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Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

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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.

With only a single vote to spare, the House passed a controversial budget bill that includes billions of dollars in tax cuts for the wealthy, along with billions of dollars of cuts to Medicaid, the Affordable Care Act, and the food stamp program — most of which will affect those at the lower end of the income scale. But the bill faces an uncertain future in the Senate.

Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. released a report from his commission to “Make America Healthy Again” that described threats to the health of the American public — but notably included nothing on threats from tobacco, gun violence, or a lack of health insurance.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.

Panelists

Anna Edney
Bloomberg News

@annaedney

@annaedney.bsky.social

Read Anna's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

@sarahkarlin-smith.bsky.social

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Among the takeaways from this week’s episode:

• House Republicans passed their “big, beautiful” bill 215-214 this week, with one Republican critic voting present. But the Senate may have its own “big, beautiful” rewrite. Some conservative senators who worry about federal debt are concerned that the bill is not fully paid for and would add to the budget deficit. Others, including some red-state Republicans, say the bill’s cuts to Medicaid and food assistance go too far and would hurt low-income Americans. The bill’s cuts would represent the biggest reductions to Medicaid in the program’s 60-year history.
• Many of the bill’s Medicaid cuts would come from adding work requirements. Most people receiving Medicaid already work, but such requirements in Arkansas and Georgia showed that people often lose coverage under these rules because they have trouble documenting their work hours, including because of technological problems. The nonpartisan Congressional Budget Office estimated an earlier version of the bill would reduce the number of people with Medicaid by at least 8.6 million over a decade. The requirements also could add a burden for employers. The bill’s work requirements are relatively broad and would affect people who are 19 to 64 years old. 
• People whose Medicaid coverage is canceled also would no longer qualify for ACA subsidies for marketplace plans. Medicare also would be affected, because the bill would be expected to trigger an across-the-board sequestration cut.
• The bill also would impact abortion by effectively banning it in ACA marketplace plans, which would disrupt a compromise struck in the 2010 law. And the bill would block funding for Planned Parenthood in Medicaid, although that federal money is used for other care such as cancer screenings, not abortions. In the past, the Senate parliamentarian has said that kind of provision is not allowed under budget rules, but some Republicans want to take the unusual step of overruling the parliamentarian.
• This week, FDA leaders released covid-19 vaccine recommendations in a medical journal. They plan to limit future access to the vaccines to people 65 and older and others who are at high risk of serious illness if infected, and they want to require manufacturers to do further clinical trials to show whether the vaccines benefit healthy younger people. There are questions about whether this is legal, which products would be affected, when this would take effect, and whether it’s ethical to require these studies. 
• HHS released a report on chronic disease starting in childhood. The report doesn’t include many new findings but is noteworthy in part because of what it doesn’t discuss — gun violence, the leading cause of death for children and teens in the United States; tobacco; the lack of health insurance coverage; and socioeconomic factors that affect access to healthy food.

Also this week, Rovner interviews University of California-Davis School of Law professor and abortion historian Mary Ziegler about her new book on the past and future of the “personhood” movement aimed at granting legal rights to fetuses and embryos.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Julie Rovner: The Washington Post’s “White House Officials Wanted To Put Federal Workers ‘in Trauma.’ It’s Working,” by William Wan and Hannah Natanson.

Alice Miranda Ollstein: NPR’s “Diseases Are Spreading. The CDC Isn’t Warning the Public Like It Was Months Ago,” by Chiara Eisner.

Anna Edney: Bloomberg News’ “The Potential Cancer, Health Risks Lurking in One Popular OTC Drug,” by Anna Edney.

Sarah Karlin-Smith: The Farmingdale Observer’s “Scientists Have Been Studying Remote Work for Four Years and Have Reached a Very Clear Conclusion: ‘Working From Home Makes Us Happier,’” by Bob Rubila.

Also mentioned in this week’s podcast:

• The New York Times’ “As Congress Debates Cutting Medicaid, a Major Study Shows It Saves Lives,” by Sarah Kliff and Margot Sanger-Katz.
• NBC News’ “Georgia Mother Says She Is Being Forced To Keep Brain-Dead Pregnant Daughter Alive Under Abortion Ban Law,” by Minyvonne Burke.
• The Washington Post’s “Trump and GOP’s Tax Bill Would Force Cuts to Medicare, CBO Says,” by Jacob Bogage and Abha Bhattarai.
• The New England Journal of Medicine’s “An Evidence-Based Approach to Covid-19 Vaccination,” by Vinay Prasad and Martin A. Makary.

click to open the transcript

Transcript: Bill With Billions in Health Program Cuts Passes House

[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, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, May 23, at 10 a.m. As always, and particularly this week, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: And Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hello there. 

Rovner: Later in this episode we’ll have my interview with law professor and abortion historian Mary Ziegler, who has a new book out on the history and possible future of the “personhood” movement. But first, this week’s news. 

So, against all odds and many predictions, including my own, the House around 7 a.m. Thursday morning, after being in session all night, passed President [Donald] Trump’s One Big Beautiful Bill — that is its actual, official name — by a vote of 215-214, with one Republican voting present. Before we get into the details of the House-passed bill, what are the prospects for this budget reconciliation bill in this form in the Senate? Very different, I would think. 

Ollstein: Yeah, this is not going to come out the way it went in. Senate is already openly talking about a “‘One, Big Beautiful’ Rewrite” — that was the headline at Politico. 

And you’re going to see some of the same dynamics. You’re going to see hard-liners saying this doesn’t go far enough, this actually adds a lot to the deficit even with all of the deep cuts to government programs. And you’re going to have moderates who have a lot of people in their state who depend on Medicaid and other programs that are set to be cut who say this goes too far. And so you’re going to have that same push and pull. And the House, barely, by one vote, got this through. And so we’ll see if the Senate is able to do the same. 

Rovner: Yeah, so all eyes on [Sen.] John McCain in 2017. This year it could be all eyes on Josh Hawley, I suspect, the very conservative senator from Missouri who keeps saying “Don’t touch Medicaid.” 

But back to the House bill. We don’t have official scores yet from the Congressional Budget Office, and we won’t for a while, I suspect. But given some last-minute changes made to pacify conservatives who, as Alice pointed out, said this bill didn’t cut deeply enough, I think it’s clear that if it became law in this form, it would represent the biggest cuts to federal health programs in the 60-year history of Medicare and Medicaid. 

Those last-minute changes also took pretty square aim at the Affordable Care Act, too, so much that I think it’s safe to call this even more than a partial repeal of the health law. And Medicare does not go unscathed in this measure, either, despite repeated promises by President Trump on the campaign trail and since he took office. 

Let’s take these one at a time, starting with Medicaid. I would note that at a meeting with House Republicans on Tuesday, President Trump told them not to expletive around with Medicaid. You can go look up the exact quote yourself if you like. But apparently he’s OK with the $700 billion plus that would be cut in the bill, which Republicans say is just waste, fraud, and abuse. Where does that money come from? And would Medicaid really continue to cover everyone who’s eligible now, which is kind of what the president and moderate Republicans are promising? 

Edney: Well, it sounds like the bulk of it is coming from the work requirements that Alice mentioned earlier. And would it be able to cover them? Sure, but will it? No, in the sense that, as Alice has talked about often on this podcast, it’s basically a time tax. It’s not easy to comply with. All federal regulations, they’re not going to a website and putting in what you did for work. Particularly, if you are a freelancer or something, it can be really difficult to meet all the requirements that they’re looking for. And also, for some people, they just don’t have the ability, even the internet, to be able to do that reliably. So they’re going to save money because people are going to lose their health care. 

Rovner: I saw a lot of people referring to them this week not as work requirements anymore but as work reporting requirements. Somebody suggested it was like the equivalent of having to file your income taxes every month. It’s not just check a box and say, I worked this month. It’s producing documentation. And a lot of people have jobs that are inconsistent. They may work some hours some week and other hours the other week. And even people who work for small businesses, that would put an enormous burden on the employers to come up with all this. 

Obviously, the CBO thinks that a lot of people won’t be able to do this and therefore people are going to lose their health insurance. But Alice, as you have told us numerous times when we did this in Arkansas, it’s not that people aren’t working — it’s that people aren’t successfully reporting their work. 

Ollstein: Right. And we’ve seen this in Georgia, too, where this has been implemented, where there are many different ways that people who are working lose their insurance with this. People who don’t have good internet access struggle. People who have fluctuating work schedules, whether it’s agricultural work, tourism work, things that are more seasonal, they can’t comply with this strict monthly requirement. 

So there are numerous reports from the ground of people who should be eligible losing their coverage. And I’ll note that one of the last-minute changes the House made was moving up the start date of the requirements. And I’m hearing a lot of state officials and advocates warn that that gives states less time to set up a system where people won’t fall through the cracks. And so the predicted larger savings is in part because they imagine more people will be kicked off the program. 

Rovner: It’s also the most stringent work requirement we’ve seen. It would cover people from age 19 through age 64, like right up until you’re eligible for Medicare. And if you lose Medicaid because you fail to meet these reporting requirements, you’re no longer eligible for a subsidy to buy insurance in the ACA exchange. Is there a policy point to this? Or are they just trying to get the most people off the program so they can get the most savings? 

Edney: If you ask Republicans, they would tell you: We’re going to get people back working. We’re going to give them the pride of working — as if people don’t want that on their own. But the actual outcome is not that people end up working more. And there are cases even where they lose their health insurance and can’t work a job they already had. On the surface, and this is why it’s such a popular program, because it seems like it would get more people working. Even a large swath of Democrats support the idea when they just hear the name — of voters. But the actual outcome, that doesn’t happen. People aren’t in Medicaid because they aren’t working. 

Rovner: Right. And I get to say for the millionth time, nobody is sitting on their couch living on their Medicaid coverage. 

Edney: Right, right. 

Rovner: There’s no money that comes with Medicaid. It’s just health insurance. The health providers get paid for Medicaid and occasionally the managed-care companies. But there’s no check to the beneficiary, so there’s no way to live on your Medicaid. 

As Alice points out, most of the people who are working and have Medicaid are working at jobs, obviously, that don’t offer employer health insurance. So having, in many cases, as you say, Anna, having Medicaid is what enables you to work. 

All right, well, our podcast pals Margot Sanger-Katz and Sarah Kliff have an excellent Medicaid story out this week on a new study that looks very broadly at Medicaid and finds that it actually does improve the health of its beneficiaries. Now this seems logical, but that has been quite a talking point for Republicans for many years, that we spend all this money and it doesn’t produce better health, because we’ve had a lot of studies that have been kind of neither here nor there on this. 

Do we finally have proof that Democrats need? Because I have heard, over many years — there was a big Oregon study in 2011 that found that it helped people financially and that it helped their mental health, but there was not a lot of physical health benefit that they saw. Of course, it was a brief. It was like two years. And it takes a longer time to figure out the importance of health insurance. But I’m wondering if maybe the Democrats will finally be able to put down that talking point. I didn’t hear it, actually, as much this week as I have in years past: Why are we spending all this money on Medicaid when we don’t know whether it’s producing better health? 

Karlin-Smith: One of the interesting things I thought about this study and sort of the timing of it, post-Obamacare expansion of Medicaid and more younger people being covered, is that it seems to really show that, not only does this study show it saves lives, but it’s really helping these younger populations. 

And I think there are some theories as to why it might have been harder to show the economic cost-effectiveness benefits people were looking for before, when you had Medicaid covering populations that were already either severely ill or older. Which doesn’t mean it’s not valuable, right? To provide health coverage to somebody who’s 75 or 80, but unfortunately we have not found the everlasting secret to life yet. 

So, but I think for economists who want to be able to show this sort of, as they show in this paper, this “quality-adjusted life year” benefit, this provides some really good evidence of what that expansion of Medicaid — which is a lot of what’s being rolled back, potentially, under the reconciliation process — did, which is, helps younger people be healthier and thus, right, hopefully, ideally, live a higher quality of life, and where you need less health coverage over time, and cost the government less. 

It’s quite interesting, for people who want to go look at the graph The New York Times put in their story, of just where Medicaid fits, in terms of other sort of interventions we spend a lot of money on to help save lives. Because I was kind of surprised, given how much health insurance does cover, that it comes out on sort of the lower end, as being a pretty good bargain. 

Rovner: Yeah. Well, we don’t have time to get into everything that’s in this bill, and there is a lot. It also includes a full ban of Medicaid coverage for gender-affirming care for both minors and adults. And it cuts reimbursement to states that use their own funds to provide coverage to undocumented people. Is this a twofer for Republicans, saving money while fighting the culture wars? 

Edney: Certainly. And I was surprised to see some very liberal states on the immigration front saying: We just have to deal with this. And this really sucks, but we have to balance our budget. And if we’re not going to get those tax dollars, then we aren’t going to be able to offer health insurance to people who are undocumented, or Medicaid to people who are undocumented. 

Rovner: Yeah, California, most notably. 

Edney: Yeah, California for sure. And they found a way to do it, hit them in the pocketbook, and that that’s a way for them to win the culture war, for sure. 

Rovner: Alice, you’ve spent a lot of time looking at gender-affirming care. Were you surprised to see it banned for adults, too? Obviously the gender-affirming care for minors has been a continuing issue for a while. 

Ollstein: Yeah, I would say not surprised, because this is sort of a common pattern that we see across different things, including in the abortion space, where first policies are targeted just at minors. That often is more politically palatable. And then it gets expanded to the general population. And so I think, given the wave of state bans on care for minors that we’ve seen, I think a lot of people had been projecting that this was the trajectory. 

I think that there’s been some really good reporting from The 19th and other outlets about what an impact this would have. Trans people are disproportionately low-income and dependent on Medicaid, and so this would have really sweeping impacts on a lot of people. 

Rovner: Well, turning to the Affordable Care Act, if you thought Republicans weren’t going to try to repeal the health law this time around, you thought wrong. There are a bucket of provisions in this bill that will make the Affordable Care Act coverage both more expensive and harder to get, so much that some analysts think it could reduce enrollment by as much as half of the 24 million people who have it now. Hasn’t someone told Republicans that many of these people are their voters? 

Edney: Yeah, that’s a good question. I don’t know what the Republican strategists are telling them. But certainly they needed to save money. And so they found their loopholes and their different things that they thought they could scrape from. And maybe no one will notice? But I don’t think that’s going to happen. 

A lot of people suddenly have much higher ACA premiums because of the way they’re going to take away this ability that the insurers have had to silver-load, essentially, the way that they deal with the premium tax credits by setting some of the savings, kind of the cost sharing that they need to do, right into the silver plan, because the silver plan is where the premiums are set off of. And so they were able to offer the plans with lower premiums, essentially, but still get paid for cost-sharing reductions. So they were able to still get that money taken away from them. 

Rovner: So let me see if I can do it. It was, and this was something that Trump tried to do in 2017, that he thought was going to hurt the marketplace plans. And it ended up doing the opposite— 

Edney: Right. 

Rovner: —because it basically shifted money from the insurance companies and the beneficiaries back to the federal government, because it made the premium subsidies bigger. 

So I think the point I want to make is that we’ve been talking all year about these extra subsidies that are going to expire, and that will make premiums go up, and the Republicans did not move to extend those subsidies. But this going back to the government paying these cost-sharing reduction payments is going to basically reverse the accidental lowering of premiums that Trump did in 2017. And therefore, raise them again. 

So now we have a double whammy. We have premiums going up because the extra subsidies expire, and then we’ll have premiums going up even more because they’re going back to this original cost-sharing reduction. And yet, as we have said many times, a lot of these additional people who are now on the Affordable Care Act are people in the very red states that didn’t expand Medicaid. These are Republican voters. 

Karlin-Smith: We haven’t talked a lot about the process of how they got this bill through this week. It was incredibly fast and done literally in the dead of night. 

Ollstein: Multiple nights. 

Karlin-Smith: So you have to wonder, particularly, if you think back to the last time Republicans tried to overturn Obamacare — and they did come pretty close — eventually, I think, that unpalatableness of taking away health care from so many of their own constituents came back to really hurt them. And you do have to wonder if the jamming was in part to make more people unaware of what was happening. You’d still think there’d be political repercussions later down the line when they realize it. But I think, especially, again, just thinking back on all the years when Republicans were saying Democrats were pushing the ACA through too fast and nobody could read the bill, or their CBO scores. This was a much, much faster version of that, with a lot less debate and public transparency and so forth. 

Rovner: Yeah, they went to the Rules Committee at 1 a.m. Wednesday, so Tuesday night. The Rules Committee went until almost 9 o’clock the next evening, just consecutively. And shout out to Rules Committee chairman Virginia Foxx, who sat there for, I think, the entire time. And then they went straight from rules to the floor. 

So it’s now Wednesday night at 10 o’clock at night, and then went all the way through and voted, I think, just before 7 a.m. I’ve done a lot of all-nighters in the Capitol. I haven’t seen one that was two nights in a row like this. And I have great admiration for the people who really were up for 48 hours to push this thing through. 

Well, finally, let’s remember President Trump’s vow not to touch Medicare. Well, Medicare gets touched in this bill, too. In addition to restricting eligibility for some legal immigrants who are able to get coverage now, and making it harder for some low-income Medicare beneficiaries to get extra financial help, mostly through Medicaid, the bill as a whole is also likely to trigger a 4% Medicare sequester. Because, even all those other health cuts and food stamp cuts and other cuts don’t pay for all the huge tax breaks in the bill. Alice, you pointed that out. Is there any suggestion that this part might give people some pause, maybe when it gets to the Senate? 

Edney: I’ve heard the Senate mostly seem upset about Medicaid. And I also feel like this idea that sequestration is coming back up into our consciousness is a little bit new. Like you said, it was pushed through and it was like, Oh, wait, this is enough to trigger sequestration. I think it certainly could become a talking point, because Trump said he would not cut Medicare. I don’t think, if senators are worried about Medicaid — and I think maybe some of us were a little surprised that that is coming from some red-state senators. Medicare is a whole different thing, and in the sense of being even more wildly popular with a lot of members of Congress. 

Rovner: Yeah, I think this whole thing hasn’t, you’re right, sort of seeped into the general consciousness yet. Alice, did you want to say something? 

Ollstein: Yeah, so a couple things, a couple patterns we’ve seen. So one, there are a lot of lawmakers on the right who have been discrediting the CBO, even in advance of estimates coming out, basically disparaging their methodology and trying to convince the public that it’s not accurate. And so I think that’s both around the deficit projections as well as how many people would be uninsured under different policies. So that’s been one reaction to this. 

We’ve seen a pattern over many administrations where certain politicians are very concerned about things adding to the deficit when the opposition party is in power. And suddenly those concerns evaporate when their own party is in power and they don’t mind running up the deficit if it’s to advance policies that they want to advance. And so I think, yes, this could bother some fiscal hawks, and we saw that in the House, but I think, also, these other factors are at play. 

Rovner: Yeah, I think this has a long way to go. There’s still a lot that people, I think you’re right, have not quite realized is in there. And we will get to more of it in coming weeks, because this has a long process in the Senate. 

All right, well, segueing to abortion, the One Big Beautiful Bill also includes a couple of pretty significant abortion provisions. One would effectively ban abortion and marketplace plans for people with lower incomes. Affordable Care Act plans are not currently a big source of insurance coverage for abortion. Many states already ban abortion from coverage in these plans. But this would disrupt one of the big compromises that ultimately got the ACA passed in 2010. 

The other provision would evict Planned Parenthood from the Medicaid program, even though federal Medicaid funds don’t and never have been used for abortions. Many, many Medicaid patients use Planned Parenthood for routine medical care, including contraception and cancer screenings, and that is covered by Medicaid. 

But while I see lots of anti-abortion groups taking victory laps over this, when the House passed a similar provision in 2017 as part of its repeal bill, the Senate parliamentarian ruled that it could not go in a budget reconciliation bill, because its purpose was not, quote, “primarily budgetary.” So is this all for show? Or is there a belief that something different might happen this time? 

Ollstein: Well, I think there is more interest in ignoring or overruling the parliamentarian among Senate Republicans than there has been in the past. We’re seeing that now on an unrelated environmental issue. And so that could signal that they’re willing to do it more in the future. Of course, things like that cut both ways, and that raises the idea that the Democrats could also do that the next time they’re in power. 

Rovner: And we should say, that if you overrule the parliamentarian in reconciliation — it’s a she right now — when she says it can’t go in reconciliation, that is equivalent to getting rid of the filibuster. 

Ollstein: Correct. 

Rovner: So I mean, that’s why both parties say, We want to keep the filibuster. But the moment you say, Hey, parliamentarian, we disagree with you and we’re just going to ignore that, that has ramifications way beyond budget reconciliation legislation. 

Ollstein: That’s right. And so that’s been a line that a lot of senators have not been willing to cross, but I think you’re seeing more willingness than before. So that’s definitely something to watch on that. But I think, in terms of abortion, I think this is a real expansion of trends that were already underway, in ever-expanding the concept of what federal dollars going to abortion means. And it’s now in this very indirect way, where it’s reaching into the private insurance market, and it’s using federal funding as a cudgel to prevent groups like Planned Parenthood, and then also these private plans, from using other non-federal money to support abortions. And so it’s a real expansion beyond just you can’t use federal money to pay directly for abortions. 

Rovner: Well, meanwhile, two other reproductive-associated health stories worth mentioning. In California, a fertility clinic got bombed. The bomber apparently died in the explosion, but this is the first time I can remember a purposeful bombing to a health center that was not an abortion clinic. How significant is it to the debate, that we’re now seeing fertility clinics bombed as well? And what do we know, if anything, about why the bomber went after a fertility clinic? 

Karlin-Smith: There has been, obviously, some pressure on the right, I think, to go after fertility processes, and IVF [in vitro fertilization], and lump that in with abortion. Although, I think Trump and others have pushed back a bit on that, realizing how common and popular some of these fertility treatments are. And also it conflicts, I think, to some extent with their desire to grow the American population. 

The motives of this particular person don’t seem aligned with, I guess, the anti-abortion movement. He sort of seems more anti-natalist movement and stuff. So from that perspective, I didn’t see it as being aligned with kind of a bigger, more common political debate we’ve had recently, which is, again, does the Republican Party want to expand the anti-abortion debate even further into fertility treatments and stuff. 

Rovner: I was going to say, it certainly has drawn fertility clinics into the abortion debate, even if neither side in the abortion debate would presumably have an interest in blowing up a fertility clinic. But it is now sort of, I guess, in the general consciousness of antisocial people, if you will, that’s out there. 

The other story in the news this week is about a woman named Adriana Smith, a nurse and mother from Georgia who was nine weeks pregnant in February when she was declared brain-dead after a medical emergency. Smith has been kept alive on life support ever since, not because her family wants that but because her medical team at Emory University Hospital is worried about running afoul of Georgia’s abortion ban, which prohibits terminations after cardiac activity can be detected. Even if the mother is clinically dead? I feel like this case could have really ominous repercussions at some point. 

Ollstein: Well, I just want to point out that, yes, the state’s abortion ban is playing a role here, but this was happening while Roe v. Wade was still in place. There were cases like this. Some of it has to do with legislation around advanced directives and pregnancy. So I will point out that this is not solely a post-Dobbs phenomenon. 

Rovner: Yeah, I think it also bears watching. Well, there was lots of vaccine news this week — I’m so glad we have Anna and Sarah here — with both the HHS [Department of Health and Human Services] and FDA [Food and Drug Administration] declaring an end to recommending covid vaccines for what seems to be most of the population. Sarah, what did they do? And what does this mean? 

Karlin-Smith: So the new director of FDA’s biologics center and the FDA commissioner released a framework for approving covid shots moving forward. And basically they are saying that, because covid, the virus, shifts, and we want to try and update our vaccines at least yearly, usually, to keep up with the changing viruses, but we want to do that in a reasonable time so that by the time when you update the vaccine it’s actually available within that time — right? — FDA has allowed companies to do studies that don’t require full clinical trials anymore, because we sort of have already done those trials. We know these vaccines are safe and effective. We’re making minor tweaks to them, and they do immunogenicity studies, which are studies that basically show they mount the proper immune response. And then they approve them. 

FDA is now, seems to be, saying, We’re only going to allow those studies to approve new covid vaccine updates for people who are over 65, or under 65 and have health conditions, because they are saying, in their mind, the risk-benefit balance of offering these shots doesn’t necessarily pan out favorably for younger, healthier populations, and we should do clinical trials. 

It’s not entirely clear yet, despite them rolling out a framework, how this will actually play out. Can they relabel shots already approved? Will this only impact once companies do need to do a strain change next as the virus adapts? Did they go about doing this in a sort of legal manner? It came out through a journal kind of editorial commentary piece, not through the Federal Register or formal guidance. There’s been no notice of comment. 

So there’s a lot of questions to remain as to how this will be implemented, which products it would affect, and when. But there is a lot of concern that there may be reduced access to the products moving forward. 

Rovner: That’s because the vaccine makers aren’t going to — it’s not probably worth it financially to them — to remount all these studies. Right? 

Karlin-Smith: First off, a lot of people I’ve talked to, and this came up yesterday at a meeting FDA had, don’t believe it’s actually ethical to do some of the studies FDA is now calling for. Even though the benefits, particularly when you’re talking about boosting people who already had a primary vaccination series for covid, or some covid, is not the same as the benefits of getting an original covid vaccine series. 

There still are benefits, and there still are benefits for pretty much everybody that outweigh the risks. On average, these are extremely safe shots. We know a lot about their safety, and the balance is positive. So people are saying, once that exists, you cannot ethically test it on placebo. Even as [FDA Commissioner Marty] Makary says, Well, so many Americans are declining to take the shot, so let’s test it and see. A lot of ethicists would say it’s actually, even if people are willing to do something that may not be ideal for their health, that doesn’t mean it’s ethical to test it in a trial. 

So, I think there’s questions about, just, ethics, but also, right, whether companies would want to invest the time and money it would take to achieve and try to do them under this situation. So that is a big elephant in the room here. And I think some people feel like this is just sort of a push by Makary and his new CBER [Center for Biologics Evaluation and Research] director, essentially, to cut off vaccine access in a little bit of a sneaky way. 

Rovner: Well, I did see, also this week, was I think it was Moderna, that was going to make a combination flu covid vaccine, has decided not to. I assume that’s related to all of this? 

Karlin-Smith: Right. So Moderna had a, what people call a next-generation vaccine, which is supposed to be an improved update over the original shot, which is a bigger deal than just making a strain change. They actually think they provide a better response to protecting against the virus. And then they also added flu vaccine into it to sort of make it easier for people to get protected from both, and also provided solid data to show it would work well for flu. 

And they seem to have probably pulled their application at this point over, again, these new concerns, and what we know Novavax went through in trying to get their covid vaccine across the finish line dealing with this new administration. So I think people have their sort of alert lights up going forward as to how this administration is going to handle vaccine approvals and what that will mean for access going forward. 

Rovner: Well, in somewhat related news, we got the long-awaited report from Health and Human Services Secretary Robert F. Kennedy Jr.’s Make America Healthy Again Commission, which is supposed to lay out a blueprint for an action plan that will come later this summer. Not much in the 68-page report seems all that surprising. Some is fairly noncontroversial, calling for more study of ultra-processed foods and less screen time and more physical activity for kids. 

And some is controversial but at this point kind of predictable, calling for another look at the childhood vaccine schedule, including, as we just discussed, more placebo studies for vaccines, and also less fluoride available, except in toothpaste. Anything jump out at you guys from the report that we should keep an eye on? 

Karlin-Smith: I think one thing to think about is what it doesn’t address and doesn’t talk about. It’s not surprising the issues they call out for harming health in America, and some of them are debatable as to how much they do or don’t harm health, or whether their solutions would actually address those problems. 

But they never talk about the U.S.’ lack of a health insurance system that assures people have coverage. They don’t mention the Republican Party’s and likely president’s willingness to sign onto a major bill that’s going to impact health. They don’t really talk about the socioeconomic drivers that impact health, which I find particularly interesting when they talk about food, because, obviously, the U.S. has a lot of healthy and unhealthy food available. And a lot of people know sort of how they could make better choices, but there are these situational factors outside of, often, an individual’s control to lead to that. 

