KFF Health News’ ‘What the Health?’: Nursing Home Staffing Rules Prompt Pushback

The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News weekly health policy news podcast, What the Health? A noted expert on health policy issues, Julie is the author of the critically praised reference book Health Care Politics and Policy A to Z, now in its third edition.

Its not surprising that the nursing home industry is filing lawsuits to block new Biden administration rules requiring minimum staffing at facilities that accept federal dollars. What is slightly surprising is the pushback against the rules from members of Congress. Lawmakers dont appear to have the votes to disapprove the rule, but they might be able to force a floor vote, which could be embarrassing for the administration.

Meanwhile, Senate Democrats aim to force Republicans who proclaim support for contraceptive access to vote for a bill guaranteeing it, which all but a handful have refused to do.

This weeks panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call. Panelists Rachel Cohrs Zhang Stat News @rachelcohrs Read Rachel's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories. Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories.

Among the takeaways from this weeks episode: In suing to block the Biden administrations staffing rules, the nursing home industry is arguing that the Centers for Medicare & Medicaid Services lacks the authority to implement the requirements and that the rules, if enforced, could force many facilities to downsize or close. Anthony Fauci, the retired director of the National Institute of Allergy and Infectious Diseases and the man who advised both Presidents Donald Trump and Joe Biden on the covid-19 pandemic, testified this week before the congressional committee charged with reviewing the governments pandemic response. Fauci, the subject of many conspiracy theories, pushed back hard, particularly on the charge that he covered up evidence that the pandemic began because dangerous microbes escaped from a lab in China partly funded by the National Institutes of Health. A giant inflatable intrauterine device was positioned near Union Station in Washington, D.C., marking what seemed to be Contraceptive Week on Capitol Hill. Republican senators blocked an effort by Senate Majority Leader Chuck Schumer to force a vote on consideration of legislation to codify the federal right to contraception. Immediately after, Schumer announced a vote for next week on codifying access to in vitro fertilization services. Hospitals in London appear to be the latest, high-profile cyberattack victims, raising the question of whether it might be time for some sort of international cybercrime-fighting agency. In the United States, health systems and government officials are still in the very early stages of tackling the problem, and it is not clear whether Congress or the administration will take the lead. An FDA advisory panel this week recommended against the formal approval of MDMA, a psychedelic also known as ecstasy, to treat post-traumatic stress disorder. Members of the panel said there was not enough evidence to recommend its use. But the discussion did provide more guidance about what companies need to present in terms of trials and evidence to make their argument for approval more feasible.

Also this week, Rovner interviews KFF Health News Bram Sable-Smith, who reported and wrote the latest KFF Health News-NPR Bill of the Month feature about a free cruise that turned out to be anything but. If you have an outrageous or baffling bill youd like to send us, you can do that here. Email Sign-Up

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Plus, for extra credit, the panelists suggest health policy stories they read this week that they think you should read, too: Julie Rovner: Abortion, Every Days EXCLUSIVE: Health Data Breach at Americas Largest Crisis Pregnancy Org, by Jessica Valenti. Alice Miranda Ollstein: The Washington Posts Conservative Attacks on Birth Control Could Threaten Access, by Lauren Weber. Rachel Cohrs Zhang: ProPublicas This Mississippi Hospital Transfers Some Patients to Jail to Await Mental Health Treatment, by Isabelle Taft, Mississippi Today. Sandhya Raman: Air Mails Roanokes Requiem, by Clara Molot. Click to open the transcript Transcript: Nursing Home Staffing Rules Prompt Pushback [Editors note: This transcript was generated using both transcription software and a humans light touch. It has been edited for style and clarity.] 

Mila Atmos: The future of America is in your hands. This is not a movie trailer, and its not a political ad, but it is a call to action. Im Mila Atmos, and Im passionate about unlocking the power of everyday citizens. On our podcast, Future Hindsight, we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.

Julie Rovner: Hello, and welcome back to What the Health? Im Julie Rovner, chief Washington correspondent for KFF Health News, and Im joined by some of the best and smartest health reporters in Washington. Were taping this week on Thursday, June 6, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Sandhya Raman of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: And Rachel Cohrs Zhang of Stat News.

Rachel Cohrs Zhang: Hi, everybody.

Rovner: Later in this episode, well have my interview with KFF Health News Bram Sable-Smith, who reported and wrote this months KFF Health News/NPR Bill of the Month. Its about a free cruise that turned out to be anything but. But first, this weeks news. Were going to start this week with those controversial nursing home staffing rules.

