fact, cover it, where Medicare covers it in a very limited, short-term basis. So the estimates of what families spend both in terms of lost work hours and what they put out-of-pockets is in, I think it’s something like $400 billion. It’s extraordinarily high. But the reason it’s been hard to fix is it’s extraordinarily expensive. And although Harris put out a plan to pay for this, that plan is going to have to be vetted by economists and budget scorers and skeptical Republicans. And probably some skeptical Democrats. It’s really expensive. It’s really hard to do. Julie has covered this for years, too. It’s just— 

Rovner: I would say this is where I get to say one of my favorite things, which is that I started covering health care in 1986, and in 1986 my first big feature was: Why don’t we have a long-term care policy in this country? Thirty-eight years later, and we still don’t, and not that people have not tried. There, in fact, was a long-term-care-in-the-home piece of the Affordable Care Act that passed Congress, and HHS [the Department of Health and Human Services] discovered that they could not implement it in the way it was written, because only the people who would’ve needed it would’ve signed up for it. It would’ve been too expensive. And there it went. So this is the continuing promise of something that everybody agrees that we need and nobody has ever been able to figure out how to do. Shefali, I see you nodding here. 

Luthra: I mean, I’m just thinking again about the pay-fors in here, which are largely the savings from Medicare negotiating drug prices. And what Harris says in her plan is that they’re going to get more savings by expanding the list of drugs that get lower prices. But that also feels very politically suspect when we have already heard congressional Republicans say that they would like to weaken some of those drug negotiation price provisions. And we also know that Democrats, even if they win the presidency, are not likely to have Congress. It really takes me back to 2020, when we are just talking about ideas that Democrats would love to do if they had full power of Congress, while all of us in Washington kind of know that that is just not going to happen. 

Rovner: Yes, I love that one of the pay-fors for this is cutting Medicare fraud. It’s like, where have we heard that before? Oh, yes. In every Medicare proposal for the last 45 years. 

Kenen: And it also involves closing some kind of international tax loopholes, and that also sounds easy on paper, and nothing with taxes is ever easy. The Democrats probably are not going to have the Senate. Nobody really knows about the House. It looks like the Democrats may have a narrow edge in that, but we’re going to have more years of gridlock unless something really changes politically, like something extraordinary changes politically. The Republicans are not going to give a President Harris, if she is in fact President Harris, her wish list on a golden platter. On the other hand there’s need for this. 

Rovner: But in fairness, this is what the campaign is for. 

Kenen: Right. There is a need for something on long-term care. 

Rovner: And everybody’s complaining: Well, what would she do? What would she do if she was elected? Well, here’s something she said she would do if she could, if she was elected. Well, meanwhile, former President [Donald] Trump has apparently abandoned a proposal that he made during his first term to require drugmakers to lower their prices for Medicare to no more than they charge in other developed countries where their prices are government-regulated. Is Trump going soft on the drug industry? Trump has been, what, the Republican, I think, who’s been most hostile towards the drug industry until now. 

Hellmann: I would say maybe. I think the “most favored nation” proposal is something that the pharmaceutical industry has feared even more than the Democrats’ Medicare negotiation program. And it’s something that Trump really pursued in his first term but wasn’t able to get done. In such a tight race, I think he’s really worried about angering pharmaceutical companies, especially after they were just kind of dealt this loss with Medicare price negotiation. And if he does win reelection, he’s going to be kind of limited in his ability to weaken that program. It’s going to be hard to repeal it. It’s extremely popular, and he may be able to weaken it. 

Rovner: “It” meaning price negotiation, not the “most favored nations” prices. 

Hellmann: Yeah. It’s going to be really hard to repeal that, and he may be able to weaken it through the negotiation process with drug companies. It’s definitely an interesting turn. 

Rovner: Joanne, you want to add something? 

Kenen: Trump rhetorically was very harsh on the drug companies right around the time of his inauguration. I think it was the week before, if I remember correctly. Said a lot of very tough stuff on drugs. Put out a list of something like dozens of potential steps. The drug companies have lots of allies in both parties, and more in one than the other, but they have allies on the Hill, and nothing revolutionary happened on drug pricing under Trump. 

Rovner: And his HHS secretary was a former drug company executive. 

Kenen: Yes, Eli Lilly. So we also pointed out here that former President Trump is not consistent in policy proposals. He says one thing, and then he says another thing, and it’s very hard to know where he’s going to come down. So Trump and drug pricing is an open question. 

Rovner: Yes, we will see. All right, well, moving on. Drug prices and Medicare aside, the biggest health issue of Campaign 2024 continues to be abortion and other reproductive health issues. And it’s not just Trump trying to back away from his anti-abortion record. We’ve had a spate of stories over the past week or so of Republicans running for the House, the Senate, and governorships who are trying to literally reinvent themselves as, if not actually supportive of abortion rights, at least anti abortion bans. And that includes Republicans who have not just voted for and advocated for bans but who have been outspokenly supportive of the anti-abortion effort, people like North Carolina Republican gubernatorial candidate Mark Robinson, New Hampshire Republican gubernatorial candidate and former U.S. Senator Kelly Ayotte, along with former Michigan Republican representative and now Senate candidate Mike Rogers. Donald Trump has gotten away repeatedly, as Joanne just said, with changing his positions, even on hot-button issues like abortion. Are these candidates going to be able to get away with doing the same thing, Shefali? 

Luthra: I think it’s just so much tougher when your name is not Donald Trump. And that’s because we know from focus group after focus group, and survey after survey, that voters kind of give Trump more leeway on abortion. Especially independent voters will look at him and say, Well, I don’t think he actually opposes abortion, because I’m sure he’s paid for them. And they don’t have that same grace that they give to Republican lawmakers and Republican candidates, because the party has a bad brand on abortion at large, and Trump is seen as this kind of maverick figure. But voters know that Republicans have a history of opposing abortion, of supporting restrictions. 

When you look at surveys, when you talk to voters, what they say is, Well, I don’t trust Republicans to represent my interests on this issue, because they largely support access. And one thing that I do think is really interesting is, once again, what we’re seeing is kind of a repeat of the 2022 elections when we saw some very brazen efforts by Republican candidates for the House and Senate try and scrub references to abortion and to fetal personhood from their websites. And it didn’t work, because people have eyes and people have memories, and, also, campaigns have access to the internet archive and are able to show people that, even a few weeks ago, Republican candidates were saying something very different from what they are saying now. I don’t think Mark Robinson can really escape from his relatively recent and very public comments about abortion. 

Rovner: Well, on the other hand, there’s some things that don’t change. Republican vice presidential candidate JD Vance told RealClearPolitics last week that if Trump is elected again, their administration would cut off funding to Planned Parenthood because, he said, and I quote, “We don’t think that taxpayers should fund late-term abortions.” Notwithstanding, of course, that even before the overturn of Roe, less than half of all Planned Parenthoods even performed abortions and almost none of those who did perform them later in pregnancy. Is it fair to say that Vance’s anti-abortion slip is showing? 

Luthra: I think it might be. And I will say, Julie, when I saw that he said that, I could hear you in my head just yelling about the Hyde Amendment, because we know that Planned Parenthood does not use taxpayer money to pay for abortions. But we also know that JD Vance has seen that he and his ticket are kind of in a tough corner talking about abortion. He has said many times, We need to rebrand — he’s very honest about that, at least — and trying to focus instead on this nonmedical term of “late term” abortions. 

It’s a gamble. It’s hoping that voters will be more sympathetic to that because they’ll think, Oh, well, that sounds very extreme. And they’re trying to shift back who is seen as credible and who is not, by focusing on something that historically was less popular. But again, it’s again tricky because when we look at the polling, voters’ understanding of abortion has shifted and they are now more likely to understand that when you have an abortion later in pregnancy, it is often for very medically complex reasons. And someone very high-profile who recently said that is Melania Trump in her new memoir, talking about how she supports abortion at all stages of pregnancy because often these are very heart-wrenching cases and not sort of the murder that Republicans have tried to characterize them as. 

Rovner: I think you’re right. I think this is the continuation of the 2022 campaign, except that we’ve had so many more women come forward. We’ve seen actual cases. It used to be anti-abortion forces would say, Oh, well, this never happened. I mean, these are wrenching, awful things that happened to a lot of these patients with pregnancy complications late in pregnancy. And it is, I know, because I’ve talked to them. It’s very hard to get them to talk publicly, because then they get trolled. Why should they step forward? 

Well, now we’ve seen a lot of these women stepping forward. So we now see a public that knows that this happens, because they’re hearing from the people that it’s happened to and they’re hearing from their doctors. I do know also from the polling that there are people who are going to vote in these 10 states where abortion is on the ballot. Many of them are going to vote for abortion access and then turn around and vote for Republicans who support restrictions, because they’re Republicans. It may or may not be their most important issue, but I still think it’s a big question mark where that happens and how it shakes out. Joanne, did you want to add something? 

Kenen: You’re seeing two competing things at the same time. You have a number of Republicans trying to moderate their stance or at least sound like they’re moderating their stance. At the same time, you also have the whole, where the Republican Party is on abortion has shifted to the right. They are talking about personhood at the moment of conception, the embryo — which is, scientifically put, a small ball of cells still at that point — that they actually have the same legal rights as any other post-birth person. 

So that’s become a fairly common view in the Republican Party, as opposed to something that just five or six years ago was seen as the fringe. And Trump is going around saying that Democrats allow babies to be executed after birth, which is not true. And they’re particularly saying this is true in Minnesota because of [Gov.] Tim Walz, and some voters must believe it, right? Because they keep saying it. So you have this trend that Shefali just described and that you’ve described, Julie, about this sort of attempting to win back trust, as Vance said. And it sounded more moderate, and at the same time as you’re hearing this rhetoric about personhood and execution. So I don’t think the Republicans have yet solved their own whiplash post-Roe. 

Rovner: Meanwhile, the abortion debate is getting mired in the free-speech debate. In Florida, Republican governor Ron DeSantis is threatening legal action against TV stations airing an ad in support of the ballot measure that would overturn the state’s six-week abortion ban. That has in turn triggered a rebuke from the head of the Federal Communications Commission warning that political speech is still protected here in the United States. Shefali, this is really kind of out there, isn’t it? 

Luthra: It’s just so fascinating, and it’s really part of a bigger effort by Ron DeSantis to try and leverage anything that he can politically or, frankly, in his capacity as head of the state to try and weaken the campaign for the ballot measure. They have used the health department in other ways to try and send out material suggesting that the campaign’s talking points, which are largely focused on the futility of exceptions to the abortion ban, they’re trying to argue that that is misinformation, and that’s not true. And they’re using the state health department to make that argument, which is something we don’t really see very often, because usually health departments are supposed to be nonpartisan. And what I will say is, in this case, at least to your point, Julie, the FCC has weighed in and said: You can’t do this. You can’t stop a TV station from airing a political ad that was bought and paid for. And the ads haven’t stopped showing at this point. I just heard from family yesterday in Florida who are seeing the ads in question on their TV, and it’s still— 

Rovner: And I will post a link to the ad just so you can see it. It’s about a woman who’s pregnant and had cancer and needed cancer treatment and needed to terminate the pregnancy in order to get the cancer treatment. It said that the exception would not allow her to, which the state says isn’t true and which is clearly one of these things that is debatable. That’s why we’re having a political debate. 

Luthra: Exactly. And one thing that I think is worth adding in here is, I mean, this really intense effort from Governor DeSantis and his administration comes at a time when already this ballot measure faces probably the toughest fight of any abortion rights measure. And we have seen abortion rights win again and again at the ballot, but in Florida you need 60% to pass. And if you look across the country at every abortion rights measure that has been voted on since Roe v. Wade was overturned, only two have cleared 60, and they are in California and they are in Vermont. So these more conservative-leaning states, and Florida is one of them, it’s just, it’s really, really hard to see how you get to that number. And we even saw this week there’s polling that suggests that the campaign has a lot of work to do if they’re hoping to clear that threshold. 