And I think the other thing that jumped out to me is, I think The Washington Post had a good line in their paragraph about just how many of the points are either overstated or misstated scientific findings. And they did a pretty good job of going through some of those. And it’s a difficult situation, I think, for the public to grapple with when you have leadership and the top echelons of our health department that is pushing so much misinformation, often very carefully, and having to weed out what is correct, where is the grains of truth, where does it go off into misinformation. 

I don’t know. I find it really hard as a journalist. And so I do worry about, again, how this all plays into public perception and misunderstanding of these topics. 

Rovner: And apparently they forgot about gun violence in all of this, which is rather notably not there. 

Ollstein: Cars and guns are the big killers. And yeah, no mention of that. 

Edney: I thought another glaring omission was tobacco. Kids are using e-cigarettes at high rates. We don’t really know much about them. And to Sarah’s point about misinformation, too, I think the hard part of being able to discern a lot of this, even as a member of the public, is everything they’ve done so far is only rhetoric. There hasn’t been actual regulation, or — this could be anything that you’re talking about. It could be food dyes. It could be “most favored nations.” We don’t know what they actually want to implement and what the potential for doing so — I think maybe on vaccines we’re seeing the most action. But as Sarah mentioned, we don’t know how that, whether it legally is going to be something that they can continue doing. 

So even with this report, it was highly anticipated, but I don’t think we got anything beyond what I probably heard Kennedy say over and over throughout the campaign and in his bid for health secretary. So I am wondering when they actually decide to move into the policymaking part of it, instead of just telling us they’re going to do something. 

Rovner: And interestingly, Secretary Kennedy was interviewed on CNN last night and walked back some of the timelines, even, including that vow that they were going to know the cause of autism by September and that they were going to have an action plan for this ready in another, I think, a hundred days. So this is going to be a hurry-up-and-wait. 

All right, well, that is as much news as we have time for in this incredibly busy week. Now we will play my interview with law professor and abortion historian Mary Ziegler, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Mary Ziegler, the Martin Luther King Jr. professor of law at the University of California-Davis. She’s also a historian of the abortion movement. And her newest book, just out, is called “Personhood: The New Civil War Over Reproduction.” 

Mary Ziegler, thanks for joining us again. 

Mary Ziegler: Thanks for having me. 

Rovner: So we’ve talked about personhood a lot on our podcast, including with you, but it means different things to different people. What’s your working definition, at least for the purpose of this book? 

Ziegler: Yeah, I’m interested in this book in the legal fight for personhood, right? Some people have religious ideas of personhood. Bioethicists have ideas of personhood. Philosophers debate personhood. But I’m really interested in the legal claim that the word “person” in the 14th Amendment, which gives us liberty and equality, applies the moment an egg is fertilized. Because it’s that legal claim that’s had a lot of knock-on effects with abortion, with IVF, and potentially even beyond. 

Rovner: So if we as a society were to accept that fetuses or embryos or zygotes were people with full constitutional rights at the moment of creation, that can impact things way beyond abortion, right? 

Ziegler: Definitely, yeah, especially if you make the moves that the anti-abortion movement, or the pro-life movement, in the United States has made, right? So one of the other things that’s probably worth saying is, if you believe the claim I laid out about fetal personhood, that doesn’t mean you necessarily think abortion should be criminalized or that IVF should be criminalized, either. 

But the people who are leading the anti-abortion movement do, in large part, right? So it would have ramifications in lots of other contexts, because there’s a conclusion not only that human life begins at fertilization and that constitutional rights begin at fertilization but that the way you honor those constitutional rights is primarily by restricting or criminalizing certain things that threaten that life, in the views of the people who advocate for it. 

Rovner: Right. And that includes IVF and forms of contraception. That’s where we sort of get to this idea that an abortion is murder or that, in this case, doing anything that harms even a zygote is murder. 

Ziegler: Yeah. And it gets us to the Adriana Smith case in Georgia, too. So there’s sort of end-of-life cases that emerge. So, it obviously would have a big impact on abortion. So it’s not wrong to think about abortion in this context. It’s just that would definitely not be the stopping point. 

Rovner: So, many people have only talked about personhood, really, since the Supreme Court overturned Roe in 2022, but the concept is a lot older than that. I started covering personhood in like 2010, I think, when a couple of states were trying to vote on it. I didn’t realize until I read your book that it goes back well beyond even that. 

Ziegler: Yeah. So I think a lot of people had that conception. And in the 2010s, there were state constitutional amendment efforts to write the idea of fetal personhood into state constitutions. And they all failed. So I think the narrative coming out of that was that you had the anti-abortion movement on the one hand, and then you had this more extreme fetal personhood movement on the other hand. 

And that narrative fundamentally is wrong. There is no one in the anti-abortion movement who’s opposed to fetal personhood. There are disagreements about how and when it can be recognized. There’s strategic disagreements. There are no substantive disagreements much to speak of on the basics of fetal personhood. 

So the idea goes all the way back to the 1960s, when states were first reforming the 19th-century criminal laws you sometimes see coming back to life as zombie laws. And initially it started as a strategic necessity, because it was very hard for the early anti-abortion movement to stop this reform wave, right? They were saying things like, Oh, abortion is going to lead to more sexual promiscuity, or, No one really needs abortion, because pregnancy is no longer dangerous. And that just wasn’t getting the job done. 

So they began to argue that no one had a choice to legalize abortion in worse circumstances, because it would violate the rights of the unborn child. What’s interesting is that argument went from being this kind of strategic expedient to being this tremendously emotionally resonant long-term thing that has lived on the American right for now like a half-century. Even in moments when, I think arguably like right now, when it’s not politically smart to be making the argument, people will continue to, because this speaks to something, I think, for a lot of people who are opposed to abortion and other things like IVF. 

Rovner: I know you’ve got access in writing this book to a lot of internal documents from people in the anti-abortion movement. I’m jealous, I have to say. Was there something there that surprised you? 

Ziegler: Yeah, I think I was somewhat surprised by how much people talked this language of personhood when they were alone, right? This was not just something for the consumption of judges, or the consumption of politicians, or sort of like a nicer way to talk about what people really wanted. This was what people said when there was no one else there. 

That didn’t mean they didn’t say other things that suggested that there were lots of other values and beliefs underlying this concept of personhood. But I think one of the important lessons of that is if you’re trying to understand people who are opposed to abortion, just assuming that everything they’re saying is just pure strategy is not helpful, right? Any more than it would be for people who support reproductive rights, to have it assume that everything they’re saying is not genuine. You just fail to understand what people are doing, I think. And I think that was probably what I was the most surprised about. 

Rovner: I was struck that you point out that personhood doesn’t have to begin and end with the criminalization of abortion. How could more acceptance of the rights of the unborn change society in perhaps less polarized ways? 

Ziegler: Yeah, one of the things that’s really striking is that there are other countries that recognize a right to life for a fetus or unborn child that don’t criminalize abortion or don’t enforce criminal abortion laws. And often what they say is that it’s not OK for the state to start with criminalization when it isn’t doing things to support pregnant women, who after all are necessary for a fetus or unborn child to survive, right? 

So there are strategies that you could use to reduce infant mortality, for example, to reduce neonatal mortality, to reduce miscarriage and stillbirth, to improve maternal health, to really eliminate some of the reasons that people who may want, all things being equal, to carry a child to term. That’s not, obviously, going to be everybody. Some people don’t want to be parents at all. 

But there are other people for whom it’s a matter of resources, or it’s a matter of overcoming racial discrimination, or it’s a matter of leaving an abusive relationship. And if governments were more committed to doing some of those things, it’s reasonable to assume that a subset of those people would carry pregnancies to term, right? 

So there are lots of ways that if a state were serious about honoring fetal life, that it could. I think one of the other things that’s striking that I realized in writing the book is that that tracks with what a subset of Americans think. You’ll find these artifacts in polls where you’ll get something like 33% of people in Pew Forum’s 2022 poll saying they thought that life and rights began at conception, but also that abortion shouldn’t be criminalized. 

So there are a subset of Americans who, whether they’re coming from a place of faith or otherwise, can hold those two beliefs at once. So I think an interesting question is, could we have a politics that accommodates that kind of belief? And at the moment the answer is probably not, but it’s interesting to imagine how that could change. 

Rovner: It’s nice to know that there is a place that we can hope to get. 

Ziegler: Yeah, exactly. 

Rovner: Mary Ziegler, thank you so much for joining us again. 

Ziegler: Thanks for having me. 

Rovner: OK, we’re back. And now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile devices. Sarah, you chose first this week. You go first. 

Karlin-Smith: I purposely chose a sort of light story from Australia, where scientists studied remote work, and the headline is “[Scientists Have Been Studying Remote Work for Four Years and Have] Reached a Very Clear Conclusion: ‘Working From Home Makes Us Happier.’” And it just goes through some of the benefits and perks people have found from working remotely, including more sleep, more time with friends and family, things like that. And it just felt like a nice, interesting read in a time where there’s a lot of heavy health news. 

Rovner: Also, scientific evidence of things that I think we all could have predicted. Anna. 

Edney: Apologies for going the other direction here, but it’s a story that I wrote this week, an investigation that I’ve been working on for a long time, “The Potential Cancer, Health Risks Lurking in One Popular OTC Drug.” So this is one, in particularly a lot of women have used. You can go in any CVS, Target, Walmart, stores like that, and buy it. Called Azo, for urinary tract infections. And all these stores sell their own generic versions as well, under phenazopyridine. 

And this drug, I was kind of shocked to learn, is not FDA-approved. There are prescription versions that are not FDA-approved, either. It’s just been around so long that it’s been grandfathered in. And that may not be a big deal, except that this one, the FDA has raised questions about whether it causes cancer and whether it needs a stronger cancer warning, because the National Cancer Institute found in 1978 that it causes tumors in rats and mice. But no other work has been done on this drug, because it hasn’t been approved. So no one’s looked at it in humans. And it masks issues that really need antibiotics and causes a host of other issues. 

There were — University of Virginia toxicologists told me they found, in the last 20 years, at least 200 suspected teen suicides where they used this drug, because of how dangerous this drug can be in any higher amounts than what’s on the box. So I went through this drug, but there are other ones on the market as well that are not approved. And there’s this whole FDA system that has allowed the OTC [over-the-counter] market to be pretty lax. 

Rovner: OK, that’s terrifying. But thank you for your work. Alice. 

Ollstein: Speaking of terrifying, I chose a piece from NPR called, “Diseases Are Spreading. The CDC Isn’t Warning the Public Like It Was Months Ago.” And this is a look at all of the ways our public health agency that is supposed to be letting us know when outbreaks are happening, and where, and how to protect ourselves, they’ve gone dark. They are not posting on social media. They are not sending out alerts. They are not sending out newsletters. And it walks through the danger of all of that happening, with interviews with people who are still on the inside and on the outside experiencing the repercussions. 

Rovner: Well, my extra credit, it helps explain why Alice’s extra credit, because it’s about all the people who were doing that who have been fired or laid off from the federal government. It’s called, “White House Officials Wanted To Put Federal Workers ‘in Trauma.’ It’s Working,” by William Wan and Hannah Natanson. 

And it’s the result of interviews with more than 30 current and former federal workers, along with the families of some who died or killed themselves. And it’s a review of documents to confirm those stories. It’s a super-depressing but beautifully told piece about the dramatic mental health impact of the federal DOGE [Department of Government Efficiency] layoffs and firings, and the impact that that’s been having on these workers, their families, and their communities. 

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks to our fill-in editor this week, Rebecca Adams, and our producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Anna? 

Edney: Both of those [X and Bluesky], @annaedney. 

Rovner: Sarah. 

Karlin-Smith: Everywhere — X, Bluesky, LinkedIn, @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice. 

Ollstein: @AliceOllstein on X and @alicemiranda on Bluesky. 

Rovner: I am off to California next week, where we’ll be taping the podcast at the annual meeting of the Association for Health Care Journalists, which we won’t post until the following Monday. So everyone please have a great Memorial Day holiday week. And until then, be healthy. 

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At the Department of Homeland Security, a man was led off the elevator in handcuffs.

But the area housing the regional office of the Department of Health and Human Services was eerily quiet.

In March, HHS announced it would close five of its 10 regional offices as part of a broad restructuring to consolidate the department’s work and reduce the number of staff by 20,000, to 62,000. The HHS Region 2 office in New York City, which has served New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands, was among those getting the ax.

Public health experts and advocates say that HHS regional offices, like the one in New York City, form the connective tissue between the federal government and many locally based services. Whether ensuring local social service programs like Head Start get their federal grants, investigating Medicare claims complaints, or facilitating hospital and health system provider enrollment in Medicare and Medicaid programs, regional offices provide a key federal access point for people and organizations. Consolidating regional offices could have serious consequences for the nation’s public health system, they warn.

“All public health is local,” said Georges Benjamin, executive director of the American Public Health Association. “When you have relative proximity to the folks you’re liaising to, they have a sense of the needs of those communities, and they have a sense of the political issues that are going on in these communities.”

The other offices slated to close are in Boston, Chicago, San Francisco, and Seattle. Together, the five serve 22 states and a handful of U.S. territories. Services for the shuttered regional offices will be divvied up among the remaining regional offices in Atlanta, Dallas, Denver, Kansas City, and Philadelphia.

The elimination of regional HHS offices has already had an outsize impact on Head Start, a long-standing federal program that provides free child care and supportive services to children from many of the nation’s poorest families. It is among the examples cited in the lawsuit against the federal government challenging the HHS restructuring brought by New York, 18 other states, and the District of Columbia, which notes that, as a result, “many programs are at imminent risk of being forced to pause or cease operations.”

The HHS site included a regional Head Start office that was closed and laid off staff last month. The Trump administration had sought to wipe out funding for Head Start, according to a draft budget document that outlines dramatic cuts at HHS, which Congress would need to approve. Recent news reports indicate the administration may be stepping back from this plan; however, other childhood and early-development programs could still be on the chopping block.

Bonnie Eggenburg, president of the New Jersey Head Start Association, said her organization has long relied on the HHS regional office to be “our boots on the ground for the federal government.” During challenging times, such as the covid-19 pandemic or Hurricanes Sandy and Maria, the regional office helped Head Start programs design services to meet the needs of children and families. “They work with us to make sure we have all the support we can get,” she said.

In recent weeks, payroll and other operational payments have been delayed, and employees have been asked to justify why they need the money as part of a new “Defend the Spend” initiative instituted by the Elon Musk-led Department of Government Efficiency, created by President Donald Trump through an executive order.

“Right now, most programs don’t have anyone to talk to and are unsure as to whether or not that notice of award is coming through as expected,” Eggenburg said.

HHS regional office employees who worked on Head Start helped providers fix technical issues, address budget questions, and discuss local issues, like the city’s growing population of migrant children, said Susan Stamler, executive director of United Neighborhood Houses. Based in New York City, the organization represents dozens of neighborhood settlement houses — community groups that provide services to local families such as language classes, housing assistance, and early-childhood support, including some Head Start programs.

“Today, the real problem is people weren’t given a human contact,” she said of the regional office closure. “They were given a website.”

To Stamler, closing the regional Head Start hub without a clear transition plan “demonstrates a lack of respect for the people who are running these programs and services,” while leaving families uncertain about their child care and other services.

“It’s astonishing to think that the federal government might be reexamining this investment that pays off so deeply with families and in their communities,” she said.

Without regional offices, HHS will be less informed about which health initiatives are needed locally, said Zach Hennessey, chief strategy officer of Public Health Solutions, a nonprofit provider of health services in New York City.

“Where it really matters is within HHS itself,” he said. “Those are the folks that are now blind — but their decisions will ultimately affect us.”

Dara Kass, an emergency physician who was the HHS Region 2 director under the Biden administration, described the job as being an ambassador.

“The office is really about ensuring that the community members and constituents had access to everything that was available to them from HHS,” Kass said.

At HHS Region 2, division offices for the Administration for Community Living, the FDA’s Office of Inspections and Investigations, and the Substance Abuse and Mental Health Services Administration have already closed or are slated to close, along with several other division offices.

HHS did not provide an on-the-record response to a request for comment but has maintained that shuttering regional offices will not hurt services.

Under the reorganization, many HHS agencies are either being eliminated or folded into other agencies, including the recently created Administration for a Healthy America, under HHS Secretary Robert F. Kennedy Jr.

“We aren’t just reducing bureaucratic sprawl. We are realigning the organization with its core mission and our new priorities in reversing the chronic disease epidemic,” Kennedy said in a press release announcing the reorganization.

Regional office staffers were laid off at the beginning of April. Now there appears to be a skeleton crew shutting down the offices. On a recent day, an Administration for Children and Families worker who answered a visitor’s buzz at the entrance estimated that only about 15 people remained. When asked what’s next, the employee shrugged.

The Trump administration’s downsizing effort will also eliminate six of 10 regional outposts of the HHS Office of the General Counsel, a squad of lawyers supporting the Centers for Medicare & Medicaid Services and other agencies in beneficiary coverage disputes and issues related to provider enrollment and participation in federal programs.

Unlike private health insurance companies, Medicare is a federal health program governed by statutes and regulations, said Andrew Tsui, a partner at Arnall Golden Gregory who has co-written about the regional office closings.

“When you have the largest federal health insurance program on the planet, to the extent there could be ambiguity or appeals or grievances,” Tsui said, “resolving them necessarily requires the expertise of federal lawyers, trained in federal law.”

Overall, the loss of the regional HHS offices is just one more blow to public health efforts at the state and local levels.

State health officials are confronting the “total disorganization of the federal transition” and cuts to key federal partners like the Centers for Disease Control and Prevention, CMS, and the FDA, said James McDonald, the New York state health commissioner.

“What I’m seeing is, right now, it’s not clear who our people ought to contact, what information we’re supposed to get,” he said. “We’re just not seeing the same partnership that we so relied on in the past.”

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The report found that 96% of the Part D plans and 88% of the Medicare Advantage drug plans agreed to cover at least one of the 10 available copycat drugs on their 2025 formularies. And some did not cover the brand-name version. This was a big jump in coverage from 2024, when only 64% of the Part D plans and 52% of the Medicare Advantage drug plans covered at least one biosimilar version of Humira.

Overall, 99% of enrollees in Part D Plans and 90% in Medicare Advantage drug plans had access to at least one Humira biosimilar in 2025. However, some plans are still restricting access to the biosimilars this year, which precludes usage. Specifically, 10% of Medicare Advantage drug plans and 1% of Part D plans cover only the brand-name medication.

Continue to STAT+ to read the full story…

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Julie Rovner
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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.

Members of Congress are back in Washington this week, and Republicans are facing hard decisions on how to reduce Medicaid spending, even as new polling shows that would be unpopular among their voters.

Meanwhile, with President Donald Trump marking 100 days in office, the Department of Health and Human Services remains in a state of confusion, as programs that were hastily cut are just as hastily reinstated — or not. Even those leading the programs seem unsure about the status of many key health activities.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Alice Miranda Ollstein of Politico, and Margot Sanger-Katz of The New York Times.

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Joanne Kenen
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Alice Miranda Ollstein
Politico

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Read Alice's stories.

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories.

Among the takeaways from this week’s episode:

• How and what congressional Republicans will propose cutting from federal government spending is still up in the air — one big reason being that the House and Senate have two separate sets of instructions to follow during the budget reconciliation process. The two chambers will need to resolve their differences eventually, and many of the ideas on the table could be politically risky for Republicans.
• GOP lawmakers are reportedly considering imposing sweeping work requirements on nondisabled adults to remain eligible for Medicaid. Only Georgia and Arkansas have tried mandating that some enrollees work, volunteer, go to school, or enroll in job training to qualify for Medicaid. Those states’ experiences showed that work requirements don’t increase employment but are effective at reducing Medicaid enrollment — because many people have trouble proving they qualify and get kicked off their coverage.
• New reporting this week sheds light on the Trump administration’s efforts to go after the accreditation of some medical student and residency programs, part of the White House’s efforts to crack down on diversity and inclusion initiatives. Yet evidence shows that increasing the diversity of medical professionals helps improve health outcomes — and that undermining medical training could further exacerbate provider shortages and worsen the quality of care.
• Trump’s upcoming budget proposal to Congress could shed light on his administration’s budget cuts and workforce reductions within — and spreading out from — federal health agencies. The proposal will be the first written documentation of the Trump White House’s intentions for the federal government.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: KFF Health News’ “As a Diversity Grant Dies, Young Scientists Fear It Will Haunt Their Careers,” by Brett Kelman. 

Joanne Kenen: NJ.com’s “Many Nursing Homes Feed Residents on Less Than $10 a Day: ‘That’s Appallingly Low’” and “Inside the ‘Multibillion-Dollar Game’ To Funnel Cash From Nursing Homes to Sister Companies,” by Ted Sherman, Susan K. Livio, and Matthew Miller. 

Alice Miranda Ollstein: ProPublica’s “Utah Farmers Signed Up for Federally Funded Therapy. Then the Money Stopped,” by Jessica Schreifels, The Salt Lake Tribune.  

Margot Sanger-Katz: CNBC’s “GLP-1s Can Help Employers Lower Medical Costs in 2 Years, New Study Finds,” by Bertha Coombs.  

Also mentioned in this week’s podcast:

• MedPage Today’s “Trump Order Targets Med School, Residency Accreditors Over ‘Unlawful’ DEI Standards,” by Cheryl Clark.
• Stat’s “Despite Kennedy’s Stated Support, Funding for Women’s Health Initiative Remains in Limbo,” by Elizabeth Cooney.
• CBS News’ “FDA Head Falsely Claims No Scientists Laid Off, as Agency Shutters Food Safety Labs,” by Alexander Tin.
• The New York Times’ “F.D.A. Scientists Are Reinstated at Agency Food Safety Labs,” by Christina Jewett.

click to open the transcript

Transcript: 100 Days of Health Policy Upheaval

[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, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 1, at 10:30 a.m. As always, news happens fast and things might change by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Margot Sanger-Katz of The New York Times. 

Margot Sanger-Katz: Good morning, everybody. 

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode we’ll have a special report on the first 100 days of the second Trump administration and what’s happened in health policy. But first, as usual, this week’s news. 

So Congress is back from its spring break and studying for midterms. Oops. I mean it’s getting down to work on President [Donald] Trump’s, quote, “big, beautiful” budget reconciliation bill. For those who may have forgotten, the House Energy and Commerce Committee is tasked with cutting $880 billion over the next decade from programs it oversees. Although the only programs that could really get to that total are Medicare and Medicaid, and Medicare has been declared politically off-limits by President Trump. So what are the options you guys are hearing for how to basically cut Medicaid by 10%, which is effectively what they’re trying to do? 

Sanger-Katz: I think it’s a bit of a scramble to decide. My sense is, there’s been for some time a menu of changes that would pull money out of the Medicaid program. There’s also kind of a small menu of other things that the committee has jurisdiction over. And as far as I can tell, all of the various options on that menu are kind of just in a constant rotation of discussion with different members endorsing this one or that one. The president weighs in occasionally or voices from the White House, but I think the committee is waiting on scores from the Congressional Budget Office, so they have to hit this $880 billion number. And so it’s kind of a complicated puzzle to put together the pieces to get to that number and they don’t know what they need. But I also think that they are facing some really difficult politics inside their own caucus in trying to decide what to do and how they can message it in a way that kind of checks everyone’s boxes. 

There are some people who have made promises to their constituents that they’re not going to cut Medicaid. There are some people who have said that they only want to do things that would target fraud and abuse. There are some people who have said that they want to make major structural changes to the program. And all of those people are sort of disagreeing about the exact mechanisms. 

Rovner: The phrase I keep hearing is that the math doesn’t math. 

Sanger-Katz: Yeah. I also think some of them are going to be surprised when the Congressional Budget Office gives them the scores. I think that the leadership has been reassuring a lot of these members, when they voted on these earlier budget bills that were more vague, more theoretical. I think that there were promises that were made to them that, Don’t worry about this. We’re going to solve your problems. This isn’t going to be a huge political headache for you. And I think the reality is is a) The cuts are going to have to be big. That’s what $880 billion means. And b) I think that they are going to be estimated to have pretty big effects on health insurance coverage, because if you’re going to cut $880 billion from Medicaid, that probably means that fewer people are going to be covered. I think some members are going to be surprised by that. 

And the other thing is, I think they’re going to start to see in the analyses and hear from local people that some states are going to get hit harder than others. I think there are some states that these members come from where the cuts are going to disproportionately fall. Now we could talk more about the options on the menu. I think some of them will hurt some states more and others will hurt other states more. And I think that is part of the politicking and debate that’s happening as well, where each of these legislators is trying to figure out how they can hit this target, keep their promises, and also protect their own districts to the best of their ability. 

Rovner: It seems like one of the things at the top of every Republican’s list that would be quote-unquote “acceptable” would be work requirements. And I heard numbers this week that the CBO is estimating something like more than $200 billion over 10 years in work requirements, which would be pretty strong work requirements. But Alice, you’re our work requirements queen here. We know that the stronger those work requirements are, the more people end up falling off who are still eligible, because most people on Medicaid already work, right? 

Ollstein: Yes. The only places in the country that have implemented work requirements for Medicaid have found that it does not increase employment, but it does kick people off the program who should qualify, either because they are working or they have a legitimate reason, they’re a full-time caretaker, they’re a student, they have a disability to not be able to work, and they lose their coverage anyway because they can’t navigate the bureaucracy. And I think what Margot is really getting to is, the fundamental dilemma that Republicans are facing right now as they try to put this together is that the proposals that are most politically palatable to them, like work requirements, won’t get them anywhere near the amount of money they need to cut, that they’ve promised to cut, that they’ve passed a bill pledging to cut in this space. And so that will mean that other things will have to be considered. 

And again, I feel like I say this every time, but we really have to be paying very close attention to semantics here. What one person considers a cut when they say the word “cut” is not necessarily what all of us would consider a cut. What some people in power are labeling waste, fraud, and abuse is people getting health care under the law legitimately. They think they shouldn’t, but they do. And so I think we really need to scrutinize the exact language people are using here. 

Rovner: There does seem to be kind of a zeroing in on what we call the expansion population, the population that was added to Medicaid under the Affordable Care Act, which were people who were not the traditional welfare moms and kids and people with disabilities and seniors in nursing homes. These were people who were otherwise low-income but didn’t have health insurance, which is kind of the point. That’s why we say most of these people are already working. You’re not going to live on your Medicaid benefits. There’s no cash involved. The cash goes to the people who provide the actual health care or in some cases the insurers. But that seems to be when — you were talking about semantics — you see Republicans talking about protecting the most vulnerable. That sounds like they really do want to go after this expansion population. But Margot, as you said, a lot of this expansion population is in red states, right? 

Sanger-Katz: Yeah. I think there’s another dynamic that’s going on right now that is important to keep track of, which is we’re at the sort of beginning of this process. So both the House and Senate have passed budgets. Those lay out these numbers, and they’ve laid out this very high number. It’s a high threshold for the Energy and Commerce Committee in the House. They have to find this $880 billion. After they do that, the entire House has to vote on the entire reconciliation package, which includes not just these changes to Medicaid but also a series of tax changes, changes to defense and homeland security spending, probably reductions in SNAP [the Supplemental Nutrition Assistance Program] and education funding. Then the whole thing goes to the Senate and the Senate has to do its own version.  

And the budget itself is a very weird document. Usually what you see with these budgets is that what the instructions are for the House and the Senate match. In this case, they do not. So the House still has to find these very large Medicaid cuts that I think will be politically problematic for certain House members. But the Senate actually doesn’t. It’s very unclear what the Senate’s plan is and whether they are going to try to go as far. And so I think it creates a difficult dynamic where I think some of these House members may not want to take a hard vote on major budget cuts, that could be politically costly to them, if it’s not even going to become law. And so I think that there’s a lot of kind of meeting of reality that is happening right now, which I think doesn’t mean that they won’t come up with a plan. It doesn’t mean that they won’t pass a plan, and it doesn’t mean that they won’t pass a plan that will affect those budgets of their home states. 