In case youve forgotten, back in May, the Biden administration finalized rules that would require nursing homes that receive federal funding, which is basically all of them, to have nurses on duty 24/7/365, as well as impose other minimum staffing requirements.

The nursing home industry, which has been fighting this effort literally for decades, is doing what most big powerful health industry players do when an administration does something it doesnt like: filing lawsuits. So what is their problem with the requirement to have sufficient staff to care for patients who, by definition, cant care for themselves or they wouldnt be in nursing homes?

Cohrs Zhang: Well, I think the groups are arguing that CMS [Centers for Medicare & Medicaid Service] doesnt have authority to implement these rules, and that if Congress had wanted these minimum staffing requirements, Congress should have done that and they didnt. So theyre arguing that theyre overstepping their boundaries, and we are seeing this lawsuit again in Texas, which is a popular venue for the health care industry to try to challenge rules or legislation that they dont like.

So, I think it isnt a surprise that we would see these groups sue, given the financial issues at stake, given the fearmongering about facilities having to close, and just the hiring that could have to happen for a lot of these facilities. So its not necessarily a surprise, but it will certainly be interesting andimpactful for facilities and for seniors across the nation as this plays out.

Rovner: I mean, basically one of their arguments is that there just arent enough people to hire, that they cant get the number of people that they would need, and that seems to be actually pretty persuasive argument at some point, right?

Cohrs Zhang: I mean, there is controversy about why staffing shortages happen. Certainly there could be issues with the pipeline or with nursing schools, education. But I think there are also arguments that unions or workers rights groups would make that maybe if facilities paid better, then they would get more people to work for them. Or that people might exit the industry because of working conditions, because of understaffing, and just that makes it harder on the workers who are actually there if their workloads are too much. Or theyre expected to do more work longer hours or overtime or their vacation is limited, that kind of thing.

So I think it is a surprisingly controversial issue that doesnt have an easy answer, but thats the perspectives that were seeing here.

Rovner: I mean, layering onto this, its not just the industry versus the administration. Now Congress is getting into the act, which you rarely see. Theyre talking about using the Congressional Review Act, which is something that Congress can do. But of course, when youre in the middle of an administration thats done it, it would get vetoed by the president. So they cant probably do anything. Sandhya, I see you nodding your head. These members of Congress just want to make a statement here?

Raman: Yeah. So Sen. James Lankford insured the resolution earlier this week to block the rules implementation, and its mostly Republicans that have signed on, but we also have [Sen.] Joe Manchin and [Sen.] Jon Tester. But the way it stands, it doesnt have enough folks on board yet, and it would also need to be taken up. It faces an uphill climb like many of these things.

Rovner: Somebody actually asked me yesterday though, can they do this? And the answer is yes, there is the Congressional Review Act. Yes, Congress with just a majority vote and no filibuster in the Senate can overturn an administration rule. But like I said, it usually happens when an administration changes its hands because it does have to be signed by the president and the president can veto it.

If the president vetoes it, then they would need a veto override majority, which they clearly dont seem to have in this case. But obviously there is enough concern about this issue. I think theres been a Congressional Review Act resolution introduced in the House too, right?

Ollstein: Its really tough because, like Rachel said, these jobs are low-paid. Theyre emotionally and physically grueling. Its really hard to find people willing to do this work. And at the same time, the current situation seems really untenable for patients. Theres been so many reports of really horrible patient safety and hygiene issues and all kinds of stuff in part, not entirely the fault of understaffing, but not helped by understaffing certainly.

I think, like, we see on so many fronts in health care, there are attempts to do something about this situation that has become untenable, but any attempt also will piss off someone and be challenged.

Rovner: Yeah, absolutely. And we should point out that nursing homes are staffed primarily not by nurses, but by nurses aides of various training levels. So this is not entirely about a nursing shortage, it is about a shortage of workers who want to do this, as you say, very grueling and usually underpaid work.

Well, speaking of controversial things, Dr. Tony Fauci, the now-retired head of the NIHs National Institute of Allergy and Infectious Diseases, and currently the man most conspiracy theorists hold responsible for the entire covid-19 pandemic, testified before the House Select Committee on the pandemic Monday. And not surprisingly, sparks flew. What, if anything, did we learn from this hearing?

Cohrs Zhang: The interesting part of this hearing was watching how Dr. Fauci positioned himself in response to a lot of these criticisms that have been circulating. The committee has been going through different witnesses, and specifically it criticized one of his deputies, essentially, who had some unflattering emails released showing that he appeared to be trying to delete emails or use personal accounts to avoid public records requests from journalists or other organizations

Rovner: Im shocked, shocked that officials would want to keep their information away from prying reporters eyes.

