With the Midterms Ahead, What’s at Stake for Health Care?

JOEL BERVELL: My guest on this episode of The Dose is Julie Rovner, chief Washington correspondent at KFF Health News, a health policy organization focused on policy research, polling, and health journalism. Julie is here to share insights as we’re just a few days out from midterm elections in the U.S. And one thing we know from multiple polls, concerns about health care, costs, access, and quality of care are top of mind for many voters and even driving some folks to the polls in search of relief and candidates who might make a difference.

For 16 years, Julie was a health policy correspondent for NPR [National Public Radio], where she helped lead the network’s coverage of the passage and implementation of the Affordable Care Act. Julie is the author of the critically praised reference book, Health Care Politics and Policy A to Z, now in its third edition. Julie is also the host of the KFF weekly podcast, What the Health?

Julie Rovner, thank you so much for joining me for this conversation on The Dose.

JULIE ROVNER: Oh, it’s my pleasure.

JOEL BERVELL: Well, I want to start off by saying that right now, Democratic and Republican candidates across the country, from Pennsylvania and Michigan to New Jersey, Florida, Idaho, Iowa, they’re all making health care a major part of their campaigns. But while many are speaking to voters’ frustrations with the health care system, not all of them are offering concrete plans to address them. And in some states, voters aren’t just choosing candidates. They’re actually voting directly on ballot measures that could shape health care policy.

So, hoping to start with the contest that’s in Michigan right now. There’s Democratic Senate candidate Abdul El-Sayed. He’s a doctor, M.D. and Ph.D./a politician, and he looks to be in the lead right now over his Republican opponent, Mike Rogers. El-Sayed is promising some real reforms, mostly coverage expansion. But I’m curious, how realistic is that in Michigan if he beats Rogers and what would have to happen in Congress for those promises to become policy?

JULIE ROVNER: Well, of course, I mean, even if Abdul El-Sayed wins this race and enters the Senate, he’ll be a very junior member of a hundred, so nothing’s going to happen right away. And I think even he would say that nothing much is likely to happen while President Trump is still in office. I look at this campaign as being sort of the setup for what’s going to happen in and after 2028. This is similar to 2006 when there was a big fight actually at the time over the Children’s Health Insurance Program [CHIP].

That was sort of the big health issue — reauthorizing CHIP — which was just reaching the end of its first 10 years. And that helped set things up for what would become the fight of the Affordable Care Act after the 2008 election. So, I think we’re in very much the same place right now. We’re kind of setting the table for what’s going to be a big debate. But obviously, Abdul El-Sayed wrote a book about Medicare for All has made health care a big part of his pitch, both in the primary and now in the general election campaign.

JOEL BERVELL: Absolutely. And then if we look across the country to California, voters are considering Proposition 40. So, that would impose a one-time 5 percent wealth tax on billionaires, with about 90 percent of that revenue then going to health care. That’s potentially tens of billions of dollars, but what would that kind of investment actually translate into better health care access and quality for low-income Californians? And how much lasting change too can you create with that type of one-time source of funding?

JULIE ROVNER: Yeah, I think the idea of this is more to fill in some of the gaps that we’re seeing from federal cuts. I don’t think it’s intended to really be a long-term thing, although it’s interesting the fight over it sort of mirrors a lot of the fights over states trying to do their own versions of health reform. I mean, Gavin Newsom, the outgoing governor who’s opposing Proposition 40, says that one of the problems is that the billionaires who would be taxed can up and leave the state if they want to.

And we’ve seen that. We’ve seen a lot of rich people going to Texas and Florida and other states that have lower taxes. This is a problem with health reform too, is that when you’re trying to raise the money to pay for these things, unless it’s being done by the federal government, then people would have to leave the country, it’s pretty easy for people to just change state lines. And that’s one of the issues I think that may convince voters that this is probably not a long-term solution to health care funding issues.

JOEL BERVELL: Yeah. Does this set a precedent that means that states are increasingly going to have to find their own solutions to make up for those federal cuts that are being lost?

JULIE ROVNER: It is, but states really can’t to some extent. Most states, almost every state, I believe, has to have a balanced budget. States can’t run deficits like the federal government can. So, it’s really hard for states to be able to come up with the money. We’re going to be looking at our states cutting services mostly or cutting payments, which results in services being less available as a general rule.