Rovner: And, of course, now they have two hurricanes to deal with, which we will deal with in a few minutes. But first, the Supreme Court is back in session here in Washington, and even though there’s no big abortion case on its official docket as of now this term, the court quickly declined to hear two cases on its first day back, one involving whether the abortion ban in Texas can override the federal emergency treatment law that’s supposed to guarantee abortion access in medical emergencies threatening the pregnant woman’s life or health. The court also declined to overrule the Alabama Supreme Court’s ruling that frozen embryos can be considered legally as unborn children. That’s what Joanne was just talking about. Where do these two decisions leave us? Neither one actually resolved either of these questions, right? 

Luthra: I mean, the EMTALA [Emergency Medical Treatment and Labor Act] question is still ongoing, not because of the Texas case but because of the Idaho case that is asking very similar questions that we’ve talked about previously on this podcast. And the end of last term, the court kicked that back down to the lower courts to continue making its way through. We anticipate it will eventually come back to the Supreme Court. So this is a question that we will, in fact, be hearing on at some point. 

Rovner: Although, the irony here is that in Idaho, the ban is on hold because there was a court stay. And in Texas, the ban is not on hold, even though we’re talking about exactly the same question: Does the federal law overrule the state’s ban? 

Luthra: And what that kind of highlights — right? — is just how much access to abortion, even under states with similar laws or legislatures, really does depend on so many factors, including what circuit court you fall into or the makeup of your state Supreme Court and how judges are appointed or whether they are elected. There is just so much at play that makes access so variable. And I think the other thing that one could speculate that maybe the court didn’t want headlines around reproductive health so soon into an election, but it’s not as if this is an issue that they’re going to be avoiding in the medium- or long-term future. These are questions that are just too pressing, and they will be coming back to the Supreme Court in some form. 

Rovner: Yes, I would say in the IVF [in vitro fertilization] case, they simply basically said, Go away for now. Right? 

Luthra: Yeah. And, I mean, right now in Alabama, people are largely able to get IVF because of the state law that was passed, even if it didn’t touch the substance of that state court’s ruling. This is something, for now, people can sort of think is maybe uninterrupted, even as we all know that the ideological and political groundwork is being laid for a much longer and more intense fight over this. 

Rovner: Well, remember back last week when we predicted that the judge’s decision overturning Georgia’s six-week ban was unlikely to be the last word? Well, sure enough, the Georgia Supreme Court this week overturned the immediate overturning of the ban, which officially went back into effect on Monday. Like these other cases, this one continues, right? 

Luthra: Yes, this continues. The Georgia case continued for a while, and it just sort of underscores again what we’ve been talking about, just how much access really changes back and forth. And I was talking to an abortion clinic provider who has clinics in North Carolina and Georgia. She literally found out about the decision both times and changed her plans for the next day because I texted her asking her for comment. And providers and patients are being tasked with keeping up with so much. And it’s just very, very difficult, because Georgia also has a 24-hour waiting period for abortions, which means that every time the decision around access has changed — and we know it very well could change again as this case progresses — people will have to scramble very quickly. And in Georgia, they have also been trying to do that on top of navigating the fallout of a hurricane. 

Rovner: Yeah. And as we pointed out a couple of weeks ago when the court overturned the North Dakota ban, there are no abortion providers left in North Dakota. Now that there’s no ban, it’s only in theory that abortion is now once again allowed in North Dakota. Well, before we leave abortion for this week, we have two new studies showing how abortion bans are impacting the health care workforce. In one survey, more than half of oncologists, cancer doctors, who were completing their fellowships, so people ready to go into practice, said they would consider the impact of abortion restrictions in their decisions about where to set up their practice. And a third said abortion restrictions hindered their ability to provide care. 

Meanwhile, a survey of OBGYNs in Texas by the consulting group Manatt Health found “a significant majority of practicing OB/GYN physicians … believe that the Texas abortion laws have inhibited their ability to provide highest-quality and medically necessary care to their patients,” and that many have already made or are considering making changes to their practice that would “reduce the availability of OB/GYN care in the state.” What’s the anti-abortion reaction to this growing body of evidence that abortion bans are having deleterious effects on the availability of other kinds of health care, too? I mean, I was particularly taken by the oncologists, the idea that you might not be able to get cancer care because cancer doctors are worried about treating pregnant women with cancer. 

Luthra: They’re blaming the doctors. And we saw this in Texas when the Zurawski case was argued and women patients and doctors in the state said that they had not been able to get essential, lifesaving medical care because of the state’s abortion ban and lack of clarity around what was actually permitted. And the state argued, and we have heard this talking point again and again, that actually the doctors are just not willing to do the hard work of practicing medicine and trying to interpret, Well, obviously this qualifies. That’s something we’ve seen in the Florida arguments. They say: Our exceptions are so clear, and if you aren’t able to navigate these exceptions, well, that’s your problem, because you are being risk-averse, and patients should really take this up with their doctors, who are just irresponsible. 

Rovner: Yes, this is obviously an issue that’s going to continue. Well, moving on. The cost of health care continues to grow, which is not really news, but this week we have more hard evidence, courtesy of my KFF colleagues via the annual 2024 Employer Health Benefit Survey, which finds the average family premium rose 7% this year to $25,572, with workers contributing an average of $6,296 towards that cost. And that’s with a distinct minority of firms covering two very popular but very expensive medical interventions, GLP-1 [glucagon-like peptide-1] drugs for obesity and IVF, which we’ve just been talking about. Anything else in this survey jump out at anybody? 

Hellmann: I mean, that’s just a massive amount of money. And the employer is really paying the majority of that, but that doesn’t mean it doesn’t have an impact on people. That means it’s going to limit how much your wages go up. And something I thought of when I read this study is these lawsuits that we’re beginning to see, accusing employers of not doing enough to make sure that they’re limiting health care costs. They’re not playing enough of a role in what their benefits look like. They’re kind of outsourcing this to consultants. And so when you look at this data and you see $25,000 they’re spending per year per family on health care premiums, you wonder, what are they doing? 

Health care, yes, it’s obviously very expensive, but you just kind of question, what role are employers actually playing in trying to drive down health care costs? Are they just taking what they get from consultants? And another thing that kind of stood out to me from this is, I think it’s said in there, employers are having a hard time lately of passing these costs on to employees, which is really interesting. It’s because of the tight labor market. But obviously health care is still very expensive for employees — $6,000 a year in premiums for family coverage is not a small amount of money. So employers are just continuing to absorb that, and it does really impact everyone. 

Rovner: It’s funny. Before the Affordable Care Act, it was employers who were sort of driving the, You must do something about the cost of health care, because inflation was so fast. And then, of course, we saw health care inflation, at least, slow down for several years. Now it’s picking up again. Are we going to see employers sort of getting back into this jumping up and down and saying, “We’ve got to do something about health care costs”? 

Hellmann: I feel like we are seeing more of that. You’re beginning to hear more from employers about it. I don’t know. It’s just such a hard issue to solve, and I’ve seen more and more interest from Congress about this, but they really struggle to regulate the commercial market. So … 

Rovner: Yes, as we talk about at length every week. But it’s still important, and they will still go for it. Well, finally, this week in health misinformation. Let us talk about hurricanes — the public health misinformation that’s being spread both about Hurricane Helene that hit the Southeast two weeks ago, and Hurricane Milton that’s exiting Florida even as we are taping this morning. President [Joe] Biden addressed the press yesterday from the White House, calling out former President Trump by name along with Georgia Republican congresswoman Marjorie Taylor Greene for spreading deliberate misinformation that’s not just undermining efforts at storm relief but actually putting people in more danger. Now, I remember Hurricane Katrina and all the criticism that was heaped, mostly deservedly, on George W. Bush and his administration, but I don’t remember deliberate misinformation like this. I mean, Joanne, have you ever seen anything like this? You lived in Florida for a while. 

Kenen: I went through Andrew, and there’s always a certain — there’s confusion and chaos after a big storm. But there’s a difference between stuff being wrong that can be corrected and stuff being intentionally said that then in this sort of divided, suspicious, two-realities world we’re now living in, that’s being repeated and perpetuated and amplified. It damages public health. It damages people economically trying to recover from this disastrous storm or in some cases storms. I don’t know how many people actually believe that Marjorie Taylor asserted that the Democrats are controlling the weather and sending storms to suppress Republican voters. She still has a following, right? But other things … 

Rovner: She still gets reelected. 

Kenen: … being told that if you go to FEMA [the Federal Emergency Management Agency] for help, your property will be confiscated and taken away from you. I mean, that’s all over the place, and it’s not true. Even a number of Republican lawmakers in the affected states have been on social media and making statements on local TV and whatever, saying: This is not true. Please, FEMA is there to help you. Let’s get through this. Stop the lies. A number of Republicans have actually been quite blunt about the misinformation coming from their colleagues and urging their constituents to seek and take the help that’s available. 

This is the public health crisis. We don’t know how many people have been killed. I don’t think we have an accurate total final count from Helene, and we sure don’t have from Milton. I mean, the people did seem to take this storm seriously and evacuated, but it also spawned something like three dozen tornadoes in places where people hadn’t been told, there’s normally no need to evacuate. There’s flooding. It’s a devastating storm. So when people are flooding, power outages, electricity, hard to get access to health care, you can’t refrigerate your insulin. All these— 

Rovner: Toxic floodwaters, I mean, the one thing … 

Kenen: Toxic, yeah. 

Rovner: … we know about hurricanes is that they’re more dangerous in the aftermath than during the actual storm in terms of public health. 

Kenen: Right. This is a life-threatening public health emergency to really millions of people. And misinformation, not just getting something wrong and then trying to correct it, but intentional disinformation, is something we haven’t seen before in a natural disaster. And we’re only going to have more natural disasters. And it was really — I mean, Julie, you already pointed this out — but it was really unusual how precise Biden was yesterday in calling out Trump by name, and I believe at two different times yesterday. So I heard one, but I think I read about what I think was the second one really saying, laying it at his feet that this is harming people. 

Rovner: Yeah, like I said, I remember Katrina vividly, and that was obviously a really devastating storm. I do also remember Democrats and Republicans, even while they were criticizing the federal government reaction to it, not spreading things that were obviously untrue. All right. Well, that is the news for this week. Now we will play a segment from our Newsmaker interview with Mark Cuban, and then we will be back with our extra credits. 

On Tuesday, October 8th, Mark Cuban met with a group of reporters for a Newsmaker lunch at KFF’s offices in Washington, D.C. Cuban, a billionaire best known as a panelist on the ABC TV show “Shark Tank,” has taken an interest in health policy in the past several years. He’s been consulting with the campaign of Vice President Harris, although he says he’s definitely not interested in a government post if she wins. Cuban started out talking about how, as he sees it, the biggest problem with drug prices in the U.S. is that no one knows what anyone else is paying. 

Mark Cuban: I mean, when I talk to corporations and I’ve tried to explain to them how they’re getting ripped off, the biggest of the biggest said, Well, so-and-so PBM [pharmacy benefit manager] is passing through all of their rebates to us. 

And I’m like: Does that include the subsidiary in Scotland or Japan? Is that where the other one is? 

I don’t know. 

And it doesn’t. By definition, you’re passing through all the rebates with the company you contracted with, but they’re not passing through all the rebates that they get or that they’re keeping in their subsidiary. And so, yeah, I truly, truly believe from there everybody can argue about the best way. Where do you use artificial intelligence? Where do you do this? What’s the EHR [electronic health record? What’s this? We can all argue about best practices there. But without a foundation of information that’s available to everybody, the market’s not efficient and there’s no place to go. 

Rovner: He says his online generic drug marketplace, costplusdrugs.com, is already addressing that problem. 