Cohrs Zhang: Its not surprising, but it is surprising to see it in writing. But this is, again, everyone is working from home and channels of communication were changing. But I think we did see Dr. Fauci pretty aggressively distancing himself, downplaying the relationship he had with this individual and saying that they worked on research together, but he wasnt necessarily advising agency policy.

So thats at least how he was framing the relationship. So he definitely downplayed that. And I think an interesting comment he made Im curious to see what you think about this, Julie was that he didnt say that the lab leak theory itself was a conspiracy, but his involvement and a cover-up was a conspiracy. And so it did seem that some of the rhetoric has at least changed. He seemed more open-minded, I guess, to a lab leak theory than I expected.

Rovner: I thought he was pretty careful about that. I think it was the last thing he said, which is that were never really going to know. I mean, it could have been a lab leak. It could have happened. It could have been an animal from the wet market. The Chinese have not been very forthcoming with information. I personally keep wondering why we keep pounding at this.

I mean, it seems unlikely that it was a lab leak and then a conspiracy to cover it up. It clearly was one or the other, and theres a lot of differences of opinions. And that was the last thing he said is that it could have been either. We dont know. Thats always struck me as the, OK, lets talk about something else. Anyway, lets talk about something else.

Raman: I was just going to add, we did see a personal side to him, which I think we didnt see as much when he was in his official role when he was talking. It was about the death threats that he and his family have been receiving when responding to a lot of the misinformation going around about that. And I thought that was striking compared to, just juxtaposed, with a lot of the other [indecipherable] with [Rep.] Marjorie Taylor Greene saying, Oh, youre not a real doctor. Theres a lot of colorful protesters. And I just thought that stood out, too.

Rovner: Yeah, he did obviously, I think, relish the chance to defend himself from a lot of the charges that have been leveled at him. And I think his wife is a prominent scientist in her own right obviously can take care of herself but I think he was particularly angry that there had been death threats leveled toward his grown daughters, which probably a bit out of line. Alice, you wanted to add something.

Ollstein: Yeah, I think its also been interesting to see the shift among Democrats on the committee over time. I think theyve gone from an attitude of Republicans are on a total witch hunt, this is completely political, this is muddying the waters and fueling conspiracy theories and will lead to worse public health outcomes. And I think based on some of the revelations, like Rachel said about emails and such, they have come to a position of, oh, there might be some things that need investigating and need accountability in here.

But I think their frustration seems to be what its always been in that how will this lead to making the country better prepared in the future for the next pandemic which may or may not already be circulating, but certainly is inevitable at some point. Either way, its all well and good to hold officials accountable for things they may have done, but how does that lead to making the country ore prepared, improving pandemic response in the future? Thats what they feel is the missing piece here.

Rovner: Yeah. I think there was not a lot of that at this hearing, although I feel like they had to go through this maybe to get over to the other side and start thinking about what we can do in the future to avoid similar kinds of problems. And obviously you get a disease that you have no idea what to do about, and people try to muddle through the best they can. All right, now we are going to move on and well talk about abortion where there is always lots of news.

Here in Washington, there is a giant inflatable IUD flying over Union Station Wednesday to highlight what seems to be Contraception Week on Capitol Hill. Not coincidentally, its also the anniversary this week of the Supreme Courts 1965 ruling Griswold v. Connecticut that created the right to birth control. Alice, what are Democrats, particularly in the Senate where theyre in charge, doing to try to highlight these potential threats to contraceptive access?

Ollstein: So this vote that happened that was blocked because only two Republicans crossed the aisle to support this Right to Contraception bill its the two you expect, its [Sen.] Lisa Murkowski and [Sen.] Susan Collins and youre already seeing Democrats really make hay of this. Both Democrats and their campaign arms and outside allied groups are planning to just absolutely blitz this in ads. Theyre holding events in swing states related to it, and theyre going hard against individual Republicans for their votes.

I think the Republicans I talked to who voted no, they had a funny mixed message about why they were voting no on it. They were both saying that the bill was this sinister Trojan horse for forcing religious groups to promote contraception and even abortion and also gender-affirming care somehow. But also, the bill was a pointless stunt that wouldnt really do anything because there is no threat to contraception. But also Republicans have their own rival bill to promote access to contraception.

So access to contraception isnt a problem, but please support my bill to improve access to contraception. Its a tough message. Whereas Democrats message is a lot simpler. You can argue with it on the merits, but its a lot simpler. They point to the fact that Supreme Court Justice Clarence Thomas has expressed interest and actually called on the court to revisit precedents that protect the right to contraception.