I mean, we’re seeing more and more differences between the states based on what they’re able to afford, based on their basically reproductive health policies. We’ve seen states that have instituted abortion bans. We’ve seen doctors leave and medical students not want to go train there. It is doctors who may be married to other doctors or partnered with other doctors in other specialties who end up leaving, and it’s people who need maternity care and other types of care. So, we are seeing these differences magnified in access to health care across state lines.

JOEL BERVELL: Absolutely. And speaking of different states, in South Dakota, voters approved just recently four years ago, Medicaid expansion, but now they’re actually being asked to reconsider the conditions under which the state would continue that coverage. There’s a new ballot measure that would end the state’s Medicaid expansion requirement if federal funding falls below 90 percent. So, what does that tell us about the future of Medicaid, and as states face increasing health care costs and uncertainty, could we see more states begin to reconsider funding coverage that they’ve already expanded now?

JULIE ROVNER: Well, it’s kind of an odd case. Only three states have actually expanded Medicaid via a constitutional amendment. So, it’s just Oklahoma and Missouri and South Dakota. All of the other states did it by legislation. So, if the federal government were to lower that match, which is now 90 percent for the expansion population in Medicaid, those other states could just, their legislatures could say, yeah, we don’t have the money to do this and they could change it.

But in those three states, including South Dakota, they wrote it into their constitutions because the legislatures didn’t do it. I mean, that’s how they ended up doing it. So, South Dakota is just trying to say, we want to be in the same position as the other 37 states that did it by regular legislation, that if they decide to lower that federal contribution, then South Dakota could scale back its Medicaid expansion.

It’s not necessarily a vote for them to scale it back because Congress hasn’t scaled back its contribution yet. But the only places we would be likely to see something like this are in one of those three states that actually use the constitutional amendment to do the Medicaid expansion.

JOEL BERVELL: Okay, I see. And then in terms of, could we see those other states as well think about reconsidering that coverage? Do you think that’d be a likely thing to happen? Is this a unique case right now?

JULIE ROVNER: We haven’t yet, but Missouri is trying to reverse an abortion resolution. I mean, the Missouri legislature has already done the, let’s go back to the voters and see if they can change their minds about something they just voted on a couple of years ago.

JOEL BERVELL: I find that so fascinating that kind of whiplash that’s happening right now, and we’ll come back to Missouri in particular because I think that abortion issue, especially when it comes to the changes since Roe v. Wade in 2022, been interesting. But is this something common that’s happened in the past of something being voted on a ballot and then just a few years later being changed? Is it becoming increasingly something that we’re going to be seeing in the future when people don’t necessarily get their way around the first time?

JULIE ROVNER: We haven’t seen it very much in health care. I mean, I think you’ll see it in taxes, I think, on and off, but if you have a ballot measure, mostly it’s a ballot measure that fails, you’ll bring it back and try to pass it again. I think it’s less common when you see a ballot measure that’s passed and people come back and then try to repeal it, but I don’t think it’s unprecedented. It’s a really good question. I haven’t really looked at it, but what’s happening right now is pretty unusual.

JOEL BERVELL: Absolutely. I mean, another example of that, so meanwhile right now in Massachusetts, they’re considering a ballot measure that would roll back legal recreational marijuana sales while preserving medical marijuana access. But for years, the conversation has been about legalization, criminal justice, generating tax revenue. Now we’re hearing more concerns about marijuana’s effects on mental health and public safety.

I’m curious when it comes to marijuana and the legalization there, are we now beginning to also see a broader shift in how states may approach that and how should policymakers weigh those health concerns against the consequences of now restricting something else previously a legal market?

JULIE ROVNER: Well, it’s certainly hard to put the genie back in the bottle because now you have all of these legal businesses who are out selling recreational marijuana and people who are used to being able to buy it. I think a lot of states that maybe sort of rushed to this legalization because it was starting to spread and they wanted that, frankly, it’s one of those things that doesn’t cost states money, it makes states money.