But I do think that they are in a little bit of a politically uncomfortable position right now, where they’re being asked to vote for something that is going to be unpopular in some quarters and where they don’t even really know if the Senate is going to hold their hand and go along with it. 

Ollstein: Just one point. We talk a lot about red states and blue states, but it’s important to remember that blue states have a lot of districts represented by Republicans, and that’s arguably the reason they even have a House majority. And so if they pass something that really sticks it to New York and California, there’s a lot of Republican House members who might be at risk. 

Rovner: Yes. And they’re already making noise. And that’s what I was going to say. The last time Republicans went hard after Medicaid after the expansion was during the effort to repeal the Affordable Care Act in 2017, obviously, and we have a brand-new poll out today from KFF, shows that, if anything, Medicaid is even more relevant to Republicans than it was eight years ago. Today’s poll found that more than three-quarters of those polled say they oppose major cuts to Medicaid, including 55% of Republicans and 79% of independents. Those are pretty big numbers. I guess it helps explain why we’re seeing so many Republicans who are looking — there’s so much hand-wringing right now when they’re trying to figure out how to get to these numbers. Go ahead, Joanne. 

Kenen: The other thing, it’s not just people who have increasingly, across party lines, grown in their affection for Medicaid, which is paying for all sorts of things. It’s paying for long-term care. It’s paying for almost half the births in this country. It’s paying for postpartum care. It’s paying for kids. It’s paying for the disabled. It is paying for a lot of drug and opioid treatment and substance abuse. It is paying for a lot of things. But in addition to the politics of individuals and families relying on — they call it an entitlement for a reason. People feel entitled to it. But once you give it to them, they don’t want to give it away. And it’s hard for politicians. They don’t want to give it up, and it’s hard for politicians to take it away. But the other thing is it’s also incredibly important to health care providers, specifically hospitals, because nursing homes are not going to get cut the way hospitals are vulnerable. 

Rural hospitals, urban hospitals — this is just a, particularly in areas where hospitals are already closing and rural states, it would be devastating to hospitals. You’re beginning to hear them talk more and more and more. Ultimately, I think this is going to come down to three syllables: Donald Trump. We are hearing all sorts of things, right?. He is really good at getting what he wants in the House, even if it’s politically difficult. Someone says, I can’t vote for it, they go back, Speaker [Mike] Johnson goes back in wherever he goes back with them and they come out and vote for it, right? It can take a day, it can take a few hours, but Trump hasn’t lost anything on the floor on the budget so far. We’ve gotten to this point. If Trump decides that he’s going to bite this bullet and go for the $800 [billion], he can probably get it through the House if he really decides that that’s what he wants. Unless they really convince him that it’ll cost the Republicans in the House, and then he has to believe them. He has to think that he really is vulnerable and that the Republicans can lose. And there’s all sorts of questions about what elections are going look like in two years. 

But I think that the providers, they’re lobbying in ways that we can see and they’re lobbying in ways that we can’t see. So that’s a part of it. And then the other thing is that there’s a really interesting dynamic with the expansion of states. The states that have not expanded Medicaid tend to be mostly, not all, in the South, Republican states. Their people are not covered. The people who fall in the gap are still not covered. So they don’t have such a dog in this fight. But as we’ve already mentioned, places with a lot of working-class Republicans, the irony is to order, to get states to accept Medicaid expansion in the first place under the ACA, the federal government gave a lot of money — 90%, right? There was more originally. They’re still paying 90%. And that cost the federal government a lot, but states don’t want to give that money up. It’s free dollars. 

And another layer of weird dynamics is a lot of the conservative states that did expand Medicaid did so with what they call a trigger. If the payment changes, the Medicaid expansion collapses. It’s gone. So there’s this weird dynamic of the states who were most skeptical of Medicaid expansion, ended up making it safe by putting in those triggers because no one wants to pull or press the trigger. 

Sanger-Katz: Can I say one more thing— 

Rovner: Yes, go ahead. 

Sanger-Katz: —about the state-by-state dynamics? Because I’ve actually been thinking about this a lot and doing a lot of reporting on this. Joanne is a 100% right. There are these states that have these triggers. They are predominantly Republican states. So those are states where, again, you’re going to see a lot of people losing coverage, because the state is just going to automatically pull back on all of the coverage for these working-class people who are getting Medicaid because they have a low income. But that’s not universally the case. I did a story a couple of weeks ago. There are three Republican states that actually have constitutional amendments that they have to cover this population. So even more so than the blue states— 

Rovner: We talked about your story, Margot. 

Sanger-Katz: Yeah? I love it. I love it. But even more so than the blue states, these are states that are really locked in. Those state governments and those state hospitals, to Joanne’s point, are going to face some really, really tough choices if we see the funding go away. And then another option that’s on this menu — and again we don’t know what they’re going to choose — but one possibility that I think a lot of the kind of right-leaning wonks are really pushing is to get rid of something called provider taxes, Medicaid provider taxes. And we don’t need to get into, fully into the weeds of how these work, because they are sort of complicated. But what I will say is that because of the way that Medicaid is financed and because of the history of how these taxes have proliferated and expanded across the country, there are quite a few Republican-led states that would be disproportionately harmed by that policy. 

So I just think all of this is a little messy. I think there’s not an easy way — even setting aside the point that Alice made that of course there are Republican lawmakers from blue states. But even if you’re only concerned about the red states, say you’re only concerned about getting the Senate votes and not the House votes, I still think it’s pretty tricky to come up with one of these policies that’s sort of just taking the money out of states where you don’t need votes. 

Rovner: Well, they’re supposed to, the committee is supposed to, start marking up its bill next week. I am dubious as to whether that is actually going to happen on time, but we shall see. Obviously much more on this to come. But I want to move on to news from the Trump administration. Last week we talked about threatening letters sent by the interim U.S. attorney in Washington, D.C., to some major medical journals, including the New England Journal of Medicine. This week we have another story from our friends over at MedPage Today about the administration going after medical student and residency accreditation agencies for their DEI [diversity, equity, and inclusion] efforts, because both organizations have long had robust programs to require medical schools and residency programs to recruit and retain racial and ethnic minorities who are underrepresented in medicine. Now, this isn’t about being woke. Racial and ethnic representation in the health care workforce is an actual health care issue, right? 

Kenen: There’s data. There’s a fair amount of data that shows that this kind of representation, patients having providers that they feel can identify with and understand them and come from a similar background. They’re not always a similar background, but there’s this perception of shared understanding. And there’s a ton of data. Not one or two little studies. There’s a ton of data that it actually improves outcomes. I’m actually working on a piece about this right now, so I’ve just read a bunch of it. 

Rovner: I had a feeling you would know this. 

Kenen: And it’s been pointed out, there was some research in The Milbank Quarterly, too. And I should disclose that Milbank is one of my funders at Hopkins, but they don’t control what I do journalistically. When the courts ruled against DEA in admissions, DEI in admissions, they were looking at sort of the intake, who comes in. And they really weren’t looking at the data of what happens to health care when the workforce is diverse. So there’s a lot of numbers on this, and they looked at one set of numbers and they didn’t look at another pretty solidly researched for many years, like: What is the impact on patients and what is the impact on American health? So if you’re talking about making America healthy again and you want everybody to be healthy, there’s really a good case to be made for a diverse, a competent, well-trained — we’re not talking about letting people in because they’re a token but getting people in who could become qualified doctors, nurses, respiratory therapists, whatever, right? And that data was sort of ignored. The outcomes, the down-the-road impact on health was ignored in that court case. 

Rovner: Also, the practical implications of this are kind of terrifying. Yanking accrediting responsibilities from these groups could make a big mess out of training the health care workforce. These groups have decades of experience devising and enforcing guidelines for medical education, much more than just DEI — what you have to teach, what they have to learn, what they have to be competent in. If the administration takes away these organizations’ recognition, it could raise real questions about the uniformity of medical education around the U.S., not to mention deprive lots of programs of lots of federal funding, because programs have to be accredited in order to draw federal funding. This could turn into a really big deal. 

Kenen: If they go away, what happens? 

Rovner: There would be alternate accrediting bodies. 

Kenen: But I have — when I read about the threats on the current accreditation bodies, I did not see, in what I read last night, I did not see: Then what? That blank was not filled in as far as I am aware. 

Rovner: I don’t think there is a then what. There are some efforts to stand up alternate accrediting bodies, but I don’t think they exist at the moment. And as I said, these are the bodies that have been doing it for now generations of medical students and medical residents. All right, well we also learned this week that the Government Accountability Office, the GAO is investigating 39 different cases of potentially illegal funding freezes, except the agency’s director told a Senate committee, the administration is not cooperating. I think I’ve said this just about every week since February, but there is a law against the administration refusing to spend money appropriated by Congress. And it feels pretty clear in many of these cases that the administration is violating it. 

Why aren’t we hearing more about impoundments and rescissions? The administration says they’re going to send up a rescission request, which is what they are supposed to do when they don’t want to spend money. They have to say: Hey, Congress, we don’t think we should spend this money. Will you vote to let us not spend this money? And yet all we do is talk about all of these cases where the administration is not spending money that’s been appropriated. 

Ollstein: You’re seeing it in grants, and you’re also seeing it in the mass layoffs of agency employees who are in many cases working on congressionally mandated programs, some of them signed into law by President Trump himself in his first term. I’m thinking of the 9/11 health program, some of the firefighter health and safety programs through NIOSH [the National Institute for Occupational Safety and Health]. So this is something I’ve been looking into. But when the enforcement mechanism is really the court’s rule and hope that the rulings are followed, and when they’re not, we’re really running into what people are calling a constitutional crisis, where the normal checks and balances are not working. And we’re finding out that a lot of it has really been on an honor system this whole time. 

Rovner: Margot. 

Sanger-Katz: I was just going to say, I think this is a huge constitutional issue that this administration is facing down. There’s this question about who gets to decide how the money is spent? The Constitution seems to say that it’s Congress. The administration is saying, no, the executive has a lot of authority to just ignore those appropriations requests. There are several cases in the courts right now on this issue related to various programs that the administration has declined to fund. But courts move pretty slowly. There have been some preliminary rulings. I think the preliminary rulings have tended to say that the money should be continuing to flow. But this is one of these issues that is absolutely a thousand percent headed to the Supreme Court and hasn’t gotten there yet. And I think the intensity of the constitutional crisis that Alice is warning about will really become more evident when the court decides. 

But I feel like I can’t talk about this issue without also talking about Congress. Because the Constitution is very clear that Congress has the power of the purse. And Congress has passed these appropriations bills over many years that include very specific funding levels. There’s a whole process. There’s a lot of people that do a lot of work. And Congress has been very weak in asserting its constitutional authority to ensure that this money is spent. We have heard very little, a few little peeps about specific things. But in general I would say the congressional leadership, and the leaders of the Appropriations Committee who have made this their lives’ work, have just not been screaming and yelling and jumping up and down about how their constitutional power has been usurped by the executive. 

And so I think that is also part of the reason why this is continuing to go on, because you see this acquiescence where Republicans in Congress are basically saying to Trump: Okay. Like, please send us a rescission package, but like we’ll go along with this for now. So I do think that we’re sort of waiting on the Supreme Court to try to issue some really definitive legal ruling, and that that is when we’re going to probably have the bigger conversation about who really gets to decide what money is spent. 

Kenen: Susan Collins, who’s the chairman of the Senate Appropriations Committee, did put out a statement yesterday that is stronger than her usual, what we’ve heard to date. But it wasn’t a line in the sand, like, I’m not going let you do this, and I’m going to go to the Supreme Court. So it was more of a toe in the water than I had seen from her before. 

Rovner: I watched that hearing, because I wanted to. This was the first hearing in the Senate Appropriations Committee this year, so the first time they’ve had a formal chance to speak. And it was on biomedical research and the state of biomedical research. And I was the one that was yelling and screaming because neither Susan Collins nor Patty Murray, the ranking Democrat, they both talked about how terrible these cuts are, without saying that they could do something about it. It’s like, you’re the Senate Appropriations Committee. This is your power that they’re taking away, and you’re both saying this is awful without suggesting that You’re taking this from us. So I got a little bit of exercise just watching it. 

Kenen: They put out a statement highlighting— 

Rovner: I know. I heard her, listened. She read the statement. 

Kenen: But what they, how they framed it in the statement was a little bit more pointed. But no, I agree it was not a call to arms. 

Rovner: No. 

Kenen: It was a statement that I hadn’t seen yet. 

Rovner: I watched it live. It didn’t come across as: Hey, this is our responsibility. We passed these bills. You’re supposed to spend this money. I’ve seen a little bit of that coming from the House. I was surprised to not see it coming more from the Senate. We do have to move on. Meanwhile, HHS [Department of Health and Human Services] Secretary Robert F. Kennedy Jr. continues to make headlines for his questionable takes on science and medicine. In an interview this week on the “Dr. Phil” show, Kennedy said that parents, quote, should do their “own research” before having their children vaccinated. And he said that, quote, “new drugs are approved by outside panels,” which they most certainly are not. Those outside panels make recommendations that the FDA [Food and Drug Administration] usually follows but sometimes doesn’t. Yet there’s still not much in the way of opprobrium coming from Republicans inside and outside the administration. Is it just not news anymore when the secretary of health and human services says kind of outlandish and false things? Is it baked in? 

Kenen: Well, we’re waiting. So far. They approved him, and Sen. Bill Cassidy of Louisiana said, I’m going to be in close contact with him, and we’re going to be talking, and I’m going to make sure nothing terrible happens. And lots of things have happened. So at this point, yeah, he’s doing what he wants without — they have said they are going to call him, but I haven’t seen a date set for the hearing. 

Rovner: There’s not a date set for the hearing. 

Kenen: Right. So at some point, at some place, he will eventually be asked about something or other maybe. But at this point, no. He’s MAHA-ing his way through HHS and cuts galore and really things that they were started before he took his job, stuff that Elon Musk started. But now that the team of FDA, C— well, not CDC [the Centers for Disease Control and Prevention] but FDA and NIH [National Institutes of Health] leadership is there, it’s going Kennedy’s way. They’re not standing up and saying, It’s my institute, and I’m going to run it the way I see fit. It’s very, particularly FDA, people who thought that he was the least radical of the officials to be appointed. 

Rovner: He, Marty Makary, the FDA commissioner. 

Kenen: Yes. Some of what he said about vaccines just this week has shocked people who thought he would be a little bit more, not a traditionalist but more traditional in how the FDA did its business. 

Rovner: More science-based, might be a fair way to put it. Well, I want to talk about the continuing cuts at HHS because things are, in a word, confusing. Last week we talked about the cancellation of the Women’s Health Initiative. That’s a decades-old project that has led to a long list of changes in how women are diagnosed and treated for a wide range of conditions. Late in the week, former California first lady and longtime women’s health advocate Maria Shriver announced on social media that she convinced her cousin, RFK Jr., not to cancel the study. But this week Stat reports that Women’s Health Initiative officials around the country have not been officially notified that the cancellation has been rescinded, so they’re kind of frozen in place and can’t really plan anything. 

Similarly, on April 25, The New York Times reported that the FDA had reversed a decision to fire scientists at its food safety lab. But that was days after FDA Commissioner Marty Makary insisted that no scientists had been terminated. Quoting from the CBS News story on Makary’s claims, quote: “‘That just made me so mad … he said no scientists were cut,’ said one laid-off FDA scientist, a chemist who had worked at the agency for years.’” Which kind of leads to the question: Are they just confused at HHS, or are they trying to sort of obfuscate what’s really happening there? I’m hearing department-wide about claims made by spokespeople about funding that’s been, quote, “restored” but that’s still not flowing, according to the people who are trying to get it. Margot, I see you nodding. 

Sanger-Katz: I think there’s just a great deal of confusion. There’s a lot of people missing, too. So I think that just some of the kind of basic mechanics of how you turn things on and off is a little bit broken. But I also think that there are disagreements among the decision-makers about what they want to turn on and off. And we have seen this throughout the Trump administration, not just at HHS but in other places where top officials have said that they’re going to restore funding that was cut or a court has ordered them to restore funding that has been cut, and then, lo and behold, the money doesn’t turn back on. So I just think there’s — this is why it’s a good time to be a journalist. I think it really bears a lot of reporting and follow-up and checking on whether they’re doing the things that they say they’re doing. Some of these things might just be confusion — it’ll take a minute. And some of them, maybe they’ve changed their minds. 

Kenen: Or like the AID [U.S. Agency for International Development] global AIDS money, which they said they were restoring, and it’s questionable still. It’s unclear how much. We certainly know not all of it’s been restored, and it’s unclear. I haven’t done any firsthand reporting on this, but from reading, it’s just uncertain how much. Some is getting through but not what they said they were going to do. I sent an email to some at the CDC yesterday asking, and I had to say: Excuse me. I’m not being facetious. It’s just hard to keep track. Is your division still there? So yes, he was still there. I couldn’t find a master list of which CDC departments are still functioning and which are not. What Elon Musk said was, We’re going to move fast and break things, which is the Silicon Valley mantra, and that We can always fix it. We’ve seen them moving fast, and we’ve seen them breaking things, but we’re waiting on the fixing it. 

Ollstein: And I think it’s been interesting that Secretary Kennedy has said publicly now, on more than one occasion, that these cuts, these program eliminations, certain ones are a mistake. He didn’t even know they happened. He said this in interviews. And then with some of the ones that they’re claiming, they’re restoring, the national firefighters union, the IAFF [International Association of Fire Fighters], said that when they met with HHS leadership, they were told that the HHS blamed mid-level bureaucrats for incorrectly canceling some of these programs. All of this sort of begs the question: Who’s in charge over there? Who’s making these decisions? Is the secretary even in the loop on them? Is this all coming from DOGE [the Department of Government Efficiency]? Yeah, and so I think Margot’s absolutely right about we just really need to keep reporting and not take what they say at face value. And we should do that for any administration. 

Sanger-Katz: The president is scheduled — any day now, we don’t know — to release his, what they’re calling the skinny budget. So this is a document from the White House that says what their spending priorities are for the next fiscal year. We think it’s just going to deal with discretionary spending, but I think it will give us some really good clues about what parts of the various cuts in HHS and other parts of the government were sort of part of the plan or will continue to be part of the plan going forward and which of the cuts were made randomly or haphazardly or at the behest of someone who hadn’t talked to the White House. I definitely am very interested to see that document when it comes out, because I think it is the first time that we’ll really see, written down in one place, what it is that the White House is intending to cut in the federal government. 

Rovner: Yeah, the appropriations committees are very interested in seeing that document, too, so they say. Also the other thing that getting a budget will trigger is having to have some of these people come to Capitol Hill to justify their budget and having Congress get a chance to ask questions. 

Finally, in this week’s news, we haven’t talked about abortion in a while. Not that there isn’t news there, it’s just been eclipsed by all of the bigger news. So I want to catch up. Well, speaking of funding being restored, Alice, you were the first to report that the Trump administration has quietly resumed Title X family planning funding to Oklahoma and Tennessee, even while it’s still frozen for some other states. Not so coincidentally, Oklahoma and Tennessee had their Title X money cut off during the Biden administration, because they were out of compliance with the Title X rules requiring women with unintended pregnancies to be counseled on all of their options, including pregnancy termination. I guess this shouldn’t be surprising except for the fact that the grant notices to these states said the money was being restored pursuant to settlement agreements that apparently don’t exist? 

Ollstein: Yes, these states are still not complying with the Title X requirements. That’s what they went to court about. Those cases have not been settled. These states weren’t even expecting this money and were surprised about it and now have to come up with how to actually administer it, because the money was going to other groups in those states that were providing services. And so, it’s really thrown everyone for a loop. And this is coming at a time when grants for a lot of other Title X providers who say they are following the rules have been indefinitely frozen. They’re allegedly being investigated for violating orders on DEI and immigration, but they have heard nothing about where that investigation stands, whether the money is coming. And in the meantime, a lot of people, hundreds of thousands, according to the National Family Planning and Reproductive Health Association, that represents all these providers, are said to lose services. And again, this is access to birth control for low-income people, STI [sexually transmitted infection] testing, a lot of things people need. 

Rovner: So, when we last visited Texas, abortion opponents and women who’d had pregnancy complications were fighting over a bill that was supposed to clarify that the state’s 2022 ban would allow pregnancy terminations in emergency medical situations. Well, apparently they reached a rapprochement, because the Texas Senate this week passed a bill by a 31-0 vote. Alice, what broke the logjam? And will this bill ultimately get signed by the governor? Is there a deal here? 

Ollstein: Well, we’ll have to see. Medical experts have been very skeptical about the provisions here and don’t trust Texas lawmakers to have patients’ best interest in mind, given the impact of previous policies on this front. And so just given the makeup of the state legislature and the officials in power, it’s definitely very possible it will become law. There could be court challenges. We’ll just have to see how it plays out. 

Rovner: Well, this is obviously not any kind of sign that Texas is going soft on abortion, because the Senate also this week passed a bill that would basically extend the state’s bounty hunter abortion law, that lets private individuals sue doctors or others who help people get abortions, would extend that to manufacturers, mailers, and deliverers of abortion pills. Alice, this would be a pretty big step in the state’s efforts to curtail abortions, right? 

Ollstein: Yeah, I think we should think about bills like this like a lot of other bills that are already in place, in that it’s not possible to fully enforce them. It’s not possible to prevent — short of opening everyone’s mail and surveilling everyone in the state — it’s not really possible to prevent medication abortion being mailed. And in the case that’s already in court about a New York doctor who is providing pills to patients in Texas and other states under a shield law, New York has said: We are not turning over this doctor. We are not going to enforce. What she’s doing is legal in our state. It’s legal in the place where she is doing the action, so you can’t have her. 

So I think the main issue here is the chilling effect. It’s a law that makes people more afraid potentially to go and order these pills online or over the phone. And so they’re hoping that that deters people, because, I think, it’s totally possible that, like the New York doctor, we’ve already seen, they pick a few cases to make an example of people and to further that chilling effect, because it’s not possible to go after everybody. 

Sanger-Katz: It just really highlights, I think, the challenges of President Trump’s approach to this issue, which is, he basically said: Let’s just leave it to the states. Let’s not have a lot of federal policy on abortion. Now, there are things that are being done through the Title X funding and everything that affect reproductive health. But in general, there just does not seem to be an appetite for big sweeping regulations that would make abortion substantially harder to get everywhere or any kind of law that would ban or restrict abortion nationwide. And the problem is is if you’re a Texas legislator and you were trying to prevent abortions in Texas, it’s a really frustrating situation, because the state boundaries are just so porous. And particularly because of these abortion pills that can be easily smuggled in through various ways, through mail or someone walking across the border or someone going and coming back, there are still a lot of abortions that are happening in Texas. 

And so I think if you’re someone whose public policy goal is to restrict or stop abortions in Texas, you start having to have to think creatively about even some of these kinds of enforcement mechanisms that, as Alice said, are kind of hard to achieve and probably are going to have a selective enforcement approach. But I think they just haven’t really been able to achieve their goals. And you look at the national abortion statistics and when you look at some of the data on even the state of residency of people who are getting abortions of various types, there just haven’t been big declines. Even in Texas, even in this very big state that has very restrictive laws, there are a lot of women from Texas who are continuing to get abortions. And I think that’s why we’re seeing the state legislature continue to reach for more ambitious ways to curtail it. 

Rovner: Yes. Much to the frustration of the people who are making the anti-abortion laws in Texas. All right. That is this week’s news. Now I want to spend a few minutes trying to synthesize all that’s happened in health policy in the now 102 days since Donald Trump began his second term. I’ve asked each of the panelists to give us a just quick summary of some specific topics. Joanne, why don’t you kick us off with how public health has changed in these last couple of months? 

Kenen: Yeah. Basically if you — when I started writing it down, I couldn’t fit it on a page. If you name anything in public health, it’s been cut or reduced or put in jeopardy. We’ve talked extensively about what’s going on. And by public health, I’m talking about federal down to cities, because they’ve lost their money. So, whether you’re in a red state or a blue, you have less to spend, you’re not allowed to talk about certain things. HIV money has been affected. Global health has been affected. Obviously measles — we did not have whatever the number of measles cases, I believe it’s over a thousand by now. I haven’t seen the last number. Data has vanished. And that data, there are some nonprofits that are trying to collate it and make it available, but years and years and years of data, which was the foundation of data-based, reality-based, and measuring gains and losses in public health, that’s been obliterated. Things are being stopped at NIH. That’s the future of public health, right? 

If you’re stopping training, if you’re stopping universities, if you’re stopping postdocs, if you’re stopping graduate school funding, that’s not just public health today but public health as far as we can see in the future. The anti-smoking, anti-tobacco-use, the suicide helpline is in danger. Mental health, opioid treatment is being rolled back. Pretty much if you think of public health, it’s really hard to think of anything that has not been affected. 

Rovner: Thank you. That was a pretty good summation. Margot, if you had to write a one-page elementary school book report on DOGE and what’s happened at HHS, what would it be? 

Sanger-Katz: Well, I think it’s highly overlapping with a lot of what Joanne was talking about. I think we’ve seen these outsiders who came into the government and just started kind of hacking and slashing. They have eliminated a lot of functions of HHS that have existed for a really long time, not just individual people who have lost their jobs but whole offices that have disappeared, whole functions that existed for a long time and don’t exist anymore. I do think — I was talking about the skinny budget — we’re going to find out the president’s plan for this. I will give Secretary Kennedy some credit for releasing a sort of blueprint for what his goals were in trying to reorganize HHS. It seemed like they did have an idea in some cases of what they were trying to do — consolidate duplication, centralize certain functions, de-emphasize and reemphasize other priorities. 

Rovner: Cut NIH from 27 institutes to eight. 

Sanger-Katz: Right. Eliminate regional offices in various ways. But I think it is worthwhile to think about the DOGE effort in terms of what its goals are and whether those goals are really aligned with particular goals around health policy. In some cases, I do think Secretary Kennedy has directed them to do things that are in line with his goals for health policy, but I think a lot of this cutting was really just cutting for cutting’s sake, trying to hit certain budgetary target numbers, trying to reduce funding to some percentage of contracts, some percentage of grants. And of course, there has also been, from the White House, a desire to target particular political enemies of the president. So we’ve seen, all the NIH grants canceled to universities where he’s having feuds over other issues, huge categories of research funding just drying up because they’re at odds with various political priorities of the president. 

So there are multiple power centers that are all kind of wrestling over this future of HHS. You have the secretary himself, you have the White House, and you have this DOGE entity, which was kind of on the outside now and now is on the inside. And I think part of what we have seen is a real wrestling around that. And just very, very large reductions across all of the functions of what the department does. 

Kenen: Some of these things that Margot and I are talking about do have, in fact — they’re about chronic disease. So if Kennedy is trying to reorient our health system to fight chronic disease, then why are you cutting diabetes programs and why are you cutting long-term women’s health studies? These are chronic disease. Diabetes is the great example of a chronic disease that we really could do better on prevention, making sure people don’t get it. But not everybody — we could make gains there. And yet some of these key programs that are supposedly in line with his priorities are also on the cutting-room floor. And I will stop there. 

Rovner: And I have said, and I made this point before, but I will make it again here because I think it’s relevant, which is that I feel like HHS is part of the Jenga tower that holds up the nation’s health care system writ large, and that they’re kind of yanking pieces out willy-nilly. And I do worry that the whole thing is going to come crumbling down at some point. Obviously it hasn’t yet, but we’re going to see what happens when they take away a lot of these things. Like I said, yanking the ability of accreditation agencies to do their jobs, things that happen in the background that are going away, that won’t happen anymore. And we’re going to have to see what happens with that. 

Sanger-Katz: And I do think some of this really long-term research, both the collection of government data and also the funding of these very large longitudinal studies, I think those are the kinds of cuts that you don’t really see the effects of those right away. It’s the things that you don’t know in the future. And I think that we see a lot of cuts of that sort, where you see the DOGE team come in and they say: Oh, data. Oh, analysis. Like, we can do this better with our own tools. We have technical expertise. We don’t need this whole office of people that are doing data. And across the government, you’re seeing this real loss of long-term data collection and analysis, data sets and studies and surveys that have been conducted for decades, and there are just going to be holes in those. And we may not know the effects of those losses for some time. 

