Dan Gorenstein: Happy New Year and welcome back to Tradeoffs.

We’re kicking it off by looking at major health policy news that we’re expecting this year.

Millions of people could end up uninsured as state Medicaid programs restart eligibility checks for the first time since the pandemic hit.

State lawmakers are pursuing new abortion laws. Some to restrict access…others that expand it.

Finally, buckle up for a lot of behind the scenes work on prescription drugs.

All in all, a busy health care year.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

DG: Our look ahead starts with the challenges state Medicaid programs face with enrollment. Since COVID, states have avoided kicking people off the programs, helping folks get through the emergency. But now, Congress is directing states to run three years of backlogged checks on 90 million people in just about one year.

Cindy Mann: I think it will be very disruptive.

DG: Cindy Mann would know. As a partner with legal and consulting firm Manatt Health, she’s talking to state officials about how to cleanly pull off this feat.

Experts project up to one in five folks on Medicaid, nearly 18 million people, could be dropped, either because they’ve moved or make too much money.

Most of them, says Cindy, will find other coverage through work or the Obamacare marketplaces.

But Cindy says some won’t.

CM: The concern really is whether people will lose coverage and…become uninsured, even though they are eligible for Medicaid or for marketplace coverage.

DG: Cindy, can you explain, if people are eligible and states are checking their rolls – how could so many people end up without insurance?

CM: [So] states are supposed to check available data sources and see if people remain eligible. If a state doesn’t have a robust system they will rely more on paperwork.

DG: But I know some state Medicaid programs still do rely on paperwork – letters, notices sent through the mail…right?

CM: Yes, and paperwork has always led to coverage losses among eligible people. That will be more true now because people have moved during the pandemic. Many states simply don’t have updated addresses or the staff resources to follow up. And this is really the critical point if a state sends paperwork through the mail and the mail is returned undelivered. The state can terminate coverage.

DG: This has happened before. Pre-pandemic in Tennessee, officials sent out paperwork to families to renew coverage. It was a disaster. More than 200,000 children lost coverage. Many families didn’t even know and ended up with major medical bills.

So, Cindy, we’ve seen this movie before. What does the evidence tell us about what happens when people lose their coverage?

CM: Well, history from studies is that people who lack health insurance avoid care. Delayed care can have serious health consequences. It can also lead to other issues – medical debt, credit issues, even trouble getting jobs or renting an apartment. And for the hospitals or the clinics that end up treating people without coverage, coverage gaps can result in greater uncompensated care and financial strain for those providers.

DG: When it’s all said and done, estimates from the Urban Institute and Robert Wood Johnson Foundation are that about four million adults and kids will end up without insurance after the eligibility checks are completed in mid- 2024.

DG: While some will lose Medicaid this year, other people, for sure in South Dakota, are in line to get coverage.

39 states and the District of Columbia have already expanded their program to include people making slightly more than the federal poverty level $18,000 a year.

There are also signs lawmakers in a few of the 11 remaining holdout states like North Carolina, Kansas and Wyoming are considering the expansion question.

Cindy I’m curious why now? States have had the chance to do this for a decade.

CM: We’ve seen over the years a steady not big blast, but a steady progression of states moving to expansion. And those are mostly the purple and the red states. Let’s talk about the 11 states that still haven’t expanded. At some point, the pros just become too overwhelming. It’s very popular with voters. It has prevailed in every state for which there was a ballot question…and in the COVID legislation there was some additional financial incentives that were provided to states.

DG: It’s a short term sweetener that’s worth hundreds of millions or billions of dollars to each state depending on its size.

For folks keeping score at home, South Dakota becomes the seventh red state where voters by ballot measure have said they want people who make just a little more than minimum wage to have basic health insurance.

Cindy, to you are South Dakota and these other states a signal that this is no longer purely political calculation?

CM: Well, you know, Medicaid is a big program. People know, people know, have neighbors, have friends, have relatives. They have cancer. They can’t get care. So, it’s also become real for people. They’re not focusing on, do I like Obamacare? Do I not like Obamacare? They’re presented with the choices. In Idaho, in South Dakota, in Nebraska, in Missouri. Do we want to make sure all our neighbors have access to health care?

DG: An opinion, for some, that has evolved dramatically over the last decade as both Obamacare and the pandemic have put Medicaid in a more normal, less stigmatized light.

Cindy, thanks for taking the time to talk to us on Tradeoffs.