And now, we’re seeing some new science on it and some of the ramifications were not necessarily what they had hoped for. I’ll be interested to see what Massachusetts voters do here, and even if this gets approved, how difficult it will be to roll it back. I think it’s a lot easier to legalize it than to illegalize it again. And obviously, they wouldn’t roll it back completely. It would be remaining legal for medical use and it would be decriminalized, I think, for up to an ounce.

JOEL BERVELL: I’m very curious as well. Like you said, genie has been out of the bottle. Can we put it back in? Will it even fit at this point?

And we touched on this a little bit, but four states now, Idaho, Nevada, Virginia, Missouri, have abortion-related measures on the ballot this November. That’s more than four years after the Supreme Court overturned Roe v. Wade in 2022.

At the same time, medication abortion and telehealth have fundamentally changed how people are accessing reproductive health care, including in the 20 states that have outright bans. I’m hoping that you can shed some light on how telehealth has changed the post-Roe landscape.

JULIE ROVNER: Well, I think telehealth changed it in a big way. I think that nobody was expecting really, because now in the states with bans, it remains relatively easy to get an abortion via telehealth from states where abortion not just remains legal, but where states have passed shield laws to protect providers who are providing these telehealth abortions to people in states with bans.

And this is obviously something that’s in the courts now. We’ve got a couple of different ways of addressing it. We’re waiting to see what the Trump administration does in terms of the FDA [Food and Drug Administration] changes that basically allowed the abortion pill mifepristone to be provided via telehealth, which was something that happened during the COVID pandemic, but that the Biden administration left in place. And so far, the Trump administration has also, much to the consternation of antiabortion forces who were hoping that that would be reversed much more quickly than it has been.

JOEL BERVELL: Mm-hmm. So, broad availability of medication abortion means that even in this post-Roe world, access in places is restricted, but access to abortion is available by prescription using telehealth.

JULIE ROVNER: Yeah, I would say we’ve seen abortion, the number of abortions actually go up, which also makes antiabortion forces extremely unhappy.

JOEL BERVELL: Mm-hmm, mm-hmm. Maternal health care in this country is a deepening crisis still, especially when it comes to women of color. What’s the relationship of the Roe ruling to this ongoing maternal health care crisis?

JULIE ROVNER: As I mentioned, I mean, one of the things that the striking down of Roe has done and the ability of states to ban abortion is that it’s left doctors in many states in sort of impossible situations where they’re afraid of basically not just having their licenses stripped, but being put in jail for providing necessary care for women with problem pregnancies, which are not rare.

I think that’s the one thing that people didn’t . . . I think a lot of the men who have been legislating this and adjudicating it in the courts did not appreciate how frequently pregnancies go wrong, and they do. And so, what we’re seeing is that in a lot of places, it’s more difficult for women who want to be pregnant to get the maternal care that they need because doctors are worried about practicing in states with bans because of the potential legal ramifications.

As I mentioned earlier, we are seeing medical students not want to go train in states with bans or do their residencies in states with bans. And this is not just ob/gyns, these are family practitioners and internists and people and emergency room clinicians. So, it is deepening the maternal health crisis. It’s really sort of making things go, I think, in the opposite direction that the pronatalist forces of people who want there to be more babies have hoped, and it really is a problem.

JOEL BERVELL: And I think what’s happening in Idaho, I think really illustrates this much broader problem with our health care system too. If you think about Idaho right now, there’s been so many ob/gyns that have left. Hospitals are closing labor and delivery units. There’s growing concern right now about access to maternity care, and we’re seeing how policies can affect not just whether people have coverage, but whether there’s actually even doctors and hospitals available to care for them now.

I think what’s interesting is this is happening at a time when health care is becoming increasingly unaffordable, even for millions of Americans who actually do have insurance. I think across both parties, there’s acknowledgement that our health care system needs reform. We’ve heard proposals like Medicare for All, mostly from Democrats, but we’re still a long way from anything resembling universal health care.

Do you think we’re getting any closer to fundamental health care reform or are we going to continue seeing smaller incremental changes? And how is that debate shaping electoral politics this time around?

JULIE ROVNER: I think we’re approaching another major debate over health care. I think one of the big differences between now and the last debate that we had in 2010, and even the one before that that I also covered in the Clinton administration, 1993 and 1994, is that sort of the watchword among those who wanted to fix the system was to not disrupt the coverage of the haves, of the people who were happy with their care. There are fewer and fewer people right now, I think, who are happy with their care.