Lots of states have thwarted attempts to enact protections for contraception. And a lot of anti-abortion groups have really made a big push to muddy the waters on medical understanding of what is contraception versus what is abortion, which we can get into later.

Rovner: Yes, which we will. Sandhya, did you want to add something?

Raman: Yeah, and I think that something that I would add to what Alice was saying is just how this is kind of at the same time a little bit different for the Democrats. Something that I wrote about this week was just that after the Dobbs [v. Jackson Womens Health Organization] decision, we had the then-Democratic House vote on several different bills, but the Democrats have not really been holding this chamber-wide vote on bills related to abortion, contraception for the most part. And so this was the first time that they are stepping into that.

Theyve done the unanimous consent requests on a lot of these bills. And even just a couple months ago when talks are really heating up on IVF, theres other things that we have to get to, appropriations and things like that, and this would just get bogged down. And they were shying away from taking floor time to do this. So I think that was an interesting move that theyre doing this now and that theyre going to vote on an IVF next week and whatever else next down the line.

Rovner: Yeah, I noticed that as soon as this bill went down, Sen. [Chuck] Schumer teed up the Right to IVF bill for a vote next week. But Alice, as you were alluding to, I mean, where this gets really uncomfortable for Republicans is that fine line between contraception and abortion. Our colleague Lauren Weber has a story about this this week [Conservative Attacks on Birth Control Could Threaten Access,], which is your extra credit, so why dont you tell us about it?

Ollstein: Yeah. So she did a really great job highlighting how, especially at the state level where a lot of these battles are playing out, anti-abortion groups that are very influential are making arguments that certain forms of birth control are abortifacients. This is completely disputed by medical experts and the FDA [Food and Drug Administration] that regulates these products. They say, just to be clear about what were talking about, were talking about some forms of emergency contraception, which is taken after sex to prevent pregnancy. It is not an abortifacient. It wont work if youre already pregnant. It prevents pregnancy. It does not terminate a pregnancy. They are also saying this about some IUDs, intrauterine devices, and even about some hormonal birth control pills.

So theres been pushback that Lauren detailed in her story, including from some Republicans who are trying to correct the record. But this misinformation is getting really entrenched, and I think its something we should all be paying attention to when it crops up, especially in the mouths of people in power.

Rovner: I mean, when I first started writing about it it was not entirely clear. There was thought that one of the ways the morning-after pill worked was by preventing implantation of a fertilized egg, which some people consider, if you consider that fertilization and not implantation, is the beginning of life. According to doctors, implantation is the beginning of pregnancy, among other things, because thats when you can test for it.

But those who believe that fertilization is the beginning of life and therefore something that prevents implantation is an abortion were concerned that IUDs, and mostly progesterone-based birth control that prevented implantation, were abortifacients. Except that in the years since, its been shown that thats not the case.

Ollstein: Right.

Rovner: That in fact, both IUDs and the morning-after pill work by preventing ovulation. There is no fertilized egg because theres no egg. So they are not abortifacients. On the other hand, the FDA changed the labeling on the morning-after pill because of this. And yet the Hobby Lobby case [Burwell v. Hobby Lobby Stores Inc.] that the decision was written by Justice [Samuel] Alito, basically took that premise, that they were allowed to not offer these forms of contraception because they believed that they were acted as abortifacients, even though science suggests that they didnt. Its not something new, and its not something I dont think is going to go away anytime in the near future.

Raman: I would add that it also came up in this weeks Senate Health [Committee] hearing, that line of questioning about whether or not different parts of birth control were abortifacients. Sen. [Patty] Murray did that line of questioning with Dr. Christina Francis, whos the head of the anti-abortion obstetrician-gynecology group and went through on Plan B, IUDs and different things. And there was a back and forth of evading questions, but she did call IUDs as abortifacients, which goes back to the same thing that were saying.

Rovner: Right, which they have done all along.

Ollstein: Yeah. I mean, I think this really spotlights a challenge here, which is that Republicans response to votes like this week and things that are playing out in the state level, theyre scoffing and saying, Its absolutely ridiculous to suggest that Republicans are trying to ban birth control. This is completely a political concoction by Democrats to scare people into voting for them in November.

What were talking about here are not bans on birth control, but there are policies that have been introduced at both the state and federal level that would make birth control, especially certain forms like we were just talking abou, way harder to access. So there are proposals to carve them out of Obamacares contraception mandate, so theyre not covered by insurance.