Rovner: I think that, too. Well, Alice, I don’t want to leave without touching on reproductive health. I’m actually a little surprised at all this administration has not done on abortion, as Margot was talking about, and other reproductive issues. So what have they done? 

Ollstein: Yeah, so I kind of have organized my thoughts into three buckets. So, it’s things they’ve done that the anti-abortion movement likes, things that the anti-abortion movement wants them to do that they haven’t done yet, and things that they’ve done that have actually pissed off the anti-abortion movement. These are not equal buckets — they’re just three categories. 

So, OK. What they have done: The anti-abortion movement was very pleased that the Trump administration rolled back a lot of Biden policies making abortion more accessible for veterans and service members. Also got reimposed the Mexico City policy, which restricts international aid for family planning programs that talk about abortion or refer people to abortion services. Of course, that’s been overshadowed by the just total decimation of foreign aid in general, but it’s still meaningful. I would say that the Trump administration switching sides in a legal battle over emergency room abortions was one of the biggest developments. We are still waiting to find out if they’re also going to switch sides in ongoing litigation over FDA regulation of abortion pills. That’s TBD but could be very big no matter which way they go. And the freeze on Title X funding that we’ve already discussed. The anti-abortion movement has been pleased by that because a lot of that has hit Planned Parenthood. Of course, it’s hitting providers beyond Planned Parenthood as well. 

So I also find it interesting that they have not done a lot of what the anti-abortion movement wants in terms of reimposing restrictions on abortion pills, saying they can’t be sent by mail, can’t be prescribed by telemedicine. So there’s a big push underway to pressure the administration to make those changes. Could still happen, but it has definitely not been something that they’ve prioritized at the beginning of the administration. 

And in this much smaller category of things they’ve done that have angered the anti-abortion movement, I’m thinking mainly of an executive order that didn’t actually do anything but purported to promote IVF [in vitro fertilization]. And he ordered his administration to study ways to make IVF more accessible and affordable. And a lot of anti-abortion groups view IVF as it’s currently practiced as akin to abortion, because some embryos are discarded. So, I sort of think of it like Trump has governed so far on abortion, a lot like he campaigns, trying to please the moderates and the conservatives and not really pleasing everyone fully and being a little all over the place. 

Rovner: Thank you. That was a great summary, and we’re on to the next hundred days. All right. That’s the news for this week. Now it is time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Joanne, why don’t you go first this week? 

Kenen: Yeah. This is a pair of articles [“Many Nursing Homes Feed Residents on Less Than $10 a Day: ‘That’s Appallingly Low’” and “Inside the ‘Multibillion-Dollar Game’ To Funnel Cash From Nursing Homes to Sister Companies”] published by New Jersey Advance but in conjunction with papers in, The Oregonian in Oregon, MLive in Michigan, and in Alabama, and it’s by Ted Sherman, Susan Livio, and Matthew Miller. And it’s a really deep two-part investigation into, basically, greed at nursing homes. I don’t think they use the word “greed,” but that’s what it is. Feeding people, like, a food budget of $10 or less a day. Splitting the ownership so that there’s various interconnected businesses, so it looks like the nursing home doesn’t have enough money, because they’re actually paying somebody else for services provided at the nursing home that has the same owner, so it’s sort of financial gamesmanship. And just not taking care of people. Really well documented. They had thousands of pages of CMS [Centers for Medicare & Medicaid] files. They had university professors and data experts helping them analyze it. There’s never been an analysis, they say, this extensive. And it just shows tremendous abuse and just asks a What next? question and Why is this allowed to happen? question. 

Rovner: It’s a really good piece. Margot. 

Sanger-Katz: I want to highlight a piece from CNBC called “GLP-1s Can Help Employers Lower Medical Costs in 2 Years, New Study Finds.” I have some cautions about this study because the full study has not been made public. It has not been published in a peer-reviewed journal, and I still have lots of questions about it. Nevertheless, I read the story and I thought about it a lot and I have been thinking about it a lot since. And so I still feel like it is worth reading and talking about. This study was done by Aon, which is a big benefits consultant, and they pooled all this data from lots of employers who are covering these anti-obesity drugs for their workers. And basically what they say they found in the story is that among those people who continued to take the drug, who had what they called very high adherence to the drug, for two years, they actually found that their health improved so much that they saved their employers health plan money over that two-year period, even when compared to the very high cost of these drugs. 

So I would say this is a pretty surprising result. These drugs are expensive, and I think there was always an expectation that they were going to reduce people’s health care needs because they prevent diabetes and cardiac events and all of these other serious diseases. But I think there was always an expectation that the payback period would be much longer because the cost is so high. One more thing that jumped out at me in this study is there are some published studies from the clinical trials of Wegovy, the first anti-obesity drug that got approved by the FDA, that found that cardiac events among people taking those drugs were significantly diminished. But I think in a clinical trial where everything is perfect, you always expect those results to look a little bit better. 

This study, again, we can’t totally look under the hood, but they found 44% reduction in major cardiac incidents among working-age people who are taking these drugs in just two years. If that holds up, I think it just is additional evidence that these drugs are really, really promising for public health. Reducing heart attacks and strokes is just — and that’s compared to the standard of care. That’s compared to other people who had employer insurance who were of similar health, who were presumably taking statins and blood pressure drugs and the other things that you do to prevent cardiac events. So, I think, let’s not overinterpret this study. There could be something weird about it. But I do think it’s another promising indication that these drugs have the potential to have big public health impact and to potentially be a little less expensive for the system than we have been thinking of them. 

Rovner: And of course there are still efforts to lower the prices, which would obviously increase the benefit. 

Sanger-Katz: The big question I have is what percentage of people who are prescribed the drug are in this very adherent group, right? Because the companies are spending a lot of money giving people drugs who then stop taking them for various reasons or take them in a way that doesn’t produce these big health results. It could still be hugely expensive relative to the savings. But at least in this group that was taking the drugs, it seems like they’re getting healthier pretty quickly. 

Rovner: Interesting. 

Kenen: But if people aren’t taking it, if — adherence is often meant, like: Oh, I take it some days and not others, I forget to take my cholesterol drug, whatever. But if people stop taking it because there are side effects, then the cost also drops off. 

Rovner: Right. Yeah. We’ll see. Alice. 

Ollstein: So I chose a sad story from ProPublica. It’s called, “Utah Farmers Signed Up for Federally Funded Therapy. Then the Money Stopped.” And this is about a program through USDA [the U.S. Department of Agriculture] to offer to fund vouchers for farmers to be able to access mental health care. Farmers are notoriously very high-risk for suicide. There are a lot of challenges in that population. And this allowed people to, sometimes for the first time in their lives, to get these services. And the federal money has run out. There’s no sign it’s getting renewed. And while some states have stepped in and provided state money to continue these programs, Utah and some others have not, and people have lost that access. And the article is about the sad consequences of that. So, highly recommend. 

Rovner: All right. My extra credit this week is from my KFF Health News colleague Brett Kelman, and it’s called “As a Diversity Grant Dies, Young Scientists Fear It Will Haunt Their Careers.” It’s about a unique early-career grant program at the NIH, now canceled by the Trump administration, aimed at boosting the careers of young scientists from backgrounds that are underrepresentative, which includes not just race, gender, and disability but also those from rural areas or who grew up poor or who were the first in their family to attend college. It’s not only a waste of money — canceling multi-year grants in the middle essentially throws away the money that went before — but in this case it’s yet another way this administration is telling young scientists that they’re essentially not wanted and maybe they should consider another career or, as many seem to be doing, seek employment in other countries. As the old saying goes, it feels an awful lot like eating the seed corn. 

All right. That is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our editor, Emmarie Huetteman, and our producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Joanne? 

Kenen: I’m at Bluesky, @joannekenen, or I use LinkedIn more than I used to. 

Rovner: Margot? 

Sanger-Katz: I’m @sangerkatz in all the places, including on Signal. If you guys want to send me tips, I’m @sangerkatz.01. 

Rovner: Excellent. Alice? 

Ollstein: @AliceOllstein on Twitter and @alicemiranda on Bluesky. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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If they couldn’t reach an agreement, he’d have to find new doctors or new health insurance.

“All my medical information is with Baylor Scott & White,” said Neary, 87, who retired from a career in financial services. His doctors are a five-minute drive from his house. “After so many years, starting over with that many new doctor relationships didn’t feel like an option.”

After several anxious weeks, Neary learned Humana and Baylor were parting ways as of this year, and he was forced to choose between the two. Because the breakup happened during the annual fall enrollment period for Medicare Advantage, he was able to pick a new Advantage plan with coverage starting Jan. 1, a day after his Humana plan ended.

Other Advantage members who lose providers are not as lucky. Although disputes between health systems and insurers happen all the time, members are usually locked into their plans for the year and restricted to a network of providers, even if that network shrinks. Unless members qualify for what’s called a special enrollment period, switching plans or returning to traditional Medicare is allowed only at year’s end, with new coverage starting in January.

But in the past 15 months, the Centers for Medicare & Medicaid Services, which oversees the Medicare Advantage program, has quietly offered roughly three-month special enrollment periods allowing thousands of Advantage members in at least 13 states to change plans. They were also allowed to leave Advantage plans entirely and choose traditional Medicare coverage without penalty, regardless of when they lost their providers. But even when CMS lets Advantage members leave a plan that lost a key provider, insurers can still enroll new members without telling them the network has shrunk.

At least 41 hospital systems have dropped out of 62 Advantage plans serving all or parts of 25 states since July, according to Becker’s Hospital Review. Over the past two years, separations between Advantage plans and health systems have tripled, said FTI Consulting, which tracks reports of the disputes.

CMS spokesperson Catherine Howden said it is “a routine occurrence” for the agency to determine that provider network changes trigger a special enrollment period for their members. “It has happened many times in the past, though we have seen an uptick in recent years.”

Still, CMS would not identify plans whose members were allowed to disenroll after losing health providers. The agency also would not say whether the plans violated federal provider network rules intended to ensure that Medicare Advantage members have sufficient providers within certain distances and travel times.

The secrecy around when and how Advantage members can escape plans after their doctors and hospitals drop out worries Sen. Ron Wyden of Oregon, the senior Democrat on the Senate Finance Committee, which oversees CMS.

“Seniors enrolled in Medicare Advantage plans deserve to know they can change their plan when their local doctor or hospital exits the plan due to profit-driven business practices,” Wyden said.

The increase in insurer-provider breakups isn’t surprising, given the growing popularity of Medicare Advantage. The plans attracted about 54% of the 61.2 million people who had both Medicare Parts A and B and were eligible to sign up for Medicare Advantage in 2024, according to KFF, a health information nonprofit that includes KFF Health News.

The plans can offer supplemental benefits unavailable from traditional Medicare because the federal government pays insurers about 20% more per member than traditional Medicare per-member costs, according to the Medicare Payment Advisory Commission, which advises Congress. The extra spending, which some lawmakers call wasteful, will total about $84 billion in 2025, MedPAC estimates. While traditional Medicare does not offer the additional benefits Advantage plans advertise, it does not limit beneficiaries’ choice of providers. They can go to any doctor or hospital that accepts Medicare, as nearly all do.

Sanford Health, the largest rural health system in the U.S., serving parts of seven states from South Dakota to Michigan, decided to leave a Humana Medicare Advantage plan last year that covered 15,000 of its patients. “It’s not so much about the finances or administrative burden, although those are real concerns,” said Nick Olson, Sanford Health’s chief financial officer. “The most important thing for us is the fact that coverage denials and prior authorization delays impact the care a patient receives, and that’s unacceptable.”

The National Association of Insurance Commissioners, representing insurance regulators from every state, Puerto Rico, and the District of Columbia, has appealed to CMS to help Advantage members.

“State regulators in several states are seeing hospitals and crucial provider groups making decisions to no longer contract with any MA plans, which can leave enrollees without ready access to care,” the group wrote in September. “Lack of CMS guidance could result in unnecessary financial or medical injury to America’s seniors.”

The commissioners appealed again last month to Health and Human Services Secretary Robert F. Kennedy Jr. “Significant network changes trigger important rights for beneficiaries, and they should receive clear notice of their rights and have access to counseling to help them make appropriate choices,” they wrote.

The insurance commissioners asked CMS to consider offering a special enrollment period for all Advantage members who lose the same major provider, instead of placing the burden on individuals to find help on their own. No matter what time of year, members would be able to change plans or enroll in government-run Medicare.

Advantage members granted this special enrollment period who choose traditional Medicare get a bonus: If they want to purchase a Medigap policy — supplemental insurance that helps cover Medicare’s considerable out-of-pocket costs — insurers can’t turn them away or charge them more because of preexisting health conditions.

Those potential extra costs have long been a deterrent for people who want to leave Medicare Advantage for traditional Medicare.

“People are being trapped in Medicare Advantage because they can’t get a Medigap plan,” said Bonnie Burns, a training and policy specialist at California Health Advocates, a nonprofit watchdog that helps seniors navigate Medicare.

Guaranteed access to Medigap coverage is especially important when providers drop out of all Advantage plans. Only four states — Connecticut, Massachusetts, Maine, and New York — offer that guarantee to anyone who wants to reenroll in Medicare.

But some hospital systems, including Great Plains Health in North Platte, Nebraska, are so frustrated by Advantage plans that they won’t participate in any of them.

It had the same problems with delays and denials of coverage as other providers, but one incident stands out for CEO Ivan Mitchell: A patient too sick to go home had to stay in the hospital an extra six weeks because her plan wouldn’t cover care in a rehabilitation facility.

With traditional Medicare the only option this year for Great Plains Health patients, Nebraska insurance commissioner Eric Dunning asked for a special enrollment period with guaranteed Medigap access for some 1,200 beneficiaries. After six months, CMS agreed.

Once Delaware’s insurance commissioner contacted CMS about the Bayhealth medical system dropping out of a Cigna Advantage plan, members received a special enrollment period starting in January.

Maine’s congressional delegation pushed for an enrollment period for nearly 4,000 patients of Northern Light Health after the 10-hospital system dropped out of a Humana Advantage plan last year.

“Our constituents have told us that they are anticipating serious challenges, ranging from worries about substantial changes to cost-sharing rates to concerns about maintaining care with current providers,” the delegation told CMS.

CMS granted the request to ensure “that MA enrollees have access to medically necessary care,” then-CMS Administrator Chiquita Brooks-LaSure wrote to Sen. Angus King (I-Maine).

Minnesota insurance officials appealed to CMS on behalf of some 75,000 members of Aetna, Humana, and UnitedHealthcare Advantage plans after six health systems announced last year they would leave the plans in 2025. So many provider changes caused “tremendous problems,” said Kelli Jo Greiner, director of the Minnesota State Health Insurance Assistance Program, known as a SHIP, at the Minnesota Board on Aging. SHIP counselors across the country provide Medicare beneficiaries free help choosing and using Medicare drug and Advantage plans.

Providers serving about 15,000 of Minnesota’s Advantage members ultimately agreed to stay in the insurers’ networks. CMS decided 14,000 Humana members qualified for a network-change special enrollment period.

The remaining 46,000 people — Aetna and UnitedHealthcare Advantage members — who lost access to four health systems were not eligible for the special enrollment period. CMS decided their plans still had enough other providers to care for them.

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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Julie Rovner
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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.

Congress returns from spring break next week and will get to work crafting a bill that would cut taxes and boost immigration enforcement — but that also could cut at least $880 billion over the next decade from a pool of funding that includes Medicaid. Some Republicans, however, are starting to question the political wisdom of making such large cuts to a program that provides health coverage to so many of their constituents.

Meanwhile, the Supreme Court heard arguments in a case challenging the requirement that most private insurance cover certain preventive services with no out-of-pocket cost for patients.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Sarah Karlin-Smith
Pink Sheet

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Tami Luhby
CNN

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Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• On the hunt for ways to pay for an extension of President Donald Trump’s tax cuts, many congressional Republicans are choosing their words carefully as they describe potential cuts to Medicaid — cuts that, considering heavy reliance on the program, especially in red states, could be politically unpopular.
• Amid the buzz over Medicaid cuts, another federal program that helps millions of Americans afford health care is also on the chopping block: the enhanced government subsidies introduced under the Biden administration that help pay premiums for Affordable Care Act plans. The subsidies expire at the end of this year, and Congress has yet to address extending them.
• One little-discussed option for achieving deep government spending cuts is Medicare Advantage, the private alternative to traditional Medicare that offers a variety of extra benefits for those over 65 — but that also costs the federal government a bundle. Even Mehmet Oz, the new head of the Centers for Medicare & Medicaid Services who once pushed Medicare Advantage plans as a TV personality, has cast sidelong glances at private insurers over how much they charge the government.
• And the Supreme Court heard oral arguments this week in a case that challenges the U.S. Preventive Services Task Force and could hold major implications for preventive care coverage nationwide. The justices’ questioning suggests the court could side with the government and preserve the task force’s authority — though that decision would also give more power over preventive care to Robert F. Kennedy Jr., the health and human services secretary.

Also this week, Rovner interviews KFF Health News’ Rae Ellen Bichell about her story on how care for transgender minors is changing in Colorado.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: MedPage Today’s “Medical Journals Get Letters From DOJ,” by Kristina Fiore.

Sarah Karlin-Smith: The Tampa Bay Times’ “Countering DeSantis, $10M Hope Florida Donation Came From Medicaid, Draft Shows,” by Alexandra Glorioso and Lawrence Mower.

Tami Luhby: Stat’s “In Ireland, a Global Hub for the Pharma Industry, Trump Tariffs Are a Source of Deep Worry,” by Andrew Joseph.

Alice Miranda Ollstein: The New York Times’ “A Scientist Is Paid to Study Maple Syrup. He’s Also Paid to Promote It,” by Will Evans, Ellen Gabler, and Anjali Tsui.

Also mentioned in this week’s podcast:

• Stat’s “New England Journal of Medicine Gets Swept Up in U.S. Attorney Inquiry Into Alleged Bias,” by Anil Oza.
• KFF’s “KFF Tracking Poll on Health Information and Trust: The Public’s Views on Measles Outbreaks and Misinformation,” by Alex Montero, Grace Sparks, Julian Montalvo III, Ashley Kirzinger, and Liz Hamel.
• Bloomberg News’ “Food Industry Says There’s No Agreement With US Health Agency to Cut Dyes,” by Rachel Cohrs Zhang.
• Politico’s “RFK Jr. Eyes Reversing CDC’s Covid-19 Vaccine Recommendation for Children,” by Adam Cancryn.
• The New Yorker’s “The Cost of Defunding Harvard,” by Atul Gawande.
• The Wall Street Journal’s “Trump’s FDA Sends a Bullish Signal to Biotech,” by David Wainer

click to open the transcript

Transcript: Can Congress Reconcile Trump’s Wishes With Medicaid’s Needs?

[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, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 24, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Tami Luhby of CNN. 

Tami Luhby: Hello. 

Rovner: And Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with my KFF Health News colleague Rae Ellen Bichell about her story about how care options are changing for trans kids in Colorado. But first, this week’s news. 

We’re going to start this week with Congress, which is still out, by the way, on spring break but does return on Monday. When members get back, it will be full speed ahead on that, quote, “big, beautiful” reconciliation bill, as the president likes to call it. But there are already some big storm clouds on the horizon, particularly when it comes to cutting Medicaid by $880 billion over the next decade. We would appear to have both moderate and conservative Republicans voicing doubts about those big Medicaid cuts. Or are they hiding behind semantics? Some of them are saying, Well, we don’t want to cut Medicaid, but it would be OK to have work requirements, which, as we’ve talked about many times, would cut a lot of people off of Medicaid. Alice, I see you nodding. 

Ollstein: Yes. So, people really need to pay attention to the specifics and press members on exactly what they mean. What do they mean by “cut”? Because some people don’t consider certain things a cut. Some people consider them efficiency or savings, or there’s a lot of different words we hear thrown around. And also, who is impacted? Who are they OK being impacted? There’s a lot of rhetoric sort of pitting the people on the Medicaid expansion, who are not parents, not people with disabilities, against people on traditional Medicaid in ways that some advocates find offensive or misleading. And so, I think when members say, I am against Medicaid cuts, I will not vote for Medicaid cuts, we really need to ask: What do you consider a cut? And who are you OK allowing to be impacted? 

Luhby: Yeah. Speaker Mike Johnson had a very telling comment on Fox News’ “Sunday Morning Futures” earlier this month where he said, “The president has made absolutely clear many times, as we have as well, that we’re going to protect Medicare, Social Security, Medicaid for people who are legally beneficiaries of those programs.” But then he goes on to say: “At the same time, we have to root out fraud, waste, and abuse. We have to eliminate on, for example, [on] Medicaid, people who are not actually eligible to be there. Able-bodied workers, for example, young men who should never be on the program at all.” 

Of course, these folks are legal beneficiaries or legal enrollees of the program thanks to the Affordable Care Act’s Medicaid expansion, which has been expanded in 40 states. But yeah as Alice was saying, they are using language like “protecting the vulnerable” or people who “really need the program.” 

The new CMS [Centers for Medicare & Medicaid Services] administrator, Mehmet Oz, has also used the same language. So he seems to be in step with them. But yeah I think we’re really going to see work requirements and other methods, such as potentially cutting the FMAP [Federal Medical Assistance Percentage] for the federal matching money for the expansion population, which is set at 90%, which is far higher than it is for the traditional population, which a lot of folks don’t think is fair. But if the federal government, if Congress, does cut that match for the expansion population, we will see a lot of people lose their coverage. 

Rovner: And for the six people that haven’t heard me say this a thousand times, there are 12 states that automatically end their Medicaid expansion if that 90% match gets cut, because they legit can’t afford to make up the difference. I’ve seen numbers this week. It’s like $620 billion that states would have to make up if Congress just reduces that 90% match to whatever the match is, because each state gets a slightly different match. Poor states get more money from the federal government. 

For a bill where the repeal of the Affordable Care Act is supposedly not on the table, it is certainly on the menu. One item that I don’t think gets talked about enough is the expiration of the expanded subsidies for ACA coverage that were implemented during the pandemic. That’s effectively doubled ACA marketplace enrollment to 24 million people. And if those subsidies end, which they do at the end of the year in the absence of congressional action — this isn’t like the Medicaid match where Congress would have to actively go in and lower it. This was temporary, and it expires unless it is renewed. If that happens, a lot of people, including a lot of Republican voters in a lot of very red states, are going to get hit with huge increases starting in 2026. 

Is that starting to dawn on some Republican members of the House and Senate? And might it change the odds that those subsidies are allowed to expire, which I think we all just assumed when [Donald] Trump got elected last November? 

Ollstein: You are not hearing as much about it as you are about Medicaid, even from Democrats. So I’m curious, when Congress returns from its recess, if that dynamic is going to change, because even advocacy groups right now are really hammering the Medicaid cuts issue in ads, TV ads, billboards, press conferences. And so I’m not sure if that same messaging will sort of expand to include the people who would be hit by these cost increases, if these supports expire, or if there will be different messaging, or if it’ll get lost in the current fight about Medicaid. 

Luhby: I was saying it had been discussed quite a bit earlier this year, but then it has completely fallen off the radar. One thing that some folks are also trying to put it now as is saying that it’s also part of the waste, fraud, and abuse, because they’re arguing that a lot of folks, because part of the expansion was that people under 150% of poverty could get pretty much no-cost, no-premium subsidy plans. They could get no-premium plans. And there have been, even during the Biden administration also, there was a lot of accusations that people were fraudulently deflating their income so that they would qualify for this, or brokers were trying to do that for them. 

Rovner: Yeah. I think the other thing, though, that where the enrollment has gone up the most are in the 10 states that didn’t expand Medicaid, because those are people who are now eligible for, as Tami was saying, these extremely low-cost and, in some cases, free plans, and those would be the people who would be either kicked off or see their costs go way up. I’ll be interested to see what happens when this starts to kind of penetrate the psyches of members as they go through this exercise, which, as I say, is just going to get underway. The big effort launches next week, so we will watch this closely. 

I wanted to talk about a related subject, Medicare Advantage. Congress could find a lot of savings in Medicare Advantage without cutting Medicaid and without cutting Medicare benefits, or at least directly cutting Medicare benefits. Instead, Medicare Advantage plans are set to get big increases next year, which has boosted insurance stock prices even as the broader stock market has kind of tanked. Yes, as we saw at the confirmation hearing last month for Mehmet Oz to lead the Centers for Medicare & Medicaid Services, some Republicans are actually questioning whether the federal government should continue to overpay those Medicare Advantage plans. Is the tide starting to turn maybe a little bit on this former Republican-favored program? 

Luhby: We’ll see. Actually, surprisingly, Dr. Oz, who long touted Medicare Advantage plans on his show and in social media, actually also during his confirmation hearing kind of cast a little shade on the insurers. And much of the increase that was announced recently was probably done, obviously, before he took office. So we’ll see what happens next year or during the course of this year. But at this point, it looks like the increase for 2026 is a step back from the Biden administration’s efforts to rein in the costs. 

Rovner: Yeah but they could, I mean, if they wanted to they could — people keep talking about Energy and Commerce, House Energy and Commerce Committee, and all the money that it needs to save, presumably from Medicaid. Well, Energy and Commerce also has jurisdiction over Medicare Advantage, and if they wanted to save some of that $880 billion, they could take it out of Medicare Advantage too if they really wanted to. I don’t know that I’m going to bet that they will. I’m just suggesting that they could. 

All right, well, turning to the Supreme Court, the justices heard oral arguments this week in the case challenging the Affordable Care Act’s no-cost coverage of preventive care. Tami, remind us what this case is about. And what would happen if the court found for the plaintiffs? 

Luhby: Well, so this is a case that’s been — it’s not as much of a threat to the Affordable Care Act as previous cases have been. This case surrounds the preventive care mandate in the ACA, which basically says that insurers have to provide no-cost care for a host of different services that are recommended by three different groups. The court case at the Supreme Court was focusing on one set of recommendations, specifically from the U.S. Preventive Services Task Force. And the plaintiffs have said basically that the task force isn’t constitutional and therefore its recommendations can’t be enforced and they shouldn’t have to provide these services at no cost. 

So it would have actually a big effect on a lot of services. The lower-court ruling was kind of strange in saying that it limited the advances to just those since the enactment of the Affordable Care Act in March of 2010 when the ACA was passed, but it would still affect a host, things like statins, increased cancer screenings for certain groups, and screenings for pregnant women. So there are a lot of things that this would really affect people. 

And so I listened to the oral arguments, and it was very interesting. A lot of the discussion — it didn’t really talk about the preventive care and what that would mean for folks — but there was a lot of discussion about whether the HHS [Department of Health and Human Services] secretary has oversight over this task force or whether the members are independent. And that’s really at the crux of the argument here. And so there were several notable comments from conservative justices, and it seemed generally that folks we spoke to as well as media coverage seemed to say that the Supreme Court was leaning in the direction of the government. And Justice Brett Kavanaugh said that members of the task force are removable at will by the HHS secretary. Truly independent agencies, he noted, typically have legal protections that require a president to show cause before firing members of a board. The— 

Rovner: Like the head of the Federal Reserve, she inserts. 

Luhby: Justice Amy Coney Barrett said, who’s another conservative, said that she described the challenger’s position as very maximalist. So it seems that potentially — we don’t know, of course — but potentially the government may prevail here. 

But interestingly, if that does happen, that will actually give HHS Secretary Robert F. Kennedy Jr. more power over preventive services requirements. And as we know, he has a different view on certain public health measures. So we could really see him putting his stamp on the recommendations. Notably, this does not focus on vaccines. That’s a different group. That’s a different group that recommends vaccines, but that is still being discussed in the lower courts. So the vaccine issue isn’t over, but it’s not part of this case, per se. 

Rovner: This particular case, though, was really about PrEP [pre-exposure prophylaxis], right? It was about HIV preventives. 