Even if you’re wealthy, health care has just gotten astronomically expensive. It’s difficult to navigate. I mean, even if you have a concierge doctor, unless you’re one of those super, super rich people who can go to the private suites up on the top floor of some of these hospitals, you’re going to get caught in the maw of our dysfunctional health care system.

I think everybody who gets health care has been caught in the maw of our dysfunctional health care system, and I think there’s an increasing demand to change it. What are we going to change it to? Who’s going to pay for it? How are we going to pay for it? Those are things that have not yet been worked out. But I do think we are on the cusp of another major debate, the first one I think since the passage of the Affordable Care Act.

JOEL BERVELL: I can feel the debate brewing already.

JULIE ROVNER: All the signs are there.

JOEL BERVELL: All the signs are there. I mean, like you said, there’s been these kind of ebbs and flows in the conversation, but right now people are, and I see this every day in the hospital, people are increasingly delaying the time that they go to the hospital, are coming in sicker right now because they said, “Hey, I can’t afford it. I don’t have insurance or my insurance for some reason isn’t going to cover this right now.”

And so, yeah, we’re definitely coming to a head right now. I want to shift from health care policy to the people actually delivering care and some adjacent issues voters won’t necessarily see on the ballots. I know we’re both concerned, obviously, we’re talking about what’s happening more broadly in medicine, starting with research funding from the federal level, student loan caps, even issues with residency right now. I’m hoping if we can start with the research. I’d love to get your take on how the current environment is impacting patient care.

JULIE ROVNER: Well, it’s certainly impacting researchers. We have seen basically this uncertainty. I mean, nobody ever thought that the National Institutes of Health was the best-functioning bureaucracy in the federal government, but it did. It fairly efficiently distributed 40 some billion dollars a year to the research enterprise, to researchers, to universities, to hospitals, to labs around the country and to some extent around the world.

And that’s been really disrupted since this Trump administration came in, not so much in the first Trump administration, but very much in this one, between the early retirements and the forced layoffs and the let us examine, let us look politically at every single grant to make sure it doesn’t have anything to do with diversity, equity, or inclusion and let’s cut off grants in the middle or let’s pay out grants in advance.

I mean, just everything has been sort of turned upside down and we’ve seen researchers have to close labs. We’ve seen Ph.D. programs curtailed, if not ended. We’ve seen students and researchers going to other countries and other countries are like, “Oh great, we can lure these really cool researchers here to Europe or to Canada or to China.” And that really is happening.

It’s not a full-fledged exodus yet, but I remain surprised that Congress kind of let this happen because the NIH and the research establishment has been very bipartisan over all of the 40 years that I’ve been covering this because it’s a huge economic engine for lots of states, including a lot of very red states with a lot of Republicans who very jealously guard the funding that comes in because it’s such an economic engine for their state. And many Democrats and a lot of Republicans are finding out just right now what’s going on and starting to maybe regret some of giving up some of their power to this administration.

JOEL BERVELL: Yeah. I mean, it’s hard not to start talking back when you start hearing that cancer funding’s being cut or that when you think about specific disease that are overlooked, that for some reason a program was cut just because it had the word diversity in it, right?

JULIE ROVNER: Or gender.

JOEL BERVELL: Or gender, exactly. Even from my own perspective, I think of it as when I went through medical school, I had to take out nearly, I think, $300,000 in loans, yet the caps now for medical students and many other health professionals are $200,000, meaning that if you are someone that can’t even afford to go to school, you likely won’t be able to have enough federal loan funding that you can grab and you have to go towards private funding, which is then going to send you into even more debt. There’s just so many different implications right now, as you mentioned.

JULIE ROVNER: Right. And immigration is a piece of this too, with difficulties getting visas. We have a lot of health care professionals who come from other countries. There’s been issues over the years about us coaching health care workers, particularly doctors and nurses from countries that may need them more, but now we need these people to fill out our residency programs and the nurses in our hospitals and nursing homes, and the administration’s made it much more difficult to get visas.

