New Delhi- The Medical Counselling Committee (MCC) is likely to begin the National Eligibility and Entrance Test-Undergraduate (NEET UG) counselling process for admission to 15% All India Quota (AIQ) seats in medical and dental colleges in India soon.

The NEET UG counselling process is likely to begin from July 1, 2025. However, MCC is yet to announce the complete details and schedule for NEET UG 2025 Counselling on the official website.

Also Read: Delhi HC upholds MCC's decision on SC children, women seats in NEET counselling

STEPS TO REGISTER FOR NEET UG 2025 COUNSELLING

STEP 1- Visit the official website of mcc.

STEP 2- Click on ‘UG Medical Counselling’.

STEP 3- Select ‘New Registration’.

STEP 4- Enter NEET 2025 Roll Number, Application Number, and Other Details.

STEP 5- Generate Login Credentials (ID & Password).

STEP 6- Fill in Personal & Academic Information.

STEP 7- Pay the Counselling Fee (as per category).

STEP 8- Save and Proceed to choice filling (when enabled). 

DOCUMENTS

Students are required to keep their following documents ready to participate in the counselling process-

1 Valid ID Proof i.e. Aadhaar/ PAN Card/ Driving License/ Passport.

2 Passport-size photographs.

3 Caste Certificate (if applicable).

4 NEET UG Scorecard 2025.

5 Class 12th certificate and mark sheet.

6 Class 10th certificate and mark sheet.

7 Provisional Allotment Letter.

8 Any other document demanded by the authorities.

9 Debit/ Credit card or Net Banking for payment of the counselling fee.

FEES

Different states have their own fee structure for NEET UG counselling. Below are some state-wise details-

S.NO

• SATE

• FEES

1

• Uttar Pradesh NEET Counselling Registration

• ₹2,000 (non-refundable)

2

• Uttar Pradesh NEET Security Deposit

• ₹30,000 (refundable)

3

• West Bengal NEET Counselling Fees

• ₹2,000 (General)

• ₹1,500 (SC/ST/OBC/PwD)

4

• Kerala NEET Counselling Fees

• ₹500 (General)

• ₹200 (SC/OBC)

MCC will conduct NEET UG counselling 2025 in four rounds to fill medical seats for 15% All India Quota (AIQ) seats, 100% MBBS, BDS seats of Banaras Hindu University, 100% MBBS seats in AIIMS, JIPMER, AMU and 15% AIQ seats in DU, IP University, VMMC and ABVIMS.

Also Read: Over 12 Lakh Qualify NEET 2025, But Only 1.18 Lakh MBBS Seats Up for Grabs

New Delhi: A recent national survey discussed for the first time the landscape of family medicine in India, especially highlighting the gap between the required number of family physicians and the lack of facilities to provide training to them.

While the Planning Commission for the 12th plan (2012-2017) estimated the need for 15,000 new family physicians per year by 2030, the recent survey titled "The landscape of family medicine in India- A cross-sectional survey study" revealed that the country does not have the required infrastructure of training to reach that goal.

This survey was conducted across 28 States and Union Territories, and it collected responses from a total of 272 family physicians. Released before the National Doctors' Day 2025, themed "Behind the Mask: Caring for Caregivers", the survey aimed to understand the implementation of Family Medicine in India to date and the potential ways in which Family Medicine may contribute to a stronger primary healthcare system.

The key findings from the survey are as follows-

Most Family Physicians from three Southern States:

In the survey, it was discovered that most Family Medicine training programs exist in three southern states- Tamil Nadu, Karnataka, and Kerala and inherently, most family physician respondents who participated in the survey were found to be working in these three states.

As per the survey, these states were the first to introduce Family Medicine training. "However, with the introduction of blended-type programs, States and institutions that are leaders in FM training support the training of family physicians across several other states. This is highlighted when almost all our respondents who completed a distance or blended type program were trained by a single institution in Tamil Nadu, CMC Vellore. However, only one-fifth of blended program learners completed their hands-on learning in Tamil Nadu. Most learners completed their hands-on training in 24 other States in India, so we see a pan-India spread where family physicians work," mentioned the survey.

Also Read: Doctors call for inclusion of 'training as family physicians' in MBBS course

Lack of recognised training programmes:

The survey found that either the Family Physicians received recognised Full-time residency training via DNB or MD in Family Medicine or they were trained via a non-recognised Part-time route. More than one-third of the family physicians who responded in the survey were trained via the second option.

This revealed the lack of required infrastructure to train willing candidates in Family Medicine. While the survey acknowledged that the DNB full-time training programs are the backbone of the recognised programs that recruit and train medical school graduates, such training programs and even MD programs are limited to date, and they have only a few training spots.

According to the survey, only thirty-nine accredited private institutes out of 276 offered the DNB-FM program as of 2023, and only 110 DNB-FM training spots were available nationally. 

Regarding the MD-FM graduates, the survey revealed that none of the responses were from MD-FM graduates. In this context, the survey highlighted how few graduates are from MD-FM programs. The first MD-FM program started in 2012 at the Government Medical College in Calicut, Kerala. It was only allocated two seats per year; between 2015 and 2020, it graduated at most ten family physicians. As of 2023, only seven government medical colleges out of 286 offer the MD-FM program

"The current number of DNB-FM and MD-FM programs alone will not be able to produce enough graduating family physicians. It is estimated that just over 1% of all accredited postgraduate training seats in India are in FM," highlighted the survey.

Family Physicians Across India: 

According to the data collected in the survey, 48.3% of the respondents in the survey are working in the primary care sector. It further revealed that 56.3 % of the respondents work in the emergency department, 68.9% in the in-patient care, 62% in Palliative care, 66.2% make home visists and 15.5% offer telemedicine facility.

Overall, the data highlighted the wide-ranging responsibilities managed by family physicians. From outpatient consultations to minor surgeries and childbirth, the role of family physicians in the primary care was highlighted in the survey.

Lack of Work Opportunities in the Public Sector: 

Two-thirds of the respondents who participated in the survey were found to be working in the private sector alone. However, the survey highlighted that this was not necessarily due to choice "but instead because of the lack of opportunity for family physicians to find positions within the government sector."

In the government sector, PHC is delivered through a network of subcenters, primary and community health centers, pointed out the survey, adding that "Currently, CHCs are meant to be staffed by four medical specialists (internal medicine, pediatrician, general surgeon, and obstetrician and gynecologist) supported by paramedical providers. However, finding specialists to work in these centres is an immense challenge; over half of the specialist positions in CHCs are vacant, resulting in many being closed."

"Introducing family physicians’ roles in government CHCs may be one way of addressing these gaps. Our research has shown that family physicians with postgraduate training have a broad set of skills, including surgical skills, overlapping and potentially encompassing the skills of the currently allocated four medical specialists," it further mentioned.

Family Physicians in Rural Areas: 

The survey highlighted that the CHC specialist positions remain vacant because, traditionally, there is an urban preference. 13.3 doctors per 10,000 are in urban areas whereas 3.9 doctors work per 10,000 iun rural areas.

Referring to this, the survey highlighted that "This skew in urbanization is even more significant for physicians with postgraduate specialization training."

Among the respondents who participated in the survey, two-fifth indicated they worked in either a town, semi-urban area, village, or rural centre. "Our finding suggests that FM training may encourage working in smaller communities irrespective of the type of training. Scaling up postgraduate FM training could support a shift towards community-based practice with family physician specialists, which has not been seen with other medical specialists who tend to be concentrated in urban settings," mentioned the survey.

Need for more Family Physicians: 

Pointing out the need for more Family Physicians to promote skilled providers in the primary care sector, the survey mentioned that 85% of medical school graduates do not get any postgraduate training in any field.

Suggesting that the Government may consider increasing the number of Family Medicine Postgraduate training seats in India, the survey opined, "Increasing the proportion of postgraduate seats in FM promotes having skilled providers in the primary care sector. This recommendation does not suggest that India should train more doctors but rather that a larger proportion of graduating doctors would benefit from having postgraduate training in FM."

"Our sample found that the proportion of family physicians working in rural areas is higher than all physicians in India, which is an important finding given the significant gaps in human resources in rural and remote regions of India. Family physicians self-report delivering a broad range of patient services and largely remain in the primary care sector. These findings support expanding postgraduate training in family medicine to improve primary care," the survey concluded.

Medical Dialogues team had reached out to Dr. Raman Kumar, Founding President of Academy of Family Physicians of India (AEPI) for his opinions on what the survey revealed. 