Cuban: The crazy thing about costplusdrugs.com, the greatest impact we had wasn’t the markup we chose or the way we approach it. It’s publishing our price list. That changed the game more than anything. So when you saw the FTC [Federal Trade Commission] go after the PBMs, they used a lot of our pricing for all the non-insulin stuff. When you saw these articles written by the Times and others, or even better yet, there was research from Vanderbilt, I think it was, that says nine oncology drugs, if they were purchased by Medicare through Cost Plus, would save $3.6 billion. These 15, whatever drugs would save six-point-whatever billion. All because we published our price list, people are starting to realize that things are really out of whack. And so that’s why I put the emphasis on transparency, because whether it’s inside of government or inside companies that self-insure, in particular, they’re going to be able to see. The number one rule of health care contracts, particularly PBM contracts, is you can’t talk about PBM contracts. 

Rovner: Cuban also says that more transparency can address problems in the rest of the health care system, not just for drug prices. Here’s how he responded to a question I asked describing his next big plan for health care. 

We’ve had, obviously, issues with the system being run by the government not very efficiently and being run by the private sector not very efficiently. 

Cuban: Very efficiently, yeah. 

Rovner: And right now we seem to have this sort of working at cross-purposes. If you could design a system from the ground up, which would you let do it? The government or— 

Cuban: I don’t think that’s really the issue. I think the issue is a lack of transparency. And you see that in any organization. The more communication and the more the culture is open and transparent, the more people hold each other responsible. And I think you get fiefdoms in private industry and you get fiefdoms in government, as well, because they know that if no one can see the results of their work, it doesn’t matter. I can say my deal was the best and I did the best and our outcomes are the best, but there’s no way to question it. And so talking to the Harris campaign, it’s like if you introduce transparency, even to the point of requiring PBMs and insurers to publish their contracts publicly, then you start to introduce an efficient market. And once you have an efficient market, then people are better able to make decisions and then you can hold them more accountable. 

And I think that’s going to spill over beyond pharm. We’re working on — it’s not a company — but we’re working on something called Cost Plus Wellness, where we’re eating our own dog food. And it’s not a company that’s going to be a for-profit or even a nonprofit, for that matter, just for the lives that I cover for my companies, that we self-insure. We’re doing direct contracting with providers, and we’re going to publish those contracts. And part and parcel to that is going through the — and I apologize if I’m stumbling here. I haven’t slept in two days, so bear with me. But going through the hierarchy of care and following the money, if you think about when we talk to CFOs and CEOs of providers, one of the things that was stunning to me that I never imagined is the relationship between deductibles for self-insured companies and payers, and the risk associated with collecting those deductibles to providers. 

And I think people don’t really realize the connection there. So whoever does Ann’s care [KFF Chief Communications Officer Ann DeFabio, who was present] — well, Kaiser’s a little bit different, but let’s just say you’re employed at The Washington Post or whoever and you have a $2,500 deductible. And something happens. Your kid breaks their leg and goes to the hospital, and you’re out of market, and it’s out of network. Well, whatever hospital you go to there, you might give your insurance card, but you’re responsible for that first $2,500. And that provider, depending on where it’s located, might have collection — bad debt, rather — of 50% or more. 

So what does that mean in terms of how they have to set their pricing? Obviously, that pricing goes up. So there’s literally a relationship between, particularly on pharmacy, if my company takes a bigger rebate, which in turn means I have a higher deductible because there’s less responsibility for the PBM-slash-insurance company. My higher deductible also means that my sickest employees are the ones paying that deductible, because they’re the ones that have to use it. And my older employees who have ongoing health issues and have chronic illnesses and need medication, they’re paying higher copays. But when they have to go to the hospital with that same deductible, because I took more of a rebate, the hospital is taking more of a credit risk for me. That’s insane. That makes absolutely no sense. 

And so what I’ve said is as part of our wellness program and what we’re doing to — Project Alpo is what we call it, eating our own dog food. What I’ve said is, we’ve gone to the providers and said: Look, we know you’re taking this deductible risk. We’ll pay you cash to eliminate that. But wait, there’s more. We also know that when you go through a typical insurer, even if it’s a self-insured employer using that insurer and you’re just using the insurance company not for insurance services but as a TPA [third-party administrator], the TPA still plays games with the provider, and they underpay them all the time. 

And so what happens as a result of the underpayment is that provider has to have offices and offices full of administrative assistants and lawyers, and they have to not only pay for those people, but they have the associated overhead and burden and the time. And then talking to them, to a big hospital system, they said that’s about 2% of their revenue. So because of that, that’s 2%. Then, wait, there’s more. You have the pre-ops, and you have the TPAs who fight you on the pre-ops. But the downstream economic impacts are enormous because, first, the doctor has to ask for the pre-op. That’s eating doctor’s time, and so they see fewer patients. And then not only does the doctor have to deal with them, they go to HR at the company who self-insures and says, Wait, my employee can’t come to work, because their child is sick, and you won’t approve this process or, whatever, this procedure, because it has to go through this pre-op. 

Or if it’s on medications, it’s you want to go through the step-up process or you want to go through a different utilization because you get more rebates. All these pieces are intertwined, and we don’t look at it holistically. And so what we’re saying with Cost Plus Wellness is, we’re going to do this all in a cash basis. We’re going to trust doctors so that we’re not going to go through a pre-op. Now we’ll trust but verify. So as we go through our population and we look at all of our claims, because we’ll own all of our claims, we’re going to look to see if there are repetitive issues with somebody who’s just trying to —there’s lots of back surgeries or there’s lots of this or there’s lots of that — to see if somebody’s abusing us. And because there’s no deductible, we pay it, and we pay it right when the procedure happens or right when the medication is prescribed. Because of all that, we want Medicare pricing. Nobody’s saying no. And in some cases I’m getting lower than Medicare pricing for primary care stuff. 

Rovner: OK, we are back. Now it’s time for our extra credits. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We will include the links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week. 

Kenen: There was a fascinating story in The New York Times by Kate Morgan. The headline was “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It.” So I knew nothing about this, and it was so interesting. Placentas have amazing healing properties for wound care, burns, infections, pain control, regenerating skin tissue, just many, many things. And it’s been well known for years, and it’s not widely used. This is a story specifically about a really severe burn victim in a gas explosion and how her face was totally restored. We don’t use this, partly because placenta — every childbirth, there’s a placenta. There are lots of them around. There’s I think three and a half million births a year, or that’s the estimate I read in the Times. One of the reasons they weren’t being used is, during the AIDS crisis, there was some development toward using them, and then the AIDS crisis, there was a fear of contamination and spreading the virus, and it stopped decades later. 

We have a lot more ways of detecting, controlling, figuring out whether something’s contaminated by AIDS or whether a patient has been exposed. It is being used again on a limited basis after C-sections, but it seems to have pretty astonishing — think about all the wound care for just diabetes. I’m not a scientist, but I just looked at the story and said, it seems like a lot of people could be healed quicker and more safely and earlier if this was developed. They’re thrown away now. They’re sent to hospital waste incinerators and biohazard waste. They’re garbage, and they’re actually medicine. 

Rovner: Definitely a scientist’s cool story. Shefali. 

Luthra: My story is from my brilliant colleague Mel Leonor Barclay. The headline is “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” and as part of this really tremendous series that she has running this week, looking at how Latinas as a much more influential and growingly influential voter group could shape gun violence, abortion rights, and housing. And in this story, which I really love, she went to Arizona and spent time talking to folks on all sides of the issue to better understand how Latinas are affected by abortion rights and also how they’ll be voting on this. 

And she really challenges the narrative that has existed for so long, which is that Latinas are largely Catholic, largely more conservative on abortion. And she finds something much more complex, which is that actually polls really show that a large share of Latina voters in Arizona and similar states support abortion rights and will be voting in favor of measures like the Arizona constitutional amendment. But at the same time, there are real divides within the community, and people talk about their faith in a different way and how it connects their stance on abortion. They talk about their relationships with family in different ways, and I think it just underscores how rarely Latina voters are treated with real nuance and care and thoughtfulness when talking about something as complex as abortion and abortion politics. And I really love the way that she approaches this piece. 

Rovner: It was a super-interesting story. Jesse. 

Hellmann: My story is from The Assembly. It’s an outlet in North Carolina. It’s called “Helene Left Some North Carolina Elder-Care Homes Without Power.” Some assisted living facilities have been without power and water since the hurricane hit. Several facilities had to evacuate residents, and the story just kind of gets into how North Carolina has more lax rules around emergency preparedness. While they do require nursing homes be prepared to provide backup power, the same requirements don’t apply to assisted living facilities. And it’s because there’s been industry pushback against that because of the cost. But as we see some more of these extreme weather events, it seems like something has to be done. We cannot just allow vulnerable people living in these facilities to go hours and hours without power and water. And I saw that there was a facility where they evacuated dozens of people who had dementia, and that’s just something that’s really upsetting and traumatizing for people. 

Rovner: Yeah, once again, now we are seeing these extreme weather events in places that, unlike Florida and Texas, are not set up and used to extreme weather events. And it is something I think that a lot of people are starting to think about. Well, my story this week is from our KFF Health News public health project called Health Beat, and it’s called “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly. And it’s one of those stories you never really think about until it’s pointed out that in areas, particularly those that had been redlined, in particular, the lack of safety infrastructure that most of us take for granted — crosswalks, sidewalks, traffic lights are not really there. And that’s a public health crisis of its own, and it’s one that rarely gets addressed, and it’s a really infuriating but a really good story. 

All right, that is our show. Next week, for my birthday, we’re doing a live election preview show here at KFF in D.C., because I have a slightly warped idea of fun. And you’re all invited to join us. I will put a link to the RSVP in the show notes. I am promised there will be cake. 

As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Stephanie Stapleton. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me for the moment at X. I’m @jrovner. Joanne, where are you? 

Kenen: @JoanneKenen sometimes on Twitter and @joannekenen1 on Threads.

Rovner: Jessie.

Hellmann: @jessiehellmann on Twitter.

Rovner: Shefali.

Luthra: @shefalil on Twitter.

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

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The IHS is supposed to provide free care to Native Americans, but it does so only at scattered clinics and hospitals the agency funds and then manages or turns over to tribes to operate. Many of those are in rural areas and offer limited services. They might not provide cancer treatment or pregnancy care, for example.

That’s where the agency’s Purchased/Referred Care program is supposed to come in.

But funding shortages, complex rules and administrative fumbles impede access to the program, my colleague Katheryn Houghton and I reported after speaking with patients, elected officials and people who work with the federal agency.

Native Americans qualify for the referred-care program if they live on tribal land — only 13 percent do — or within their tribe’s “delivery area,” which usually includes surrounding counties. Those who live in another delivery area are eligible in some cases.

Jonni Kroll, a member of the Little Shell Tribe of Chippewa Indians of Montana, doesn’t qualify, because she lives in Washington state, nearly 400 miles from her tribe’s headquarters.

Tying program eligibility to tribal lands, Kroll said, echoes old government policies meant to keep Indigenous people in one place, even if it means reduced access to jobs, education and health care.

“What do we do? Sell our homes, leave our families and our jobs?” she said.

What about eligible Native Americans? They aren’t guaranteed funding or timely help. Some of the IHS’s 170 units exhaust their annual pool of referred-care funding or reserve it for the most serious medical concerns.

In fiscal 2022, for example, the program denied or deferred nearly $552 million in spending for about 120,000 requests from eligible patients.

Connie Brushbreaker, a member of the Rosebud Sioux Tribe in South Dakota, has been denied or wait-listed for funding at least 14 times since 2018. In March, she received a letter saying her referred-care program is reserved for patients at imminent risk of dying. It doesn’t make sense to her that the agency refuses to pay for treatment that will be approved once a health problem becomes more serious and expensive.

Another obstacle is the estimated 34 percent of program staffing positions that are vacant.

Multiple patients told us that staff rarely pick up the phone or return messages, or that they share confusing information about eligibility and the application process.

Brendan White, an agency spokesperson, said improving the referred-care program is a top IHS goal. He said about 83 percent of the health units it manages have approved all eligible funding requests this year.