Thats not a ban. You can still go pay out-of-pocket, but I remember all the people who were paying out-of-pocket for IUDs before Obamacare: hundreds and hundreds of dollars for something that is now completely free. And so what were seeing right now are not bans, but I think its important to think about the ways it would still restrict access for a lot of people.

Rovner: Before we leave the nations capital it seems that the Supreme Courts upcoming decision on the abortion pill may not be the last word on the case. While it seemed likely from the oral arguments that the justices will agree that the Texas doctors who brought the case dont have standing, there were three state attorneys general who sought to become part of the case when it was first considered back in Texas. So it would go back to Judge [Matthew] Kacsmaryk, our original judge who said that the entire abortion pill approval should be overturned. It feels like this is not the end of fighting about the abortion pills approval at the federal level. I mean, I assume that thats something that the drug industry, among others, wont be happy about.

Ollstein: Courts could find that the states dont have standing either, that this policy does not harm them in any real way. In fact, Democratic attorneys general have argued the exact opposite, that the availability of mifepristone helps states: saves a lot of money; it prevents pregnancy; it treats peoples medical needs. So obviously, Kacsmaryk has a very long anti-abortion record and has sided with these challenges in a lot of cases. But that doesnt mean that this would necessarily go anywhere.

But your bigger point that the Supreme Courts upcoming ruling on mifepristone is not the end, it certainly is not. Theres going to be a lot more court challenges, some already in motion. Theres going to be state-level policy fights. Theres going to be federal-level policy fights. If Trump is elected, groups want him to do a lot of things through executive order to restrict mifepristone or remove it from the market entirely through the FDA. So yes, this is not going to be over for the foreseeable future.

Rovner: Well, meanwhile, in a case that might be over for the foreseeable future, the Texas Supreme Court last week officially rejected the case brought by 20 women who nearly died when they were unable to get timely care for pregnancy complications. The justices said in their ruling that while the women definitely did suffer, the fault lay with the doctors who declined to treat them rather than the vagueness of the states abortion ban. So where does that leave the debate about medical exceptions?

Ollstein: So anti-abortion groups response to a lot of the challenges to these abortion bans and stories about women in medical emergencies who are getting denied care and suffering real harm as a result, their response has been that theres nothing wrong with the law. The law is perfectly clear, and that doctors are either accidentally or intentionally misinterpreting the law for political reasons. Meanwhile, doctors say its not clear at all. Its not clear how honestly close to dead someone has to be in order to receive an abortion.

Rovner: And its not just in Texas. This is true in a bunch of states, right? The doctors dont know

Ollstein: In many states.

Rovner: right?

Ollstein: Exactly.

Rovner: when they can intervene.

Ollstein: Right. And so I think the upcoming Supreme Court ruling on EMTALA [Emergency Medical Treatment and Active Labor Law], which weve talked about, could give some indication either way of what doctors are and are not able to do, but that wont really resolve it either. There is still so much gray area. And so patients and doctors are going to state courts to plead for clarity. Theyre going to their legislatures to plead for clarity. And theyre going to state medical boards, including in Texas, to plead for clarity. And so far, they have not gotten any.

Most legislatures have been unwilling to revisit their bans and clarify or expand the exceptions even as these stories play out on the ground of doctors who say, I know that providing an abortion for this patient is the right thing medically and ethically to do, but Im so afraid of being hit with criminal charges that I put the patient on a plane out of state instead. Yeah, its just really tough.

And so what we wrote about it is we keep talking about doctors being torn between conflicting state and federal law, and thats absolutely true, but what we dug into is that the state law just looms so much larger than the federal laws. So when youre weighing, should I maybe violate EMTALA or should I maybe violate my states ban, theyre not going to want to violate their states ban because that means jail time, that means losing their license, that means having their freedom and their livelihood taken away.

Whereas an EMTALA violation may or may not mean a fine somewhere down the road. The enforcement has not been as aggressive at the federal level from the Biden administration as a lot of doctors would like it to be. And so, in that environment, theyre really deferring to the state law, and that means some people are not getting care that they maybe need.

Rovner: I say in the meantime, we had yet another jury just last week about a woman who had a miscarriage and could not get a D&C [dilation and curettage procedure] basically. When she went in there was no fetal heartbeat, but she ended up miscarrying at home and almost dying. She was sent away, I believe, from three different facilities. This continues to happen because doctors are concerned about when it is appropriate for them to intervene. And they seem, youre right, to be leaning towards the lets not get in trouble with the state law, so lets wait to provide care as long as we think we can.