When asked about the reason for such a gap between the training for Family Physicians and the required number of such specialists across India, Dr. Kumar, told Medical Dialogues, "It is not included in the MBBS course, it is not included as one of the subjects."

"Family Medicine is not taught at MBBS level. Although it is available at postgraduate level, at the MBBS training, there is no subject, examination, training, or internship in Family Medicine. That is one of the primary root causes," he added.

Pointing out that three southern states have maximum number of family physicians, he mentioned, "They have efficient health systems and they also have large number of medical education institutions, which proportionately is larger than the northern side of India. Whatever happens, it has more impact in South. Even 3/4th of the medical colleges are located in the southern states of India. Same is reflected in the training of Family Physicians. Also, probably, their public health systems are efficient. People are more aware of the need of family physicians."

When asked about the role of DNB courses to fulfill the requirement of family physicians, Dr. Kumar said, "Normally, teaching hospitals would not have a Department of Family Medicine for family physicians. So, that is a challenge. But still, under government policies, it has started in many district hospitals. Many States have started it and even private hospitals can start it. So, that is an easier way to start postgraduate training. But MD level- that is a problem because in National Medical Commission-controlled medical colleges there is no department of family medicine. So, unless there is a department, they cannot apply for a postgraduate department."

As opposed to this, he pointed out that "DNB is a main source of training of Postgraduate Family Medicine in India, because there are few colleges in India- around 8 or 10- which are offering MD Family Medicine."

Pointing out that "Family Physicians are community-based", Dr. Kumar mentioned how during the pandemic time, patients were told to be managed at home. "That is the reason it became more obvious that we need more family physicians."

While highlighting that India has the largest medical education system in the world, Dr. Kumar opined that without any department of Family Medicine for the Family Physicians at the undergraduate level, the need for Family Physicians cannot be met.

Also Read: Mandatory Family Medicine Department in Each Medical College: Kerala HC tells state to decide

So far in 2025, 128 cases of dengue fever, a viral disease transmitted through the bite of the Aedes aegypti mosquito, have been recorded. The surveillance system has also reported 435 cases of malaria, a febrile disease transmitted through the bite of infected female Anopheles mosquitoes.

Regarding dengue, Espaillat province accounted for 10.9% of cases, La Vega 9.4%, and Puerto Plata 7.8%. These are the three provinces with the highest incidence.

Malaria

Four cases of malaria were reported, three in the province of San Juan and one in Azua, both endemic areas that maintain active outbreaks of the disease. So far this year, 435 cases have been confirmed, with 50% concentrated in the Azua outbreak, followed by San Juan with 41%, and Elías Piña, which has registered 6% of the cases. Regarding nationality, 71% of those affected are of Dominican origin, while 29% are Haitian citizens. The most affected group is women between 20 and 29 years old. The Epidemiology Directorate reports in its bulletin that no new cases of cholera, leptospirosis, or COVID-19 were recorded.

Good news

The Ministry of Health, in its 24th bulletin, reports that no maternal deaths were reported in the country, which represents the strengthening of care provided to pregnant women in health centers.

As of week 24, 79 maternal deaths have been reported in the Dominican Republic, representing a decrease of eight deaths compared to the same period last year, when 87 were reported.

Recommendations

The Ministry of Health recommends that pregnant women attend their prenatal checkups on time and maintain a balanced diet.

Also, avoid alcohol, tobacco, and other harmful substances, rest, avoid stress, and take the vitamins and supplements prescribed by your medical staff.

Respiratory viruses

During epidemiological week 24, the Doctor Defilló National Public Health Reference Laboratory processed 70 respiratory samples.

The circulation of different viruses has been confirmed, including Influenza A (H1N1)pdm09, Influenza A (H3N2), Influenza B (Victoria lineage), SARS-CoV-2, and Parainfluenza virus.

The positivity rate for influenza was 12.9%, while for SARS-CoV-2 it was 2.9%. For other respiratory viruses, the rate was 4.3%, and for respiratory syncytial virus (RSV), no positive cases were recorded.

Infant mortality

Regarding infant deaths this epidemiological week, 23 deaths were reported. The cumulative number of infant deaths over the past 25 weeks has been 771. Compared to the 2024 period, a reduction of 242 deaths is observed, according to the report.

Drug use

Regarding the commemoration of the International Day against Drug Abuse and Illicit Trafficking, the official report urges strengthening joint actions to prevent drug use, control trafficking, and protect the health and safety of the population. In the Dominican Republic, strategies to prevent and combat drug abuse and illicit trafficking have been strengthened, it states.

The country is working to strengthen its prevention efforts, according to a report from the General Directorate of Epidemiology.

Four cases of malaria were reported, three in the province of San Juan and one in Azua, both endemic areas that maintain active outbreaks of the disease.

So far this year, 435 cases have been confirmed, of which 50% (217) were concentrated in the Azua outbreak, followed by San Juan with 41% (177) and Elías Piña, which registered 6% (26) of the cases. Regarding nationality, 71% (310) of those affected are of Dominican origin, while 29% (125) are Haitian citizens. The most affected group is women between 20 and 29 years old.

During epidemiological week 24, the Doctor Defilló National Reference Laboratory for Public Health processed 70 respiratory samples, confirming the circulation of different viruses, including Influenza A (H1N1)pdm09, Influenza A (H3N2), Influenza B (Victoria lineage), SARS-CoV-2, and Parainfluenza virus.

The positivity rate for influenza was 12.9%, while for SARS-CoV-2, it was 2.9%. For other respiratory viruses, the rate was 4.3%, and for respiratory syncytial virus (RSV), no positive cases were recorded.

Infant deaths

Of infant deaths reported this epidemiological week, 23 were reported. In the Dominican Republic, as of SE-24 2025, 771 infant deaths have been recorded, a decrease of 242 compared to the 2024 period.

Punta Cana.- Private hospitals across Central America and the Caribbean are well-positioned to develop a regional hospital network offering high-quality services aligned with the growing medical tourism industry. This vision was shared by Carlos Prato, secretary of the board of the Association of Private Hospitals of Central America, Panama, and the Dominican Republic, during the opening of the Second International Congress on Quality and Innovation in Health in Bávaro-Punta Cana.

Prato emphasized the potential for countries in the region to join forces and market themselves collectively as a single medical tourism destination. He highlighted the region’s capacity to provide affordable, efficient healthcare, particularly appealing to patients from the U.S. and Canada. The event aims to promote collaboration among hospitals in areas like referrals, shared best practices, education, and procurement strategies.

The congress features more than 30 conferences, with topics spanning digital transformation, robotic surgery, medical ethics, electronic health records, personalized medicine, and financial inclusion in healthcare. Institutions such as the World Bank, IDB, IFC, and FEDEFARMA are participating, alongside private clinics from across the region.

Santo Domingo.- The Dominican Republic is expanding its global reputation beyond sun and beaches, positioning itself as a growing health and wellness tourism hub. The medical tourism sector now generates over US$1.3 billion annually, making it one of the five most important contributors to the national economy—alongside traditional tourism, medical device exports, gold, and tobacco.

This high-value industry integrates healthcare, tourism, foreign investment, transportation, education, innovation, and hospitality. Beyond generating foreign revenue and quality jobs, it also raises national healthcare standards by driving structural improvements, standardization of practices, and workforce professionalization. The sector presents a key opportunity to diversify the economy, enhance the national brand, and activate value chains that benefit both public and private sectors.

A Key Institutional Step: Decree 787-21

President Luis Abinader took a significant step by issuing Decree 787-21, officially declaring health and wellness tourism a matter of national interest. This recognizes the strategic importance of the sector and establishes a foundation for state-level coordination and long-term development.

“Medical tourism has shifted from being a trend to becoming a national development strategy with real economic and social impact,” said Dr. Alejandro Cambiaso, president of the Dominican Association of Health Tourism (ADTS). He emphasized that while the decree is a milestone, its successful implementation requires a clear roadmap, institutional backing, and continuity over time.

International Promotion: A Pending Task

Despite its strong potential, the country still lacks a structured strategy to promote medical tourism internationally. ADTS vice president Amelia Reyes Mora stressed that medical tourism should be marketed with the same strategic focus as traditional tourism, as the Dominican Republic offers a unique and competitive value proposition.

To strengthen its global presence, the country must actively participate in international expos, build partnerships with global platforms, and enhance its digital visibility in priority markets such as the Caribbean, North America, Europe, and Latin America. Boosting international visibility would help attract high-value patients, drive investment, and strengthen the country’s reputation as a modern, reliable healthcare destination.