Ollstein: Well, basically, the challengers, these conservative employers in Texas, in going after PrEP specifically, also are going after all preventive services. And the piece of the case that focused specifically on PrEP, where they said that requiring them to cover this HIV prevention drug would violate their religious rights, that piece did not go to the Supreme Court. So, lower courts have allowed these specific employers to opt out of covering PrEP, but because that ruling was not applied to anybody else in the country, the Biden Justice Department did not appeal it up to the Supreme Court. Probably, I’m just reading the tea leaves, not wanting to give this Supreme Court an opportunity to go after that. 

So that piece of it was not at issue, but the experts I talked to said that PrEP would still be really vulnerable if there was a broader ruling against preventive care, because PrEP is extremely expensive. And unlike other preventive services that insurers may see as really saving them money, they may see this as costing them and would drop that coverage, which could be really devastating to the U.S. effort to end the spread of HIV. 

Rovner: So I think one of the big surprises in this case was not that the Biden administration sued but that the Trump administration continued the position of the Biden administration. And one theory of why the Trump administration is defending the USPSTF [U.S. Preventive Services Task Force] is that it wants to exercise more power over not just that advisory panel but others, too, which brings us to a report in Politico that HHS Secretary Kennedy is considering unilaterally ordering the ACIP — that’s the advisory committee on immunizations — to drop its recommendation that children continue to receive the vaccine to protect against covid. 

Now, Sarah, isn’t this exactly what Kennedy promised Sen. Bill Cassidy that he wouldn’t do during his confirmation hearings? Personally meddle with scientific recommendations? 

Karlin-Smith: Kennedy did make a very explicit promise related to the vaccine schedule, I think, and I think we’ve seen multiple times already, and I’m sure Bill Cassidy is getting tired of reporters asking him, Are you going to do something about this? But I think Kennedy has already probably walked back, really not kept the thrust of a lot of his commitments to Cassidy. And a change to the vaccine schedule for the covid vaccine for children could essentially impact insurance coverage. It might make it no longer eligible for the Vaccines for Children Program, which ensures people with lower incomes or no insurance can afford vaccines for their children. And so I think this is a particularly concerning step for people. Even though it wouldn’t necessarily take the vaccine away, it could make it really inaccessible and unaffordable. 

I did want to quickly say about the idea in [Kennedy v.] Braidwood that the government wins, RFK gets more authority. I heard a really interesting comment yesterday about that thread, and the head of the American Public Health Association was trying to emphasize, like, it’s sort of status quo. If the Braidwood case goes the way of the government, anybody can technically misuse the authority, and the thing they’ll be watching for is to see what happens there or pushing for a legislative construct so that he can’t really misuse it, because, I think, in their minds, a lot of public health associations and leaders want a win here. So I think they’re sort of pushing back on the messaging about exactly what this means for Kennedy. 

Rovner: So there are also some indications that the public is starting to buy what RFK Jr. is selling, at least when it comes to vaccines, even as measles and now whooping cough cases continue to mount. A new poll from my colleagues here at KFF finds a growing share of adults who have heard the false claims, including that the measles vaccine causes autism or that the vaccine is more dangerous than getting measles, both of which are not true. 

Sarah, you were at the World Vaccine Congress here in Washington this week. What are the folks there feeling about all of this? 

Karlin-Smith: So I overheard someone in the hallway say yesterday that everybody here is shell-shocked, and I think that is probably a good characterization of the mood in the vaccine world. The environment they operate in has sort of been turned on its head very quickly, and there is concern about the future. 

I went to one panel where lawyers were sort of very optimistic that the way the country has sort of set up our vaccine system and authorities, a lot of authority rests in the hands of the states and state laws that may protect our ability to access and get vaccines, as well as they seem to feel that this Supreme Court as well, when it comes to vaccine issues and any attempts by the federal government to encroach more power, would lean in favor of the states and having the power in the states. There was a lot of hope there. I think that does rely on the rule of law sort of being followed by this administration, which doesn’t always happen. 

The other thing that I think will be interesting to watch moving forward is those assumptions that we have systems in place to protect our vaccine infrastructure and access do rely on the vaccines actually being approved. And to get to that point, particularly with new vaccines, you have to have the federal government approve them. And that the buck could kind of stop there. And we’ve already seen some signs that FDA [Food and Drug Administration] and HHS politicals are interfering in that process. So certainly, again, the vaccine community is nervous and feeling like they have to defend something that, as somebody said, change the world from one where you didn’t know if your children would live to go to school to one where you can just sort of assume that, and that’s a really dramatic difference in our health and our lives. 

Rovner: Well, that is a perfect segue into what I wanted to talk about next, which was the continuing impact of the cuts at HHS. This week, we’ve learned of the shutting down of some major longitudinal studies, including the landmark Women’s Health Initiative, which has tracked more than 160,000 women in clinical trials and even more outside of them since the 1990s and has led to major changes in how women are diagnosed and treated for a variety of health conditions. Also, apparently being defunded is a multistate diabetes study as well as the CDC’s longitudinal study of maternal health outcomes. 

Alice, you have a story this week on how clinics are starting to close due to the cutoff of Title X family planning funding. A lot of these things are going to be difficult or even impossible to restart even if the courts eventually do say that, No, administration, you didn’t have the authority to do this and you have to restore them, right? 

Ollstein: Yeah. So in the Title X context, I’ve been talking to providers around the country who had tens of millions in funding frozen. And it was frozen indefinitely. They don’t know when or whether they’ll get it. They’re being investigated for possible violations of executive orders. They submitted evidence trying to prove they aren’t in violation, and they just have no idea what’s going to happen, and they’re really struggling to keep the lights on. And they were explaining, yeah. once you lay off staff, once you lay off doctors and nurses, and once you close clinics, you can’t just flip a switch and reopen, and even if the funding comes through again later. 

And I think that’s true in the research context as well. Once you halt research, once you close down a lab, even if the funding is restored, either as a result of a court case on the sooner side or buy a future administration, you can’t just unplug the government and plug it back in again. 

Rovner: Atul Gawande has a story in The New Yorker this week that I will link to about what’s going on at Harvard, which is, obviously, gets huge headlines because it’s Harvard. But the thing that really jumped out at me was there’s an ongoing study of a potential, a really good, vaccine for TB, which scientists have been looking for for a hundred years, and they were literally just about to do sort of the TB challenge for the macaques who have been given this vaccine, and now everything is frozen. And it seems that it’s not just that it would ruin that, but you would have to start over. It’s a waste of money. That’s what I keep trying to say. This seems like — this does not seem like it is saving money. This seems like it is just trying to basically wreck the scientific establishment. Or is that just me? 

Karlin-Smith: No, I think there’s plenty of examples of that where, again, they’ve wrapped a lot of this in the idea that they’re going after government efficiency and waste. And when you look at what is actually falling to the cutting-room floor, there’s a lot of evidence that shows it’s not waste of you think of these long-term studies like the diabetes study or the Woman’s Health Initiative they’ve been running for so many years, to then have to lose those people involved in that and to replicate it would cost, I saw one report was saying, maybe a million dollars just to kind of get it back up and running on the ground again. 

And it also conflicts with other Kennedy and health administration priorities that they’ve called for, which is to improve chronic disease treatment and management in the U.S. So there’s a lot of misalignment, it seems like, between the rhetoric and what they’re saying and what’s actually happening on the ground. 

Rovner: Well, Secretary Kennedy does continue to make news himself after last week announcing that he planned to reveal the cause of autism by this September. This week, the secretary says, as part of that NIH [National Institutes of Health]-ordered study, the department will create a registry of people with autism. The idea is to bring together such diverse databases as pharmacy, medication records, private insurance claims, lab tests, and other data from the VA [Department of Veterans Affairs] and the Indian Health Service, even data from smartwatches and fitness trackers. What could possibly go wrong here? 

Ollstein: There’s a lot of anxiety in the autism community and just among people who are concerned about privacy and concerned about this administration in particular having access to all of these records. There’s concern about people being included or excluded in such a registry in error, since we’ve seen, I think, a lot of what the administration has been doing has been relying on artificial intelligence to make decisions and comb through records. And there have been some very notable errors on that front so far. So, yes, a lot of skepticism, and I think there will be some interesting pushback on this. 

Rovner: Yeah. I just, I think anytime somebody talks about making registries of people, it does set off alarm bells in a lot of communities. 

Well, meanwhile, the secretary held a press conference Tuesday to announce that he’s reached an agreement with food-makers to phase out petroleum-based food dyes by next year. Except our podcast pal Rachel Cohrs Zhang over at Bloomberg reports that no agreement has actually been reached, and The Wall Street Journal is reporting that biotech is warming up to the new leadership at the FDA that’s promising to streamline approval in a number of ways. So, Sarah, which is it? Is this HHS cracking down on manufacturers or cozying up to them? 

Karlin-Smith: I think it’s a complicated story. I think the food dye announcement is interesting because, again, they sort of suggested they had this big accomplishment, and then you look at the details, and they’re really just asking industry to do something, which I find ironic because Kennedy’s criticism of the FDA and the food industry’s relationship and the fact that we have these ingredients in our food in the first place has been that FDA has been too reliant on the food industry to self-police itself, and they really aren’t starting the regulatory process that would actually ban the products. 

And again, I think there’s sort of mixed research on how much, if any, harm comes from these products to begin with, so that picture isn’t really great. But there’s, again, these incredible ironies of the reports also coming out this week that they’re not inspecting milk the way they should and other parts of our food system and them touting this as this big health achievement. But at the same time, it does seem like the food industry is somewhat willing to work with them. 

I think on the biotech side, I maybe take slight disagreement with The Wall Street Journal. I think there are some positive signs for companies in that space from Commissioner [Martin] Makary in terms of his thinking about how to maybe make some products in the rare disease space go through the approval of process faster. I would just caution that Makary was very vague in how he described it, and it’s not even clear if he’s really thinking about something that would be new or what he would implement. 

And at the same time, again, you have to count all of that with the other elements coming out of the administration, including for Makary, that are kind of concerning about how they view vaccines. Makary also made some comments at the food dye event that are very reminiscent of RFK’s remarks, where he was very critical about the pharmaceutical industry and our use of drugs for treating obesity, depression, and other things that just repeats this sort of thread that kind of undermines the value of pharmaceuticals. So I think people are very hopeful in the industry about Makary and that he’d be a kind of counterbalance to Kennedy, but I think it’s too soon to really say whether he’s going to be a positive for that industry. 

Rovner: In other words, watch what they say and what they do. All right. Well, finally this week, I’m going to do my extra credit early because I want to let you guys comment on it, too. The story’s from MedPage Today. It’s by Kristina Fiore, and it’s called “Medical Journals Get Letters From DOJ,” and the story is a lot more dramatic than that. 

It seems that the interim U.S. attorney here in Washington, D.C., is writing to medical journals — yes, medical journals — accusing them of partisanship and failing to take into account, quote, “competing viewpoints.” And breaking just this morning, the prestigious New England Journal of Medicine has apparently gotten one of these letters, too. Now, none of these are so-called pay-to-play journals, which have their own issues. Rather, these are journals whose articles are peer-reviewed and based on scientific evidence. 

This strikes me as more than a little bit chilling and not at all in keeping with the radical transparency that this administration has promised. I honestly don’t know what to make of this. I’m curious as to what your guys’ take is. Is this one rogue U.S. attorney or the tip of the spear of an administration that really does want to go after the entire scientific establishment? 

Ollstein: I think we can see a pattern of the administration going after many entities and institutions that they perceive as providing a check on their power and rhetoric. So we’re seeing that with universities. We’re seeing that with news organizations. We are seeing that with quasi-independent government agencies and nonprofits. Now we’re seeing it with these medical journals. 

I’m not sure what their jurisdiction is here. These are not federally run or supported entities. These are private entities that theoretically have the right to set their own criteria for publication. But this may be intimidating and, like you said, chilling to some. So we’ll have to see what the response is. 

Rovner: Sarah, what are you hearing? 

Karlin-Smith: I think that it is interesting to me that they’re going after medical journals, because I’ve noticed a lot of the parts of the health industry are not willing to speak out and go after [President] Trump, even though probably privately behind the scenes a lot of people are very nervous about some of the activities. And the medical journals have been one place where I think you’ve seen a bit more freedom and seen the editorials and the viewpoints that have been harsher. 

So I wouldn’t be surprised if these are the entities that are willing to sort of cave to this kind of pressure, but I do think we’re in a very difficult environment. Again, being at this vaccine conference and talking to people about what you are doing to try and preserve your products that are so valuable to society, people don’t know what to do. They don’t know when pushing back will end up with them being in a worse situation. They don’t know when doing nothing will end up with them being in the worse situation. And it’s a really difficult place for all different kinds of groups, whether it’s a medical journal or a university or a drug company, to navigate. 

Rovner: We’ll add this to the list of stories that we are watching. All right, that is this week’s news. Now, we’ll play my interview with KFF Health News’ Rae Ellen Bichell. Then we will come back and do our extra credits. 

I am so pleased to welcome back to the podcast my KFF Health News colleague Rae Ellen Bichell, who’s here to talk to us about a story she did on how services are changing for transgender youth and their families in Colorado. Hi, Rae. 

Rae Ellen Bichell: Hi. Thanks for having me. 

Rovner: So, Colorado has long been considered a haven for gender-affirming care, but even there, health care for transgender youth temporarily flickered as hospitals responded to executive orders from the Trump administration trying to limit what kinds of care can be provided to minors. Let’s start with, what kind of health care are we talking about? 

Bichell: There’s a lot of different things that count as gender-affirming care. It can really be anything from talk therapy or a haircut all the way to medications and surgery. 

For medical interventions, on that side of things, the process for getting those is long and thorough. To give you an idea, the guidelines for this typically come from the World Professional Association for Transgender Health, and the latest document is 260 pages long. So this was very thorough. 

With medications, there’s puberty blockers that pause puberty and are reversible, and then the ones that are less reversible are testosterone and estrogen. So patients who need and want them will get puberty blockers first as puberty is setting in — so the timing matters, just to put everything on the ice — and then would start hormones later on. It is important to note, lots of trans kids don’t get these medications. Researchers found that transgender youth are not likely to get them, and politicians like to talk about surgery, of course, but it’s really rare for teens to get surgery. So for every 100,000 trans minors, fewer than three undergo surgery. 

Rovner: So when we talk about transgender care, as you said, particularly the Trump administration presents this as go to school one gender and come home another. That’s not what this is. 

Bichell: It is not an easy or fast process by any measure. 

Rovner: So, remind us what the president’s executive order said. 

Bichell: There were two of them. So one, right out of the gate on his first day in office, said it is a, quote, “false claim that males can identify as and thus become women and vice versa.” And then a second one called puberty blockers and hormones, for anyone under age 19, a form of chemical, quote, “mutilation” and a, quote, “a stain on our Nation’s history.” And that one directed agencies to take steps to ensure that recipients of federal research or education grants stop providing that care. 

Rovner: And that’s where the hospitals got involved in this, right? 

Bichell: Right. That’s where we started to see changes in Colorado and in other states as well. Here, there were three major health care organizations — so that’s Children’s Hospital Colorado, Denver Health, and UCHealth — and they all announced changes to the gender-affirming care that they provide to patients under 19. So this is in direct response to the executive order. 

Those changes were effective immediately and included no new hormone or puberty blocker prescriptions for patients who hadn’t had them before, limited or no renewals for those who had had such prescriptions before, and no surgeries. Some of that care has since resumed, and that happened after Colorado joined a U.S. District Court lawsuit in Washington state. And the situation there is there’s a preliminary injunction that’s blocking the orders from taking effect but only applies to the four states that are involved in the lawsuit. 

But even though the care has been restored, even though Colorado joined that Washington lawsuit, it was still enough to shake people’s confidence in this state. 

Here’s Louise. We’re using her middle name. She’s the mom of a trans teenager. 

Louise: I mean, Colorado, as a state, was supposed to be a safe haven, right? We have a law that makes it a right for trans people to have health care, and yet our health care systems are taking that away and not making sure that our trans people can have health care, especially our trans kids. 

Rovner: So what kind of impact did that have on patients, even if it was just temporary? 

Bichell: Pretty profound. One family I spoke to with a 14-year-old, they predicted this might happen. They started stockpiling testosterone, the mom said, as soon as the election happened. And what that means is kind of just saving anything that was left over in the vial after the teen took his dose so they could stretch it for as long as possible. 

That teen also had a kind of surprise moment where even his birth control came into question. And that’s because his birth control suppresses his period, which is considered part of his gender-affirming care. So his doctor had to have this special meeting just to make sure that he could keep getting that prescription, too. 

And then one part of this health care that has not turned back on is surgery. And so, even though it’s rare, for the patients who want and need it, that’s a significant gap. 

Rovner: And what does that mean for patients? 

Bichell: So, Louise’s son, David — that’s his middle name, too. He’s 18 years old. And I visited him in his dorm room in Gunnison. That’s a mountain town here. He told me that testosterone has helped him a lot. 

David: I don’t know if you noticed, but there are no mirrors in here. 

Bichell: I did not notice that. 

David: Yeah. 

Bichell: You’re right. 

David: My sister and best friend will come up and stay the weekend or something like that. And every time they come up, they complain that I don’t have a mirror. And I’m like, I don’t want to look at myself, because, I don’t know, for the longest time I just had so much body dysphoria and dysmorphia that it can be kind of hard to look in the mirror. But when I do, most of the time I see something that I really like. 

Bichell: So his confidence and mental health has really improved with the testosterone, but he also would really like to get a mastectomy and thought that he could do it this summer so that he’d have enough recovery time before the new school year started in the fall. But he’s not aware of anyone now in Colorado who will do this surgery for 18-year-old patients, so he has to wait until he turns 19. He has taken a significant mental health hit because of having to wait. 

The irony here is that he could easily get surgery to enhance his breasts but can’t reduce or remove them. And the other irony here is that cisgender men and boys can still get gender-affirming breast reduction surgeries and do. In fact, they’re more likely to get that kind of surgery than transgender men and boys. 

Rovner: So what do things look like going forward in Colorado? 

Bichell: There is a bill making its way through the state capitol right now. It’s about protecting access to gender-affirming care. So let’s see where that lands. But in the meantime, the families that I’ve been speaking with, a moment that really stood out to them was, in early April, the Trump administration came out with a proclamation that said, quote, “One of the most prevalent forms of child abuse facing our country today is the sinister threat of gender ideology,” end quote. So they’re still feeling pretty apprehensive about the future. 

Rovner: Well, we’ll watch this as it goes forward. Rae Ellen Bichell, thank you so much. 

Bichell: Thanks again. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. I’ve already done mine. Alice, you’ve got a lighter story this week. Why don’t you go next? 

Ollstein: A sweeter story, you might say. So I have a piece from The New York Times that is about — it’s a great exposé of a researcher who is in the pocket of Big Maple Syrup, according to this reporting. The article is “A Scientist Is Paid to Study Maple Syrup. He’s Also Paid to Promote It.” This is a great piece of how he exaggerated the health benefits of maple syrup. He cherry-picked findings that appeared to make this a health-promotion food more than the findings really showed. 

But it all really, on a serious note, made me think about the current federal cuts to research and how, in the absence of that taxpayer public support, more and more scientists may need to turn to industry support for their work. And that brings all of these ethical problems that you really see in this article. Pressure to come to certain findings. Pressure to not release certain findings if they don’t fit with the agenda, etc. So I think this is a little bit silly but also serious. 

Rovner: I was personally disappointed to read this story because maple is my favorite sweetener. 

Ollstein: Well— 

Rovner: And I was really happy when I started seeing the research that said it’s really good for you. It will still be my favorite sweetener. Sarah. 

Karlin-Smith: I took a look at a story from Alexandra Glorioso and Lawrence Mower of the Miami Herald/[Tampa Bay] Times [“Countering DeSantis, $10M Hope Florida Donation Came From Medicaid, Draft Shows”] that documents how it appears that Gov. [Ron] DeSantis in Florida steered about $10 million that the state got back through a settlement with one of their Medicaid contractors to a nonprofit run by his wife, and then seeming to having to kept steering the money to political committees that are supporting Republicans. 

And as Julie mentioned, this is probably one of those things that would’ve gotten tons of attention, much slower news time, but it’s a fascinating story and just very interesting to watch just how they were able to figure out and document how all this money was being transferred. And that even the, in some of the stories you see, even the Republican lawmakers and Congress and their state legislature are pretty frustrated about it. 

Rovner: Local journalism still matters. Tami. 

Luhby: I looked at a story out of Stat News by Andrew Joseph titled “In Ireland, a Global Hub for the Pharma Industry, Trump Tariffs Are a Source of Deep Worry.” So, many of us, including me, have been writing about the potential for tariffs on pharmaceutical imports since Trump, unlike his first term, has been promising to impose them on the drug industry. 

Well what I liked about this story was that it focused on drug manufacturing in Ireland, with Joseph reporting from Dublin and County Cork. I’d like to get that assignment myself. But he shows how America pharma companies, how important they are to the Irish economy. Ireland has lured them with low taxes and concerted efforts to build its manufacturing workforce. And interestingly, the country started to move foreign investment in the 1950s. It mentions, interestingly, that President Trump had specifically called out pharma operations in Ireland, criticizing the U.S. trade balance while meeting with the Irish prime minister for St. Patrick’s Day. 

But there were a lot of good details in the piece. Of the 72.6 billion euros’ worth of exports that Ireland sent to the U.S. last year, 58.3 billion were classified as chemical and related products, the bulk of them pharmaceutical goods. The biopharma industry now employs 50,000 people in Ireland. 

And, another little tidbit that I liked, the National Institute for Bioprocessing Research and Training in Dublin actually has a mock plant where thousands of workers have been trained for careers in the industry. And it talks about, even getting down to the county and local levels, how Ireland is concerned that tariffs could prompt American drugmakers to invest less in the country in the future, which will hurt Ireland’s export business, its corporate tax base, the jobs, and the economy overall. 

Rovner: Yeah, globalization’s a real thing, and you can’t just turn it off by turning a switch. It was a really interesting story. 

All right, that is this week’s show. As always, if you enjoy 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. Thanks, as always, to our editor, Emmarie Huetteman, and our producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys hanging these days? Sarah. 

Karlin-Smith: I feel like I’m trying to be everywhere on social media. So you can find me, @SarahKarlin or @sarahkarlin-smith on Bluesky, LinkedIn, all those fun places. 

Rovner: Alice? 

Ollstein: Mainly on Bluesky, @alicemiranda. Still on X, @AliceOllstein. 

Rovner: Tami. 

Luhby: Mostly at CNN at cnn.com. 

Rovner: There you go. We’ll be back in your feed next week. Until then, be healthy. 

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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.

A week into the reorganization of the Department of Health and Human Services announced by Secretary Robert F. Kennedy Jr., the scope of the staff cuts and program cutbacks is starting to become clear. Among the biggest targets for reductions were the nation’s premier public health agencies: the Centers for Disease Control and Prevention, the National Institutes of Health, and the FDA.

Meanwhile, Kennedy did not show up as invited to testify before the Senate Health, Education, Labor and Pensions Committee, known as HELP, but he did visit families in Texas whose unvaccinated children died of measles in the current outbreak and called for an end to water fluoridation during a stop in Utah.

This week’s panelists are Julie Rovner of KFF Health News, Victoria Knight of Axios, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

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Victoria Knight
Axios

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Read Victoria's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Amid a dearth of public information about federal health cutbacks, HHS employees currently on administrative leave report they were given no opportunity to hand off their responsibilities, suggesting important work will simply be discontinued. Critical staff members have been cut from the FDA offices funded by user fees, for instance — affecting the drugmakers that pay the fees in exchange for timely evaluation of their products, as well as the patients hoping for access to those drugs. Even if the cuts were reversed, the damage could linger, especially in areas where there will be gaps in data such as disease surveillance.
• Meanwhile, the temporary public communications freeze implemented in the Trump administration’s early days apparently has not ended. State officials, desperate for information from federal health officials about ongoing programs, are receiving no response as they seek guidance from offices in which most or all staffers were laid off.
• President Donald Trump issued an executive order this week that instructs federal department heads to summarily repeal any regulation they deem “unlawful.” The order threatens to effectively short-circuit the federal regulatory process, which involves public notices and opportunities to comment. Businesses rely on that process to make decisions, and Trump’s order could create further instability for health care and other industries.
• And Kennedy traveled West this week, using his public appearances to call for removing fluoride from the water supply and to discuss the measles outbreak. He issued his strongest endorsement of the measles vaccine yet, but he also praised doctors who have used alternative and unapproved remedies to treat measles patients. Senators had called him to testify before Congress this week about the ongoing upheaval at HHS, but the hearing was canceled.
• Legislators in a growing number of states are introducing abortion bans that would punish women seeking abortions as well as abortion providers, suggesting a long game for abortion opponents that goes well beyond overturning a nationwide right to the procedure.

Also this week, Rovner interviews Georgetown Law School professor Stephen Vladeck about the limits of presidential power.

Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too: 

Julie Rovner: The New York Times’ “Why the Right Still Embraces Ivermectin,” by Richard Fausset.  

Victoria Knight: Wired’s “Dr. Oz Pushed for AI Health Care in First Medicare Agency Town Hall,” by Leah Feiger and Steven Levy.  

Alice Miranda Ollstein: The Guardian’s “‘We Are Failing’: Doctors and Students in the US Look to Mexico for Basic Abortion Training,” by Carter Sherman.  

Sandhya Raman: CQ Roll Call’s “In Sweden, a Focus on Smokeless Tobacco,” by Sandhya Raman. 

Also mentioned in this week’s podcast:

• The New York Times’ “The Three States That Are Especially Stuck if Congress Cuts Medicaid,” by Sarah Kliff and Margot Sanger-Katz.
• The AP’s “Ex-Official Says He Was Forced out of FDA After Trying To Protect Vaccine Safety Data From RFK Jr.,” by Matthew Perrone.

Click to open the transcript

Transcript: The Dismantling of HHS

[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, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 10, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

Rovner: And Victoria Knight of Axios news. 

Victoria Knight: Hello, everyone. 

Rovner: Later in this episode we’ll have my interview with Georgetown University law professor Stephen Vladeck, who will talk about the limits of presidential power — if there are any left. But first, this week’s news. 

So the dust is starting to settle, sort of, in that ginormous reorganization of the Department of Health and Human Services launched by Secretary Robert F. Kennedy Jr. last week, which I am now calling “The Great Dismantling.” Here’s some of what we know about the casualties at the CDC [Centers for Disease Control and Prevention]. Offices that worked on sexually transmitted disease prevention, injury prevention, lead poisoning surveillance, and tobacco were basically gutted. At NIH [the National Institutes of Health], the chronic pain division was eliminated, as was the Office of Long Covid. And at the FDA [Food and Drug Administration], offices handling veterinary medicine, generic drugs, and food safety were dramatically reduced. Now that we’ve had a week to absorb what’s been done and, despite claims of the contrary from Secretary Kennedy, we are told there is no plan to hire back some of those workers who were apparently let go in error, what are you guys hearing about where we are? 

Ollstein: Yeah, there’s a lot of people who were put on administrative leave, which is going to run out in a few weeks. By and large, they are not expecting to be called back. They are holding out hope. They would love to be called back. They keep telling me that they would love to get back to the work they were doing. They’re really worried about it not continuing without them, but they’re mostly assuming that these cuts are permanent for now. And contrary to claims from HHS that work isn’t being eliminated, it’s just being consolidated or folded in or there’s different words they’re using, all of these different laid-off workers told me from different divisions that they were basically given no opportunity to hand over their ongoing projects to anyone else, to train anyone else, to make sure it keeps going. So as far as they know, a lot of this surveillance work, research work, coordination work is just not going to be happening going forward. 

Rovner: As far as I can tell, money that’s supposed to be going out the door from places like the NIH isn’t. 

Knight: Yeah, you hit some of the offices, programs that have been cut, but also I think at FDA, we did some reporting this week on the user drug fee program and how staff that do the evaluating drugs and things like that have been cut. And it’s interesting because pharmaceutical companies pay these fees hoping that they’ll get timely evaluations of their drugs, and also— 

Rovner: They pay these fees and are told they will get timely evaluation of these drugs in exchange. That’s the deal. 