CM: I appreciate you having me.

DG: Moving to another health care topic that will be a focus for state lawmakers during 2023. Abortion.

In this new Post Roe era, states have been busy. The country’s divided. About half of states are trying to seal off access to abortion care. Each action – a new brick in the wall to limit access. And the other half of states, along with the Biden Administration, want to make it easier to get abortions. Get around those bricks.

Elizabeth Nash with the Guttmacher Institute, an abortion rights health research group, has been following all this brick laying.

Elizabeth Nash: I track legislation, regulation, judicial action in all 50 states around reproductive health.

DG: Elizabeth joined me to survey the landscape and talk about what she’s expecting this year through four numbers.

The first is 19. That’s the current number of states where it’s really hard for women to get an abortion. Either because its illegal, barriers are high or all the providers have left.

EN: When we’re thinking about 2023, there are still states that haven’t banned abortion that we’re expecting to. So, we’re thinking about states like Nebraska, Ohio, Florida.

DG: Elizabeth has tracked state abortion legislation for 24 years, and what interests her now when it comes to red states is that lawmakers must actually craft actionable policies.

As long as Roe guaranteed a constitutional right to care states could pass extreme, but symbolic bills. Now what they pass will actually take effect and voters are going to hold them accountable.

That’s why Elizabeth is curious whether legislatures will pass total bans or make exceptions, like for the health of the mother.

EN: The legislators have a base. A lot of that base has said we want an abortion ban without exceptions. Yet the vast majority of the American public supports abortion rights. Legislators kind of, you know, thread that needle through exceptions. And how many exceptions could they add and not upset their base.

DG: Elizabeth says conservative state lawmakers are trying to fill any holes in these brick walls that help women to still get abortions. One area of focus is medication abortions done at home. Elizabeth anticipates red states will try to make it harder for people to get those meds.

Which brings us to our next number, 18. Eighteen states that are limiting how patients can use telemedicine to complete medication abortions.

EN: Before Roe fell and Dobbs, you know, overturned abortion rights, over half of abortions were through medication. So, of course, if you want to restrict access to care, then you would try to limit access to medication abortion. And so, we’re anticipating states to pass to laws like banning the mailing of pills, requiring the manufacturers and distributors to be licensed in their state.

DG: As fast as red states are building up the wall, blue states and the federal government are working to dismantle it.

NEWS CLIP: CVS and Walgreens two of the biggest US pharmacy chains say they plan to offer abortion pills…

DG: The Food and Drug Administration has recently determined patients can now use telehealth to get these prescriptions, and pick them up at retail pharmacies or get them sent through the mail

Even with the telehealth option, people will certainly continue to travel this year for abortion – pills or procedures.

And that leads to our third number, $2,000. That’s how much aid groups told the New York Times they’re spending for patients to travel for abortion care. It’s double what it used to cost because women now must go further.

So, Elizabeth expects anti-abortion lawmakers to go after the businesses and aid groups, often called abortion funds, that pay travel costs.

EN: They probably won’t pass travel bans, but they will try to limit how businesses can provide abortion care and support patients who need abortion care or how the abortion funds can operate.

DG: Texas lawmakers have already filed a bill to eliminate tax breaks for the businesses that do this.

At the same time, the coastal and midwestern states that host these traveling patients passed a record number of abortion protections last year. And that brings us to our final number – 77.

EN: We’re really talking about a couple of things. Helping the abortion clinics expand capacity. Right. So, infrastructure and staffing, for example. And establishing funding to help people pay for abortions. There are states that are pouring millions of dollars into these funds. And this is really the first time in decades that we’ve seen state dollars being used to really pay for abortion.

DG: In your mind Elizabeth, I’m curious what do you think is the most common bill that you will see passed in states that want to protect abortion access in 2023.

EN: I think probably, the most popular bill will be something around…what have been called shield laws. And these are legal protections for mostly abortion providers. But the idea is if a person provides an abortion, they are legally protected in that state…We’re not going help you with your investigation, we will not extradite the provider to you. We will not participate in a summons. Those sorts of things. So, putting that sort of legal bubble wrap around providers.

DG: The other thing Elizabeth’s on the lookout for is evidence on how red state bans and restrictions affect the overall health of women.

Elizabeth, thanks.

EN: For sure, it was a pleasure.

DG: After the break the price of prescription drugs. Medicare starts to flex its new muscles. And another new controversial Alzheimer’s drug.