The Coordinating Role of the ADTS

The Dominican Association of Health Tourism (ADTS) has played a pivotal role in bridging the healthcare, tourism, financial, and business sectors. It has supported the adoption of international standards, fostered strategic partnerships, conducted market research, and organized high-profile forums, such as the International Congresses on Health and Wellness Tourism, to promote the country to key global stakeholders.

Recommendations for Strengthening the Sector

To solidify the Dominican Republic’s position as a regional leader in medical tourism, several actions are recommended:

• Promote international certifications and accreditations to ensure service quality and patient safety.

• Combat unlicensed practitioners and unauthorized clinics to protect both the country’s reputation and patients.

• Include medical tourism in national strategies for service exports, healthcare, foreign investment, and tourism development.

• Offer fiscal incentives and financing options to encourage infrastructure growth and the development of specialized human capital.

• Strengthen public-private collaboration and interinstitutional governance to ensure long-term sustainability and patient-centered care.

• Launch and coordinate international promotion campaigns aligned with global standards and driven by both public and private sectors.

“A lot of times, health care comes with a job.”

Sen. John Thune (R-S.D.), in an interview with KOTA on May 30, 2025

Millions of people are expected to lose access to Medicaid and Affordable Care Act marketplace health insurance plans if federal lawmakers approve the One Big Beautiful Bill Act, President Donald Trump’s domestic policy package, which is now moving through the Senate.

Senate Majority Leader John Thune discussed health care and the pending legislation in an interview with KOTA, a South Dakota TV station. But he focused on a different kind of health insurance — employer-sponsored insurance.

“A lot of times, health care comes with a job,” Thune said.

Thune’s comments in the interview were made in the context of highlighting part of the GOP’s economic policy objective. “Creating those better-paying jobs that come with benefits is ultimately the goal here,” he said.

KFF Health News reached out to Thune’s office to find out the basis for this comment. His communications director, Ryan Wrasse, responded by reiterating Thune’s message: “Getting a job has the potential to lead a worker to acquiring health care.”

Paul Fronstin, director of health benefits research at the Employee Benefit Research Institute, said Thune’s comment may also be alluding to discussions surrounding Medicaid work requirements. The One Big Beautiful Bill Act would let nondisabled adults enroll in Medicaid only if they prove they’re volunteering, working, or searching or training for work.

Medicaid, funded by the federal government and states, is the country’s main health insurance program for people with low incomes. Some people with disabilities also qualify.

Some Republicans have built on the jobs talking point in defending the Medicaid cuts and work requirements. Sen. James Lankford (R-Okla.), for instance, told CNBC the bill isn’t about “kicking people off Medicaid. It’s transitioning from Medicaid to employer-provided health care.”

But the health policy experts we checked with made clear that getting a job isn’t a guarantee for getting work-sponsored insurance.

Employer-Sponsored Health Insurance: The Basics

These experts said most jobs do offer health insurance. But they also said the link between employment and work-based coverage is not always straightforward.

“When I see this statement, I’m like, ‘I’ve got so much more to say about this.’ But I’m not arguing with the statement,” Fronstin said.

Matthew Rae, an associate director focused on researching private insurance at KFF, a health information nonprofit that includes KFF Health News, also weighed in.

“Employer-sponsored coverage remains the bedrock of how people get health insurance in the United States,” Rae said. “I would say that getting a job is not a guarantee you’re going to have health insurance. It just increases your chances of getting it.”

About 60% of Americans younger than 65 receive health insurance through their job or as the spouse, child, or other dependent of someone insured through their work, according to 2023 KFF data.

Among workers ages 18 to 64 who were eligible but didn’t sign up for their workplace insurance, 28% said the reason they decided not to enroll was that the plans were too expensive, 2023 KFF data showed.

Most of these workers found health insurance elsewhere, such as through a relative’s workplace plan. But a small percentage of eligible employees, 3.7%, were uninsured.

Health insurance has been “the most valued benefit in the workplace” since businesses began offering it to recruit employees in a tight labor market during World War II, Fronstin said.

Federal law also encourages companies to offer plans. Under the Affordable Care Act, employers with 50 or more full-time workers are penalized if they don’t offer most employees insurance that the federal government considers affordable.

As of last year, 54% of companies offered health insurance to at least some employees, according to KFF.

But that’s not the main way the ACA helped lower the rate of people without health insurance, said Melissa Thomasson, a professor at Miami University in Ohio who specializes in the economic history of health insurance. “Nearly all of that” change, she said, came from the ACA creating private marketplace plans and allowing states to expand Medicaid eligibility.

Health policy analysts say the One Big Beautiful Bill would make it more difficult for people to qualify or afford marketplace plans, with proposals that would increase paperwork, shorten enrollment periods, and allow enhanced tax credits to fizzle out. Thomasson also noted that political rhetoric surrounding jobs and health insurance doesn’t always align.

“We often talk about small businesses being the engine of job creation,” but those are the businesses that often can’t afford to offer workplace insurance, she said.

So Who Isn’t Insured Through Workplace Insurance?

The most obvious category of people who don’t have workplace insurance are those who don’t have a job. This group includes children and retirees, people searching for work, people who choose not to work, and those who can’t work, because of a disability or illness.

Another group without employer-provided insurance is the 25% of people ages 18 to 64 who have a job but are unable to obtain such insurance, according to 2023 data from KFF.

Some of these people work for companies that don’t offer health insurance. These employers tend to be small businesses or part of certain industries, such as farming and construction.

Others are part-time, temporary, or seasonal workers at companies that offer health insurance only to full-time employees. Workers with low incomes are significantly less likely than those with higher incomes to be eligible for workplace insurance, according to 2023 KFF data.

People who aren’t employed or don’t get insurance through their job can get coverage in other ways. Some are insured through a relative’s workplace plan, while others purchase plans and may qualify for subsidies on the ACA marketplace.

Others get insurance through Medicaid or Medicare, the federal health insurance program for people 65 or older and some people with disabilities.

Cost and Quality — And Therefore Access to Care — Vary

Just because someone has health insurance doesn’t mean they’ll get the health care they need. People may skip or delay care if their plans are unaffordable or if they limit in-network providers.

“Health benefits come in all shapes and sizes,” Fronstin said. “Some employers offer very generous benefits, and others less so.”

KFF data shows that premiums and enrollees’ cost-sharing expenses grew faster than wages from 2008 to 2018 but have slowed in recent years.

Whether workplace insurance is affordable significantly varies by income. According to 2020 KFF data, lower-income families insured through a full-time worker spent, on average, 10.4% of their income on premiums and out-of-pocket costs. That’s more than twice the rate when looking at families across all incomes.

Our Ruling

Thune said, “A lot of times, health care comes with a job.”

This statement is partially accurate. Most workers in the U.S. get health coverage through work. But it glosses over aspects of our nation’s job-based health insurance system — such as how costs and coverage, especially for those with lower incomes, can make an employer plan out of reach even if it is available.

Bottom line: Not all jobs provide health insurance or offer plans to all their workers. When they do, cost and quality vary widely — making Thune’s statement an oversimplification.

We rate this statement Half True.

Sources

KOTA interview with Sen. John Thune, May 30, 2025.

CNBC interview with Sen. James Lankford, June 5, 2025.

KFF, “2024 Employer Health Benefits Survey,” Oct. 9, 2024.

KFF, “Employer Responsibility Under the Affordable Care Act,” Feb. 29, 2024.

KFF, “Employer-Sponsored Health Insurance 101,” May 28, 2024.

Peterson-KFF Health System Tracker, “What Are the Recent Trends in Employer-Based Health Coverage?” Dec. 22, 2023.

Peterson-KFF Health System Tracker, “How Affordability of Employer Coverage Varies by Family Income,”March 10, 2022.

Peterson-KFF Health System Tracker, “Tracking the Rise in Premium Contributions and Cost-Sharing for Families With Large Employer Coverage,” Aug. 14, 2019.

Manhattan Institute, “Put Employees in Control of Health Insurance with ‘Worker’s Choice ICHRA,’” May 22, 2025.

Brookings, “Uninsurance Rates Have Fallen Significantly Following the Affordable Care Act,” July 22, 2024.

Harvard Business Review, “Why Do Employers Provide Health Care in the First Place?” March 15, 2019.

Congressional Budget Office letter on the One Big Beautiful Bill Act increasing the number of uninsured people, June 4, 2025.

Phone interview with Paul Fronstin, director of health benefits research at the Employee Benefit Research Institute and a member of the Commonwealth Fund’s National Task Force on the Future Role of Employers in the U.S. Health System, June 6, 2025. 