The agency is tackling staff shortages and recently improved how funding is prioritized, he said. The IHS is also studying whether it can afford to create statewide eligibility in the Dakotas.

But many advocates say the only way to improve the referred-care program is to fully fund it — or even better, fully fund the IHS so patients don’t need as much outside care in the first place.

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Desde 2021, en más de 20 estados se han promulgado nuevas leyes para frenar la facturación abusiva de los hospitales, ampliar la atención caritativa a los pacientes con ingresos más bajos y frenar a los recaudadores de deudas.

Los demócratas impulsaron la mayoría de las medidas. Pero estas iniciativas legislativas a menudo fueron aprobadas también con el apoyo de los republicanos. Incluso, en algunos estados, los legisladores republicanos lideraron los proyectos para ampliar la protección a los pacientes.

“Independientemente de cuál sea su partido político, independientemente de su origen… cualquier procedimiento médico importante puede llevar a las personas a la bancarrota”, dijo en una entrevista el presidente de la Cámara de Representantes de Florida, Paul Renner, un republicano conservador. “Este es un problema real”.

Renner, que ha liderado controversiales medidas para frenar el derecho al aborto y ampliar la pena de muerte en Florida, también encabezó este año un proyecto para limitar los casos en los que los hospitales podían enviar las cuentas impagas de los pacientes a agencias de cobros. Obtuvo el apoyo unánime de la Legislatura de Florida.

Las medidas bipartidistas adoptadas en otros estados han ido más lejos, prohibiendo que estas facturas médicas figuren en los informes crediticios de los consumidores y restringiendo la posibilidad de que los proveedores médicos embarguen las viviendas de los pacientes.

Según KFF Health News, unas 100 millones de personas en el país están agobiadas por algún tipo de deuda relacionada con la atención médica, lo que obliga a millones a utilizar sus ahorros, pedir segundas hipotecas o recortar los gastos en alimentos y otros artículos de primera necesidad. Una cuarta parte de quienes tienen deudas debían más de $5.000 en 2022.

“En la Legislatura, los republicanos parecen más abiertos a proteger a la gente de la deuda médica que de cualquier otro tipo de deuda”, opinó Marceline White, directora ejecutiva de Economic Action Maryland, una organización sin fines de lucro que ayudó a liderar los esfuerzos en ese estado para detener a los proveedores médicos que pretendían embargar los salarios de los pacientes de bajos ingresos. El proyecto de ley recibió el apoyo unánime de demócratas y republicanos.

“Parece existir un amplio consenso en que no se debe perder la casa o los ahorros de toda la vida por haberse enfermado”, dijo White. “Es un nivel básico de justicia”.

La deuda médica sigue siendo un tema controversial en Washington, donde la administración Biden ha impulsado varias iniciativas para abordar el problema, incluida una propuesta de reglamentación por parte de la Oficina de Protección Financiera del Consumidor (CFPB), que prohibiría que cualquier deuda médica aparezca en los informes de crédito de los consumidores.

La vicepresidenta Kamala Harris, que encabeza la iniciativa del gobierno contra la deuda médica, se ha referido a estas iniciativas en la campaña presidencial. Harris también ha pedido que se refuercen las medidas para ayudar a millones de estadounidenses a pagar su deuda médica.

El ex presidente Donald Trump no suele hablar de la deuda médica cuando hace campaña. Pero los congresistas republicanos han criticado la propuesta de la CFPB, que el presidente del Comité de Servicios Financieros de la Cámara, Patrick McHenry (del Comité Nacional Republicano), calificó de “extralimitación regulatoria”.

Sin embargo, el encuestador Michael Perry, que ha investigado ampliamente lo que opinan los estadounidenses sobre la atención médica, comentó que los votantes conservadores, que suelen desconfiar del gobierno, parecen ver la deuda médica de otra manera. “Creo que sienten que está todo tan en su contra que ellos, como pacientes, realmente no tienen voz”, explicó. “Las divisiones políticas que normalmente vemos, en esta cuestión simplemente no están presentes”.

Cuando los defensores de los consumidores de Arizona propusieron en las boletas electorales de 2022 una medida para limitar los tipos de interés de las deudas médicas, el 72% de los votantes se pronunció a favor de la iniciativa.

Del mismo modo, encuestas a nivel nacional han revelado que más del 80% de los republicanos y demócratas respaldan la implementación de límites en los cobros de deudas médicas y que se fijen requisitos más estrictos para que los hospitales ofrezcan ayuda financiera a los pacientes.

Perry sacó a relucir otro factor que puede estar impulsando el interés de ambos partidos por la deuda médica: la creciente desconfianza de los ciudadanos a medida que los sistemas de salud se hacen más grandes y actúan como grandes corporaciones. “Los hospitales ya no son lo que eran”, dijo. “Eso está dejando claro que el lucro y la codicia son los que están dirigiendo gran parte de la toma de decisiones”.

No obstante, no todos los esfuerzos estatales para hacer frente a la deuda médica han obtenido un amplio apoyo tanto de demócratas como de republicanos.

El año pasado, cuando Colorado se convirtió en el primer estado que prohibió la inclusión de las deudas médicas en los informes de crédito de los residentes, sólo un legislador republicano respaldó la medida.

Y en Minnesota un proyecto de ley similar se aprobó este año sin un solo voto del Partido Republicano.

En otros lugares, medidas igual de estrictas se han aprobado sin inconvenientes.

Por ejemplo en Illinois, este año, se votó por unanimidad en el senado estatal, y se aprobó por 109 votos a favor y dos en contra en la Cámara de Representantes, un proyecto de ley que prohíbe el reporte de deuda médica en los informes de crédito.

En Rhode Island ningún legislador del Partido Republicano se opuso a la prohibición del reporte de crédito.

Finalmente, cuando la Legislatura de California examinó un proyecto de ley de 2021  para exigir a los hospitales del estado que proporcionen más asistencia financiera a los pacientes, la propuesta fue aprobada por 72 votos a favor y ninguno en contra en la Asamblea estatal y por 39 a 0 en el Senado.

Incluso algunos estados conservadores, como Oklahoma, han tomado medidas, aunque más modestas. Una nueva ley prohíbe a los proveedores médicos reclamar deudas a los pacientes si no han hecho públicas sus tarifas. La resolución, firmada por el gobernador republicano del estado, fue apoyada por unanimidad.

Steve Neville, senador republicano por Nuevo México, que respaldó una ley para restringir los cobros abusivos a pacientes de bajos ingresos en ese estado, dijo que simplemente estaba siendo pragmático.

“No era muy beneficioso dedicar mucho tiempo a intentar cobrar a pacientes indigentes”, dijo Neville. “Si no tienen dinero, no tienen dinero”. Tres de los 12 senadores republicanos apoyaron la medida.

El tesorero estatal de Carolina del Norte, Dale Folwell, republicano que como legislador estatal encabezó en 2012 un intento para prohibir el matrimonio entre personas del mismo sexo, dijo que todos los funcionarios electos, sin que importe su partido, deberían preocuparse por el modo en que las deudas médicas están afectando a los pacientes.

“No importa si, como conservador, estoy diciendo estas cosas, o si Bernie Sanders está diciendo estas mismas cosas”, dijo Folwell, en referencia al senador liberal de Vermont. “Al fin y al cabo, todos deberíamos asumir la responsabilidad de defender a aquellos que permanecen invisibles ante la sociedad”.

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In KFF’s latest employer health benefits survey, company officials were asked how much of the rebates collected from drugmakers by pharmacy benefit managers, or PBMs, is returned to them. In recent years, the pharmaceutical industry has tried to deflect criticism of high drug prices by saying much of that income is siphoned off by the PBMs, companies that manage patients’ drug benefits on behalf of employers and health plans.

PBM leaders say they save companies and patients billions of dollars annually by obtaining rebates from drugmakers that they pass along to employers. Drugmakers, meanwhile, say they raise their list prices so high in order to afford the rebates that PBMs demand in exchange for placing the drugs on formularies that make them available to patients.

Leaders of the three largest PBMs — CVS Caremark, Optum RX and Express Scripts — all testified in Congress in July that 95% to 98% of the rebates they collect from drugmakers flow to employers.

For KFF’s survey of 2,142 randomly selected companies, officials from those with 500 or more employees were asked how much of the rebates negotiated by PBMs returned to the company as savings. About 19% said they received most of the rebates, 27% said some, and 16% said little. Thirty-seven percent of the respondents didn’t know.

While a larger percentage of officials from the largest companies said they got most or some of the rebates, the answers — and their contrast with the testimony of PBM leaders — reflect the confusion or ignorance of employers about what their drug benefit managers do, said survey leader Gary Claxton, a senior vice president at KFF, a health information nonprofit that includes KFF Health News.

“I don’t think they can ever know all the ways the money moves around because there are so many layers, between the wholesalers and the pharmacies and the manufacturers,” he said.

Critics say big PBMs — which are parts of conglomerates that include pharmacies, providers, and insurers — may conceal the size of their rebates by conducting negotiations through corporate-controlled rebate aggregators, or group purchasers, mostly based overseas in tax havens, that siphon off a percentage of the cash before it goes on the PBMs’ books.

PBMs also make money by encouraging or requiring patients to use affiliated specialty pharmacies, by skimping on payments to other pharmacies, and by collecting extra cash from drug companies through the federal 340B drug pricing program, which is aimed at lowering drug costs for low-income patients, said Antonio Ciaccia, CEO of 46brooklyn Research.

The KFF survey indicates how little employers understand the PBMs and their pricing policies. “Employers are generally frustrated by the lack of transparency into all the prices out there,” Claxton said. “They can’t actually know what’s true.”

Billionaire Mark Cuban started a company to undercut the PBMs by selling pharmaceuticals with transparent pricing policies. He tells Fortune 500 executives he meets, “You’re getting ripped off, you’re losing money because it’s not your core competency to understand how your PBM and health insurance contracts work,” Cuban told KFF Health News in an interview Tuesday.

Ciaccia, who has conducted PBM investigations for several states, said employers are not equipped to understand the behavior of the PBMs and often are surprised at how unregulated the PBM business is.

“You’d assume that employers want to pay less, that they would want to pay more attention,” he said. “But what I’ve learned is they are often underequipped, underresourced, and oftentimes not understanding the severity of the lack of oversight and accountability.”

Employers may assume the PBMs are acting in their best interest, but they don’t have a legal obligation to do so.

Prices can be all over the map, even those charged by the same PBM, Ciaccia said. In a Medicaid study he recently conducted, a PBM was billing employers anywhere from $2,000 to $8,000 for a month’s worth of imatinib, a cancer drug that can be bought as a generic for as little as $30.

PBM contracts often guarantee discounts of certain percentage points for generics and brand-name drugs. But the contracts then contain five pages of exclusions, and “no employer will know what they mean,” Ciaccia said. “That person doesn’t have enough information to have an informed opinion.”

The KFF survey found that companies’ annual premiums for coverage of individual employees had increased from an average of $7,739 in 2021 to $8,951 this year, and $22,221 to $25,572 for families. Among employers’ greatest concerns was how to cover increasingly popular weight loss drugs that list at $2,000 a month or more.

Only 18% of respondents said their companies covered drugs such as Wegovy for weight loss. The largest group of employers offering such coverage — 28% — was those with 5,000 or more employees.

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In states like Connecticut and Indiana, legislators have passed bills restricting these so-called “facility fees.”

In this episode of “An Arm and a Leg,” host Dan Weissmann takes a close look at Kari’s bill, alongside Christine Monahan, an attorney and assistant research professor focused on facility fees and state efforts to limit them.

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Dan: Hey there– 

Kari Greene lives in Portland. She’s got a couple of auto-immune disorders– mostly under control these days. She sees her rheumatologist a couple times a year — just to check in. 

And last year she noticed a charge on top of the $40 copay she was used to. 