Knight: Exactly. And I know pharmaceutical companies are definitely concerned about this, and it’s also concerning for patients who may be waiting for certain drugs to be approved and things like that. And I think it’s interesting, also, Republicans like to talk a lot about innovation and getting new drugs approved and things like that, and this would harm that process if the staff are not rehired. I haven’t really heard an update on that, so— 

Raman: I would also add that part of it is that we just don’t have a lot of information, right? We had Secretary Kennedy invited to come testify before the Senate HELP Committee this week and go through some of these things and explain the rationale and get into that, and that did not happen. 

Rovner: Yeah, we’ll get to that. 

Raman: Yes, and I think, at the same time, a lot of those cuts were also to the communications folks within those agencies that could be disseminating this information to external folks, to internal folks to provide more clarity about where things would be going. And we don’t have those there now, so it will take some time to kind of see where things are going, and even when there’s going to be a delay in some of that stuff, getting that information out is going to be difficult. 

Ollstein: Sandhya is absolutely right about the communications issue here, and I’m just hearing that on so many fronts. States are desperate to get in contact with someone in the federal government to understand what’s going on. Do they have to keep collecting data and sending it to the federal government even though there’s no one left to compile and process it? They’re reaching out asking: Are certain grants going to continue or not? What should we do? Are we going to be in legal trouble if we continue some of this work? And there’s just no one answering, sometimes because all the people that would’ve answered have been let go. But also the communications freeze that was supposed to be temporary at the very beginning of the administration, a lot of federal workers told me that never really ended. 

So there are these email accounts that they were ordered to stop checking and responding to. So one example is the entire team that worked on IVF [in vitro fertilization], evaluating which IVF clinics had the best pregnancy success rates, monitoring safety, all of that — they were all eliminated. And one consequence of that is that there was this email account that doctors, patients, anybody could reach out to for information and to ask questions, and no one’s checking it, no one’s responding. 

Rovner: I don’t know about you guys. I am starting to hear from health care stakeholders. The federal government is so intertwined in, basically it’s a fifth of the economy, what we spend on health care, and it’s creating so much uncertainty. As you were saying, people don’t know if they’re going to get in trouble for not doing things or for doing things. But we do know, as we said, we talked about last week, FDA missed a deadline to rule on a Novavax vaccine. This is going to have ramifications way beyond just the people who are losing their jobs in the federal government, right? 

Raman: There’s so many people that receive the services that we contract out, that we put grants through across the country. And I think that even in speaking to some of these employees that have lost their jobs, one of the top concerns is not even for their own job but that no one else can do the work that they did. Or in some cases, the only person that could have done that work has also already been let go. And just that those things are going to fall through the cracks for a lot of vulnerable communities. 

Ollstein: Some of the folks also told me that even if this is reversed in the future, the damage will just be there for a very long time, especially on things like surveillance and data collection. If you have a gap in there, that skews things. That messes things up for the future. It makes it harder to make comparisons. It makes it harder to know if things are getting better or worse on, like, asthma rates and levels of lead in people’s blood, all kinds of things, things that are not politically controversial or partisan. And so it’ll just be really difficult going forward to know which programs are working, which interventions are working or not working. 

Rovner: So things are happening almost too fast to keep track of. But in his latest round of executive orders on Wednesday, President [Donald] Trump signed one called Directing the Repeal of Unlawful Regulations, in which he basically instructs the heads of all departments to repeal rules they consider unlawful, without notice or comment, which is not how this is supposed to work. I’m not sure even, though, quite what to make of all this. And it seems to be going mostly unnoticed in all of the attention, deservedly, to the other news that’s happening, some of which we’ll get to. But repealing rules basically on a whim could be as important to how the federal government functions as firing all these people, right? 

Raman: Yeah, there’s a reason that the rulemaking process is the way it is, that it takes a certain amount of time. You allow stakeholders to weigh in, to meet, to revise, and that the things aren’t changing too drastically. And there are some rules that go back and forth between the administrations, but a lot of things last over time, and the process is the way it is to make sure that you get the best possible result for whatever you’re changing and— 

Rovner: That you get stability. 

Raman: Yes. 

Rovner: I think that’s the theme here, is that that’s what we’re lacking right now. Nobody can count on what the rules are. 

Knight: And I was going to say, from an industry perspective, industries make decisions based on these rules and knowing when they’re going to come out and when they might change. Think about the insurance industry, physicians, people within the health care industry. And so that could really impact those groups as well a lot. So, and exactly, going back to what you said about stability, so it’ll make it really hard to make business decisions. 

Rovner: Right. So this goes along with the stuff with the tariffs, is that we have no idea what the rules of the road are going to be going forward if rules can be sort of disappeared in a matter of days the way staff is being. Well, let’s move to Congress. Remember Congress? Late last Friday, or I guess it was technically early Saturday, the Senate passed what was supposed to be a compromise Republican budget resolution between the House and the Senate. For those who have forgotten, while the House passed a resolution that would lead to a single gigantic budget reconciliation bill, including tax cuts and likely big cuts to Medicaid, the Senate’s original budget resolution would only have led to a bill on immigration and energy, saving the tax and health fights for later in the year. 

Well, it seems like the compromise, which is kind of a vaguer version of the House blueprint, didn’t go over so well in the House, where Speaker Mike Johnson had hoped to push it through this week. A vote was scheduled for Wednesday, then it got delayed, then it got shelved, at least for the night. They’re apparently trying to regroup and do this this morning. Where are we in this? 

Knight: Yeah, so you gave a pretty good rundown. I was here late last night talking to Freedom Caucus members, the House Freedom Caucus, the hard-liners. Their concerns with, this is basically a Senate amendment to the House’s resolution. And so what the Senate passed was an amendment, and it technically really just gives instructions for the Senate. It didn’t touch the House’s resolution. So the House’s budget resolution they passed is the same thing, but House Freedom Caucus members had issue that the Senate ceilings for cuts is much lower than the House’s. And so they’re saying— 

Rovner: It’s in the billions instead of trillions. 

Knight: Exactly. Exactly. So coming out, they holed up with Speaker Johnson last night and House GOP leadership and were saying, We need more binding cuts on the Senate side, and were like: We need you guys to commit to this, otherwise we’re unhappy with this amount of cuts. This is going to increase spending. There’s been a lot of discussion on how to do the budget math for these things, but it’s pretty clear the Senate’s resolution would not cut spending as much as the House’s. So that was what they came out demanding last night. This morning, Speaker Johnson and Senate Majority Leader John Thune came out, did a press conference, and said: We’re going to proceed with this. We’ll see if that changes. But it was interesting to note that Thune said, he noted that there are Senate Republicans that do want cuts that may be up to the $1.5 trillion, but he did not commit to making cuts on his side. So we’ll see how this goes. That seems to be the state of play. It’s very in flux. That could change over time. So if anyone has anything to add, I think that’s a rundown. 

Rovner: Yeah, it feels like they’re kind of buying time to see if they can keep together what’s clearly a very fractious group here. 

Knight: Yeah, and jet fumes are always a good motivator, and also holidays. So there’s supposed to be a two-week recess right after this, and Passover starts this weekend and Easter next weekend, so we’ll see if that motivates people to vote for it. I will say, an argument that we’ve heard from a lot of the moderates that are concerned about the Medicaid cuts, when they voted for these, they’ve said: This is just an outline. It’s just a blueprint. It’s not committing us to anything. But hard-liners don’t seem to like that argument as much. So can they convince them that way? I don’t know. 

Rovner: Well, let’s talk about those Medicaid cuts for a minute, which, by the way, as you pointed out, Victoria, is not really what’s holding up the vote in the House. Our New York Times podcast pals Sarah Kliff and Margot Sanger-Katz had a really interesting story over the weekend about three red states that would really be stuck if Medicaid gets cut. Oklahoma, Missouri, and South Dakota all passed their Medicaid expansions by ballot measure, including it as part of their state constitutions. Now this is exactly the opposite of those states that would immediately cancel their expansions if Congress cuts the Medicaid match. These three states would be totally stuck, unless they could have another ballot measure that would then eliminate what they added. I guess that helps explain why very conservative Missouri Republican Sen. Josh Hawley says he is so opposed to reducing the Medicaid match. But he seems OK with Medicaid work requirements that would also cut people off the rolls, just not necessarily in a way that would cost the state so much money, right? 

Ollstein: Yeah, I think we’re going to see a lot of interesting semantic games going forward. I think we’re going to see a lot of different interpretations of what a cut is. We’re going to see a lot of claims made about who does and doesn’t deserve Medicaid coverage. We’ve been seeing this for a long time, but as these tough decisions have to be made on the Hill, I think a lot of that is going to come to a head. And so I think you see a lot of conservatives wrestling with believing very strongly in cutting government spending but also recognizing that a lot of their constituents could be harmed by these policies and they would be very angry with their members if that happened. 

And so trying to thread that needle, we’ll see how they do it, whether they can do it successfully without getting a lot of political blowback. Even though there has been a lot of turnover in Congress, you have a decent number of folks who were there last time Congress tried to take a big whack at Medicaid in the Affordable Care Act repeal fight. 

Rovner: In 2017. 

Ollstein: Exactly. Exactly. And the impact on Medicaid is one of the biggest things that garnered a backlash. And Capitol Hill was covered in folks with disabilities protesting, and it was a really bad look, and it contributed to that effort failing. 

Knight: And I think interesting talking about Hawley, but also the Republican Governors Association joined up with some other conservative groups this week to start an ad saying, Don’t cut Medicaid, basically. And so we’re starting to hear that from the states. States are really concerned how this could affect their budgets. They’ve already expanded the program. It would be really hard for them to have to make up in the state that amount of money if the federal government takes away money from the Medicaid program for them or caps it or whatever. It’s interesting to see people walk that line. And House GOP moderates, they are more likely to fold, I think, than hard-liners, but they keep telling me when I talk to them, We’re OK with work requirements, but anything past that might be really hard for us to vote for. But who knows? They could fold if they have enough pressure, but they’re trying to walk the line at this moment. 

Rovner: This is going to be a very different Medicaid fight than it was in 2017. Well, turning to this week in “Make America Healthy Again,” I think we mentioned last week that HHS Secretary RFK Jr. had been invited to testify before the Senate Health, Education, Labor, and Pensions Committee today. Well, as Sandhya pointed out, that did not happen. We’re not entirely sure why, but the secretary continues to do things, well, things he kind of promised senators that he wouldn’t, like saying that he’s going to order the CDC to stop recommending adding fluoride to public water supplies, which he did on a trip to Utah this week. Once more for those in the back, why do most public health professionals support water fluoridation? 

Raman: It really reduces dental decay, by like 25%. ADA [the American Dental Association] has been recommending fluoride for years. So it’s a big proponent of that. 

Rovner: And as someone pointed out, it’s against dentists’ interests to be recommending something that gives them less work and yet they’re still recommending it. 

Ollstein: And even though we have a very silly system in the U.S. where dental care is siloed off from the rest of health care, it does impact your overall health a lot. So it could lead to lung issues, heart issues, all kinds of things if you have dental issues. So it’s not just a cosmetic problem, it can be a very serious health problem. And I will say, too, people should keep in mind that there’s a lot of pointing at studies about negative health impacts from excessive consumption of fluoride, but those studies have a level that is much, much higher than what’s in the U.S. tap water right now. So anything in excess can be bad for you — even just plain water can kill you if you have too much of it. And so I think that people should keep that in mind and remain skeptical about claims being made. 

Rovner: Well, RFK Jr. also continues to make news in his handling of the measles outbreak in Texas, which is now the largest in the nation in the past 30 years, having sickened nearly 600 people, mostly unvaccinated children. Kennedy traveled to the heart of the outbreak last week and visited with the families of the two children that we know have died so far of the virus. He also praised the measles vaccine, but then just hours later posed with and praised two doctors who are using unapproved treatments for measles, including one who was disciplined by Texas medical regulators. Meanwhile, Peter Marks, the FDA vaccine official forced to resign last month, is speaking out, calling Kennedy’s actions thus far, quote, “very scary” in an interview with The Wall Street Journal and telling the AP [Associated Press] that he got fired for trying to keep Kennedy’s team from editing or possibly erasing the very sensitive Vaccine Adverse Event Reporting System kept by the FDA. Is there any way we didn’t see all of this coming? 

Knight: Well, going back to the congressional aspect. The HELP chair, [Sen.] Bill Cassidy, he had both the HELP hearing and the Senate Finance hearing where he questioned Kennedy repeatedly about his views on vaccines, his views on the link between vaccines and autism, I think also measles and autism. And he didn’t really ever get a super substantial answer from Kennedy. And yet the compromise was somewhat that Cassidy said, You’ll have to come quarterly before the HELP Committee and testify about what’s going on, what your views are. And we saw Cassidy try to do that last week. And Kennedy has, as far as I know, the latest is that he received the request but he hasn’t accepted it yet, and unclear if he will. 

So that congressional oversight was supposed to be the way to keep him in check, somewhat. And that’s not happening. It’s not really that enforceable. So I think it’s pretty predictable what’s happening. I think what will be interesting is if the White House gets unhappy with some of Kennedy’s things that he’s doing. There’s been some stories of how they’re having to take over his communications because there’s been no communications from HHS on it, and so they’re kind of unhappy with that. We’ll see if that reaches to a level where they could change leadership or something. But, not there yet, certainly, but something to watch. 

Rovner: Again, so much going on. I think this would normally rise to a higher level than it has given all of the other news that’s happening. Moving on to abortion. We talked last week, or maybe it was the week before, about the Overton window moving towards criminalizing women who have or even seek abortions. That’s apparently the point of a bill introduced in the Alabama Legislature. In North Carolina, a new bill could subject anyone convicted of performing or receiving an abortion to life in prison. We talked a few weeks ago about a similar bill in Georgia that got a legislative hearing. Even if none of these bills pass — and it seems that none of them will pass, at least this year — it certainly seems that claims by the anti-abortion movement that they don’t want to punish women are either not true or falling on deaf ears. 

Ollstein: So the anti-abortion movement, just like the pro-abortion-rights movement, is not a monolith. And just like the political parties, there are moderates and hard-liners. There are people who disagree on tactics. And so I think for so long the movement appeared united because their main goal was just overturning Roe v. Wade. And they were able to paper over other divisions by focusing pretty exclusively on that, or not exclusively but that being the overriding goal. And now that they’ve accomplished that and now that there are a lot more opportunities for them, you’re seeing these divisions. And we’ve seen that over the past few years. There were people who said, OK, a 15-week ban is better than nothing, and we can build on it. And there are people who say: No, that’s an unacceptable compromise, and it has to be a total ban or nothing. And if you do a 15-week ban, you’re endorsing the murder of most babies, because most abortions happen before 15 weeks of pregnancy. 

So I think this is a continuation of that. And it’s also a reflection that there is a lot of frustration in the anti-abortion movement that not only have abortions not ceased when states enact bans, in some cases they’ve gone up, nationally. And that’s a combination of people traveling, that’s a combination of people using telehealth and getting pills mailed to them. That’s become a huge thing that people rely on. And so looking at ways to crack down on those things, including this kind of criminalization of the pregnant patient that’s been sort of a third rail that is now more in the conversation. Of course, people have been proposing such things for a while now, but it’s getting more prominent attention than before. 

Rovner: Yeah. And that was my question, is it used to be a real outlier, and now we’ve seen legislation introduced in 10 states that would criminalize the woman in some way, shape, or form. Sandhya, you wanted to add something. 

Raman: I was going to say it’s also a long game. There are things that we’ve had proposed years ago that I think garnered attention then as being very outside the realm of something that people would consider. And then a few years later, when we first saw some of these personhood bills years ago, I think those got attention as being a little different than some of the other things that were being considered. And now that has become more mainstream. We see that in a lot of states now. And I think that something like this, even though it is very different than the messaging we’ve seen in the past, it doesn’t mean that, down the line, a greater portion of the movement pivots toward this. Because we’ve seen so much of this throw the spaghetti at the wall with seeing different things that they can see, what can pass, what doesn’t get litigated, that kind of thing. So a lot of this is kind of a long game. 

Ollstein: Yeah. And there is an imbalance between the two sides where the right is much more willing to throw spaghetti at the wall and see what sticks, much more willing to throw out things that could anger people, could generate controversy, could generate backlash, but they do believe will advance the goal. And you’re not really seeing the same willingness on the left. You’re not really seeing states propose, Let’s get rid of all abortion restrictions in total. And so you have this imbalance of what each side is willing to even consider, where the left has been, overall, not exclusively, but overall much more cautious and much more consensus-seeking. 

Rovner: Well, meanwhile, in Texas, where over the past few years we’ve had story after story about women with wanted pregnancies nearly dying from complications, the legislature finally has before it a compromise bill that would better define when doctors can end a doomed pregnancy without risking going to prison, except it’s turning out to be not as much of a compromise as its backers had hoped. Is there any way to actually find a compromise on what is a necessary abortion and what is saving the woman’s life? They write these things and they say: Well, look. Here are the exceptions, and they should work. But now they’re trying to spell out the exceptions and they can’t seem to agree on those, either. 

Ollstein: So it’s really a catch-22. And I was just in Texas. I was interviewing OB-GYNs, and they were explaining — and those in other states with bans have said the same thing — that, look, it’s really tough, because if a law is too broad and too vague, then doctors don’t feel comfortable doing even things they feel are absolutely medically necessary. But if a law is too prescriptive — if, for example, it tries to list every single possible condition that would necessitate an emergency abortion or an abortion to save someone’s life for health — you’re never going to be able to list everything. So many things can go wrong during a pregnancy, and so any attempt to be comprehensive will inevitably leave something out. And so if you go the route of listing specific conditions and someone comes in with a condition that’s not on the list, doctors won’t feel comfortable, because they’ll feel that, Oh, well, because the law lists these other conditions, that must mean that anything else is not allowed. 

But on the other hand, if it’s too vague, you have the opposite problem. And so really a lot of mainstream medical groups like ACOG, the American College of Obstetricians and Gynecologists, have really come down on, like: Just don’t legislate this at all. Just let us do our jobs. Because they are in this conundrum. I will say, there are divides within the medical community despite that, where some feel like, OK, well, if we can add a few more exceptions and that can even help a few more people, that’s at least something to consider, where others think, OK, no, if we endorse these quote-unquote “fixes,” that kind of in a way is endorsing the underlying ban, and we don’t want to do that. And so there’s some tension there as well. 

Rovner: Yeah, this is going to continue to be an issue going forward. All right, well, finally this week there is some other policy news. The Trump administration last week reversed a Biden administration decision to start covering those GLP-1 [glucagon-like peptide 1] drugs for people with obesity as well as those with diabetes. According to The New York Times, the administration didn’t attribute the decision to Secretary Kennedy’s known dislike of the drugs, which he has said are inferior to people just, you know, eating better, and that it may reconsider the decision in the future. But obviously cost is a huge issue here. These drugs are less expensive than they were, but they are still super expensive if they’re going to be taken by the millions of people who would qualify for an indefinite period of time. Is there any talk of finding a way to bring that cost down? That would obviously be popular and something that President Trump has said he wants to do in terms of drug prices overall. 

Raman: I have not heard of anything on bringing the cost down. I think that the only discussions that really come about are really tailoring who would qualify within that bucket, and to narrow that as a piece to bring the cost down rather than the cost of the specific drugs. And we’ve been — yeah. 

Rovner: I would say, I know that Ozempic is on the list of Medicare drugs to be negotiated this year, but I think that’s only for the diabetic indication. So on the one hand, that could bring down the cost for— 

Ollstein: And that wouldn’t help people for years and years. Yeah. 

Rovner: Exactly. So I mean we might — if you have diabetes, Medicare could start saving money on one of the GLP drugs, but I guess it’s going to be a while before we see the cost fall. And of course, we didn’t even talk about the potential tariffs on prescription drugs, because we’re not going to talk about that this week. 

That is this week’s news. Now we will play my interview with law professor Stephen Vladeck, then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Stephen Vladeck, professor at Georgetown University Law School and author of the invaluable Substack “One First,” which helps explain the workings of the Supreme Court to us lay folks. Steve Vladeck, welcome to “What the Health?” 

Stephen Vladeck: Thanks, Julie. Great to be with you. 

Rovner: So I’ve asked you to help us with the next in a series I’m calling “How Things Are Supposed to Work in Health Policy.” And I’m particularly interested in how much power the president has vis-à-vis Congress and the courts. Is there kind of a 30-second law school description of who has the power to do what? 

Vladeck: It’s a little longer than 30 seconds, but to make the long version shorter: Congress makes laws, the president carries those laws into effect, and the courts decide whether everyone’s playing by the rules and abiding by those laws. That’s how it’s supposed to go — and if only that were how it actually was. 

Rovner: Now, I’m not a lawyer, but I have been at this for a long time, and I always understood that executive orders from presidents were mostly for show. They were expressions of intent that needed to be carried out by someone else in the executive branch most of the time, usually using the formal regulatory process. But that is not at all what this administration is doing with its executive orders, right? 

Vladeck: So, Julie, I think part of the problem is that we really are at the apex of something that’s been building for a while, which is that as Congress has stopped doing its job, as Congress has stopped passing statutes to respond to our pressing issues of the day, presidents of both parties have been left to govern more and more aggressively based on increasingly, for lack of a better word, creative interpretations of old statutes and constitutional authorities. And so, yes, I think we’re seeing differences in both degree and kind from President Trump, but some of this has been building for a while where, we haven’t had meaningful immigration reform since 1986. We haven’t had meaningful financial systems reform in 25 years. And so in those spaces, presidents are going to do what they can to try to accomplish their policy goals, which means more and more executive orders where the presidents are at least purporting to interpret authorities that they’ve been given, either by statute or the Constitution, as we get further and further away from those authorities themselves. 

Rovner: So this is the unitary executive theory that we’ve, those of us who play to be lawyers sometimes, have heard about. But how abnormal is what Trump is doing now? Is this even legal, a lot of what he’s doing? 

Vladeck: So a lot of what he’s doing is not legal, but some of it is legal. And one of the complications is that the illegalities are at scales and in ways that we haven’t really seen before and that therefore our existing legal processes aren’t necessarily well set up to respond to. I would break Trump’s behavior into a couple of categories. So I think there’s the internal stuff, which is firing tons of people, hollowing out the bureaucracy, demanding political fealty from even those who are civil servants. And we’ve seen, Julie, I think, flash points of those before. What’s novel about what’s happening now is just the sheer scale on which it’s happening. I think the biggest area of real novel action is the effort by Trump really to sort of change how all federal money is spent, right? Money is supposed to be Congress’s, like, superpower. Not only is appropriations Congress’ most important function, but it’s actually the only thing that the Constitution specifically says only Congress can do. 

And yet we’re seeing really novel assertions by the president of the power to not spend money Congress has appropriated, of the power to stop paying for contracts where the work has already been performed, of the power to threaten Maine and other jurisdictions with the withholding of federal funds if they don’t just bend the knee to Trump. And that is really, I think, both shocking and dangerous because it basically means that the president’s trying to seize unilateral control over what has historically been Congress’ principal vehicle for doing policy. And at that point, you don’t really have much of a separation of powers anymore. You’ve just got a president. 

Rovner: Could Congress take back this authority if it wanted to? 

Vladeck: Sure. But just before letting folks get too optimistic, one of the problems is that taking back this authority probably means, at the very least, passing new statutes, and Trump’s not going to sign those statutes. So one of the things that has been a fear of separation-of-power scholars for a long time is that when Congress delegates authority to the president, or when Congress acquiesces in the drift of power to the president, it’s actually really hard for Congress to get that power back, because it’s usually going to require veto-proof supermajorities, and really hard to see in our current political climate a veto-proof supermajority agreeing even to the fact that today is Tuesday, let alone that we should take back power from the president. So Congress could do tons of things. The problem is that assuming Congress won’t, we really are left to these series of confrontations between the president and the courts, because the courts are all that’s left. 

Rovner: Which brings me to something that I think most people would think would be not really health-policy-related but really is, which are all these threats against these big law firms. How does that play into this whole thing? 

Vladeck: So I think it’s a big piece of the puzzle because what the threats, I think, are really intended to do is to cow law firms into submission, to try to increase the cost both economically and politically of bringing lawsuits challenging what the federal government’s doing. And Julie, I think that the long-term idea is to chill people from suing the federal government, to chill people from hiring folks who worked in administrations from the wrong party in ways that I think are really disruptive not just to the economics of law firms but to the courts. The courts depend upon a strong, robust, and independent bar that is able to actually move freely when it comes to challenging the government. Courts can’t go out and find cases. Lawyers bring the cases to them. And if the lawyers are for some reason disincentivized from bringing those cases, part of the separation of powers breaks down even further. 

Rovner: Or basically, in this case, I guess they’re promising not to bring cases that the administration doesn’t like. 

Vladeck: Exactly. We should be terrified. No matter what you think of lawyers, no matter what you think of the administration, we should want a world in which there’s no disincentive to challenge what the government’s doing in court. We should want a world, as James Madison put it, where ambition is counteracting ambition, where the branches are pushing up against each other, not where they are stunned into submission. 

Rovner: And finally, you’re an expert in the Supreme Court. Is there any chance that the Supreme Court’s going to rescue us here? 

Vladeck: No, but I think what I would say — to try to both be a little more optimistic and to try to put a little more depth into my one-word answer — it’s not the Supreme Court’s job to rescue us. It’s the Supreme Court’s job to protect the separation of powers. And as you and I are sitting here, we’ve seen a couple of early rulings from the court that have kind of sided with Trump in these sort of very, very fleeting technical emergency postures without actually saying anything about what he’s doing is legal. I have at least a modicum of faith, Julie, that when the courts get to the legality questions, they’re going to find that most of this stuff actually is illegal. 

I think the question is, what happens then? And this is why, although I’m as big a believer in a powerful and independent judiciary as anyone, the courts alone can’t save us, right? What we need is we need the courts backed by Congress, by the people, by our other institutions, universities, law firms. I mean it should be all of the institutions of our civil society, not opposing Trump to oppose Trump but standing up for the notion that our institutions matter and that the way that we can be confident that the government is working the way it’s supposed to is when the institutions are pushing up against each other with all their might and without the fear of what’s going to happen to them if they lose. 

Rovner: I feel like one of the bright spots out of this is that finally the nation is getting the lesson in civics that it’s needed for a while. 

Vladeck: I couldn’t agree more. I think we are seeing the very, very real costs of generations of insufficient civics education, but I also think this opens the door to real conversation about how to fix this. And in the short term, some of it is about stopping a lot of what Trump is doing, and that’s what a lot of these lawsuits are about. When we talk about, Julie, building back institutions, whether it’s in the public health space or more broadly, I hope that we keep having the civics lesson, and I hope that we don’t forget that it’s actually really important to have independent agencies, and it’s important to have a civil service, and it’s important to have institutions that are actually not just subject to the whims of whoever happens to be the current president. And the more that we can build off of that going forward, maybe the more that we can prevent what has happened already over the first 11 weeks of the second Trump administration from becoming a permanent feature of our constitutional system. 

Rovner: Well, we will keep at it. I hope you’ll come back and join us again. 

Vladeck: I’d love to. Thanks for having me. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Sandhya, why don’t you go first this week? 

Raman: So my piece for extra credit is from me, on Roll Call. It’s called “In Sweden, a Focus on Smokeless Tobacco,” and it’s the first in my series I’m doing through the Association of Health Care Journalists, where I went to Sweden to learn about smoking cessation and public health between Sweden and what we can learn in the U.S. And the story looks at the different political factions of the Parliament over there and how they found some common ground in areas to become hopefully the first country in Europe below 5% daily smokers, and just what lessons the U.S. can learn as they’re trying to reduce smoking here as well. 

Rovner: So jealous that you got to do this. Alice, why don’t you go next? 

Ollstein: I chose a piece from The Guardian by Carter Sherman [“‘We Are Failing’: Doctors and Students in the US Look to Mexico for Basic Abortion Training”] on an issue that has interested me for a long time, which is how U.S. residents are learning how to provide abortions when their training opportunities have been eliminated in so many states. I’ve been covering those who have been traveling to different U.S. states, but this piece is about a small but growing number who are traveling to Mexico for this training. Mexico, like many countries in Latin America and really around the world over the last few years, has moved in the direction of decriminalizing abortion as the U.S. has moved in the opposite direction and is very eager to help train more people. 