Phone interview with Melissa Thomasson, professor and health economist at Miami University, June 6, 2025.

Phone interview with Maanasa Kona, associate research professor at the Center on Health Insurance Reforms at Georgetown University, June 6, 2025. 

Phone interview with Matthew Rae, associate director for the Health Care Marketplace Program at KFF, June 10, 2025. 

Phone interview with Sally Pipes, president and CEO of the Pacific Research Institute, June 11, 2025.

Email correspondence with Ryan Wrasse, communications director for Sen. John Thune, June 10, 2025.

KFF Health News, “Some Employers Test Arrangement To Give Workers Allowance for Coverage,” Oct. 2, 2024.

KFF Health News, “Trump’s ‘One Big Beautiful Bill’ Continues Assault on Obamacare,” June 3, 2025.

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

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The Host

Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

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.

It’s not exactly news that our nation’s health care system is only a “system” in the most generous sense of the word and that no one entity is really in charge of it. Notwithstanding, there are some specific responsibilities that belong to the federal government, others that belong to the states, and still others that are shared between them. And sometimes people and programs fall through the cracks.

Speaking before a live audience on June 23 at Aspen Ideas: Health in Colorado, three former governors — one of whom also served as secretary of the Department of Health and Human Services — discussed what it would take to make the nation’s health care system run more smoothly.

The session, moderated by KFF Health News’ Julie Rovner, featured Democrat Kathleen Sebelius, a former governor of Kansas and HHS secretary under President Barack Obama; Republican Chris Sununu, former governor of New Hampshire; and Democrat Roy Cooper, former governor of North Carolina.

Panelists

Kathleen Sebelius
Former HHS secretary, former Kansas governor (D)

Chris Sununu
Former governor of New Hampshire (R)

Roy Cooper
Former governor of North Carolina (D)

Among the takeaways from the discussion:

• States — and the governors who lead them — are major “customers” of the federal health system. For instance, states run research universities with the aid of federal grants from the National Institutes of Health. States also run Medicaid, the joint state-federal program for those with low incomes and disabilities, through which most of the nation’s care for issues such as mental health and substance use disorders is funded. In fact, most federal money sent to states is for Medicaid.
• Cuts to Medicaid outlined in the House and Senate versions of President Donald Trump’s One Big Beautiful Bill Act would leave a huge hole in state budgets — one that the states, already facing budget constraints, would be unable to fill without making difficult choices. Notably, the bill does not make substantive cuts Medicare, a program that has a significant amount of excess spending and is expected to be insolvent within a decade.
• Controlling health care costs is a major concern for the future of the nation’s fragmented health care system, as is maintaining the health care workforce. More people without insurance coverage means higher overall costs. Pandemic burnout, immigration raids, and even the cost of college are putting pressure on a dwindling workforce. The federal government could do more to encourage medical professionals to go into primary care and rural health care.

Video of this episode is available here on YouTube.

Click to open the transcript

Transcript: Live From Aspen — Governors and an HHS Secretary Sound Off

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, coming to you this week from the Aspen Ideas: Health conference in Aspen, Colorado. For this week’s podcast, we’re presenting a panel I moderated here with three former governors and one former HHS [Department of Health and Human Services] secretary, on how states and the federal government work together. This was taped on Monday, June 23, before a live audience. So, as we say, here we go. 

Good morning. Thank you all for being here. I’m Julie Rovner. I’m chief Washington correspondent at KFF Health News, and I’m host of our weekly health news podcast — “What the Health?” — which we will do double duty this week for this panel. I am so thrilled to be here, and I welcome you all to Aspen Ideas: Health. As a journalist who’s covered health policy at the federal and state level for, let us just say, many years, I am super excited for this panel, which brings together those with experience in both. 

I will start by introducing our panelists. Here on my left is Kathleen Sebelius. She served as HHS secretary during the Obama administration from 2009 to 2014, presiding over the passage and implementation of the Affordable Care Act. I hope you were all around last night for the wonderful panel where they were reminiscing. Prior to her tenure in Washington, Secretary Sebelius served two terms as Kansas’ elected insurance commissioner and two more as governor. Today she also consults on health policy and serves on several boards, including — full disclosure — that of my organization, KFF. 

Next to her is Chris Sununu. He’s the former Republican governor of New Hampshire. Opposed, he was elected to a record four times before returning to the private sector. He’s also the only trained environmental engineer on this panel. 

Finally, Roy Cooper is the former Democratic governor of North Carolina, where he served alongside Gov. Sununu. I’m sure they have many stories to tell. As a state lawmaker, Mr. Cooper wrote the state’s first children’s health insurance program in the 1980s and as governor championed the state’s somewhat belated Medicaid expansion in 2023, which we’ll also talk about. He’s currently teaching at the Harvard School of Public Health. 

So here’s what we’re going to do. I’m going to chat with these guys for, I don’t know, 30, 40 minutes, and then we will open it to questions from the audience. There will be someone with microphones. I will let you know when it’s time. Just please make sure your question is a question. 

So, I want to set the stage. It’s not exactly news that our nation’s health care system can only be called a system in the very most generous sense of that term. Nobody is really in charge of it. Notwithstanding that, there are some specific responsibilities that belong to the federal government, others that belong to the states and or counties and cities, and still others that are shared between them. Kathleen, you’re the one on this panel who has served as both governor and as HHS secretary, so I was hoping you could give us two or three minutes on what you see as the primary roles for health care at the federal level at HHS, and those for states. And then I’ll let the rest of you weigh in. 

Kathleen Sebelius: Well, good morning, everybody, and thanks, Julie, for moderating. It’s lovely to be with my colleagues. That’s one of my former lives, as governor, so it’s great to be with governor colleagues. And just to make it clear, we’re not trying to gang up on Chris Sununu. Alex Azar, former HHS secretary in the first Trump administration, was supposed to be here today and had a family health issue, so he couldn’t join us. So it was supposed to be a little more balanced just to— 

Chris Sununu: My conservative lifeline has abandoned me, and he’ll buy me dinner in D.C. next time I’m in town. 

Sebelius: So, as Julie said, I think the health system, if you want to call it that, is definitely interrelated. And I think it’s one of the reasons that a lot of HHS secretaries have actually been governors, because we’re customers, if you will, of the federal health system. But just to break down a couple of categories: I was the elected insurance commissioner, which is an unusual spot. Only 11 states elect an insurance commissioner. Most are appointed as part of a governor’s Cabinet, but insurance is an over $3 trillion-a-year industry, still regulated at the state level. It’s the only multitrillion-dollar industry that there is no federal insurance regulator, and it still has a lot of control over health issues at the state level. The insurance commissioners regulate the marketplace plans. They look out for every company selling private insurance. They regulate Medicare supplemental plans. They’re very involved in consumer protection issues for insurance. And that’s all at the state level. 

Then the governor is clearly in charge of health at the state level. Runs the state employee plan in every state, which often is the largest insurance pool. I don’t know about in North Carolina or New Hampshire, but it certainly was in Kansas. Runs Medicaid, a huge health program. Is in charge of mental health, of the whole issues around the opioid crisis and drug issues. So a broad swath. In charge of prison health and corrections. A lot of health issues at the state level. And then you get to HHS, which is an agency that probably interacts more with states than any other Cabinet agency. I wrote down some of these numbers just so I wasn’t making them up off the top of my head, but 69% of all federal grants to states are Medicaid, and HHS transfers more money to state governments than all the other domestic agencies put together. 

So it’s largely Medicaid, but it also is mental health block grants. It’s all the children and families programs. It’s Head Start. It’s agencies on aging. There’s a real interaction. So governors are often good customers, if you will, of HHS. They need to be intertwined. They need to know what’s going on, what grants are on the table. Runs the whole Indian Health Service. A number of us had tribes in our states. So there is a lot of interaction. And even though I wasn’t able to quickly quantify the number, the other thing — and it’s become more apparent with the cuts on the table — is states run universities, which rely on research grants from the federal government. 

So the recently announced NIH [National Institutes of Health] cuts have huge implications in Kansas. We have three major universities, which are losing hundreds of millions of dollars in research projects. But that’s gone on all over the country. So there is a lot of interaction between the state and federal government. And as I say, with the insurance commissioner, we had to build an office at HHS to regulate the marketplace, because there were no federal regulators. So I brought in a lot of my former colleagues who had been in insurance departments around the country, to help set up that regulatory system and that oversight. 

Rovner: So I would like to ask the two former governors who’ve not been HHS secretaries, if you can, to give us an example of cooperation between the federal government and state government on health care that worked really well and an example of one that maybe didn’t work so well. 