MIDROLL

DG: Welcome back. We’re talking today about top health policy issues to watch in 2023. Before the break we talked about what will likely consume states this year.

Now we turn to the federal level. Where there’s a lot of action with prescription drugs. To walk us through it we talked with Rachel Cohrs.

Rachel Cohrs: I cover Congress, public health and the business of health care in Washington.

DG: Rachel is a Washington Correspondent for STAT News.

RC: I think the theme of 2023 is a lot of policy making behind the scenes to shape what patients are actually going to see a couple of years down the road.

DG: One of the best examples is the Food and Drug Administration’s greenlighting of the Alzheimer’s drug Leqembi.

The big question Rachel, will Medicare pay for this?

RC: So, usually when the FDA approves a drug. Medicare pays for it. But that hasn’t been the case with these drugs because they’re so new. And there’s a really strange process that Medicare has been using for these Alzheimer’s drugs and deciding who gets them or in what situations are going to pay for them.

DG: A bit of background. Because Medicare officials worried another Alzheimer’s drug – named Aduhelm – did little to improve health and carried real safety risks, the agency decided to limit coverage to only those people included in clinical trials for Aduhelm.

That restriction on payments applies to all similar Alzheimer’s drugs, including this new one Leqembi.

So, Rachel, do you think Medicare, really officials at the Centers for Medicare and Medicaid Services, could change its mind here?

RC: I think there’s a good chance that we could see a reconsideration here…In the data that we’ve seen so far, there is a more convincing case that Leqembi has a clinical benefit for patients…there’s going to be pressure on CMS to make a decision based on this new data, not cover this new drug based on old data.

DG: It’s not clear when Medicare officials will make this decision. But officials have signaled they’re open to it. If the agency does change its policy, Rachel, could this impact other Alzheimer’s drugs that are in the pipeline?

RC: The stakes are very high. We are expecting another drug from Eli Lilly that’s kind of similar to these drugs later this year….Drugmakers really need a win in the Alzheimer’s space. And if this drug gets fully approved, shows some clinical benefit for patients and is able to get some substantial coverage…. I think that would be a very good signal for other drugs in the pipeline.

DG: Sticking with your 2023 theme, Rachel, of behind the scenes prescription drug regulation that will have an impact down the road – Medicare is staffing up to start using its new power to negotiate drug prices. By this September, the agency will reveal the first 10 drugs it’s choosing to negotiate prices on. And while those prices won’t kick in until 2026, Rachel, this is a whole new world.

What question fascinates you most as this all gets underway?

RC: I think I am most interested to see what drugmaker’s reaction is going to be when there’s actually a list, because it’s been Wall Street’s favorite parlor game since the Inflation Reduction Act passed to guess which drugs might be on this list. But once we actually have something on paper, I think it all becomes very real.

DG: Very real. What does that mean?

RC: People that I have spoken with expect some legal action. This is a big hit to the industry. I think it’s a long shot for it to be successful under some of the arguments that I’ve seen so far as to whether this program is constitutional or not…. [but] I wouldn’t be surprised in the slightest to see industry take an aggressive stance in court.

DG: Rachel when you pause to take all this in. There’s really a lot happening here right now. Medicare negotiating drug prices. You’ve got the diabetic seniors now paying a maximum of $35 bucks a month for their insulin.

Regulators looking hard at pharmacy middlemen. You’ve even got billionaire Mark Cuban’s company built on a transparent drug pricing model now expanding.

Does it seem to you, like the nation is at some kind of inflection point…and consumers will start to see lower drug prices at the pharmacy counter?

RC: I wouldn’t say that point is coming in 2023. I think what we’re seeing right now is some scrambling behind the scenes to start to make some of this stuff happen. The shift that we’ve seen on drug pricing in the United States has really been 20 years in the making, if not longer. And I think in 2022, Democrats were able to find that magic goldilocks moment where they were able to get some really meaningful legislation through. And I think looking forward, the dam has kind of broken…There’s going to be a huge push by the executive branch to operationalize the policy that lawmakers have passed. And I think this is such an exciting moment.

DG: Even though no one is expecting major health policy homeruns in 2023, the year is shaping up to have some incredibly consequential changes that will impact lots of people. And we’ll be watching.

DG: Rachel, thanks for taking the time to talk to us on Tradeoffs.

RC: Absolutely. Thanks for having me.

DG: I’m Dan Gorenstein, this is Tradeoffs.