$88 for an “observation room fee.” 

She says she called her insurance. 

Kari Greene: And the person I spoke with was like, this seems weird. 

Dan: She says they promised to investigate, but Kari never heard back. Eventually, she paid the bill and moved on with her life. 

After Kari’s appointment at the start of this year, the fee was there again. But instead of $88, now it was $99. Kari was pissed. She still is. 

Kari Greene: I’m like, how? How dare you? it’s such a slap in the face where you’re like, I already paid my copay 

Dan: Now they want a hundred bucks on top of that. For no reason Kari can see. And Kari’s pretty sure it’s not just her. 

Kari Greene: That’s the part that galls me it’s like, there’s this Scrooge McDuck back there going, Oh, we’ve got this doctor who works her little tushy off and she sees, five patients an hour. 

And, we can add this charge on to every single one of these office visits. 

Dan: Kari’s definitely right that this isn’t just her. We haven’t found Scrooge McDuck and his swimming pool full of currency — yet. 

But researchers and advocates have been talking for years about these kinds of extra charges — called “facility fees.” 

They can get tacked onto office visits by hospitals, when the hospital owns the doctor’s office. 

And with hospitals buying more and more doctors’ offices, those researchers say these fees keep popping up more and more often. 

So we asked: Would anybody who had gotten a bill for one please share it with us? Kari was one of a bunch of people who responded. 

And took time to talk with us. 

Teresa: oh, it made me so mad, so mad. 

Anne Gaffney: I mean, it’s a 10 minute appointment for a prescription. Amanda: I don’t understand any of it. 

where did this number come from? 

Dan: We dug a little deeper with Kari’s story, partly because it fit so closely with what we’d been hearing about: A fee that wasn’t there one year, and the next it was. For a brief office visit — Kari thinks maybe ten minutes– in a normal setting. 

Kari Greene: It’s a regular doctor’s office room. it’s got the little bed with the paper on it, you know. And it’s got the like blood pressure cuff thing on the wall, there’s nothing that makes it special, 

Dan: Except, when it comes time to bill, for the fact that a hospital owns it. 

And our first question, of course, was: Can they really freaking DO that?!? How is that even allowed? 

The “how” is long and complicated and honestly boring. But by and large, it’s legal. They can do that. 

Except, as far as we can tell — for the most part — in a few states. Especially Connecticut.

Legislators and policy-makers there have been working on this issue for a decade. And bit by bit, they’ve worked to outlaw charges like the ones on Kari’s bills. 

And other states have started working on following Connecticut’s lead. We talked with someone who’s been tracking those efforts. 

Christine Monahan: My name is Christine Monahan. I’m an assistant research professor at the Center on Health Insurance Reforms, which is part of Georgetown University’s McCourt School of Public Policy. 

Dan: Christine and her colleagues issued a report over the summer looking at efforts to restrict facility fees like these across all fifty states. 

And she has some good news: 

Christine Monahan: there’s bipartisan interest in this issue. We are seeing these reforms bubble up across the states. 

Dan: The less-good news: It could take other states a lot of years to catch up. And they’re hitting opposition every step of the way. 

We’ll have a progress report. But first we’ll go deeper with Kari’s story, which turns out to have a twist. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you a show that’s entertaining, empowering, and useful. 

Kari’s in her mid-fifties, works in public health. For a long time, she’d had problems that no doctor ever found a cause for: Joint pain, migraines, fatigue. 

Then in 2020, she got COVID, and things took a turn. Weird sores. She says her fingers swelled up like sausages. 

Kari Greene: when these like Sores were showing up and like I couldn’t move my hands and they were super fat that was at least something that I could be like, see, it’s not just the joint pain. It’s not just the fatigue. It’s not just the migraines. It’s not just the, like, look at my hand. This is not normal. Right. 

Dan: Friends helped her find her rheumatologist. 

Kari Greene: She was able to figure out what was going on. And, she’s, I, I mean, I will get weepy talking about her because she is just, rheumatologists are like detective doctors, you know, they are amazing diagnosticians, they’re incredible listeners 

Dan: After a bunch of listening, a bunch of labs, this doctor got Kari a diagnosis — diagnoses — and some meds that help a lot. So, Kari is pretty devoted to this doctor. 

Kari Greene: Anytime I consider switching, you know, when open enrollment comes around, I’m like, Okay, I see that I could spend a lot less money on a different plan, but there’s no way I’m giving her up. 

Dan: These extra fees aren’t enough to send her away either. But Kari is doing what she can to avoid charges like this with another specialist she sees. 

Kari Greene: My, my neurologist is in the same building and last year he was like, we can switch to telehealth. You don’t have to come in. 

Dan: But Kari says the rheumatology consult is different. More hands-on. 

Kari Greene: Rheumatologists really need to be able to touch your joints and manipulate. To be able to, see, disease progression or even just be able to do, like, diagnostics. 

Dan: So Kari’s back at that office every six months, paying that extra fee. 

She says she’s lucky it’s more of an annoyance than a real financial hardship for her, but when she’s in the waiting room, she worries about the other folks she sees there.

Kari Greene: these are not young, healthy people who are like out in the workforce, like just live in their best lives. 

Dan: After her January visit this year, when the “observation room fee” went up from $88 to $99, Kari called her insurance again, looped in the benefits person from her work. 

The upshot: The insurer didn’t have a problem with the charge. They said the hospital had the right to bill for it. 

Kari Greene: But just because you have the right to do it, does that mean you should be able to do it? 

Dan: And actually, here’s the thing: Maybe the hospital DIDN’T have the right to do it, either. 

Christine Monahan — the Georgetown researcher who’s been tracking efforts to clamp down on these kinds of fees? 

She’s also an attorney — and she’s a bulldog. She helped us really dig into Kari’s bills and insurance paperwork. We waded deep into the alphabet soup. 

Christine Monahan: She has a um, E/M CPT code on her EOB. Hospital’s billing a G 0 4 6 3 

Dan: I’ll spare you more of that. But here’s where Christine patiently led us: Based on written policies from Kari’s insurance company, Christine thinks Kari probably never should have gotten charged for anything beyond that 40 dollar copay. 

Christine Monahan: I think there’s a good argument to kind of question why she should be paying more 

Dan: Mmhmm. Dang. 

Dan: Now, our producer Emily Pisacreta was on the call with Christine too — to help make sure I didn’t get lost.

And then it was time for Emily and me to test how well we’d followed Christine through that strong argument: By summing it up and running it by Kari’s insurance company and the hospital. 

We went back to documents Christine had dug up. 

Emily: This is… 

Dan: This is the, uh, this is the reimbursement policy manual. 

Emily: The reimbursement policy manual. 

Dan: YEP. That one. It’s a section from the insurer’s REIMBURSEMENT POLICY MANUAL– which spells out what they do and don’t pay for. 

Christine had grabbed policy number 0h-Six-one: Clinic Services in the Outpatient Setting. Like Kari’s doctor’s office. 

And it turned out to tell basically the whole story. Emily and I got excited, talking over each other. 

Dan: Now that we’re looking at it. 

Emily: And they’re like not allowed to this. 

Dan: I mean, like I got confused even talking through it with Christine, but this seems crystal clear. They’re like not allowed to do this. 

Emily: Mmhmm. 

Dan: Here’s what it says: 

“For clinic visits and services performed in the hospital outpatient setting, we do not allow split-billing” 

And a couple sentences down that gets spelled out even more clearly: 

“Do not split-bill clinic-based services, billing part of the service as a facility charge, and part of the service as a professional charge”

That sure looks like it means: Don’t double-dip with a professional charge– a bill for the doctor’s service — AND a facility fee. 

We reached out to Kari’s insurance company and the hospital that sent the bills. Asking them: Are we missing something here? 

We haven’t heard back. 

Which leads me to think somebody may owe Kari some kind of refund. Which feels very satisfying to know. But it’s not exactly satisfactory. 

Because as Christine said when we talked with her: This is not the sort of thing a regular person could be expected to run down, on their own time. 

Christine Monahan: Most consumers are not going to know to look up the reimbursement policy. 

Dan: Or how to interpret it. I mean, Emily and I look at this kid of stuff as part of our jobs. We’re not brand new at it. But even with Christine leading us every step of the way, it took us some time to follow it all. 

Christine Monahan: I think it, really just highlights how opaque all of this is and there may well be some insurers that are not paying these facility fees, or at least that say on paper that they are not going to, but it’s a whole mishmash of different policies and they’re not always followed. And the consumer is really left in the dark. 

Dan: Which is why legislators in states from Connecticut to Colorado have started saying: Hey, maybe this shouldn’t be a fight that individual people have to get into. 

Maybe there should be RULES about fees like this. 

Maybe there should be rules against them. 

That’s next. 

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News. That’s a national newsroom that produces in-depth journalism about health issues. Their reporters do incredible work, and I’m honored to work with them. 

Before we start talking about efforts to regulate facility fees, we wanted to hear the case FOR them. We asked the American Hospital Association to make that case. 

They sent us a statement from Molly Smith, their group vice president for policy, and she recorded it as a voice memo. Here’s the bulk of it: 

Molly Smith: The cost of care delivered in hospitals and health systems and any associated sites of care operated by the hospital takes into account the many unique services that only they provide to their communities. This includes the cost of maintaining standby capacity for traumatic events and delivering 24/7 care to all who come through the emergency department, regardless of ability to pay or insurance status. 

They provide access to critical healthcare services that may not be otherwise available, especially in low income, rural, and other medically underserved communities. Hospital facilities also treat patients who are sicker and have more chronic conditions than non hospital facilities, which requires a greater use of resources. 

In addition, hospital facilities must comply with a much more comprehensive scope of licensing, accreditation, and other regulatory requirements than do other sites of care. Facility fees are one way that hospitals may bill for overhead costs to maintain all of the essential services they provide to their patients and communities 

Dan: Molly Smith also takes a long swipe at insurers, including Medicare, for not paying enough. 

And I think it’s fair to sum this up as: Operating a hospital is expensive. Facility fees are one way we try to get money to meet those expenses. 

Which, according to Christine Monahan from Georgetown, is what hospitals tell state legislators when facility-fee regulations get proposed. 

Christine Monahan: Hospitals will come in and tell horror stories about how devastating it will be to their finances if we were to do even the itsy bitsiest of reforms, and it can be hard for advocates and policy makers to go in and fact check those statements by the hospitals.

An Arm and a Leg Season 12, Episode 4 September 26, 2024 p.9 

Dan: Because they don’t have the data. Hospitals have it, but there’s a lot they’re not required to share. 

Christine Monahan: The hospitals continue to have all of that information kind of in a black box about like exactly how much revenue are they getting, where are the facility fee revenues going, how much are going to profits, how much are going to cost, and if so, what are the costs, 

Dan: That’s a LOT of unknowns. 

Christine Monahan: It can be scary to policymakers when a hospital industry comes in and says, this is going to ruin us and they don’t have the data to come back and say, well, no, it really won’t. Even if they may be very skeptical that that what the hospitals are saying is accurate. 

Dan: Mm. That is super interesting. There’s like this information asymmetry. 

Christine Monahan: Yes. Yeah, we’ve been calling it an information monopoly . 

Dan: Look, here’s just one example: How often are hospitals charging facility fees for visits to doctors offices? Like actual offices that aren’t anywhere near the hospital, but that the hospital now owns? 

Where could you find that out, if you were a state official? Well, a lot of states have databases with all insurance claims that got paid. Maybe you could look at insurance claims that included facility fees. 

But how would you know where a particular appointment happened? The claim has a provider number. But a hospital doesn’t have to use a new provider number for every location, every doctor’s office. 

Christine Monahan: Often they will be using a single identifier number for all their claims, or maybe a single health system might have a handful of identifier numbers. And they’ll put those identifier numbers on the claims forms. And they might use the same identifier for if you’re at the hospital, or if you’re out 20 miles away in a physician’s practice that they’ve recently acquired.