Sununu: So I would argue they don’t work well more than they work well, unfortunately. So a big issue I think, across the entire country, is rural access to care, right? So a lot of these grants — and the secretary’s right — a lot of the grants that come in through Medicaid, they’ll go to population centers and population health. That’s really, really important aspects. But rural access to care, where you talk about mental health, the opioid crisis, that’s really where so many folks get left out of the mix. We went down and I inherited — I don’t want to say “inherited” — New Hampshire was at the tip of the spear for the drug crisis, right? The opioid crisis, 2017, we had the second-highest death rate in the country, and we realized the overdose rate, the death rate, was four times higher in rural New Hampshire than our inner cities, right? Four times. Why? It wasn’t that — it’s because nobody was putting services out there. 

Because it’s so much easier to put the services in the city. So a good example is, we went down to D.C. We worked with, at the time, Secretary Azar, the head of CMS —CMS is the center of Medicaid services and Medicare services, that’s really the overseer of these massive, massive programs — to get some flexibility with the grants to be able to do a little more with our dollars and create a hub-and-spoke system for rural access to care. And that worked really, really, really well. And I’m not here to tout [President Donald] Trump or anything, but at the time the Trump administration really got that and it worked well. 

But I would say, more often than not, if you want something done a little different — we call them [Section] 1115 waivers, not to get wonky — you want to try something, the challenge isn’t that D.C. won’t let you do it. The challenge is it can take forever to get it done. It takes six months for my team to put together an 1115 application and then a year and a half sometimes for Washington to decide, after a hundred lawyers look at it, whether they’ll allow you to do it. So I would always argue, at the base of all this, is — Gov. Cooper, at the time, and his team, they know what North Carolina needs in terms of health care, specialized services, better than Washington, right? Or Mississippi. Or New Hampshire. The states know. They’re on the ground. 

And my argument has always been: The best thing Washington can do if you want to save money and get better outcomes in health care, go more to a block-grant-type system. I know people don’t like to hear that, but let the states who are on the ground have more flexibility with those Medicaid dollars, create the efficiency at a localized level, where the patient interactions there with a — because again, I had an opioid crisis. Maybe there’s a huge mental health crisis in North Carolina. Maybe there’s an acute-care crisis in urban populations in California. Let them have flexibility and the ability to make more immediate returns on that. And so that’s why I say more often than not, it doesn’t work, because of the time delay. The bureaucracy, the lawyers. No offense to the — well, I don’t care if you take offense. But the lawyers in the room, the lawyers that get a hold of this thing and then give you a hundred reasons why it can’t happen. 

And then the last thing I’ll throw out there is billing codes. Do you know there’s 10,000 Medicaid billing codes? Trying to ask a small nonprofit who’s providing local health care services and a volunteer to understand 10,000 Medicaid billing codes, and what happens? Often it’s not nefarious, but they get them wrong and then it comes back and it goes back and forth and the cash gets held up because of Washington, as opposed to just having a localized, We have our problem, let’s fix it on the ground, and move forward and get the help they need. So my challenge is always with the bureaucracy and slowing things down more than anything. 

Rovner: Gov. Cooper. 

Roy Cooper: Glad to be with you, Julie, and I worked closely with Gov. Sununu. We served as governors at the same time, and glad to have then-Gov. Sibelius, working with her when I was attorney general of North Carolina. I was an OK governor, but I’ve got the greatest first lady in the history of North Carolina with my wife, Kristin, who’s with us today. And thank you for all the work that you did. Somebody asked me what I miss most about being governor, and I said ingress and egress to sporting events was what I — because I had to learn to drive again. 

So I look at this relationship as the federal government being a major funder to reach goals, but that states have the flexibility within those guidelines to deal with individual challenges that states have. And I don’t disagree completely with Gov. Sununu about how the waiver system is working, but when you get it working, it does some miracles. 

For example, we got the first 1115 waiver in the country, to invest Medicaid dollars in social determinants of health. We called it Healthy Opportunities. And we’ve talked so much again and again about prevention and how investment there can make such a huge difference. We also got another waiver with hospital-directed payments to require all of our 99 hospitals to take part in a medical debt relief plan. When we expanded Medicaid in North Carolina, which we’ll talk a little bit about in a minute, more than 652,000 people were so grateful to have health insurance, but many of them owed so much money in medical debt that it prevented them from buying a house or getting a credit card and was causing all kinds of problems. So we got a waiver to put a requirement in the directed payments that hospitals are getting to make sure that we wipe off the books that $4 billion in medical debt in North Carolina, and that is happening as we speak. 

People are getting the books cleared, all people who were on Medicaid and those making 350% or less of the federal poverty level. And then going forward, in order to continue to get the directed payments, they have to automatically enroll people at that income level into their programs for charity. So the cost of health care is being borne by those who can least afford it. And Medicaid has given us the opportunity and the flexibility with Medicaid has given us an opportunity to make those investments, and that’s why I worry, Governor, about what this bill that’s coming — you talk about red tape now. You look at red tape that’s coming if this legislation passes Congress right now. It’s going to make it 10 times worse. 

So when you think about what Medicaid has done and this system with all of its faults — it has many — we’re at the lowest uninsured rate we’ve been right now. So that thus far has been a success. We’ve got a long way to go, but I think that we need to continue to work to make the investments angle toward prevention and keeping that symbiotic relationship between the federal and the state, make it smoother, eliminate red tape. But I think we’re making some progress. 

Rovner: So let’s talk about Medicaid, which is kind of the elephant in the room right now since the Senate is presumably going to take up a bill that would make some significant cuts to the program, possibly as soon as this week. You’ve all three run Medicaid programs as governors. One of the Republican talking points on this bill is that what’s supposed to be a shared program, states are using loopholes and gimmicks to make the federal government pay more. What would happen if these cuts actually went through? Would states be able to just say: OK, you caught us. Now we’re just going to have to pay up? 

Sebelius: Well, I can talk a little bit about it. So I live in a state, unfortunately, that has not expanded Medicaid. Kansas is one of the 10 states, although 40 states and the District of Columbia have used the Affordable Care Act provision to enroll slightly higher-income working folks in Medicaid. And it’s a huge federal-state partnership, with the federal government paying 90% of the premium cost of that additional population. 

Rovner: And that was because the states didn’t think they had the money to expand otherwise? 

Sebelius: That’s correct. So it was a generous offer, but after the Supreme Court it was a voluntary program. So there are still 10 states in the country, and what you can see easily looking at the map of the country is what the health outcomes are in the states that have not expanded. Expansion was available on Jan. 1, 2014. So we have a 10-year real-time experiment in health outcomes, in budget outcomes, in what has happened to the state economy. And we know a couple of things from a national level. More hospitals have closed, mostly rural hospitals, in states that have not expanded than the states that expanded. There are fairly significant health differences now. There were health differences before, but they have been accelerated. 

There are more maternal-health deaths in states that have not expanded, not because the woman may not be eligible for Medicaid but because the hospital closes and now she’s 50 miles away from her birthing center and transportation issues and don’t have gas in the car and whatever. We are losing women having children, which is really shocking in the United States of America. So I think that not only is Medicaid a huge portion — I had a good friend who some of you may know, Brian Schweitzer, who was the former governor of Montana, and Brian used to say what a governor does is pretty easy. We medicate, we educate, we incarcerate, and the rest is chump change. You can find it in the couch, but it— 

Sununu: Well, I disagree with that. Totally different discussion. 

Sebelius: In terms of where the money is. Those are the big chunks of — and Medicaid in most state budgets, it’s a huge chunk of money. So when you talk about potentially $700 billion in cuts to Medicaid, it will blow up state budgets across the country, and it will leave, to Gov. Sununu and Gov. Cooper’s points, literally millions of people uninsured. The estimates out of the House bill — the Senate bill still hasn’t been scored — out of the House bill is 8- to 9 million people, but I think that’s likely to go up with a Senate bill. 

Sununu: I would add, expanded Medicaid has been — we were an expanded Medicaid state. It’s been wonderful. Health outcomes are definitely a lot better. There’s a lot more access to services, and these are, again, the difference in the population, these are able-bodied working adults as opposed to the traditional Medicaid population that deal with either poverty issues or disability and all this other stuff. So it’s a 50-50 versus split on traditional versus 90-10. I don’t have a problem with changes. The way they’re doing it is awful. So as a state, if you want — they are really adamant about dropping it, and it would lead to bad outcomes, there’s no question — I would say, OK, do it over 10 years. We’re going to drop it 5% a year. Allow states to gradually come in, right? Allow states to alter their budgets. No state can alter their budget and take up — in California it might even be a trillion, hundreds of billions of dollars. 

