Who Is Running Iran, and How Doctors Cashed In on a Consumer Protection Law

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0:35Meaghan Tobin:From the New York Times, it's the headlines. I'm Tracy Mumford. Today's Thursday, April 23rd. Here's what we're covering.

0:47Meaghan Tobin:One of the key questions swirling as the U.S. attempts to negotiate an end to the war in Iran is, who is really running Iran? The new supreme leader, Ayatollah Mojtah Barhamenei, was wounded in airstrikes at the start of the war, which killed his father, the previous supreme leader, and he's been in hiding while he recovers. He still has not been seen in public since he took over, and that has fed into uncertainty about the country's leadership. To try and trace Iran's new power structure, the Times spoke with senior Iranian officials, members of the Islamic Revolutionary Guards Corps, and others familiar with the country's inner workings.

1:26Meaghan Tobin:Several officials told The Times that Khamenei's injuries are severe. He's had surgery on his hand and leg, and his face and lips were badly burned, making it difficult for him to speak. They say he's sharp and engaged, but he hasn't released a video or audio message because he doesn't want to appear weak in his first public address. Also, because of fears he could be targeted again, Messages to him are handwritten, sealed in envelopes, and relayed via a human chain from one courier to the next. They travel on highways and back roads, in cars and on motorcycles, until they reach his hideout. His responses go back the same way.

2:05Meaghan Tobin:That combination of his injuries and the challenge of reaching him has led Hominay to delegate decision-making to commanders in the Revolutionary Guards Corps. It's essentially left the hardline military calling the shots. Those generals were the ones who came up with the strategy of closing the Strait of Hormuz and of striking neighboring countries in the Gulf. They were the ones who agreed to the temporary ceasefire and who decided to pull the plug on more peace talks this week because they felt President Trump was trying to pressure Iran to surrender. Overall, Iranian officials tell The Times the generals are feeling confident in this moment, like they've been able to prevent the U.S.

2:47Meaghan Tobin:and Israel from toppling the regime, and that the country still has leverage in the conflict.

2:57Meaghan Tobin:Now, a few more quick updates on the war.

2:59Sarah Kliff:I can confirm that there was an attack against the Krikal cargo ship.

3:04Meaghan Tobin:Yesterday, there were reports that Iran fired on and seized two ships in the Strait of Hormuz as it tightens its stranglehold on the waterway. Before the war, more than 130 vessels went through the strait every day, and there was hope the ceasefire would get those numbers back up. But with Iran renewing its attacks, traffic in the strait has pretty much come to a halt. Also,

3:29Farnaz Fassihi:I was approached by more than 10 of the most vulnerable and poorest countries in terms of energy, and they ask us to extend that sanction.

3:39Meaghan Tobin:Treasury Secretary Scott Besant doubled down yesterday on the Trump administration's decision to extend a sanctions exemption on Russian oil as a way of trying to ease the energy crisis sparked by the war. Russian oil had previously been blacklisted because of the war in Ukraine, But the Treasury Department said it wants to ensure, quote, all oil is available to those who need it. Besant first paused the sanctions in March, saying it was temporary. According to one analysis, that move caused Russian oil revenues to surge, nearly doubling last month and providing a financial lifeline for the Kremlin.

4:17Meaghan Tobin:And last update on the war. President Trump is staring down a looming deadline for U.S. military operations in Iran. By law, the president can wage war for 60 days without getting congressional approval. But at that point, lawmakers need to authorize it to continue. For Trump, that date is May 1st, next Friday. While Republicans in Congress have largely backed his campaign so far, some have signaled they won't continue that support after that deadline. If lawmakers don't authorize the war, Trump will either have to pull back immediately or give himself a one-time 30-day extension that would be used to safely withdraw U.S.

4:57Meaghan Tobin:forces. There's also a chance he could push past the deadline altogether, though, which would not be unprecedented. In 2011, President Obama continued military operations in Libya past 60 days, which prompted bipartisan backlash.

5:19Meaghan Tobin:A couple of years ago, Republican and Democratic lawmakers banded together to take on one of the most costly and frustrating parts of medical care. Surprise billing. Every year, millions of Americans who unexpectedly saw a doctor out of network, often in emergency rooms, would be hit with far higher bills than what their health plans normally covered. So Congress passed the No Surprises Act, which barred out-of-network doctors from billing patients directly. Instead, physicians can take their claim to a government-approved arbitrator to try and make a case for how much they think the patient's insurance company should pay them.

5:56Sapna Maheshwari:This new law, by all accounts, did do a lot to solve the problem of surprise medical bills, so patients are no longer in the middle of these billing disputes between insurers and doctors. But what we found is that doctors have been flooding this new arbitration system with millions of claims and getting paid rates much, much higher than they did in the past.

6:17Meaghan Tobin:Sarah Cliff is an investigative health reporter at The Times who's been looking into how the new system works.