Dan: So to start with, policy-makers may have no way of knowing where these fees are even being charged. 

So when Connecticut started passing laws in 2014, the first ones were really just about information. Requiring hospitals to post signs about them. And commissioning a study. 

The next year, Connecticut passed a much bigger bill. It prohibited a lot of facility fees for regular office visits — what’s called “evaluation and management” services on insurance forms. And required hospitals to make annual reports on facility fees. 

And in a separate law, Connecticut banned facility fees for telehealth. That’s a step Christine says a lot of other states have followed. 

Christine Monahan: I mean, how egregious is it to get a facility charge for a telehealth visit where you did not leave your home? 

Um, that just does not make any sense. And so that’s really easy pickings as far as hospital reforms go for regulated policymakers to look at and say, this, this doesn’t make sense 

Dan: Since then, Connecticut has passed a dozen more laws– requiring new disclosures here, tightening loopholes there. 

And the state still may not have closed them all. We heard from a listener in Connecticut who was trying — and failing — to find a place he could get a stress test that wouldn’t charge him a facility fee. 

But even if more loopholes get closed, there’s a problem. One economist we talked with said: Outlawing fees like this, it’s like squeezing part of a balloon. Other parts of it just get bigger. 

Christine Monahan agreed. 

Christine Monahan: hospitals, particularly those with more market power, are best able to then, you know, shift their revenue somewhere else. If you say you can’t impose a facility fee for XYZ services, okay, we’re going to start imposing facility fees on these other services, or maybe we’re just going to increase rates overall. And so it may not necessarily contain total system costs because of the balloon effect.

Dan: the, if I’m running a hospital, I’m like, well, my costs are this. Like, I’m gonna like, my, my, my, my revenue goal is this. Like, you’re telling me I can’t charge that. What else can I charge? How else am I gonna get that money? 

Christine Monahan: Yeah. 

Dan: And as Christine alluded to in that exchange: not all hospitals are created equal. Some are big and rich, running surpluses — profits — in the hundreds of millions of dollars a year. Others — smaller hospitals, rural hospitals — struggle to keep their doors open. Some do close every year. 

Christine and her colleagues found, the big ones can use their poorer counterparts as political shields. 

Christine Monahan: We spoke with a few hospital executives as part of our research last year. And, you know, one hospital executive we spoke with, he, represents kind of a smaller, less market powerful hospital, and he expressly acknowledged they carry the water for other hospitals in their state before the state legislature. 

Dan: So, when a state like Indiana passed restrictions on facility fees in 2023, the law only applied to the state’s biggest hospitals. 

Indiana’s story illustrates Christine’s point that this isn’t a partisan issue — where Democrats hold majorities in Connecticut, Indiana is solidly Republican. The Employers Forum of Indiana has led the charge there. 

Their story also illustrates Christine’s point that change happens slowly. 

Gloria Sachdev is executive director of the Employers Forum of Indiana. When she started the job in 2015, she went around to meet with employers.. 

Gloria Sachdev: I asked them, what is your biggest pain point? And all of them said, healthcare costs, they’re not sustainable. They’ve been going up, you know, four or five, six, seven, 8 percent every year. 

Dan: The group spent years conducting studies. Among their finidngs: Indiana hospitals charged more than hospitals in other states. And more than independent medical practices that offered some of the same services. Oh, also: Hospitals were buying up those practices, and jacking up prices.

Gloria Sachdev: And nothing was changing about the service. It was just that they owned it now and were able to tack on a hospital facility fee. 

Dan: In 2020, the Employers Forum started lobbying for changes. Restricting facility fees was one of several issues. And it got maybe the most pushback. 

Gloria Sachdev: the Indiana Hospital Association was fairly masterful at, uh, bringing forward Physicians from all across the state, they had school nurses showing up. 

Dan: School nurses who were employed by local hospitals. 

Gloria Sachdev: They said, Oh my gosh, you know, the, we’d have to shut down the school nurse program. 

Dan: The Employers Forum lost that round. Getting a win took three years. And the bill that passed was narrowly tailored. It wouldn’t apply to smaller, financial-strapped hospitals: Just the state’s five largest hospital systems. And it only applied to “off-campus” locations — like a doctors office the hospital just happened to own. 

Gloria Sachdev: So if they’re in a strip mall, you know, 20 miles away. They can’t charge a hospital facility fee. 

Dan: According to this year’s report from Christine Monahan’s team at Georgetown, Indiana is now one of nine states with some restrictions on facility fees. 

Another dozen states have passed other laws, including ones that require hospitals to disclose data. Data that may help advocates and policy-makers chip away at the information monopoly– the one that Christine calls an obstacle to change. 

Christine Monahan: we are making baby steps, um, in a very difficult environment. And so I count that as progress. 

Dan: We’ll have links to Christine Monahan’s reports in our newsletter. You can check to see what steps your state has taken so far. We’ll also link to reports on facility fees from the Public Interest Research group, which has also been pushing for reforms. 

We’ll also highlight some other stories we’re watching right now. I’m telling you: Our newsletter is pretty good. You might want to sign up! You can do that at arm and a leg show dot com, slash, newsletters. 

Thank you for sharing your stories, and your bills, with us for this series. We’ve learned more from you than we’ve been able to share so far. We’ll keep looking for ways to bring that to you. 

We’ll have a new episode for you in a few weeks right here. 

Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport — and edited by Ellen Weiss. 

Big thanks to the many experts who talked with us about facility fees, especially Patricia Kelmar of the Public Interest Research Group and medical-bill coding expert Shelley Safian. 

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Bea Bosco is our consulting director of operations. 

Sarah Ballama, who has been our operations manager since early 2022, just left to take a very cool full-time job in another state. Sarah, we’ll miss you so much! 

Lucky for us, the amazing Lynne Johnson has come aboard to run the operations side for us. Welcome, Lynne! And thanks so much for joining us. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. You can join in any time at arm and a leg show, dot com https://armandalegshow.com/support/. Thank you so much for pitching in if you can — and, thanks for listening.

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

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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

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Voters are being asked whether California should increase accountability in the 340B drug discount program, which provides money for community clinics, safety net hospitals and other nonprofit health-care providers.

The program requires pharmaceutical companies to give drug discounts to these clinics and nonprofit entities, which can bank revenue by charging higher reimbursement rates.

Advocates pushing the measure, Proposition 34, say some entities are using the drug discount program as a slush fund, plowing money into housing and homelessness initiatives that don’t meet basic patient safety standards. Researchers and advocates have called for greater oversight.

“There are 340B entities that are misusing these public dollars,” said Nathan Click, a spokesperson for the pro-Proposition 34 campaign. “The whole point of this program is to use this money to get more low-income people health-care services.”

The initiative wouldn’t bar 340B providers from using health-care funds for housing or homelessness programs. Instead, it targets providers that spend more than $100 million on purposes other than direct patient care over 10 years. It would mandate that 98 percentof 340B revenues go to direct patient care. It also targets 340B providers with health insurer contracts and pharmacy licenses and those serving low-income Medicaid or Medicare patients that have been dinged with at least 500 high-severity housing violations for substandard or unsafe conditions.

That has placed a bull’s eye on the Los Angeles-based AIDS Healthcare Foundation, a nonprofit that provides direct patient care via clinics and pharmacies in California and other states, including Illinois, Texas and New York. It also owns housing for low-income and homeless people.

A Los Angeles Times investigation found that many residents of AIDS Healthcare Foundation properties are living in deplorable, unhealthy conditions.

Michael Weinstein, the foundation’s president, disputes those claims and argues that Proposition 34 proponents, including real estate interests, are going after him for another ballot initiative that seeks to implement rent control in more communities across California.

“It’s a revenge initiative,” Weinstein said, arguing that the deep-pocketed California Apartment Association is targeting his foundation — and its health and housing operations — because it has backed ballot measures pushing rent control across California. “This is a two-pronged attack against us to defeat rent control.”

Weinstein is locked in a feud with the apartment association, the chief sponsor of the initiative, which has contributed handsomely to pass Proposition 34. Opponents argue that the initiative is “a wolf in sheep’s clothing.”

Weinstein acknowledged to KFF Health News that his nonprofit uses money from 340B drug discounts to support its housing initiatives but argued they are helping treat and house some of the most vulnerable people, who would otherwise be homeless.

The apartment association declined several requests for comment. But Proposition 34 backers say they aren’t going after rent control — or Weinstein and his nonprofit.

Supporters argue that “rising health care costs are squeezing millions of Californians” and say that the initiative would “give California patients and taxpayers much needed relief, and lowers state drug costs, while saving California taxpayers billions.”

If the initiative passes and 340B providers do not spend 98 percent of the revenue on direct patient care, they could lose their license to practice health care and their nonprofit status.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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

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Current enrollees who do not update their information or select an alternative will be automatically reenrolled in their current plan or, if that plan is no longer available, into a plan with similar coverage.

Last year marked a record enrollment of about 21 million people. This time around, consumers will find a few things have changed.

Don’t Fall for Advertising Scams

While some health plans offer small-dollar gift cards or other incentives to encourage participation in wellness efforts, they would not offer cash cards worth thousands of dollars a month to help with groceries, gas, or rent. Even so, social media and online sites are rife with such promises.

Such ads are among the avenues allegedly used by unscrupulous brokers who enroll or switch plans without the express permission of consumers, according to a lawsuit filed in Florida.

Also, be cautious about the websites you use to search for coverage.

Type “Obamacare” or “cheap health insurance” into a search engine and often what pops up first are sponsored private sector websites unaffiliated with the official state or federal government marketplaces for ACA coverage.

While they may try to look official, they are not. Many such sites offer various options, including non-ACA coverage with limited benefits, a “secret shopper” study found in 2023. Such non-ACA coverage would not qualify for federal subsidies to help consumers pay premiums.

The fine print on some websites says that consumers who provide personal information automatically consent to be contacted by sales agents via phone calls, emails, text messages, or automated systems with prerecorded messages.

When exploring plans, always start with the official federal marketplace’s website, healthcare.gov.

Even if you don’t live in one of the 29 states served by the federal marketplace, its website provides the link to your official enrollment site when you select your state, or the District of Columbia, from a drop-down list. The federal and state marketplaces also have call centers and other ways to get enrollment assistance. The “find local help” link on healthcare.gov, for example, gives consumers a choice of finding assisters or sales agents near them.

Is It Real Insurance?

Another concern: Regulators are seeing an increase in complaints from consumers about offers of health coverage requiring consumers to join a limited liability corporation, or otherwise attest they are working for a specific company. Indeed, at least two states — Maryland and Maine — have issued warnings, saying that instead of comprehensive ACA coverage, these are often non-ACA products, amounting to a hodgepodge of discount cards, for example, or limited-indemnity plans. This type of plan pays a flat-dollar amount — say, $50 for a doctor visit or $1,000 for a hospital stay — and is meant to buttress more comprehensive coverage, not replace it.

“Unlike major medical plans, some of these self-funded plans only cover preventive services such as a yearly check-up or annual health screening,” the warning from the Maine Bureau of Insurance says.

Premiums Might Be Higher … and Other New Things

Some insurers will lower premium rates for 2025, but many others are increasing them.

Although final numbers are still being crunched, experts estimate a median increase of 7% for premiums, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. Most people who buy ACA coverage are eligible for a subsidy to help with the premiums, which is likely to offset much of the increase, although the higher cost means the government will be paying out more for those subsidies.

Rising health costs — including for hospital care and the new class of weight loss drugs — are contributing to the increase.