Sebelius: Yeah. 

Sununu: So it’s so much money. So no state can do that. And so obviously you’d have a collapse of the system. It would be terrible to do that, and they’ve taken that off the table. The meta-scam piece is much more complicated, where states tax hospitals, match it with federal funds and send it back to hospitals in terms of uncompensated care. That’s a bad practice that everybody does, so we should keep it. I don’t know a better way to say it. And I say that because New Hampshire was the first one.  

Sebelius: And it’s legal. It’s legal. 

Sununu: We invented it in ’92. It’s legal. It’s fine. It’s become precedent in practice. It’s OK. And so we should keep doing that. And what they’re going to do is lower the amount that states can tax the hospitals and therefore lower the amount that we would get. And that, really, for us — I don’t know how other states use their dollars — we put a large portion of that back to hospitals for that uncompensated population, the ones that truly are unregistered. I don’t mind going after — we should get the cost at some point, right? You all owe $37 trillion, by the way. I hope you know that. So the savings have to come from somewhere, but Washington has to be smart about how to do it, what the actual outcomes are going to be, and how to ratchet it down so you’re not, again, throwing everybody off the cliff. And that’s what this bill would do. It would throw people right off a cliff. 

Cooper: Yeah, I think the answer is absolutely no states can’t afford it. We governors have to balance budgets. The federal government obviously doesn’t. They just continue to raise the debt ceiling, problems in and of itself, but that’s where the funding should come from. I think there are a few billionaires we could tax a little bit more in order to create more funding to do the work that we need to do, but— 

Sununu: There’s a basket at the door if you all want to drop something in on the way out. 

Sebelius: A big basket. 

Cooper: That, too. But I think that if we’re going to rely on the states — what’s happening now, I think, is a sneaky way to do this. I think they have understood that just openly and notoriously telling the states they have to pay more is not going to work and it’s not politically feasible. But what they have done is gone through the back door and created all of this red tape that’s going to end up with people being pushed off who are otherwise eligible. It’s going to end up with states having to make horrible choices, like with SNAP [Supplemental Nutrition Assistance Program] benefits, for example. 

In North Carolina, we’ll have a shortfall of about $700 million. Now with SNAP benefits, not only do you feed hungry people who need food, but there’s an economic benefit to our state. It’s like a $1.80 economic benefit generated from $1 of SNAP benefit. But I don’t see my Republican legislature putting in an extra $700 million in SNAP benefits in order to be able to feed hungry people. So the choices that states are going to make are going to be bad, because states are limited as to the decisions that they have to make. And this is going to be really tough, particularly if this Senate bill doesn’t change a whole lot. States are going to have a significant problem. 

Sebelius: All I wanted to say is in addition to the Medicaid issue hitting a big portion of the lower-income working population is a corresponding Affordable Care Act hit that isn’t in the bill, because it’s a tax incentive that will expire at the end of this year. So not acting on the additional premium tax credits for the Affordable Care Act hits almost the same — in a state like Kansas, which has not expanded Medicaid, a lot of that population is in the marketplace plans with an enhanced tax credit. That goes away at the end of the year. So we’re looking at potentially 11 million people in states across this country. 

And no governor has the ability to write a check and say: OK, I’m going to just provide, out of 100% state funds, I’ll help you buy your health insurance. But not having health insurance means you don’t get doctors paid, more hospitals go on —it has a ripple. People can’t take their meds. They can’t go to work. They have mental health issues. It is a really spiraling impact. And as Gov. Cooper and Sununu have said, we have the lowest rate of uninsured Americans right now that we’ve ever had in history, and that could change pretty dramatically. 

Sununu: The only other piece I was going to bring up just to highlight the cowardice of Washington, D.C.: Why are they focusing on Medicaid, but no one wants to talk Medicare? Well, it’s easy because states, right? Because they can blame states. Well, we made changes, but it’s up to the states whether they want to keep it or not, right? And they’re going to blame the governors and blame what’s happening at the state level, whether expanded Medicaid survives or not. Meanwhile, it’s the crisis that they’re creating. Then you have Medicare, which, by the way, everyone agrees there’s massive waste and fraud and abuse, and that system needs a massive overhaul because that system, by the way, is going bankrupt, right? It’ll be insolvent in nine or 10 years, something like that, right?. But no one wants to talk about that piece, right?. But that’s an integral piece because both those left and right hands of Medicaid and Medicare drive the non-private sector of health care, right? Which creates not a competitive — we can get into the whole reducing competition in a free market in health care to actually get costs down. 

But it’s really hard as a governor, I think, and I think I speak for all 50, to hear Washington talk about all these massive cuts they want to make to Medicaid, but they’re not going to touch Medicare, because that’s a federal program. And so they have to do both in some way, and they have to do it in a smart way, in an even-keeled way. It has to take place over time. It has to look at population health outcomes. But they don’t think like that. They just don’t. They look at top-line numbers, top-line issues. Maybe they’ll get to the bill in a few weeks. Maybe they won’t. They’ll be on vacation most of the summer. It’ll be very frustrating. Even if it passes in the Senate, it won’t even — what? September, maybe? Maybe they take it up in September? 

Rovner: You don’t think they’re going to make it by July Fourth? 

Sununu: The Senate might, but then they vacation. They’ve got to go on vacation. So isn’t that the frustration we all have? We have a major crisis here. Here’s an idea. Do your jobs. 

Sebelius: Just a small addendum, too. 

Sununu: Sorry. I’m frustrated. 

Sebelius: Gov. Sununu, because he’s the baby of the group, if you can tell, and I’m part of the gray tsunami. Part of the reason Medicare is running out of money is at least when my parents were involved in Medicare, there were six or seven workers for every retiree. We’re now down to two. And I want to know those two workers. I got to tell you, I’m at a point in my life I’d like to bring them home with me, feed them on a regular basis, get them — but we have an aging country. We have many more people enrolled in Medicare right now than we have had in the past and fewer in the workforce. So the math, you’re right, is daunting going forward, but it isn’t, I would suggest, massive waste, fraud, and abuse as much as a changing demographic in our population. 

Sununu: I was quoting [Rep. Nancy] Pelosi on that one. Sorry. 

Rovner: I want to pick up on something. For those who were not there last night for the Affordable Care Act session, one of the things that no one brought up is that in the intervening 15 years since the Affordable Care Act passed, I think, every single one of the funding mechanisms to help offset the cost of the bill has been repealed by Congress. The individual mandate is gone. Most of the industry-specific taxes are gone. The Cadillac tax that was going to try and deter very generous health plans is gone. States don’t have this kind of opportunity to say, We’re going to pass something that pays for itself, and then get rid of the pay force, right? 

Cooper: That’s a really good point. And right now the Affordable Care Act is working to insure a lot of people, but it’s continuing along with all of our system that’s set up to drive up the cost. And I know we’re going to talk a little bit about cost in just a minute, but again, I agree with Gov. Sununu — that’s the coward’s way out. All of the lobbyists come with their special interests who are paying something and should be paying something, but they get it removed piece by piece by piece. And then the only way to get it is from the very people who need it the most. And they’re the ones who end up suffering. And I think it was mentioned last night — $14,600 a person in the United States for investment in health care. That’s wrong on many levels. 

Rovner: So let’s talk about cost. Who is responsible for controlling the cost of health care? Both sides point at each other. And as I mentioned at the opening, we don’t really have a system, but we obviously have the federal government responsible for a lot of health care bills and the state government’s responsible for a lot of health care bills. So at what point does somebody step up and say, We really need to get this under control? 

Sununu: I’ll throw a couple things in there. The average cost to spend overnight, in America, in a hospital: $32,000 — a night. That’s insane, right? That’s insane. And so the argument that I always have is, let’s look at the cost to stay in a hospital. And I know this is going to seem far afield, but it’s all part of health care. What I pay my average social worker — which, by the way, we need a lot more social workers. And if a social worker’s making 50 grand a year, they’re lucky doing it and God bless them. They’re doing incredibly hard work. So why do we have a system that is driving these costs here, that haven’t gotten any of those costs under control, still make it really difficult to pay the workforce? And I think workforce is a huge part of this crisis. 

Rovner: Next question. 