But the article stresses that this is not a solution for everyone in the U.S. who needs this training, because you have to be able to speak fluent Spanish in order to do it. You have to already have some abortion experience, which not every medical resident has. And it’s also expensive. There are fellowships, but the trip and the training and everything costs thousands of dollars. And so I think it’s a very interesting opportunity for some people. And the article also talks about folks who are doing some training in the U.K., as well. And so I wonder if these international opportunities will become more of a piece of the puzzle in the future. 

Rovner: Victoria. 

Knight: OK, my extra credit for this week is an article in Wired called “Dr. Oz Pushed for AI Health Care in First Medicare Agency Town Hall.” So basically this was Dr. [Mehmet] Oz’s first town hall talking to CMS [Centers for Medicare & Medicaid Services] staff, and he talked about a lot of his personal story and not as much of the goals of the agency, seemed to be the vibe of the meeting. But also, interestingly, he talked about using AI avatars instead of actual people. So that’s like people that do simple health diagnoses using AI instead to diagnose people, is kind of what it sounded like. And that’s in part because— 

Rovner: My comment to this story was: Not at all creepy. Sorry. 

Knight: Right. And— 

Rovner: I interrupted you, Victoria. 

Knight: No, no, that’s OK. But he was saying the benefit of this is that it could cost less because it could only cost maybe like $2 an hour versus a doctor could be a hundred dollars for a consult. And so people interviewed in the story were CMS employees that felt very concerned about that and also felt like it could come off a bit tone-deaf when there have been a bunch of CMS staff also just recently let go. And CMS was actually on the agencies that was hit with less workforce cuts. But even so, people are still upset about it. And so, it was like, Why are you replacing great people that worked here with AI? It was just an interesting look at his first week at the agency 

Rovner: Yeah. And it’s a big agency with a lot of money. All right, my extra credit this week is from The New York Times. It’s called “Why the Right Still Embraces Ivermectin,” by Richard Fausset. And it’s a pretty hair-raising story of medical malfeasance, foisted on people by those seeking political or financial gain or both. Quoting from the story: “Ivermectin has become a sort of enduring pharmacological MAGA hat: a symbol of resistance to what some of the movement described as an elitist and corrupt cabal of politicians, scientists and medical experts.” This is another in a long list of unproven remedies people take just to thumb their noses at treatments that have, you know, actual scientific evidence behind them. It’s a really interesting read. 

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you folks these days? Alice, you’re the birthday girl. Where can we all wish you a happy birthday? 

Ollstein: Mainly on Bluesky, @alicemiranda, but still hanging on X, @AliceOllstein. 

Rovner: Sandhya. 

Raman: On X and Bluesky, @sandhyawrites. 

Rovner: Victoria. 

Knight: I’m just on X, @victoriaregisk. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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The Host

Julie Rovner
KFF Health News

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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.

Two months into the new administration, federal workers and contractors remain off-balance as the Trump administration ramps up its efforts to cancel jobs and programs — even as federal judges declare many of those efforts illegal and/or unconstitutional.

As it eliminates programs deemed duplicative or unnecessary, however, President Donald Trump’s Department of Government Efficiency is also cutting programs and workers aligned with Health and Human Services Secretary Robert F. Kennedy Jr.’s “Make America Healthy Again” agenda.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Rachel Roubein of The Washington Post.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories.

Among the takeaways from this week’s episode:

• Kennedy’s comments this week about allowing bird flu to spread unchecked through farms provided another example of the new secretary of health and human services making claims that lack scientific support and could instead undermine public health.
• The Trump administration is experiencing more pushback from the federal courts over its efforts to reduce and dismantle federal agencies, and federal workers who have been rehired under court orders report returning to uncertainty and instability within government agencies.
• The second Trump administration is signaling it plans to dismantle HIV prevention programs in the United States, including efforts that the first Trump administration started. A Texas midwife is accused of performing illegal abortions. And a Trump appointee resigns after being targeted by a Republican senator.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Washington Post’s “The Free-Living Bureaucrat,” by Michael Lewis.

Rachel Roubein: The Washington Post’s “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” by Carolyn Y. Johnson.

Sarah Karlin-Smith: KFF Health News’ “Scientists Say NIH Officials Told Them To Scrub mRNA References on Grants,” by Arthur Allen.

Jessie Hellmann: Stat’s “NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease,” by Elaine Chen.

Also mentioned in this week’s podcast:

• The Wall Street Journal’s “Trump Administration Weighing Major Cuts to Funding for Domestic HIV Prevention,” by Liz Essley White, Dominique Mosbergen, and Jonathan D. Rockoff.
• The Washington Post’s “Disabled Americans Fear Losing Protections if States’ Lawsuit Succeeds,” by Amanda Morris.

click to open the transcript

Transcript: Federal Health Work in Flux

[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, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi. 

Rovner: Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hello. 

Rovner: No interview today, but, as usual, way more news than we can get to, so let us jump right in. In case you missed it, there’s a bonus podcast episode in your feed. After last week’s Senate Finance Committee confirmation hearing for Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services, my KFF Health News colleagues Stephanie Armour and Rachana Pradhan and I summarized the hearing and caught up on all the HHS [Department of Health and Human Services] nomination actions. It will be the episode in your feed right before this one. 

So even without Senate-confirmed heads at — checks notes — all of the major agencies at HHS, the department does continue to make news. First, Robert F. Kennedy Jr., the new HHS secretary, speaks. Last week it was measles. This week it was bird flu, which he says should be allowed to spread unchecked in chicken flocks to see which birds are resistant or immune. This feels kind of like what some people recommended during covid. Sarah, is there any science to suggest this might be a good idea? 

Karlin-Smith: No, it seems like the science actually suggests the opposite, because doctors and veterinary specialists are saying basically every time you let the infection continue to infect birds, you’re giving the virus more and more chances to mutate, which can lead to more problems down the road. The other thing is they were talking about the way we raise animals, and for food these days, there isn’t going to be a lot of genetic variation for the chickens, so it’s not like you’re going to be able to find a huge subset of them that are going to survive bird flu. 

And then the other thing I thought is really interesting is just it doesn’t seem economically to make the most sense either as well, both for the individual farmers but then for U.S. industry as a whole, because it seems like other countries will be particularly unhappy with us and even maybe put prohibitions on trading with us or those products due to the spread of bird flu. 

Rovner: Yeah, it was eyebrow-raising, let us say. Well, HHS this week also announced its first big policy effort, called Operation Stork Speed. It will press infant formula makers for more complete lists of ingredients, increase testing for heavy metals in formula, make it easier to import formula from other countries, and order more research into the health outcomes of feeding infant formula. This feels like maybe one of those things that’s not totally controversial, except for the part that the FDA [Food and Drug Administration] workers who have been monitoring the infant formula shortage were part of the big DOGE [Department of Government Efficiency] layoffs. 

Roubein: I talked to some experts about this idea, and, like you said, they thought it kind of sounded good, but they basically needed more details. Like, what does it mean? Who’s going to review these ingredients? To your point, some people did say that the agency would need to staff up, and there was a neonatologist who is heading up infant formula that was hired after the 2022 shortage who was part of the probationary worker terminations. However, when the FDA rescinded the terminations of some workers, so, that doctor has been hired back. So I think that’s worth noting. 

Rovner: Yes. This is also, I guess, where we get to note that Calley Means, one of RFK Jr.’s, I guess, brain trusts in the MAHA movement, has been hired as, I guess, in an Elon Musk-like position in the White House as an adviser. But this is certainly an area where he would expect to weigh in. 

Hellmann: Yeah, I saw he’s really excited about this on Twitter, or X. There’s just been concerns in the MAHA movement, “Make America Healthy Again,” about the ingredients that are in baby formula. And the only thing is I saw that he also retweeted somebody who said that “breast is best,” and I’m just hoping that we’re not going back down that road again, because I feel like public health did a lot of work in pushing the message that formula and breast milk is good for the child, and so that’s just another angle that I’ve been thinking about on this. 

Rovner: Yes, I think this is one of those things that everybody agrees we should look at and has the potential to get really controversial at some point. While we are on the subject of the federal workforce and layoffs, federal judges and DOGE continue to play cat-and-mouse, with lots of real people’s lives and careers at stake. Various judges have ordered the reinstatement, as you mentioned, Rachel, of probationary and other workers. Although in many cases workers have been reinstated to an administrative leave status, meaning they get put back on the payroll and they get their benefits back, but they still can’t do their jobs. At least one judge has said that does not satisfy his order, and this is all changing so fast it’s basically impossible to keep up. But is it fair to say that it’s not a very stable time to be a federal worker? 

Karlin-Smith: That’s probably the nicest possible way to put it. When you talk to federal workers, everybody seems stressed and just unsure of their status. And if they do have a job, it’s often from their perspective tougher to do their job lately, and then they’re just not sure how stable it is. And many people are considering what options they have outside the federal government at this point. 

Rovner: So for those lucky federal workers who do still have jobs, the Trump administration has also ordered everyone back to offices, even if those offices aren’t equipped to accommodate them. FDA headquarters here in Maryland’s kind of been the poster child for this this week. 

Karlin-Smith: Yeah, FDA is an interesting one because well before covid normalized working from home and transitioned a lot of people to working from home, FDA’s headquarters couldn’t accommodate a lot of the new growth in the agency over the years, like the tobacco part of the FDA. So it was typical that people at least worked part of their workweek at home, and FDA really found once covid gave them additional work-from-home flexibilities, they were able to recruit staff they really, really needed with specialized degrees and training who don’t live near here, and it actually turned out to be quite a benefit from them. 

And now they’re saying everybody needs to be in an office five days a week, and you have people basically cramped into conference rooms. There’s not enough parking. People are trying to review technical scientific data, and you kind of can’t hear yourself think. Or you’re a lawyer — I heard of a situation where people are basically being told, Well, if you need to do a private phone call because of the confidentiality around what you’re doing, go take the call in your car. So I think in addition to all of the concerns people have around the stability of their jobs, there’s now this element of, on a personal level, I think for many of them it’s just made their lives more challenging. And then they just feel like they’re not actually able to do, have the same level of efficiency at their work as they normally would. 

Rovner: And for those who don’t know, the FDA campus is on a former military installation in the Maryland suburbs. It’s not really near any public transportation. So you pretty much have to drive to get there. And I think that the parking lots are not that big, because, as you pointed out, Sarah, the workforce is now bigger than the headquarters was created to accommodate it. And we’re seeing this across the government. This week it happened to be FDA. You have to ask the question: Is this really just an effort to make the government not work, to make federal workers, if they can’t fire them, to make them quit? 

Hellmann: I definitely think that’s part of the underlying goal. If you see some of the stuff that Elon Musk says about the federal workforce, it’s very dismissive. He doesn’t seem to have a lot of respect for the civil servants. And they’ve been running into a lot of pushback from federal judges over many lawsuits targeting these terminations. And so I think just making conditions as frustrating as possible for some of these workers until they quit is definitely part of the strategy. 

Roubein: And I think this is overlaid with the additional buyout offers, the additional early retirement offers. There’s also the reduction-in-force plans that federal workers have been unnerved about, bracing for future layoffs. So it’s very clear that they want to shrink the size of the federal workforce. 

Rovner: Yeah, we’ve seen a lot of these people, I’ve seen interviews with them, who are being reinstated, but they’re still worried that now they’re going to be RIF-ed. They’re back on the payroll, they’re off the payroll. I mean there’s nothing — this does not feel like a very efficient way to run the federal government. 

Karlin-Smith: Right. I think that’s what a lot of people are talking about is, again, going back to offices, for many of these people, is not leading to productivity. I talked to one person who said: I’m just leaving my laptop at the office now. I’m not going to take it home and do the extra hours of work that they might’ve normally gotten from me. And that includes losing time to commute. FDA is paying for parking-garage spaces in downtown Silver Spring [Maryland] near the Metro so that they can then shuttle people to the FDA headquarters. I’ve taken buses from that Metro to FDA headquarters. In traffic, that’s a 30-minute drive. They’re spending money on things that, again, I think are not going to in the long run create any government efficiency. 

And in fact, I’ve been talking to people who are worried it’s going to do the opposite, that drug review, device review, medical product review times and things like that are going to slow. We talked about food safety. I think The New York Times had a really good story this week about concerns about losing the people. We need to make sure that baby formula is actually safe. So there’s a lot of contradictions in the messaging of what they’re trying to accomplish and how the actions actually are playing out. 

Rovner: Well, and finally, I’m going to lay one more layer on this. There’s the question of whether you can even put the toothpaste back in the tube if you wanted to. After weeks of back-and-forth, the federal judge ruled on Tuesday that the dissolution of USAID [the U.S. Agency for International Development] was illegal and probably unconstitutional, and ordered email and computer access restored for the remaining workers while blocking further cuts. But with nearly everybody fired, called back from overseas, and contracts canceled, USAID couldn’t possibly come close to doing what it did before DOGE basically took it apart, right?. 

Karlin-Smith: You hear stories of if someone already takes a new job, they’re lucky enough to find a new job, why are they going to come back? Again, even if you’re brought back, my expectation is a lot of people who have been brought back are probably looking for new jobs regardless because you don’t have that stability. And I think the USAID thing is interesting, too, because again, you have people that were working in all corners of the world and you have partnerships with other countries and contractors that have to be able to trust you moving forward. And the question is, do those countries and those organizations want to continue working with the U.S. if they can’t have that sort of trust? And as people said, the U.S. government was known as, they could pay contractors less because they always paid you. And when you take that away, that creates a lot of problems for negotiating deals to work with them moving forward. 

Rovner: And I think that’s true for federal workers, too. There’s always been the idea that you probably could earn more in the private sector than you can working for the federal government, but it’s always been a pretty stable job. And I think right now it’s anything but, so comes the question of: Are we deterring people from wanting to work for the federal government? Eventually one would assume there’s still going to be a federal government to work for, and there may not be anybody who wants to do it. 

Roubein: Yeah, you saw various hiring authorities given to try and recruit scientists and other researchers who make a lot, lot more in the public health sector, and some of those were a part of the probationary workforce because they had been hired recently under those authorities. 

Rovner: Yeah, and now this is all sort of coming apart. Well, meanwhile, the cuts are continuing even faster than federal judges can rule against them. Last week, the administration said it would reduce the number of HHS regional offices from 10 to four. Considering these are where the department’s major fraud-fighting efforts take place, that doesn’t seem a very effective way of going after fraud and abuse in programs like Medicare and Medicaid. Those regional offices are also where lots of beneficiary protections come from, like inspections of nursing homes and Head Start facilities. How does this serve RFK Jr.’s Make America Healthy Again agenda? 

Karlin-Smith: I think it’s not clear that it does, right? You’re talking about, again, the Department of Government Efficiency has focused on efficiency, cost savings, and Medicare and Medicaid does a pretty good job of fighting fraud and making HHS OIG [Office of Inspector General], all those organizations, they collect a lot of money back. So when you lose people— 

Rovner: And of course the inspector general has also been laid off in all of this. 

Karlin-Smith: Right. It’s not clear to me, I think one of the things with that whole reorganization of their chief counsel is people are suggesting, again, this is sort of a power move of HHS wanting to get a little bit more control of the legal operations at the lower agencies, whether it’s NIH [the National Institutes of Health] or FDA and so forth. But, right, it’s reducing head count without really thinking about what people’s roles actually were and what you lose when you let them go. 

Rovner: Well, the Trump administration is also continuing to cut grants and contracts that seem like they’d be the kind of things that directly relate to Make America Healthy Again. Jessie, you’ve chosen one of those as your extra credit this week. Tell us about it. 

Hellmann: Yeah. So my story is from Stat [“NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease”], and it’s about a nationwide study that tracks patients with prediabetes and diabetes. And it was housed at Columbia University, which as we know has been the subject of some criticism from the Trump administration. They had lost about $400 million in grants because the administration didn’t like Columbia’s response to some of the protests that were on campus last year. But that has an effect on some research that really doesn’t have much to do with that, including a study that looked at diabetes over a really long period of time. 

So it was able to over decades result in 200 publications about prediabetes and diabetes, and led to some of the knowledge that we have now about the interventions for that. And the latest stage was going to focus on dementia and cognitive impairment, since some of the people that they’ve been following for years are now in their older ages. And now they have to put a stop to that. They don’t even have funding to analyze blood samples that they’ve done and the brain scans that they’ve collected. So it’s just another example of how what’s being done at the administration level is contradicting some of the goals that they say that they have. 

Rovner: Yeah, and it’s important to remember that Columbia’s funding is being cut not because they deemed this particular project to be not helpful but because they are, as you said, angry at Columbia for not cracking down more on pro-Palestinian protesters after Oct. 7. 

Well, meanwhile, people are bracing for still more cuts. The Wall Street Journal is reporting the administration plans to cut domestic AIDS-HIV programming on top of the cuts to the international PEPFAR [President’s Emergency Plan for AIDS Relief] program that was hammered as part of the USAID cancellation. Is fighting AIDS and HIV just way too George W. Bush for this administration? 

Hellmann: It’s interesting because President [Donald] Trump unveiled the Ending the HIV Epidemic initiative in his first term, and the goal was to end the epidemic in the United States. And so if they were talking about reducing some of that funding, or I know there were reports that maybe they would move the funding from CDC [the Centers for Disease Control and Prevention] to HRSA [the Health Resources and Services Administration], it’s very unclear at this point. Then it raises questions about whether it would undermine that effort. And there’s already actions that the Trump administration has done to undermine the initiative, like the attacks on trans people. They’ve canceled grants to researchers studying HIV. They have done a whole host of things. They canceled funding to HIV services organizations because they have “trans” in their programming or on their websites. So it’s already caused a lot of anxiety in this community. And yeah, it’s just a total turnaround from the first administration. 

Rovner: I know the Whitman-Walker clinic here in Washington, which has long been one of the premier AIDS-HIV clinics, had just huge layoffs. This is already happening, and as you point out, this was something that President Trump in his first term vowed to end AIDS-HIV in the U.S. So this is not one would think how one would go about that. 

Well, it’s not just the administration that’s working to constrict rights and services. A group of 17 states, led by Texas, of course, are suing to have Biden-era regulations concerning discrimination against trans people struck down, except as part of that suit, the states are asking that the entirety of Section 504 of the Rehabilitation Act be declared unconstitutional. Now, you may never have heard of Section 504, but it is a very big deal. It was the forerunner of the Americans With Disabilities Act, and it prevents discrimination on the basis of disability in all federally funded activities. It is literally a lifeline for millions of disabled people that enables them to live in the community rather than in institutions. Are we looking at an actual attempt to roll back basically all civil rights as part of this war on “woke” and DEI [diversity, equity, and inclusion] and trans people? 

Hellmann: The story is interesting, because it seems like some of the attorneys general are saying, That’s not our intent. But if you look at the court filings, it definitely seems like it is. And yeah, like you said, this is something that would just have a tremendous impact. And Medicaid coverage of home- and community-based services is one of those things that states are constantly struggling to pay for. You’re just continuing to see more and more people need these services. Some states have waiting lists, so— 

Rovner: I think most states have waiting lists. 

Hellmann: Yeah. It’s something, you have to really question what the intent is here. Even if people are saying, This isn’t our intent, it’s pretty black-and-white on paper in the court records, so— 

Rovner: Yeah, just to be clear, this was a Biden administration regulation, updating the rules for Section 504, that included reference to trans people. But in the process of trying to get that struck down, the court filings do, as you say, call for the entirety of Section 504 to be declared unconstitutional. This is obviously one of those court cases that’s still before the district court, so it’s a long way to go. But the entire disability community, certainly it has their attention. 

Well, we haven’t had any big abortion news the past couple of weeks, but that is changing. In Texas, a midwife and her associate have become the first people arrested under the state’s 2022 abortion ban. The details of the case are still pretty fuzzy, but if convicted, the midwife who reportedly worked as an OB-GYN doctor in her native Peru and served a mostly Spanish-speaking clientele, could be sentenced to up to 20 years in prison. So, obviously, be watching that one. Meanwhile, here in Washington, Hilary Perkins, a career lawyer chosen by FDA commissioner nominee Marty Makary to serve as the agency’s general counsel, resigned less than two days into her new position after complaints from Missouri Sen. Josh Hawley that she defended the Biden administration’s position on the abortion pill mifepristone. 

Now, Hilary Perkins is no liberal trying to hide out in the bureaucracy. She’s a self-described pro-life Christian conservative hired in the first Trump administration, but she was apparently forced out for the high crime of doing her job as a career lawyer. Is this administration really going to try to evict anyone who ever supported a Biden position? Will that leave anybody left? 

Roubein: I think what’s notable is Sen. Josh Hawley here, who expressed concerns and I had heard expressed concerns to the White House, and the post on X from the FDA came an hour before the hearing. There were concerns that he was not going to make it out of committee and— 

Rovner: Before the Marty Makary hearing. 

Roubein: Yes, sorry, before the vote in the HELP [Health, Education, Labor and Pensions] Committee on Marty Makary. And Hawley said because of that, he would vote to support him. What was interesting is two Democrats actually ended up supporting him, so he could have passed without Hawley’s vote. But I think in general it poses a test for Marty Makary when he’s an FDA commissioner, and how and whether he’s going to get his people in and how he’ll respond to different pressure points in Congress and with HHS and with the White House. 

Rovner: And of course, Hawley’s not a disinterested bystander here, right? 

Karlin-Smith: So his wife was one of the key attorneys in the recent big Supreme Court case that was pushed down to the lower courts for a lack of standing, but she was trying to essentially get tighter controls on the abortion pill mifepristone. But it seems like almost maybe Hawley jumped too soon before doing all of his research or fully understanding the role of people at Justice. Because even before this whole controversy erupted, I had talked to people the day before about this and asked them, “Should we read into this, her being involved in this?” And everybody I talked to, including, I think, a lot of people that have different views than Perkins does on the case, that they were saying she was in a role as a career attorney. You do what your boss, what the administration, wants. 

If you really, really had a big moral problem with that, you can quit your job. But it’s perfectly normal for an attorney in that kind of position to defend a client’s interest and then have another client and maybe have to defend them wrongly. So it seems like if they had just maybe even picked up the phone and had a conversation with her, the whole crisis could have been averted. And she was on CNN yesterday trying to plead her case and, again, emphasize her positions because perhaps she’s worried about her future career prospects, I guess, over this debacle. 

Rovner: Yeah, now she’s going to be blackballed by both sides for having done her job, basically. Anyway, all right, well, one big Biden initiative that looks like it will continue is the Medicare Drug Price Negotiation program. And we think we know this because CMS announced last week that the makers of all of the 15 drugs selected for the second round of negotiations have agreed to, well, negotiate. Sarah, this is news, right? Because we were wondering whether this was really going to go forward. 

Karlin-Smith: Yeah, they’ve made some other signals since taking over that they were going to keep going with this, including last week at his confirmation hearing, Dr. Oz, for CMS, also indicated he seemed like he would uphold that law and they were looking for ways to lower drug costs. So I think what people are going to be watching for is whether they yield around the edges in terms of tweaks the industry wants to the law, or is there something about the prices they actually negotiate that signal they’re not really trying to get them as low as they can go? But this seems to be one populist issue for Trump that he wants to keep leaning into and keep the same consistency, I think, from his first administration, where he always took a pretty hard line on the drug industry and drug pricing. 

Rovner: And I know Ozempic is on that list of 15 drugs, but the administration hasn’t said yet. I assume that’s Ozempic for its original purpose in treating diabetes. This administration hasn’t said yet whether they’ll continue the Biden declaration that these drugs could be available for people for weight loss, right? 

Karlin-Smith: Correct. And I think that’s going to be more complicated because that’s so costly. So negotiating the price of drugs saves money. So yes, basically because Ozempic and Wegovy are the same drug, that price should be available regardless of the indication. But I’m more skeptical that they continue that policy, because of the cost and also just because, again, HHS Secretary Robert F. Kennedy seems to be particularly skeptical of the drugs, or at least using that as a first line of defense, widespread use, reliance on that. He tends to, in general, I think, support other ways of medical, I guess, treatment or health treatments before turning to pharmaceuticals. 

Rovner: Eating better and exercising. 

Karlin-Smith: Correct, right. So I think that’s going to be a hard sell for them because it’s just so costly. 

Rovner: We will see. All right, that is as much news as we have time for this week. Now, it is time for our extra-credit segment, that’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Jessie, you’ve done yours already this week. Rachel, why don’t you go next? 

Roubein: My extra credit, the headline is “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” In The Washington Post by my colleague Carolyn Y. Johnson. And I thought the story was particularly interesting because it really dove into the personal level. You hear about all these cuts from a high level, but you don’t always really know what it means and how it came about. So the backstory is the National Institutes of Health terminated dozens of research grants that focused on why some people are hesitant to accept vaccines. 

And Carolyn profiled one researcher, Nisha Acharya, but there was a twist, and the twist was she doesn’t actually study how to combat vaccine hesitancy or ways to increase vaccine uptake. Instead, she studies how well the shingles vaccine works to prevent the infection, with a focus on whether the shot also prevents the virus from affecting people’s eyes. But in the summary of her project, she had used the word “hesitancy” once and used the word “uptake” once. And so this highlights the sweeping approach to halting some of these vaccine hesitancy research grants. 

Rovner: Yeah that was like the DOD [Department of Defense] getting rid of the picture of the Enola Gay, the plane that dropped the atomic bomb, because it had the word “Gay” in it. This is the downside, I guess, of using AI for these sorts of things. Sarah. 

Karlin-Smith: I took a look at a KFF story by Arthur Allen, “Scientists Say NIH Officials Told Them to Scrub mRNA References on Grants,” and it’s about NIH officials urging people to remove any reference to mRNA vaccine technology from their grants. And the story indicates it’s not yet clear if that is going to translate to defunding of such research, but the implications are quite vast. I think most people probably remember the mRNA vaccine technology is really what helped many of us survive the covid pandemic and is credited with saving millions of lives, but the technology promise seems vast even beyond infectious diseases, and there’s a lot of hope for it in cancer. 

And so this has a lot of people worried. It’s not particularly surprising, I guess, because again, the anti-vaccine movement, which Kennedy has been a leader of, has been particularly skeptical of the mRNA technology. But it is problematic, I think, for research. And we spent a lot of time on this call talking about the decimation of the federal workforce that may happen here, and I think this story and some of the other things we talked about today also show how we may just decimate our entire scientific research infrastructure and workforce in the U.S. outside of just the federal government, because so much of it is funded by NIH, and the decisions they’re making are going to make it impossible for a lot of scientists to do their job. 

Rovner: Yeah, we’re also seeing scientists going to other countries, but that’s for another time. Well, my extra credit this week, probably along the same lines, also from The Washington Post. It’s part of a series called “Who Is Government?” This particular piece [“The Free-Living Bureaucrat”] is by bestselling author Michael Lewis, and it’s a sprawling — and I mean sprawling — story of how a mid-level FDA employee who wanted to help find new treatments for rare diseases ended up not only figuring out a cure for a child who was dying of a rare brain amoeba but managed to obtain the drug for the family in time to save her. It’s a really good piece, and it’s a really excellent series that tells the stories of mostly faceless bureaucrats who actually are working to try to make the country a better place. 

OK, that’s this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys these days? Sarah? 

Karlin-Smith: A little bit everywhere. X, Bluesky, LinkedIn — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Jessie. 

Hellmann: I’m @jessiehellmann on X and Bluesky, and I’m also on LinkedIn more these days. 

Rovner: Great. Rachel. 

Roubein: @rachelroubein at Bluesky, @rachel_roubein on X, and also on LinkedIn. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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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.

As abortion and other reproductive issues gain more prominence in the looming election, some Republicans are trying to moderate their anti-abortion positions, particularly in states where access to the procedure remains politically popular. 