Well, moving on, we have two stories this week about efforts to treat post-traumatic stress disorder, particularly in military veterans. On Tuesday, an FDA advisory committee recommended against approval of the psychedelic MDMA, better known as ecstasy, for the treatment of PTSD. My understanding is that the panel didnt reject the idea outright that this could be helpful, only that there isnt enough evidence yet to approve it. Was I reading that right? Rachel, you guys covered this pretty closely.

Cohrs Zhang: Yes. Yeah, my colleagues did cover this. Certainly I think whats a discouraging sign, I dont think theres any way around it, for some of these companies that are looking at psychedelics and trying to figure out some sort of approval pathway for conditions like PTSD.

One of my colleagues, Meghana Keshavan, she chatted with a dozen companies yesterday and they were trying to put a positive spin on it, that having some opinion or some discussion of a treatment like this by the advisory committee could lay out more clear standards for what companies would have to present in order to get something approved. So I think obviously they have a vested interest in spinning this positively.

But it is a very innovative space and certainly was a short-term setback. But it certainly isnt a long-term issue if some of these companies are able to present stronger evidence or better trial design. I think there were some questions about whether trial participants actually could figure out whether they were placebo or not, which if youre taking psychedelic drugs, yeah, thats kind of a challenge in terms of trial design.

So I think there are some interesting questions, and I am confident that thisll be something the FDA and industry is going to have to figure out in a space thats new like this.

Rovner: Yeah, its been interesting to follow. Well, in something that does seem to help, one of the first controlled studies of service dogs to treat PTSD has found that mans best friend can be a therapist as well. Those veterans who got specially trained dogs showed much more improvement in their symptoms than those wh were on the doggy wait list as determined by professionals who didnt know who had the dogs and who didnt. So pet therapy for the win here?

Raman: I mean, this is the biggest study of this kind that weve had so far, and it seems promising. I think one thing will be interesting is if theres more research, if this would change policy down the line for the VA [Department of Veterans Affairs] or other agencies to be able to get these kinds of service dogs in the hands of more vets.

Rovner: Yeah, I know theres a huge demand for these kinds of service dogs. I know a lot of people who basically have started training service dogs for veterans. Obviously they were able to do this study because there was a long wait list. They were able to look at people who were waiting but hadnt gotten a dog yet. So at least in the short term, possibly some help for some people.

Finally this week, in a segment Im calling Misery Loves Company, its not just the U.S. where big health systems are getting cyberhacked. Across the pond, quoting here from the BBC, major hospitals in London have declared a critical incident after a cyberattack led to operations being canceled and emergency patients being diverted elsewhere. This sounds painfully familiar.

Maybe we need an international cybercrime fighting agency. Is there one? Is there at least, do we know, is there a task force working on this? Obviously the bigger, more centralized your health care system, the bigger problem this becomes, as we saw with Change Healthcare belonging to United[Healthcare], and this is now … I guess its a contractor that works for the NHS [National Health Service]. You can see the potential for really bad stuff here.

Cohrs Zhang: Thats a good question about some international standards, Julie, but I think what we have seen is Sen. Ron Wyden, who leads the Senate Finance Committee, did write to HHS [Department of Health and Human Services] this week and asked HHS to add to multiple-factor authentication as a condition of participation for some of these facilities to try to institute standards that way.

And again, I think there are questions about how much HHS can actually do, but I think its a signal that Congress might not want to do anything or think they can do anything if theyre asking the administration to do something here. But were still in the very early stages of systems viewing this as worthy of investment and just education about some of the best practices here.

Yeah, certainly its going to be a business opportunity for some consulting firms to help these hospitals increase their cybersecurity measures and certainly will be a global market if we see these attacks continue in other places, too.

Rovner: Maybe our health records will be as protected as our Spotify accounts. It would apparently be a step forward. All right, well, that is the news for this week. Now we will play my Bill of the Month interview with Bram Sable-Smith, and then we will come back and do our extra credits.

I am pleased to welcome back to the podcast my KFF Health News colleague Bram Sable-Smith, who reported and wrote the latest KFF Health News-NPR Bill of the Month about a free cruise that turned out to be anything but. Welcome back to the podcast, Bram.

Bram Sable-Smith: Thanks for having me.

Rovner: So tell us about this months patient, who he is, and what happened to him. This is one of the wilder Bills of the Month, I think.

Sable-Smith: Right. So his name is Vincent Wasney. He lives in Saginaw, Michigan. Never been on an airplane before, neither had his [fiance], Sarah. But when they bought their first house in 2019, their Realtor, as a gift, gifted them tickets for a cruise. My Realtor gave me a tote bag. So, what a Realtor, first of all! What an incredible gift.