Sununu: Yeah, that’s another the question, especially the social workers and whatnot and generationally and nurses and all that to get them in there. If you don’t have the workforce, it’s not going to work. So the disparity of costs. And then there are certain aspects, let’s talk pharmaceuticals, where you are all, we are all effectively paying massive costs on pharmaceuticals because we’re subsidizing the rest of the world, right? Because they’re developed here. There’s massive cost controls in Europe, so we pay a huge amount of money. And again, I’m going to bring up Trump only because he brought up the “fat shot.” Is that what he called it? The other—? Yeah. The fact that Ozempic here is $1,200 but a hundred bucks in Europe. Why? Because they have cost controls there, and our fairly unregulated system forces those types of costs on the private sector here. 

So I’m a free-market guy. I’m always a believer that the more private sector investment you get and the more, I’ll just call it competition, especially smaller competition, can create better outcomes. But we just don’t have that. There’s no private sector. There’s no competition in health care, because so much of it is driven by Medicaid and Medicare. So I would just argue that you have to look at finding the balance here in the U.S., but don’t forget there’s other issues across the rest of the world that are affecting your costs as well. 

Cooper: And I’ll give you two things. One that you don’t do to affect the cost issue. You may be tempted to reduce your budget to throw people off of coverage, but more people without coverage increases costs significantly, and we all pay for it when you have indigent patients going into those hospitals. They go to the private sector first, which is why a lot of businesses in North Carolina supported our expansion of Medicaid, because 44% of small businesses don’t even provide coverage for their customers. So we should not be kicking people off coverage. In order to reduce costs, we need to cover more people. And the second thing we should do, and this we say a lot here and it was said last night, but collectively, if we can come together and make these short-term investments for long-term gain on primary care and prevention, that is the best way to lower costs to make sure people are healthier. Because our system is geared to spend all the money when it is most expensive and not when it is least expensive and can do the most good to delay that spending at the other end. 

And there are a lot of ways that we can approach this, but what frustrates me about Washington is that you don’t see any real effort there to concentrate on prevention and primary care and making those investments that we know — we know — not only save lives but save money and reduce the cost of health care. And I think that can be a bipartisan way that we can come together to deal with this. Things you mentioned, certainly driving up the cost, but that is a basic thing that we know will make people healthier and will cost the system less. 

Sebelius: I don’t think there’s any disagreement in all of us and probably all of you that we pay way too much for health care per capita. And we have pretty indifferent health results. We have great care for some of the people some of the time. But in terms of universally good care for people across this country, regardless of where you live, it just doesn’t happen. It isn’t delivered, regardless of the fact that we spend much more money. I would say that it’s beginning to have some impact, but a couple things occurred as part of the framework of the Affordable Care Act and other changes at the D.C. level. First, Medicare began to issue value-based payment contracts. They were nonexistent before 2010, and that just means you begin to pay for outcomes. Not just doing more stuff makes more money, but what happens to the patient? Is it a good recovery? Do you come back to the hospital too soon? Is somebody following up? 

So that has shifted now to most Medicare payments are really in a value-based payment outcome. And that has made a difference. I think it makes a difference in patient outcomes. It makes a difference across the board. There has been some change, not nearly enough, in primary care reimbursement. We need a whole lot more of that. Specialty care pays so much more than primary care, and it discourages young docs from going into a primary care field, a gerontology field, a pediatric field. We desperately need folks. I’d say third that a lot of hospitals, and particularly in rural areas, to your point, Gov. Sununu, are beginning to look at a range of services, not just, as we call it, butts in beds, but they’re running long-term care services. They’re running a lot of outpatient. 

And we just had a session on rural health care, and the amount of outpatient care provided by rural hospitals is now up to about 80%. So actually they’re trying to do prevention, trying to meet people where they are. We have to keep some support systems under those hospitals, because if their only payment is how many bed spaces you fill per night, it’s counterintuitive to have hospitals doing prevention and then their bottom line is affected. But I think Gov. Cooper is just absolutely right on target. There was a huge prevention fund for the first time in the Affordable Care Act. It went to states and cities, not to some federal government. It was called, for years, a big slush fund. But it has engaged, I think, a lot of people, a lot of mayors, a lot of governors in everything from bike trails to healthy eating to scratch kitchens in schools, to doing a range of reintroducing physical education back into education classes. But we need to do a lot more of that. 

Sununu: Can I ask a question? Were you guys a managed Medicaid state? 

Cooper: Yeah, we are now. 

Sununu: Were you at the time? So for those who know, maybe 40 states, 41, 42 states? 

Sebelius: I think it’s almost 45. 

Sununu: So the states, I don’t know when this started. It had started right around the time I got in New Hampshire. We hired a couple large companies to basically manage our Medicaid. But to the Gov. Cooper’s point, theoretically you bring those companies in to look at the whole health of the individual and more on the prevention services, more on that side as opposed to just fee-for-service, fee-for-service, right? Where you get inefficiency and waste and all that sort of thing. It’s worked, kind of. I think most of the models still have a lot of fee-for-service built into them. And so it’s not quite there. You have these very large companies, the Centenes and some of these other really, really large companies that are effectively deciding whether — they’re insurance companies that are deciding whether someone should get care or not, or that service is required or not. 

Usually it works, but obviously we have a lot of tragic stories of families getting rejected for service or things like that. So, I think if given more flexibility that it could theoretically work, but I think the managed-care model is mostly working but not great. But it was designed to deal with exactly what Gov. Cooper’s talking about, the whole health of the individual, more preventive care. Don’t wait for the person on Medicaid to lose all their teeth — right? — because they’re a meth addict and they have massive heart and liver issues, right? Get them those prevention services early on because they’re into a recovery program and the whole health of the individual exponentially saves you money and increases their health outcomes and all that. But if you have somebody looking at that from a holistic perspective, theoretically it comes out better. I don’t know. You probably have a better perspective than anyone whether you think it really has worked or not. 

Sebelius: Well, I think it’s beginning to work and it works better in some places than others. But I think that the federal programs, arguably both Medicare and Medicaid, provide, if you will, the most efficient health insurance going. Private plans, in all due deference to your market competition, run anywhere from 15 to 20% overhead. Medicare runs at a 2% overhead. Medicaid is about that same thing. So delivery of health benefits on an efficient basis is really at the public sector, less at the private sector, which is why we were hoping to have a public option in the Affordable Care Act to get that market competition. Medicare Advantage provides market competition now to fee-for-service. And some of the companies do a great job with holistic care. Some of the companies do a really bad job, far more denials, far more issues of people not being able to get the benefits they need. So it is a balanced thing. 

Sununu: And smaller states, we had a trouble because we couldn’t find many companies that wanted to come into a small state like New Hampshire, because the population wasn’t going to be huge. We have the lowest population on Medicaid in the country. So if I got a third company and maybe they get 35-, 40,000 people, what’s the risk pool of those individuals? They might be like, Nah, it’s not going to work for us, right? So the smaller states, because they’re managed at the state level, have challenges. We tried to actually partner with Vermont and Maine. 

Sebelius: Regional. 

Sununu: Right? Regional opportunities. The feds wouldn’t let us do that. Very frustrating. But not you. 

Sebelius: I did a waiver for New Hampshire to have a regional program. 

Sununu: No, I blame Alex for that. That’s another thing — I’ve yelled at Alex for that for years. 

Sebelius: Maybe the next guys took it away. 

Rovner: So we keep talking about people getting care or people not getting care. We haven’t talked a lot about the people who deliver the care. Obviously the health care workforce is a continuing frustration in this country, as we know. We have too many specialists, not enough primary care doctors, not enough primary care available in rural areas. What’s the various responsibility of the federal government and the states to try and ensure that — obviously states need to worry about workforce development. Isn’t that one of the things that states do? 

Sununu: All right, I’ll kick things off because I’ll say something really liberal that you’ll all love. Do you know what the key is? Honestly? It’s an immigration reform bill. 

Sebelius: I was just— 

Sununu: It’s immigration reform. Because this generation is not having kids, right? We’re losing population. So just the math on bodies, if you will, in terms of entering any workforce is going to be challenging as the United States goes forward. More and more if you look at the number of people, social workers, people in recovery, MLADCs [master licensed alcohol and drug counselors] in recovery programs, nurses, whatever it is, those tend to be more people that are born outside of this country, that come to this country. They go to nursing school — whatever it is they become, it’s great. 

But until we get a good immigration reform bill that opens those doors bigger and better and with more regulation on top of them, but open those doors, I think it’s going to be a challenge. It’s not necessarily an issue for the government to — government can’t create people, right? Maybe we can incentivize more schools and that sort of thing. And I think most governors do that. We put in nursing schools in our university system and all that, but you still have to fill the seats and you still have to encourage the young people to want to get into those types of programs. 