Some other changes this open season:

• People often referred to as “Dreamers” because they qualified for the Deferred Action for Childhood Arrivals — a federal program offering some protection to those brought to the country as children without proper immigration documentation — can now enroll in ACA coverage and are eligible for subsidies.
• Short-term plans, which are technically not ACA coverage and not subject to its benefit rules and preexisting benefit protections, can be issued for, at most, only four months of coverage, based on a Biden administration action that took effect with plans starting Sept. 1. It walks back a Trump administration rule that loosened requirements to allow insurers to offer coverage that ranged up to 364 days, and allowed insurers the option of renewing the policies for up to two additional years. Existing plans and those issued before Sept. 1 don’t fall under the new rules. But consumers who relied on the longer periods need to check their plans’ details and consider enrolling in an ACA plan instead to avoid a situation in which their short-term plan expires early or midyear, potentially leaving them unable to get coverage elsewhere for the remainder of the year.

The Sign-Up Process Might Take Longer, Too

Federal regulators this year wrestled with a growing number of complaints — 200,000 in the first six months alone — from consumers who were being enrolled into or switched from ACA plans without their express permission by agents seeking to gain commissions.

To thwart such efforts, they put new rules in place.

What does that mean for most consumers? If you are working with a new agent — one who wasn’t already listed on your ACA plan — you will likely need to get on a three-way call with the federal marketplace to confirm that you are, indeed, authorizing that agent to make changes to your policy for the coming year. Plan on this taking additional time. No one knows how busy the call lines will get during open enrollment.

You don’t need to use a broker to enroll. But sorting through the dozens of options on the marketplace is challenging, so most people do seek assistance. Consumers need to weigh not only the monthly premium cost, but also variations in deductibles and copayments for such things as doctor visits, hospitalization, and drugs.

Shop Around

Experts say another consideration when choosing a plan is to check whether its network includes the doctors and hospitals you typically see, as well as whether its formulary covers your prescription medications, and how much it charges for them.

To help with making comparisons, rules kicked in two years ago requiring insurers to include some “standardized plans” as options, which must all have the same deductibles, and costs for such things as doctor visits, emergency room care, and other consumer cost sharing.

Even so, many people have dozens of options available, which can be daunting.

But one piece of advice remains constant: Whether you are enrolling for the first time or have an existing plan, it’s always worth it to shop around. Even if you don’t change plans, you can make sure the one you have is still your best option.

In most states, consumers must enroll by Dec. 15 to get coverage that begins Jan. 1. Heads up in Idaho, where open enrollment starts earlier — Oct. 15 — but also ends sooner, closing on Dec. 15. In California, New Jersey, New York, Rhode Island, and the District of Columbia, residents can enroll through Jan. 31.

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

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Los consumidores que no actualicen su información o seleccionen una alternativa serán automáticamente reinscriptos en su plan actual o, si ese plan ya no está disponible, en uno con cobertura similar.

El año pasado se registró un récord de inscripciones, con unas 21 millones de personas. Esta vez, los consumidores descubrirán que han cambiado algunas cosas.

No seas víctima de estafas publicitarias

Aunque algunos planes de salud ofrecen tarjetas de regalo de poco valor u otros incentivos para fomentar la participación en iniciativas de bienestar, nunca ofrecerían tarjetas en efectivo por valor de miles de dólares al mes para ayudar a pagar las compras, la gasolina o el alquiler. Aun así, las redes sociales y los sitios web están plagados de promesas de este tipo.

Según una demanda presentada en Florida, este tipo de anuncios es una de las vías supuestamente utilizadas por corredores sin escrúpulos que inscriben o cambian de plan sin el permiso expreso de los consumidores.

Además, hay que tener cuidado con los sitios de internet que utilizamos para buscar cobertura.

Si escribes “Obamacare” o “seguro médico barato” en un buscador, a menudo, lo que aparece en primer lugar son sitios web patrocinados por el sector privado no afiliados a los mercados federales o estatales oficiales para la cobertura de ACA.

Aunque intenten parecer oficiales, no lo son. Muchos de estos sitios ofrecen varias opciones, incluida cobertura que no es de ACA con beneficios limitados, según descubrió en 2023 un studio de “comprador secreto”. Con estas coberturas no se pueden obtener subsidios federales para ayudar a los consumidores a pagar las primas.

La letra chica de algunos sitios web dice que los consumidores que facilitan información personal consienten automáticamente que agentes de ventas se pongan en contacto con ellos a través de llamadas telefónicas, correos electrónicos, mensajes de texto o sistemas automatizados con mensajes pregrabados.

Cuando busques un plan, empieza siempre por el sitio web oficial del mercado federal, cuidadodesalud.gov (healthcare.gov).

Incluso si no vives en uno de los 29 estados en los que funciona el mercado federal, el sitio web proporciona el enlace a tu sitio oficial de inscripción cuando seleccionas tu estado, o el Distrito de Columbia, en una lista desplegable.

Los mercados estatales y el federal también tienen centros de llamadas y otras formas de obtener ayuda para la inscripción. Por ejemplo, el enlace “encuentre ayuda local” en cuidadodesaludgov, ofrece a los consumidores la posibilidad de encontrar asistentes o agentes de ventas cerca de sus domicilios.

¿Es un seguro real?

Otra preocupación: los reguladores han observado un aumento en las quejas de los consumidores sobre ofertas de coberturas de salud en las que se les exige que se afilien a una corporación de responsabilidad limitada o que den fe de que trabajan para una empresa concreta.

De hecho, al menos dos estados —Maryland y Maine—- han emitido advertencias, señalando que en lugar de una cobertura completa de ACA, a menudo se trata de productos que no pertenecen a ACA, y que equivalen a cosas como una mezcla de tarjetas de descuento o planes de indemnización limitada.

Este tipo de plan paga una cantidad fija —por ejemplo, $50 por una visita al médico o $1,000 por una hospitalización— y está pensado para reforzar una cobertura más completa, no para sustituirla.

“A diferencia de los planes medicos grandes, algunos de estos planes autofinanciados sólo cubren servicios preventivos, como un chequeo o un examen médico anual”, advierte la Oficina de Seguros de Maine.

Las primas podrían ser más altas… y otras novedades

Algunas aseguradoras reducirán las primas para 2025, pero muchas otras las aumentarán.

Aunque todavía no hay cifras oficiales, los expertos estiman un aumento promedio del 7% para las primas, según un análisis de KFF. La mayoría de las personas que compran cobertura médica en los mercados de seguros de ACA son elegibles para recibir subsidios para ayudar con las primas, lo que probablemente compensará gran parte del aumento, aunque el mayor costo significa que el gobierno pagará más por esos subsidios.

El aumento de los costos de salud —incluida la atención hospitalaria y la nueva clase de medicamentos para adelgazar— contribuye a este incremento.

Otros cambios en esta temporada:

—Las personas a menudo conocidas como “Dreamers” porque calificaron para la Acción Diferida para los Llegados en la Infancia (DACA) —un programa federal que ofrece cierta protección a los traídos al país cuando eran niños sin documentación migratoria adecuada— ahora pueden inscribirse en la cobertura de ACA y son elegibles para los subsidios.

—Los planes de corto plazo, que técnicamente no son parte de la cobertura de ACA y no están sujetos a sus normas de beneficios y protecciones de beneficios preexistentes, pueden ser emitidos por sólo cuatro meses de cobertura, como máximo, según lo dispuesto por la administración Biden, que entró en vigencia  con planes que empezaron el 1 de septiembre.  Esto ha revocado una norma de la administración Trump que flexibilizaba los requisitos para permitir a las aseguradoras ofrecer una cobertura de hasta 364 días, con la opción de renovar las pólizas hasta por dos años más. Los planes existentes y los emitidos antes del 1 de septiembre no caen bajo las nuevas reglas. Pero los consumidores que contaban con períodos más largos deben comprobar los detalles de sus planes y considerar la posibilidad de cambiar a un plan de ACA para evitar una situación en la que su plan a corto plazo expire antes de tiempo o a mediados de año, arriesgándose así a no poder obtener otra cobertura por el resto del año.

El proceso de inscripción también podría alargarse

Este año, los reguladores federales han tenido que hacer frente a un número creciente de quejas —200,000 sólo en los primeros seis meses— de consumidores que estaban siendo inscritos o transferidos a otros planes de ACA sin su permiso por agentes que pretendían obtener comisiones.

Para evitarlo, se han establecido nuevas normas.

¿Qué significa esto para la mayoría de los consumidores? Si trabajas con un nuevo agente —uno que no estaba ya en la lista en tu plan de ACA— es probable que tengas que ser parte de una llamada con dos representantes del mercado federal para confirmar que autorizas a ese agente para hacer cambios en tu plan para el próximo año. Esto te llevará más tiempo. Nadie sabe lo ocupadas que estarán las líneas telefónicas durante la inscripción abierta.

No es necesario recurrir a un intermediario para inscribirse. Pero la búsqueda entre las docenas de opciones del mercado es un reto, por lo que la mayoría de las personas busca ayuda. Los consumidores deben sopesar no sólo el costo mensual de la prima, sino también las variaciones en deducibles y copagos por cosas como visitas al médico, hospitalización y medicamentos.

Compara precios

Los expertos señalan que otra consideración a tener en cuenta al elegir un plan es comprobar si tu red incluye los médicos y hospitales a los que sueles acudir, y si se cubren tus medicamentos recetados y cuánto cobran por ellos.

Para facilitar las comparaciones, hace dos años entraron en vigencia unas normas que obligan a las aseguradoras a incluir como opciones algunos “planes estandarizados”, que deben tener los mismos deducibles y costos por conceptos como visitas al médico, atención en urgencias y otros gastos compartidos por el consumidor.

Aun así, muchas personas disponen de docenas de opciones, lo que puede resultar desalentador.

Pero hay un consejo que no cambia: tanto si te inscribes por primera vez, como si ya tienes un plan, vale la pena comparar precios. Aunque no cambies de plan, puedes asegurarte de que el que tienes sigue siendo tu mejor opción.

En la mayoría de los estados, los consumidores deben inscribirse antes del 15 de diciembre para obtener cobertura a partir del 1 de enero. Atención a Idaho, donde la inscripción abierta empieza antes, el 15 de octubre, pero también termina antes, el 15 de diciembre. En California, Nueva Jersey, Nueva York, Rhode Island y el Distrito de Columbia, los residentes pueden inscribirse hasta el 31 de enero.

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

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New laws to curb aggressive hospital billing, to expand charity care for lower-income patients, and to rein in debt collectors have been enacted in more than 20 states since 2021.

Democrats championed most measures. But the legislative efforts often passed with Republican support. In a few states, GOP lawmakers led the push to expand patient protections.

“Regardless of their party, regardless of their background … any significant medical procedure can place people into bankruptcy,” Florida House Speaker Paul Renner, a conservative Republican, said in an interview. “This is a real issue.”

Renner, who has shepherded controversial measures to curb abortion rights and expand the death penalty in Florida, this year also led an effort to limit when hospitals could send patients to collections. It garnered unanimous support in the Florida Legislature.

Bipartisan measures in other states have gone further, barring unpaid medical bills from consumer credit reports and restricting medical providers from placing liens on patients’ homes.

About 100 million people in the U.S. are burdened by some form of health care debt, forcing millions to drain savings, take out second mortgages, or cut back on food and other essentials, KFF Health News has found. A quarter of those with debt owed more than $5,000 in 2022.

“Republicans in the legislature seem more open to protecting people from medical debt than from other kinds of debt,” said Marceline White, executive director of Economic Action Maryland, which helped lead efforts in that state to stop medical providers from garnishing the wages of low-income patients. That bill drew unanimous support from Democrats and Republicans

“There seems to be broad agreement that you shouldn’t lose your home or your life savings because you got ill,” White said. “That’s just a basic level of fairness.”

Medical debt remains a more polarizing issue in Washington, where the Biden administration has pushed several efforts to tackle the issue, including a proposed rule by the Consumer Financial Protection Bureau, or CFPB, to bar all medical debt from consumer credit reports.

Vice President Kamala Harris, who is spearheading the administration’s medical debt campaign, has touted the work on the presidential campaign trail while calling for new efforts to retire health care debt for millions of Americans.