6:22Sapna Maheshwari:Each side submits what they think is a fair price for the medical care rendered. They submit some arguments and then the arbitrator selects one of them. There is no middle ground. Somebody is going to win. And once the arbitrator picks someone, that is the final decision.

6:38Meaghan Tobin:There is no route to appeal.

6:40Sapna Maheshwari:Sometimes the numbers that insurers and doctors bring to the table are wildly different. There was one case that we looked at where the insurance company offered$2 ,600 for a test of blood flow to the brain. The doctor asked for$330 ,000, and they won that dispute and got that money. We saw this happening repeatedly in this massive data set that had millions of claims. We saw gynecologists who were getting 600 times the normal rates for placing a contraceptive called an IUD. And the doctors are overwhelmingly winning these disputes. We found that in 88 % of the cases, they win, and they're often winning hundreds of times of what they used to get paid before this law passed.

7:27Sapna Maheshwari:One of the mysteries is why the results are so lopsided. It surprised the lawmakers who wrote this law when we asked them about it. There are a few theories. One is that the arbitrators are paid on a per-case basis, so they have an incentive to render decisions favorable to doctors, to have doctors continue bringing them disputes. Another is that doctors are just viewed more positively by the public than insurance plans are, and maybe arbitrators have those same kind of biases that the general public does.

7:55Meaghan Tobin:Sarah says as a result of the huge new payouts doctors are getting, some insurance companies say they're having to raise premiums for patients, essentially passing along the cost of this new arbitration system.

8:14Meaghan Tobin:A study out this week found that after a national suicide prevention effort went into effect a few years ago, the rate of youth suicides in the U.S. dropped.

8:24Robert Jimison:Three numbers helped me find the help I needed.

8:27Meaghan Tobin:988 Suicide and Crisis Lifeline. The idea was to basically create the 911 of mental health, taking a 10-digit hotline number and simplifying it to just 988. Lawmakers also put more than a billion dollars towards supporting crisis centers. Now, researchers have found that in the first two and a half years after the hotline launched, the rate of suicides among young people was 11 percent below projections. There could be other factors driving the drop. For one thing, the hotline launched right as the country was coming out of the depths of the pandemic. But to try and get a true sense of the hotline's impact, the study compared suicide rates between states.

9:07Meaghan Tobin:It found that in places that had the biggest surge in calls to 988, youth suicide rates dropped significantly more than places that saw a smaller uptick in calls. Overall, since 988 launched, it's fielded more than 25 million calls, texts, and online chats, according to the Department of Health and Human Services. The agency has asked Congress for another half billion dollars to fund the program for next year.

9:37Meaghan Tobin:And finally.

9:39Margot Sanger-Katz:I feel like I see them everywhere I look.

9:41Farnaz Fassihi:It's so fun to say, too, right?

9:43Margot Sanger-Katz:Labubu.

9:43Meaghan Tobin:The LaBooBoo craze over the last few years has meant that the furry little monster dolls have been everywhere, from backpack keychains to high-fashion runways.

9:52Ana Swanson:We're talking lines through the mall, wrapped around the block, no sleep, no shame.

9:56Meaghan Tobin:People have waited hours to buy them. Some of them go for thousands and thousands of dollars. But now, some of the toys have been found to contain cotton that's actually banned in the U.S. because of concerns about forced labor. The U.S. government has restricted imports of cotton from the Xinjiang region of China, citing human rights violations after China carried out a vast crackdown on ethnic minorities there, including detaining people in camps. A nonprofit group that advocates on behalf of Uyghurs, one of those minority groups, commissioned a test of a libubu last year and found the sample contained cotton grown in Xinjiang.

10:36Meaghan Tobin:The Times then commissioned its own testing, which confirmed that some Libuboos have cotton from that region. There could be serious consequences for Popmart, the Chinese company that sells Libuboos. Companies found to have violated the U.S. import restrictions could have all their products banned. A spokeswoman for Popmart told the Times it would conduct an investigation into its supply chains and that the company held itself and its suppliers to the highest standards. One U.S. lawmaker who co-chairs a congressional commission on China said, quote, Pop Mart should prove that all of its dolls in the United States are slave labor free.

11:17Meaghan Tobin:Those are the headlines. Today on The Daily, a look at what the recent monopoly case over Live Nation could mean for concert goers. You can find that in the New York Times app or wherever you get your podcasts. I'm Tracy Mumford. We'll be back tomorrow with the latest and the Friday News Quiz.

11:39Ana Swanson:This podcast is supported by USA for UNHCR, a dire new report from the UN Refugee Agency. As the numbers of people fleeing war escalate, funding shortages have left them without the basics to survive. The impact is devastating. Families who've lost everything now struggle in overcrowded camps without food, water or shelter. Your gift can rush clean water, hygiene kits, and shelter materials within 72 hours of an emergency. Donate at unrefugees.org slash headlines.