Rovner: My Realtor gave me a wine opener, which I do still use.

Sable-Smith: If it sailed to the Caribbean, itd be equivalent. So their cruise got delayed because of the pandemic, but they set sail in December 2022. And they were having a great time. One of the highlights of their trip was they went to this private island called CocoCay for Royal Caribbean guests, and it included an excursion to go swimming with pigs.

Rovner: Wild pigs, right?

Sable-Smith: Wild pigs, a big fancy water park, all kinds of food. They were having a great time. But its also on that island that Vincent started feeling off. And so in the past, Vincent has had seizures. About 10 years earlier, he had had a few seizures. They decided he was probably epileptic, and he was on medicine for a while. He went off the medicine because they were worried about liver damage, and hed been relatively seizure-free for a long time. Itd been a long time since hed had a seizure.

But when he was on that island having a great time, its when he started to feel off. And when they got back on the cruise ship for the last full day of the cruise, he had a seizure in his room. And he was taken down to the medical center on the cruise ship and he was observed. He was given fluids for a while, and then sent back to his room, where he had a second seizure. Once again, went down to the medical center on the ship, where he had a third seizure. It was time to get him off the boat. He needed to get onto land and go to a hospital. And so they were close enough to land that they were able to do the evacuation by boat instead of having to do something like a helicopter to do a medevac that way. And so a rescue boat came to the ship. He was lowered off the ship. He was in a stretcher and it was lowered down to the rescue boat by a rope.

His fiance, Sarah, climbed down a rope ladder to get into the boat as well to go with them to land. And then he was taken to land in an ambulance ride to the hospital, et cetera. But, before they were allowed to disembark, they were given their bill and told Its time to pay this. You have to pay this bill.

Rovner: And how much was it?

Sable-Smith: So the bill for the medical services was $2,500. This was a free cruise. They had budgeted to pay for internet, $150 for internet. They had budgeted to pay for their alcoholic drinks. They had budgeted to pay for their tips. So they had saved up a few hundred dollars, which is what they thought would be their bill at the end of this cruise. Now, that completely exploded into this $2,500 bill just for medical expenses alone.

And as theyre waiting to evacuate the ship, theyre like, We cant pay this. We dont have this money. So that led to some negotiations. They ended up basically taking all the money out of their bank accounts, including their mortgage payment. They maxed out Vincents credit card, but they were still $1,000 short. And they later learned once they were on land that Vincents credit card had been overdrafted by $1,000 to cover that additional expense.

Rovner: So it turns out that he was uninsured at the time, and well talk about that in a minute. But even if he had had insurance, the cruise ship wasnt going to let him off the boat until he paid in full, even though it was an emergency? Did I read that right?

Sable-Smith: Thats certainly the feeling that they had at the time. When Vincent was short the $1,000, eventually they were let off the ship, but they did end up, as we said, getting that credit card overdrafted. But I think whats important to note here is that even though he was uninsured at the time, even if he had had insurance, and even if he had had travel insurance, which he also did not have at the time, which we can talk about, he still wouldve been required to pay upfront and then submit the receipts later to try to get reimbursed for the payments.

And thats because on the cruises website, they explain that they do not accept land-based health insurance plans when theyre on the vessel.

Rovner: In fact, as you mentioned, a lot of health insurance doesnt cover care on a cruise ship or, in fact, anywhere outside the United States. So lots of people buy travel insurance in case they have a medical emergency. Why didnt they?

Sable-Smith: So travel insurance is often purchased when you purchse the tickets. Youll buy a ticket to the cruise and then it will prompt you, say, Hey, do you want some travel insurance to protect you while youre on this ship? And thats the way that most people are buying travel insurance. Well, remember, this cruise was a gift from their realtors, so they never bought the ticket. So they never got that prompting to say, Hey, time to buy some travel insurance to protect yourself on the trip.

And again, these were inexperienced travelers. Theyd never been on an airplane before. The furthest either one of them had been from Michigan was Vincent went to Washington, D.C., one time on a school trip. And so they didnt really know what travel insurance was. They knew it existed. But as Vincent explained, he said, I thought this was for lost luggage and trip cancellations. I didnt realize that this was something for medical expenses you might incur when youre out at sea.

Rovner: And its really both. I mean, it is for lost luggage and cancellation, right?

Sable-Smith: And it is for lost luggage and cancellation. Yeah, thats right.

Rovner: So what eventually happened to Vincent and what eventually happened to the bill?