So, we’re looking at a shortage plus the crackdown on immigration for people who’ve been here and working legally at some of these lower-level jobs, particularly a lot of Haitian immigrants who work in nursing homes and in hospitals who are either going back on their own or being deported back. I mean, we’re looking at a potential labor crisis in health care.

JOEL BERVELL: On top of one that we have already that we know is coming in the future.

JULIE ROVNER: Right, and on top of the one that we’re creating by making it harder to get a medical education and by cutting all of the funding to a lot of these teaching centers.

JOEL BERVELL: Absolutely. Well, as we start to come to the end of the conversation, I want to look ahead. There was a recent New York Times report that said, “Top House Democrats are planning a shock-and-awe legislative sprint to demonstrate within hours of taking power that they’re passing bills to deliver on their promises, including restoring health care subsidies and Medicaid resources.” If that scenario plays out, what do you think the most realistic and consequential moves might be?

JULIE ROVNER: Well, I think a lot of this will be making statements. I’ve read there’s a hundred-page Democratic memo from the House Democrats to their leaders, likely incoming Speaker [Hakeem] Jeffries, about things that they should do in the first hundred hours and things that they should do in the first hundred days and things that they should do as the session plays out.

Now, obviously, even if the Democrats take the House back, President Trump will still be president. The Senate may or may not flip to Democratic majority, but it seems nobody is predicting that they’re going to get a 60-vote supermajority, or even more important, a 67-vote, what they would need to override a veto. So, the idea of actually restoring the Medicaid cuts and restoring the subsidies is unlikely, at least for the next two years, but they are likely to vote for it to make their stand and say, “This is what we believe, this is what we want, this is what we think the voters are asking us to do.”

So, I think we’ll see a lot of position-taking, staking out their claims and saying, “If you give us the power to actually do this, this is what we’ll do.” That’s what I would expect.

I would also expect a lot more investigations and calling up of some of these people in the administration to try and explain some of the things that they have done that in my many years as being a reporter covering Capitol Hill, things that I thought were Congress’s responsibility that the administration didn’t have the authority to do, and things that, frankly, Congress has said the administration said rather specifically the administration doesn’t have authority to do, but the administration has done anyway.

So, I would expect there to be a lot more of rounding people up, dragging them up to Capitol Hill, and asking them pointed questions.

JOEL BERVELL: Mm-hmm. We’ll have results on November 3rd and then immediately begin looking ahead to 2028. I’m curious what you see as the most consequential questions for voters to be asking themselves and the candidates as their concerns roll into the next general election.

JULIE ROVNER: I think it’s: What kind of health system do we want to have? Right now, our health system has just sort of run on its own. Congress has managed it and Congress and the president has managed to steer it in one direction or another, but it really sort of continues to become more expensive and less efficient and less functional, less user-friendly, if you will.

I mean, we’ve done a really good job on the science side and on the research side and advancing new treatments for things, which is awesome and great. Although as we said, that could go away too if other countries managed to take away our research establishment. But I think everybody is pretty unhappy with the way the health care system functions now, including people who are in it, including . . . I mean, I’m including doctors and nurses and even people who run hospitals and medical schools and everything.

Everybody is pretty unhappy. That’s just about where we were in 2006 when everybody was unhappy. I like to say we got the Affordable Care Act because all of the stakeholders sued for peace. We’re getting there again. In 1993 and 1994, we were in the same place and didn’t manage to get anything accomplished. In 2010, they barely managed to get something accomplished. So, in 2029, I’ll be interested to see.

JOEL BERVELL: Well, fingers crossed, we can make it happen this time.

Julie, thank you so much for joining me on The Dose and helping us understand what’s really at stake for health care in this election. So, as we head into the midterms, I’m hoping this conversation encourages everyone to look beyond campaign promises and think about what these policies actually mean for their health and their communities. Julie, thank you again. And to everyone listening, thanks for tuning in to The Dose.

JULIE ROVNER: Thank you.

JOEL BERVELL: This episode of The Dose was produced by Jodi Becker, Richard Shapiro, and Naomi Leibowitz. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There, you’ll be able to learn more about today’s episode and explore other resources. That’s it for The Dose. I’m Dr. Joel Bervell, and thank you for listening.