Former President Donald Trump doesn’t typically talk about medical debt while stumping. But congressional Republicans have blasted the CFPB proposal, which House Financial Services Committee Chairman Patrick McHenry (R-N.C.) called “regulatory overreach.”

Nevertheless, pollster Michael Perry, who has surveyed Americans extensively about health care, said that conservative voters typically wary of government seem to view medical debt through another lens. “I think they feel it’s so stacked against them that they, as patients, don’t really have a voice,” he said. “The partisan divides we normally see just aren’t there.”

When Arizona consumer advocates put a measure on the ballot in 2022 to cap interest rates on medical debt, 72% of voters backed the initiative.

Similarly, nationwide polls have found more than 80% of Republicans and Democrats back limits on medical debt collections and stronger requirements that hospitals provide financial aid to patients.

Perry surfaced something else that may be driving bipartisan interest in medical debt: growing mistrust as health systems get bigger and act more like major corporations. “Hospitals aren’t what they used to be,” he said. “That is making it clear that profit and greed are driving lots of the decision-making.”

Not every state effort to address medical debt has garnered broad bipartisan support.

When Colorado last year became the first state to bar medical debt from residents’ credit reports, just one Republican lawmaker backed the measure. A Minnesota bill that did the same thing this year passed without a single GOP vote.

But elsewhere, similarly tough measures have sailed through.

A 2024 Illinois bill to bar credit reporting for medical debt passed unanimously in the state Senate and cleared the House of Representatives 109-2. In Rhode Island, not a single GOP lawmaker opposed a credit reporting ban.

And when the California Legislature took up a 2021 bill to require hospitals in the state to provide more financial assistance to patients, it passed 72-0 in the state Assembly and 39-0 in the Senate.

Even some conservative states, such as Oklahoma, have taken steps, albeit more modest. A new law there bars medical providers from pursuing patients for debts if the provider has not publicly posted its prices. The measure, signed by the state’s Republican governor, passed unanimously.

New Mexico state Sen. Steve Neville, a Republican who backed legislation to restrict aggressive collections against low-income patients in that state, said he was simply being pragmatic.

“There was not much advantage to spending a lot of time trying to do collections on indigent patients,” Neville said. “If they don’t have the money, they don’t have the money.” Three of 12 GOP senators supported the measure.

North Carolina state Treasurer Dale Folwell, a Republican who as a state legislator spearheaded a 2012 effort to ban same-sex marriage, said all elected officials, no matter their party, should care about what medical debt is doing to patients.

“It doesn’t matter if, as a conservative, I’m saying these things, or if Bernie Sanders is saying these things,” Folwell said, referencing Vermont’s liberal U.S. senator. “At the end of the day, it should be all our jobs to advocate for the invisible.”

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

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Vice President Kamala Harris at the ABC News presidential debate, Sept. 10

Since Vice President Kamala Harris entered the presidential race, she and former President Donald Trump have sparred over their approaches to lowering prescription drug costs. Harris has described this as an important campaign promise that Trump made but didn’t deliver on.

“Donald Trump said he was going to allow Medicare to negotiate drug prices,” Harris said during the ABC News debate on Sept. 10 in Philadelphia. “He never did. We did.”

She previously told CNN that Trump’s promise to pursue such negotiations “never happened” during his administration.

During the 2016 presidential campaign, Trump repeatedly promised, if elected, to take steps to allow the government to negotiate drug prices. He never enacted such a policy in office. The Trump administration pursued smaller, temporary programs aimed at lowering drug costs.

However, experts say the effect of Trump’s moves fell far short of the expected effect of the Medicare drug price negotiation program included in President Joe Biden’s Inflation Reduction Act and of what Trump promised.

Medicare Drug Price Negotiation Policy, Explained

The Inflation Reduction Act — a sweeping climate and health care law Biden signed in August 2022 — included a measure authorizing the Centers for Medicare & Medicaid Services to negotiate Medicare prescription drug prices directly with pharmaceutical companies.

“The idea behind drug price negotiation is that Medicare can use its buying power to get a better price than what is currently being negotiated for these drugs,” according to Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.

Medicare covers more than 67 million Americans, giving it enormous potential influence over prices for U.S. drugs and medical services.

In August, CMS announced it had secured significant discounts on the list prices of 10 drugs because of its negotiations. Those discounts ranged from a 38% reduction for blood cancer medication Imbruvica on the low end to a 79% cut for diabetes drug Januvia on the high side. (List prices and the prices Medicare drug plans pay can differ.)

The new prices are expected to save Medicare $6 billion in the first year, with Medicare beneficiaries set to save an additional $1.5 billion in out-of-pocket costs, according to the White House.

Those new prices aren’t set to take effect until 2026 — though Biden and Harris have highlighted other aspects of the law that are bringing down drug costs sooner, such as a $35-a-month out-of-pocket price cap on insulin for Medicare enrollees and a $2,000 yearly out-of-pocket spending cap for Part D drugs effective in January. The Part D program covers most generic and brand-name outpatient prescription drugs.

CMS will start negotiating prices for the next group of drugs — 15 a year for the next two years — in early 2025, and those talks will continue annually at least through the end of the decade.

Trump’s Promises Versus His Actions

As a presidential candidate in 2016, Donald Trump pledged to pursue prescription drug price negotiation programs — and sometimes overstated such a policy’s power to cut prices.

During multiple campaign rallies and media interviews that year, Trump suggested allowing the government to negotiate drug prices directly with manufacturers would save $300 billion a year, a claim a fact-checker said was “absurd” then.

“The problem is, we don’t negotiate,” Trump said during an MSNBC town hall in Charleston, South Carolina, on Feb. 17, 2016. “We’re the largest drug buyer in the world. We don’t negotiate.” He went on to say: “If we negotiated the price of drugs, Joe, we’d save $300 billion a year.”

Similarly, at a Feb. 24, 2016, rally in Virginia Beach, Virginia, Trump reiterated his interest in making this change. “If you bid them out we’ll save $300 billion … and we don’t even do it. We’re going to do it.” The pharmaceutical industry would push back, he said, but he added: “Trust me I can do it.”

In office, however, Trump backed away from those promises, rejecting a bill spearheaded by then-House Speaker Nancy Pelosi (D-Calif.) to authorize such negotiations. The Democratic-led House ultimately passed that legislation, though the Republican-led Senate didn’t consider it.

“Pelosi and her Do Nothing Democrats drug pricing bill doesn’t do the trick,” Trump wrote on X, the social platform then known as Twitter.

Trump pursued smaller initiatives that sought to lower drug costs. One such program, the “most favored nation” model, tried to cap the cost of some Part B medications — those administered in a doctor’s office or hospital outpatient setting — at the lowest price paid in certain peer nations with a per capita GDP of at least 60% that of the United States.

“Medicare is the largest purchaser of drugs anywhere in the world by far,” Trump said in announcing the program. “We’re finally going to use that incredible power to achieve a fairer and lower price for everyone.”

The Trump campaign didn’t respond to an inquiry about prescription drug price negotiations or the most favored nation model.

The program would have started in January 2021 and lasted seven years. CMS officials estimated the government would save more than $85 billion on Part B spending. But some of those savings came from assumptions that Medicare beneficiaries would lose access to some Part B medications under the model, with some manufacturers unlikely to sell products at the lower, foreign prices.

Trump’s program never took effect. Amid lawsuits from several drug companies and industry groups, a federal judge stayed the plan in December 2020. The Biden administration scrapped it in 2022.

Even if the most favored nation model had been enacted, experts say it wouldn’t have come close to saving Americans or the government as much money as the IRA’s drug price negotiation provisions. A contemporaneous analysis of Trump’s proposal estimated that 7% of the 60 million Medicare beneficiaries in 2018 would have benefited.

More importantly, the most favored nation model did not authorize the government to negotiate prescription drug prices with manufacturers — the policy Trump promised to implement.

What Comes Next?

A recent KFF poll shows 85% of Americans, including more than three-quarters of Republicans, favor allowing Medicare to negotiate prices with drug companies.

And lowering drug costs continues to be a key issue for both campaigns, with Trump and Harris sparring over everything from the price of insulin to the impact of the Inflation Reduction Act on Medicare spending.

“I’ll lower the cost of insulin and prescription drugs for everyone with your support, not only our seniors,” Harris told supporters at an Aug. 16 campaign event in Raleigh, North Carolina, promising to extend the IRA’s price caps.

A Trump campaign spokesperson, meanwhile, previously told KFF Health News that the former president “will do everything possible to lower drug costs for Americans when he’s back in the White House, just like he accomplished in his first term.” She provided no specifics.

Trump, however, has also repeatedly promised to repeal parts of the Inflation Reduction Act — though he has never specifically mentioned the drug price negotiation provision — and to rescind unspent money. Congressional Republicans have spoken publicly about their intentions to roll back the drug price negotiation provision.

Even without legislative changes, the next president will have the opportunity to steer Medicare’s prescription drug price negotiation process.

“An administration that wants to be more lenient on drug companies might be more lax in the negotiations process,” said Tricia Neuman, a senior vice president at KFF and the executive director of its Program on Medicare Policy. “Or the administration could perhaps be tougher than the Biden administration.”

Our Ruling

As a presidential candidate in 2016, Donald Trump promised to let the government negotiate prescription drug prices directly with pharmaceutical companies. As president, however, he instead tried to tie some U.S. drug prices to their costs in other countries. Drugmakers and industry groups sued, challenging the move, and courts blocked it.

Harris, therefore, is correct that Trump never was able to open Medicare up to drug negotiations despite his sweeping campaign promises.

We rate Harris’ claim True.

Our Sources:

ABC News, “READ: Harris-Trump Presidential Debate Transcript,” Sept. 10, 2024

Axios, “Hill GOP Sets Sights on Scrapping Drug Price Talks,” Sept. 17, 2024

Centers for Medicare & Medicaid Services, “Trump Administration Announces Prescription Drug Payment Model To Put American Patients First,” Nov. 18, 2020

CNN, “READ: Harris and Walz’s Exclusive Joint Interview With CNN,” Aug. 30, 2024

Congress.gov, “H.R.3 – Elijah E. Cummings Lower Drug Costs Now Act,” accessed Sept. 17, 2024

Factbase, “Donald Trump Attends an MSNBC Town Hall in Charleston, South Carolina,” Feb. 17, 2016

Factbase, “Donald Trump in Pawleys Island, SC,” Feb. 19, 2016

Federal Register, “42 CFR Part 513,” Nov. 27, 2020

KFF, “A Status Report on Prescription Drug Policies and Proposals at the Start of the Biden Administration,” Feb. 11, 2021

KFF, “KFF Health Tracking Poll September 2024: Support for Reducing Prescription Drug Prices Remains High, Even As Awareness of IRA Provisions Lags,” Sept. 13, 2024

KFF, “Most People Are Unlikely To See Drug Cost Savings From President Trump’s ‘Most Favored Nation’ Proposal,” Aug. 27, 2020

KFF Health News, “5 Things To Know About the New Drug Pricing Negotiations,” Aug. 30, 2023

KFF Health News, “Harris Did Not Vote To ‘Cut Medicare,’ Despite Trump’s Claim,” Aug. 20, 2024

KFF Health News, “Trump Is Wrong in Claiming Full Credit for Lowering Insulin Prices,” July 18, 2024

Phone interview with Tricia Neuman, a senior vice president at KFF and the executive director of its Program on Medicare Policy, Sept. 13, 2024

Reuters, “Federal Judge Blocks Trump Administration Drug Pricing Rule,” Dec. 23, 2020

The Washington Post, “Trump’s Truly Absurd Claim He Would Save $300 Billion a Year on Prescription Drugs,” Feb. 18, 2016

The White House, “Remarks by President Trump at Signing of Executive Orders on Lowering Drug Prices” July 24, 2020

The White House, “Remarks by Vice President Harris at a Campaign Event in Raleigh, NC,” Aug. 16, 2024

X, then known as Twitter, “@RealDonaldTrump,” Nov. 22, 2019

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

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