Sebelius: I think the government at the state and local level and federal level can do more. More residency programs. The federal government can actually move the needle on some of the payment systems for specialty vs. primary care. And we haven’t moved fast enough on that. I think that’s no doubt. What’s pending right now with ICE [Immigration and Customs Enforcement] raids all over the country and people being terrified to come here or stay here is going to make the workforce issue significantly worse. Home health care workers, folks in nursing homes, people who are LPNs [licensed practical nurses] are now being discouraged from either coming or staying. And I think we’re in for an even bigger shock. 

A lot of folks got burned out in covid. There’s no question that we lost vital health care workers. We need to be on a really massive rebuilding program, and instead we have put up a big red flag. And a lot of people who are here who are providing care, who may have a family member or somebody else who is not at legal status, and they’re gone or they’re not going to go to work or they’re not going to provide those services. And I think we’re about to hit even a bigger wall. 

Cooper: You’ve mentioned compensation. Obviously gearing more toward the preventive side, the primary care side is important. I also think one thing that’s working some, and I think we could do more, obviously requires funding, but providing scholarship money for doctors, nurses, others who agree to give a certain number of years of service in primary care and particularly in rural areas. We’re seeing some of that work. There are a lot of people who feel compelled. You mentioned, when I was up at the Chan School at Harvard and I was teaching a graduate school class, and I love public health people because they care so passionately about others and they want to get in this field. Making it financially viable for them to be able to complete the mission that they feel in their heart, I think, is something that I think is worthy of greater investment. 

Sununu: To that point, I think it’s a great idea and it definitely works. But even before that, just look at what it costs to go to a four-year college now, right? I’m a parent. I have a 20-, 19-, and a 12-year-old. So we’re all absolutely looking at what college costs, and I don’t mind picking on a few of them. Like NYU [New York University], what, a $100,000? So my daughter’s not going to be a nurse, even think about being a nurse, because questioning whether she even goes to college, right? Because she might go to take community college classes instead or do something else. So, or she’s got to find that other pathway. So the initial steps to getting to be a doctor or higher-level primary care physician even, there’s a huge barrier before the barrier. 

And so I think we just need to think holistically about how young people and why they’re making certain choices, and the financial aspects of going to college, I think, over the next 10 years are going to really blow up and create a massive problem. And sometimes it’s very healthy, right?. Sometimes it’s great that young people are thinking differently. It’s not, Go to a four-year college or you don’t have value. No, they think totally different. They know they can have a great life path in other areas, but that postsecondary first-four-year barrier right now is just, we’re just scratching the surface of how big it will be in terms of preventing them from entering the four-year. 

Rovner: We’re running out of time. I do want to let the audience— 

Sebelius: Can I just— 

Rovner: Yes. 

Sebelius: One thing to Gov. Sununu’s point. So there is the national commissioned health corps, which does pay off medical debt for nursing students blah blah blah. What we found, though, is a lot of people couldn’t even get to the medical debt, because they can’t get their college paid off. They can’t get into medical school. So moving that to a much more upstream, into high school, into early college, is the way we get— 

Sununu: Certificate programs in high school, like pre-nursing programs, social-work programs in your vo-tech schools — huge opportunities there. You get like a 14- or 15-year-old excited about helping someone. You’re giving them a certificate. They could enter the workforce at 19 in some ways. And then the workforce is helping them pay off that schooling or expanding those community— 

Sebelius: Or sending them on. 

Sununu: Yeah. There’s all these other ways to do it. So I think that’s the gateway that we have to keep opening. 

Sebelius: It’s got to be earlier though. 

Sununu: Much earlier. 

Rovner: All right, we have time for a couple of questions. I see a lot of hands. Wait until a microphone gets to you. OK. 

Stephanie Diaz: Hi, and thank you for this amazing conversation. My name is Stephanie Diaz. I’m with a corporate venture fund attached to a health system. Really thrilled for this conversation, and where it ended on workforce is really compelling. The Big Beautiful Bill and the Senate version has a cap on financial aid for degrees like medical programs. Considering what you just said, what are the goals of legislation like that and what can— 

Sebelius: No idea. 

Diaz: Why? 

Cooper: Save money. 

Sununu: Yeah, yeah. 

Cooper: Finding a way. 

Rovner: What would the impact be? I think that’s probably a fairer question. 

Sununu: Well, in this field would be devastating, right? I would imagine. I don’t know what the cap is. I don’t know what they’re basing that on. I don’t know if they’re— 

Diaz: $150,000. And we know that a medical degree costs, well, more than $150,000 for a student. 

Rovner: I think they’ve said the goal is that they want to push — they want to force down tuition. 

Sununu: Well, the government forced up tuition. That’s a whole different conversation. 

Cooper: They’re going to force out med students is what they’re going to do. 

Sununu: Look, I’ll be the devil’s advocate$150,000 for primary care, for example. If you’re a primary care — any medical degree, yeah. I don’t know what the thought process is other than they’re probably saying, well, these doctors, once you get your degree, you’re making a heck of a lot of money. These guys can pay stuff off. Let’s move that tuition or scholarship money to the social workers, to the MLADCs, to the community colleges, because that’s where you find more low-income families that can’t pay even $7- or $10,000 at a community college. That’s the real barrier. Low-income families as opposed to, look, giving $150,000, that’s a lot of money. And if these guys — if there’s anyone in America that can actually pay off college debt, it’s a doctor. So I’m being a little bit devil’s advocate because I don’t know the heart of the program, but that’s a heck of a lot of money and that’s a lot more tuition and scholarship funds than any other profession in the country. So I think it’s just about finding a balance. I am being a little devil’s advocate because I don’t know the details. 

Rovner: All right, I think I have time for one more question. 

Speaker: I’m a CFO at an ACO [accountable care organization] in Nebraska, and if I have to brag, our per cost, per beneficiaries, under $10,000 per reported on the latest 2023 numbers. Can you speak to the administration’s thought on value-based care contracting? And I know in Project 2025 it was referenced that — you’re laughing. 

Sununu: No, I hate hearing those words. 

Speaker: I did dig into that. And it is talked about to be attacked, value-based care contracts moving forward. So I was hoping that you could speak to that, maybe the intention of this administration, so thanks. 

Cooper: You want to talk about the intent of this administration? 

Sebelius: I’m not going to speak about this administration. You can speak about that. 

Sununu: No, I have no idea what the intent was. And every time I hear Project 2025 I shudder because it’s like, ah, I hate that thing. But, I don’t know why. 

Speaker: No not why but for behind the scenes do you think there’s still support for— 

Sebelius: I can tell you it’s one of the areas I think there’s huge bipartisan support inside Congress. So folks have come after it often from the health system because they really didn’t — they’d much rather, in some cases, have the fee-for-service payment. If I operate, I want to get my money. If I’m an anesthesiologist, I want to get my money. So value-based care really began to shake up the health system itself, health providers. I don’t know what this administration intends to do, but I know Congress has really wrapped their arms around value-based care and is really pushing the administrative agencies inside D.C. to continue and go faster. Bundled care for an operation where you put all the providers together and look at outcome. A lot of things that the ACOs are doing, congratulations. But that notion didn’t even exist before 2010, and I think it is absolutely on a trajectory now that it’s not going to go back. 

Sununu: And I’ll add this: As kooky as your successor is, the current HHS secretary, because he’s kooky, he’s not on board, either. So I think, again, regardless of what the administration wants, I don’t think that— 

Sebelius: Oh, not on board with getting rid of that. 

Sununu: Yeah, exactly. Not on board with getting— 

Sebelius: I just wanted to clarify. 

Sununu: I don’t think there’s going to be changes. I don’t think Congress is there. I don’t think the current secretary is there. I don’t know where the current secretary is on a lot of different things. He seems to change his mind quite often, but just don’t eat the red dye and you’ll be fine. 

Sebelius: But it’s one of the few places I would say— 

Cooper: Is there anything in the BBB [Big Beautiful Bill] on that? 

Rovner: We are officially out of time before Gov. Sununu gets himself into more trouble. I want to thank the panel so much and thank you to the audience, and enjoy your time at Aspen. 

OK. That’s our show for this week. As always, if you enjoyed the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our producer, Francis Ying, holding down the fort in Washington, and our editor, Emmarie Huetteman, here on the ground with me in Aspen. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, all one word. Or you can tweet me. I’m @jrovner. Or on Bluesky, @julierovner. We’ll be back in your feed from Washington next week. Until then, be healthy. 

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