Sable-Smith: Well, once he got taken to the hospital, he got an additional bill, or actually several additional bills, one from the hospital, two from a couple doctors who saw him at the hospital who billed separately, and also one from the ambulance services. As we know, he had already drained his bank account and maxed out his credit card and had it overdrafted to cover the expenses on the ship. So he was working on paying those off. And then for the additional bills he incurred on land, he had set up payment plans, really small ones, $25, $50 a month, but going to four separate entities.

He actually missed a couple payments on his bill to the hospital, and that ended up getting sent to collections. Again, none of these are charging interest, but these are still quite some burdens. And so he was paying them off bit by bit by bit. He set up a GoFundMe campaign, which is something that a lot of people end up doing who never expect to have to cover these kinds of emergency expenses, or reach out publicly for help like that. And they got quite a bit of help from family and friends. Including, Vincent picked up Frisbee golf during the pandemic, and hes made quite a lot of good friends that way. And that community really came through for them as well. So with those GoFundMe payments, they were able to make their house payment. It was helpful with some of these bills that they had lingering leftover from the cruise.

Rovner: So whats the takeaway here, other than that nothing that seems free is ever really free?

Sable-Smith: Yeah, right. Well, the takeaway is to be informed before you leave about a plan for how are you going to cover medical expenses when youre going traveling. I think this is something that a lot of people are going to be doing this summer, going on vacations. Ive got vacations planned. Whats your plan for covering medical expenses? And if youre leaving the country, if youre going on a cruise, someplace where your land-based American health insurance might not cover you, you should consider travel insurance.

And when youre considering travel insurance, they come in all sorts of varieties. So you want to make sure that theyre going to cover your particular cases. So some plans, for example, wont cover pre-existing conditions. Some plans wont cover care for risky activities like rock climbing. So you want to know what youre going to be doing during your trip, and you want to make sure when youre purchasing travel insurance to find a plan thats going to cover your particular needs.

Rovner: Very well explained. Bram Sable-Smith, thank you very much.

Sable-Smith: Always a pleasure.

Rovner: And now its time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device.  Alice, youve gone already. Sandhya, why dont you go next?

Raman: So my extra credit is Roanokes Requiem, and its an Air Mail from Clara Molot. And this is a really interesting piece. So at least 16 alumni from the classes of 2011 to 2019 of Roanoke have been diagnosed with cancer since 2010, which is a much higher rate when compared to the rate for 20-somethings in the U.S. and 15-times-higher mortality rate. And so the piece does some looking at some of the work thats being done to uncover why this is happening.

Rovner: Its quite a scary story. Rachel?

Cohrs Zhang: Yes. So the story I chose, it was co-published by ProPublica in Mississippi Today. The headline is This Mississippi Hospital Transfers Some Patients to Jail to Await Mental Health Treatment, by Isabelle Taft. And I mean, truly such a harrowing story of … obviously we know that theres capacity issues with mental health treatment, but the idea that patients would be involuntarily committed, go to a hospital, and then be transferred to a jail having committed no crime, having no recourse.

I mean, some of these detentions happened. It was like two months long where these patients who are already suffering are then thrown out of their comfortable environments into jail as they awaited county facilities to open up spots for them. And I think the story also did a good job of pointing out that other jurisdictions had found other solutions to this other than placing suffering people in jail. So yeah, it just felt like it was a really great classic example of investigative journalism thatll have an impact.

Rovner: Local investigative journalism not just investigative journalism which is really rare, yet it was a really good piece. Well, my extra credit this week is from Jessica Valenti, who writes a super-helpful newsletter called Abortion, Every Day. Usually its an aggregation of stories from around the country, but this week she also has her own exclusive [EXCLUSIVE: Health Data Breach at Americas Largest Crisis Pregnancy Org,] about how Heartbeat International, which runs the nations largest network of crisis pregnancy centers, is collecting and sharing private health data, including due dates, dates of last menstrual periods, addresses, and even family living arrangements.

Isnt this a violation of HIPAA, you may ask? Well, probably not, because HIPAA only applies to health care providers and insurers and the vast majority of crisis pregnancy centers dont deliver medical care. You dont need a medical license to give a pregnancy test or even do an ultrasound. Among other things, personal health data has been used for training sales staff, and until recently was readily available to anyone on the web without password protection. Its a pretty eye-opening story.

All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Stephanie Stapleton. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, Im at @jrovner. Sandhya?

Raman: @SandhyaWrites.

Rovner: Alice?

Ollstein: @AliceOllstein.

Rovner: Rachel?

Cohrs Zhang: @rachelcohrs.

Rovner: We will be back in your feed next week. Until then, be healthy. Credits Francis Ying Audio producer Stephanie Stapleton Editor

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