Meanwhile, open enrollment is underway for Medicare, even as some health plans are challenging in court the federal government’s decision to reduce their quality ratings — with millions of dollars at stake. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Sarah Karlin-Smith of the Pink Sheet, and Victoria Knight of Axios.

Panelists

Rachel Cohrs Zhang
Stat News

@rachelcohrs

Read Rachel's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Among the takeaways from this week’s episode:

• With polls showing more voters citing abortion as a top voting issue, some candidates with long track records opposing abortion rights are working to moderate their positions.
• Many older Americans will spend less on prescription drugs next year due to a new out-of-pocket pricing cap, among other changes in store as provisions of the 2022 Inflation Reduction Act take effect. But some are realizing the limits on those benefits, as deeper problems persist in drug pricing, insurance coverage, and access.
• The FDA is reconsidering a weight-loss drug decision that caused confusion for patients and compounding pharmacies. Compounded drugs are intended for individual issues, like needing a different dosage — and while the process can be used to augment mass manufacturing during times of drug shortages, it is not well suited to address access and pricing issues.
• In abortion news, a comprehensive study shows abortions have increased since the overturn of Roe v. Wade, even among women in states with strict restrictions — and those states are seeing higher infant mortality rates, according to separate research. And an effort is underway to revive in a Texas court the challenge to mifepristone’s FDA approval. The last challenge failed because the Supreme Court found the plaintiffs lacked standing.

Also this week, Rovner interviews Tricia Neuman, senior vice president of KFF and executive director of its Program on Medicare Policy, about Medicare open enrollment and the changes to the program for 2025. 

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: NBC News’ “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks.  

Sarah Karlin-Smith: Vanity Fair’s “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health,” by Katherine Eban. 

Rachel Cohrs Zhang: The Atlantic’s “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch.  

Victoria Knight: NPR’s “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year,” by Rosemary Westwood and Jack Jenkins.

Also mentioned on this week’s podcast:

• The New York Times’ “Abortions Have Increased, Even for Women in States With Rigid Bans, Study Says,” by Claire Cain Miller and Margot Sanger-Katz.
• CNN’s “Infants Died at Higher Rates After Abortion Bans in the US, Research Shows,” by Deidre McPhillips.

click to open the transcript

Transcript: Less Than Two Weeks To Go

[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, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 24, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this, so here we go. 

Today we are joined via video conference by Rachel Cohrs Zhang of Stat News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: Victoria Knight of Axios. 

Victoria Knight: Hello, everyone. 

Rovner: And Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Later in this episode we’ll have my interview with my friend and KFF colleague Tricia Neuman about Medicare open enrollment and what to expect in Medicare in the coming year. 

But first, this week’s news. We will start on the campaign trail since Election Day is now less than two weeks away. Let that sink in. Abortion is, at least according to many polls, on the upswing as a voting issue and, probably not coincidentally, abortion-adjacent issues, like contraception, are also getting more attention. But while it’s clear that Democrats are still pretty much the party of abortion rights and Republicans are pretty much the party representing anti-abortion activists, we’re seeing some Republican candidates working pretty hard to muddy the waters. Yes? 

Knight: Yeah, it’s been interesting this election cycle. We have seen some Republicans saying that they are pro-choice. And this is at a time when, finally, on the Democratic side in Congress, there really are not many anti-abortion Democrats left. We have in the House congressman Henry Cuellar [of Texas] is really the only one left. [Pennsylvania] Sen. Bob Casey, we’ve kind of seen him swing over time to be more in the camp of pro-choice, pro-abortion rights and so … 

Rovner: … which was really, in Casey’s case, really interesting, because his father, who was the governor of Pennsylvania, was sort of the original anti-abortion Democrat back in the early 1990s. 

Knight: Yeah. I’m interested to see if this works in — we’re seeing, particularly in some more moderate, swinging House seats, that Republicans are trying to message in this way that they’re more moderate on abortion, saying they’re more pro-choice. I’m interested to see if this actually works. And then we have perhaps this caucus within the House, if that works, that are more moderate. I mean, you already see in the current makeup of the House, there are some House Republicans, particularly the New York Republicans, that were really careful in this 118th Congress when they were having to vote on certain bills that would restrict, for example, access to mifepristone. That was kind of a rider in the FDA appropriations bill, and they didn’t want to vote for it, and they helped cause chaos on the House floor for that bill, particularly, because they didn’t want to pass it because they knew that would look bad on their record and they were having to run for the House again. So, will this messaging work for the kind of new people that are running this cycle? I’m not sure, but we’ll see. 

Rovner: I was kind of surprised to see Liz Cheney this week (who was out campaigning with Vice President [Kamala] Harris), who’s strongly anti-abortion, has been her entire career, actually pipe up on her own — and she’s not running for anything; she’s basically a person without a party at the moment — but say that even though she’s anti-abortion, she is not in favor of some of the things that are happening with some of these abortion bans, like women having miscarriages not being able to get immediate medical [care]. I was fascinated to see somebody who, with as strong anti-abortion credentials as she has, speak out about these things that one would assume even people who are anti-abortion would not be against. We do see the anti-abortion group saying making abortion illegal doesn’t make it illegal to treat ectopic pregnancies and miscarriage care, even though it gets all muddled when you’re actually on the ground doing it and you’re a doctor facing potential jail time. 

Knight: Well, and I think the thing is, people are seeing the realities of the abortion bans a couple of years in. I think that’s really the consequences. … When these first happened two years ago, people can say all these kind of things, but now that they’ve been in place for a couple years and women have died, we’re hearing these stories from news outlets of how that happens and it’s often women that want the babies. It’s like people are having to moderate their stances somewhat, I think. 

Rovner: It’s — there’s nuance. … Politics is not great with nuance, but we’re seeing nuance. 

Well, one abortion-adjacent story that jumped out at me this week is happening in Florida, where it seems that the office of Florida Gov. Ron DeSantis himself was behind legal threats to TV stations running ads in favor of the ballot measure that would enshrine abortion rights in the state’s constitution. According to the Tampa Bay Times, “Florida Department of Health general counsel John Wilson said he was given prewritten letters from one of DeSantis’ lawyers … Oct. 3 and told to send them under his own name, he wrote in a sworn affidavit.” Wilson subsequently resigned rather than send out more letters. In between, a judge warned the state to cease and desist with the threat, saying, and I quote, “It’s the First Amendment, stupid.” I have honestly never seen anything quite like this, although I would also point out I’ve never seen anything quite like Florida’s surgeon general recommending against people getting vaccines. What the heck is going on in Florida? 

Cohrs Zhang: I think we’ve seen state officials in Florida try to enact their will and challenge public health recommendations. Certainly, we saw that happen during the covid-19 pandemic. They were trying to put out their own guidelines on vaccination, and so I don’t think it’s a particular surprise. I think it is just uglier than usual now that we get the full backstory on how these letters came to be. And court cases take a long time, and I think that’ll extend to beyond the next couple of weeks. But it’s an interesting publicity stunt for what it is, and yeah I … 

Rovner: I wouldn’t want to be one of the TV stations threatening to have its license canceled, although the head of the FCC, I think, got involved too and said, “Um, this is not how this works.” 

Cohrs Zhang: Yeah, I think so. I don’t expect that the court would find that political ads you don’t like are illegal, so, yeah. 

Rovner: Yeah, I don’t think the governor can tell you to pull political ads that they don’t like. Pretty sure that’s not how these things work. 

Well, meanwhile, given the very real possibility that Donald Trump will return to the White House, the D.C. rumor mill is already spinning out names of those who could fill Cabinet and other senior health posts. What are you guys hearing? And is RFK Jr. really going to end up in some big health policymaking job? 

Knight: That’s funny that you say that because I was just having a talk with my editors about the names that we’re hearing. I have heard, and I am sure Rachel and Sarah have names on their mind as well, but someone said this to me, I think it’s funny: A very 2004 pick would be Bobby Jindal. He’s at the America First Policy Institute, which has a lot of former Trump administration people there, and it’s kind of seen this swing, I think recently, now that Project 2025 is kind of like no one wants to touch Project 2025 anymore. It seems like more people are, like, OK, AFPI is the place to pick people from if there’s a new Trump administration. And there’s been some stories this week about the chief of staff potentially coming from AFPI. So, people have been telling me Bobby Jindal, but I think he seems to have some solid grounding in that. You probably are more familiar with him, Julie, than I am, but … 

Rovner: Oh, yes. I’ve known him since 2004. I’ve known him since before 2004. He was actually … he was brought to Washington by Democratic Sen. John Breaux to staff a Medicare commission back in, I think it was the very late 1990s. He served in Congress, he was the governor of Louisiana, and he served in HHS [the Department of Health and Human Services] in the George W. Bush administration. So he’s got lots of experience, and he’s coincidentally all over Twitter this week with a paid ad, trashing Kamala Harris’ support for “Medicare for All,” which, of course, she hasn’t supported since 2019. But yeah, suddenly Bobby Jindal, who we hadn’t seen in a while, is kind of everywhere. He was one of the bright young lights about, what, eight years ago? 

Knight: Right, right. 

Rovner: But I guess before Trump, he was one of the bright young Republican lights. So yeah, I keep hearing his name too. 

Cohrs Zhang: I don’t know … 

Rovner: Go ahead, Rachel. 

Cohrs Zhang: I was just going to say that I don’t think there are a lot of people that we’ve been talking to who are worried about RFK himself getting appointed to one of these posts, but I think there has been a lot of buzz about some of his allies, like Calley and Casey Means. I know my colleague Isa Cueto did a great — just, profile of kind of who they are and kind of how their rise has just been so meteoric, and I think we’re also seeing some allies. So people who rose in the conservative movement over skepticism, over vaccine mandates, and just like the whole public health establishment have really gotten a new platform. And so I think people are a little nervous, as we’ve reported, both health care industry leaders who are worried about anti-pharmaceutical industry sentiment, anti-science sentiment, and even establishment Republican leaders and officials who served in prior Trump administrations that the picks could be more extreme than a Bobby Jindal establishment-Republican type and that this could be taking a turn. 

Rovner: Sarah, what are you hearing with FDA? 

Karlin-Smith: I mean, it’s a little less clear, I think, who might end up in FDA, but the sentiment has been probably a more typical Trump pick than maybe we got last time. FDA was sort of insulated in some ways, I think, from some of the drama, if you will, of the Trump administration last time. Scott Gottlieb was able to run FDA with pretty hands-off from other parts of the administration, and I think he ran FDA more like you would expect a traditional Republican to run FDA, not necessarily a Trump Republican. And I think people are recognizing that FDA will be a lot more vulnerable this time around that we’re probably not going to get another kind of Scott Gottlieb to save FDA if Trump is president. There’s certainly more concerns about how that impacts staff turnover as well, among civil service folks. 

Rovner: Yeah, we will see. 

All right, well, moving on. Open enrollment for Medicare began last week and continues until Dec. 7. That’s when people on Medicare can join or change their private prescription drug and/or Medicare Advantage plans. We explore this in more detail in my interview later in this episode with KFF’s Tricia Neuman. We know that most people with Medicare and most people with private insurance, where they can change plans during an open enrollment season, don’t actually bother to do anything. But this year there really are a lot of changes coming in Medicare, particularly on the prescription drug side. Why is it extra important this year that people take a look at their coverage? 

Karlin-Smith: So, some of the big changes with the IRA [Inflation Reduction Act] that kick in this year for Medicare and the prescription side, like the $2,000 out-of-pocket cap. Your plan actually has to cover that. One thing, I was at a conference this week and they’re saying that drug has to be, actually be on your plan for you to reap those savings of hitting that cap, which seems obvious, but … 

Rovner: Oh, I don’t know. I think people don’t quite realize that. It’s like they think that there’s a $2,000 cap no matter what, and it’s important. It’s, like, if your drug is not one of the drugs that’s covered by your plan, does not count. 

Karlin-Smith: Right, and so it’s looking for all of those things to make sure all the pieces of your plan actually fit together with your medical needs. There’s been, I think, a reduction, in some degree, into the amount of particularly Part D stand-alone plans for people who elect to use traditional Medicare for their other health benefits. So you may just want to look a little bit more closely at what the options are, what the premiums are, because some of these changes to Part D have impacted premiums a bit, though the federal government has stepped in to try to alleviate that. 

But I think this is seen as an adjustment year for the plans because one of the ideas behind the IRA is to put both health insurance companies as well as the pharmaceutical companies more on the hook, in some ways, for the cost of drugs. The old way Part D plans worked, the government ended up bearing a lot of the costs of the drugs to a point where it didn’t give a lot of incentives for both the drug companies to want to lower the prices, for the insurance companies to push for that. So I think it may take a little bit of time for them to figure out now how to adjust the benefits and the premiums and so forth, given this new dynamic. So people just may want to pay a little bit more close attention for premium aspects and others as well to the plans they’re picking. 

Rovner: And if you’re helping someone on Medicare, which I know many people are, it’s good to do a little extra homework this year. 

Well, another story that caught my eye is a survey of independent drugstores that suggests many of them won’t stock the very expensive drugs that Medicare negotiations are making less expensive, because they would actually lose money dispensing them. Sarah, is this an unexpected glitch, and can it be fixed, or is this just the price of bringing down drug prices? 

Karlin-Smith: I would say not entirely unexpected. These independent pharmacies have warned CMS [the Centers for Medicare & Medicaid Services] and tried to push in guidance so that when they’re dispensing a drug, basically, they will be entitled to get quicker rebates from the drug companies so that they can make stocking these drugs more reasonable for them. And these pharmacies, I think in particular, have been raising alarm bells outside of Medicare drug price negotiations for a while now, that they’re being placed in these difficult positions where they have to buy drugs at whatever the wholesale acquisition cost is. And then there’s all of this insurance back-end stuff going on, and they sometimes get reimbursed by the plans and so forth for less than they’ve actually bought the drugs. 

So it’s not just a Medicare drug price negotiation issue here. Some of it is, again, about the time that the pharmaceutical companies have to rebate the costs and they ask Medicare for a bit of leeway. And others, it’s just this broader way our system works, where they’re buying wholesale. You have a patient come to the counter that pays their small portion of it, their plan pays, whatever, and everybody has to sort of, right at the end … and these pharmacies are saying, “We can’t afford to do that.” I do think, politically, if this becomes a problem, if patients can’t get the negotiated prices/drugs at the pharmacies they’re used to, this could be politically problematic for the IRA moving forward. Even though, again, I’m not entirely sure. It’s illuminating a broader problem in the system that I think existed without it. 

Rovner: Right, it’s all a big mess, and it’s underlining it. 

Karlin-Smith: Right, but that doesn’t mean that politics won’t come into play and blame drug price negotiation. And certainly, anytime an opposing party hates something — we know Democrats are really into this, Republicans aren’t, and I’m sure they will try and blame it on the IRA as much as possible. And we’ll see if CMS maybe realizes that they had a little more leverage to try and make this a little bit easier and fixes it for the next round. 

Rovner: Yeah. Before we leave Medicare, I want to talk briefly about Medicare Advantage. This Medicare Advantage market is so valuable to insurers and so competitive that we now have at least two lawsuits charging that Medicare wrongly lowered the number of quality stars some plans received. Now, this feels like a restaurant suing Yelp for lowering its rating from four stars to three, but in Medicare Advantage, this is a really big deal, right, when they lose a star? 

Cohrs Zhang: Right, I think if the Yelp rating was worth $70 million, or whatever that figure is, then yeah, maybe they would sue. So I think we certainly — I think it’s a measure that is so important to insurers, to regulators, but that individual people might not understand. And there were some really interesting details from that lawsuit about the potential that there was one call-center call that tipped the balance into a quality measure and that there might’ve been some technical difficulties, and it does just cast these larger questions that I think I’ll be interested to see what documents come out during these lawsuits. And just questioning how useful these metrics really are, if that really was the case. 

Rovner: Yeah, I found it, I also was taken aback. It’s like, really, one call to a customer service center didn’t happen properly, and so the whole plan loses a star? That seemed a little bit dramatic, but yes, like you, I’ll be interested to see. There’s a lot of pressure on Medicare Advantage from every conceivable angle, but we are now in litigation over it. 

Well, while we are on the subject of private health companies suing the federal government, the compounding pharmacies who have been legally selling unapproved copies of the very popular and very expensive diabetes/obesity drugs Mounjaro and Zepbound have apparently successfully gotten the FDA to reverse its earlier finding, based on the pharmaceutical manufacturers’ say-so, that those drugs are no longer in shortage. That’s a decision that would’ve made it illegal for the compounders to continue to make and sell those drugs. At the same time, Novo Nordisk, maker of the very popular and very expensive diabetes/obesity drugs Ozempic and Wegovy, are trying to get the FDA to stop compounders from copying their drugs, which are still in shortage. Can somebody please explain what’s going on here? 

Karlin-Smith: So, basically, compounding is where pharmacists can sometimes make drugs in a more customized fashion because a person maybe can’t swallow a pill or needs a slightly different dose or a different inactive ingredient, but there’s not … 

Rovner: And they add flavoring for kids too, right? 

Karlin-Smith: Right. 

Rovner: Isn’t that a big compounding thing? 

Karlin-Smith: But it’s not supposed to be something that takes the place of mass-manufactured drugs. But one of the times when it kind of can — and FDA, after some big safety incidents in 2013, developed a sort of scheme where there can be some degree mass compounding, but there’s a little bit more safety oversight from their end. 

And one of the cases where you can do more compounding is when a drug is in shortage. But once FDA flipped the switch and said, “Oh, OK, actually, these drugs are no longer in shortage,” that makes it illegal. So these companies sued. My understanding from talking to legal experts is it’s not necessarily clear that FDA is entirely reversing course and agreeing that drugs aren’t in shortage. They’re agreeing to re-look at their decision, which may mean they are going to bolster their case so when they get back into court, they have a much clearer documentation of why the drugs are actually out of shortage. But in the meantime, we have probably at least another four weeks or so where everybody can compound these products. 

At the same time, I think Novo Nordisk and, actually, Eli Lilly before them had also submitted a similar citizen petition to FDA trying to basically get these drugs from being on lists where you really could not compound them at all. And there’s clearly a lot of money at stake here. These are probably some of the most well-known drugs right now with huge markets in the U.S., but they’re also really expensive and they haven’t been picked up and covered by a lot of insurance plans, particularly when you’re talking about the weight loss element. I think for Type 2 diabetes, there’s pretty good coverage. And the thing here that’s really so significant is this is probably one of the first times in the U.S. where we’ve seen this mass-market compounding for a drug kind of at the beginning-ish of its exclusivity, at least when you’re talking about weight loss — again, not diabetes. And it’s not like a niche thing. So many people are using it,  through compounding. And again, it’s really like … 

Rovner: The advertising is everywhere on social media. 

Karlin-Smith: Right, I mean, that just surprised me, I think, at first to begin with, how open these companies were about it being available via compounding pharmacies. And so I think FDA is in a really tricky position, particularly if they can clearly document it’s not a shortage situation anymore, because there still probably is going to be a lot of demand because of the cheaper prices coming from compounders, because of health insurance coverage issues. But, again, the compounding system is not meant to address those sorts of price and access issues. Right? It’s supposed to be for very particular situations where people really can’t use the exact manufactured drug, in most cases. And so maybe this tension will force us to address the other issues of price and insurance coverage, but it’s an awkward position for FDA to be in. 

And again, because, I think, it’s just also important just to go backtrack and remember, you know, FDA facilitates an important role of inspecting the manufacturing facilities, ensuring every lot is being manufactured to a consistent quality, approving the drug to begin with. So there’s certainly this delicate dance of you want people to be able to get drugs they need and you also don’t want this kerfuffle to undermine the entire drug-approval system we have that ensures that when you get a drug, a prescription drug, you know it’s a certain quality. 

Rovner: And it is what it says it is. 

Karlin-Smith: Right. 

Rovner: Yes. All right, well, turning back to abortion. A new study out this week suggests that not only has the number of abortions not gone down since the Supreme Court overturned Roe v. Wade, it actually might’ve gone up. Now there are lots of caveats with these numbers and, clearly, one big reason is the loosening of restrictions on obtaining abortion medication by mail. We also have a separate study this week that found infant mortality in states with abortion bans are rising, perhaps due to less available medical care in some of those states, as well as more fetuses with deadly anomalies being carried to term. But I have to wonder what these numbers will prompt from the anti-abortion side. Are they going to double down on efforts to impose some sort of nationwide restrictions or bans if Republicans regain control of the White House and Congress? And how are they going to address the rising infant mortality numbers? Victoria, are you hearing anything from the anti-abortion side? I’ve heard kind of not a lot. I’ve been surprised at how much I have not heard. 

Knight: Yeah, I mean I think this has been an interesting election for them because I think Trump has said different things throughout this election cycle on his stance on abortion and being — taking credit for appointing the Supreme Court justices who overturned Roe, but then at the same time being, like, it’s a states issue. And I’ve seen some reporting on that a lot of these groups are frustrated with Trump, but they kind of are sticking with him for the moment because they’re, like, this is the guy we have. 

So I think that perhaps they will put more pressure, depending on what the makeup of Congress is, and I think it’s important to remember it really depends on the majorities, this upcoming Congress, what will that look like? So if there is a Republican sweep, how many senators will be there? How many Republican senators? Also in the House, it may not be a huge majority either. And as we talked about earlier in this episode, there are some Republicans that are trying to walk the line more and be more moderate on abortion. And will they want to vote for a national abortion ban? That seems doubtful to me. And, for now, the filibuster is still in place in the Senate, so you still need 60 votes to pass anything. So, I think that they’re being quiet for now, but I think, depending on what Congress looks like, they could up their ante later. 

Cohrs Zhang: Again, I think Congress just has no appetite really to talk about these things, and I don’t expect that to change, especially, like you said, with narrow majorities. And I just think that the cost-benefit, maybe we’re going to see new leadership in the Senate Republican party too, and I think a lot of that could shape how much appetite they have to pick a fight on this. So yeah, just a lot of unknowns at this point. 

Rovner: And, as we’ve discussed before, if Trump is elected, he can do a lot from the executive branch that wouldn’t require Congress, and I completely agree with Rachel: I think Congress does not have a whole lot of appetite for this. 

Knight: Right. 

Rovner: Possibly on either side. 

Knight: And I think one more thing also interesting to point out is that the current House speaker, Mike Johnson, is very anti-abortion. Throughout his congressional career and even his career as a state lawmaker, he’s always been very anti-abortion, but he’s been in power now over a year, at least a year, and he has done, really, nothing on this. And he has a slim majority, but also I think you see that, yeah, as Rachel said, there’s just not an appetite for it, so … 

Rovner: He doesn’t have the votes. 

Knight: Yeah, exactly. He doesn’t have the votes, but he’s staunchly anti-abortion, has done really nothing, so. 

Rovner: Well, Sarah, you have a story on the revived lawsuit challenging the FDA over its rules for the abortion pill mifepristone. This is my chance to say I told you so, when the Supreme Court ruled that the original plaintiffs in this case did not have standing to sue. We said at the time: not over. Not over, right? 

Karlin-Smith: Yeah, three states are trying to revive that case in the court in Texas, where it originated. And it’s not particularly a surprise, like you said, the Supreme Court didn’t totally throw out the case. They said, “You guys don’t have standing,” that the doctors’ group that filed suit there. One of the interesting things now, given the timing, is as this case moves forward and if Trump wins the election, it’s not really clear to me whether his FDA and his Justice Department and so forth would actually want to defend this case or whether they would just, again, use the powers they have and push FDA to go back to the older restrictions around mifepristone’s availability. And basically make it … 

Rovner: We’re no longer talking about pulling it from the market right now? We’re just talking about the changes that were made in 2016 that makes it more easily available? 

Karlin-Smith: Right, so they sort of … 

Rovner: Is that a fair way to put it? 

Karlin-Smith: That’s like one change, which by the time we got to the Supreme Court, we were largely arguing about this as well, but they had initially started to just — by trying to get it off the market entirely. But now we’re basically arguing about changes that have made it easier to take later in pregnancy, so up to 10 weeks, and just made it easier to access. So you can now get it via telehealth and via mail and so forth, which has been really important given some of the state-specific bans on abortion. And it’s why abortion pills have become a really much more popular method for abortion. So a lot of legal experts don’t actually think these three states have standing either, or have jurisdiction, certainly in this court. However, I think they also acknowledge there’s a good chance this case proceeds and proceeds very similarly to how it did before, if for no other reason than the judges involved in the past have been willing to let these states be heard in their courtroom. 

Rovner: Yeah, it is in the 5th Circuit land of mostly Republican anti-abortion judges. 

Karlin-Smith: Right. So there’s a good chance, again, barring this sort of scenario where Trump administration comes in and just says, “We’re not going to defend this. We’re going to revert to the old restrictions anyway.” But under a Democratic administration, they could end up back all the way at the Supreme Court having to defend mifepristone’s newer availability as well. 

And the other thing that there’s been a number of mifepristone cases around the country, but there’s one that’s very similar in the 9th Circuit, where judges have basically ruled that the entire, what’s known as a REMS [risk evaluation and mitigation strategy], these restrictions related to mifepristone should actually be removed altogether. And they, actually, in some ways, want to make it more easily accessible. So whenever you have a circuits … but you also know that the Supreme Court is likely to take things up against. So yeah, I think the big thing is if people thought that last June’s Supreme Court ruling was kind of like Eh, it’s over, mifepristone is here to stay, that was just sort of the first round of many fights in access and availability of that in the courts. 

Rovner: Could a Trump administration just say, “The FDA should never have approved this drug,” and pull it from the market? Or does somebody have to file a petition for that to happen? 

Karlin-Smith: Ooh, that’s a good, tough question. I mean, there are very formal processes that go around withdrawing a drug. I think it would be challenging because at least the generic companies that manufacture the drug still want to be manufacturing it at this point. And I would imagine there would be quite a process FDA would have to go through, particularly to try and declare it no longer safe and effective to be marketed. And you, again, to raise strange history, I think if you looked at all the documents in science, because you have FDA scientists who over the years have declared it’s safe and effective and said, “Actually, as we’ve got more use with this, we realize you can actually give it to more women at different parts of pregnancy, and it’s safer than we thought. We don’t need to monitor a woman at a doctor’s office while she takes it.” So I think it would be challenging. I certainly wouldn’t put it past them trying this. 

But it does get to, I think, what’s been worrying about this mifepristone case to begin with for just people outside of the abortion space, but who follow FDA and the drug industry, which is this lack of certainty you start to lose when politicians come in and start trying to undermine the scientific drug-approval process and using politics instead, and their whims, to shift what is available or not available, because, obviously, it undermines FDA’s authority. 

And for the drug industry, I mean, a big thing they dislike is certainty, right? You’re investing millions, maybe even billions, of dollars to bring a drug to market. You want some confidence that if it’s successful and FDA says yes, it’s going to stay there unless some new, real, true safety event happens, which it does occasionally happen, but for the most part, you don’t want a new president to come into office or a new member of the Congress to flip and all of a sudden you have a drug that they’ve decided to challenge. So it’s an abortion case that’s always had these broader undertones of just confidence and trust and certainty around our scientific agencies in the U.S. 

Rovner: Yet another space we will continue to watch. All right, that is this week’s news. Now we’ll play my interview with KFF’s Tricia Neuman, and then we’ll come back and do our extra credits. 

I am so pleased to welcome to the podcast Tricia Newman, who’s KFF’s senior vice president and executive director of KFF’s Program on Medicare Policy, and senior adviser to the president, and the person I always turn to first when I have a question about Medicare and have done so for more than three decades. Tricia, welcome back to “What the Health?” 

Tricia Neuman: Hi, Julie. Thanks for having me back. 

Rovner: So, as anybody who watches over-the-air or cable TV knows, it’s Medicare open enrollment right now until Dec. 7. What should people in Medicare or people helping people in Medicare know about changes coming for 2025? 

Neuman: This is the time for people to really compare coverage options. What we’ve seen in our own research is that most people don’t compare options during the open enrollment period, but plans change, people’s needs change, and this is a great moment. People have between now until Dec. 7, as you said. The important thing to do is figure out what is actually most important to either yourself or the person you’re helping. 

Some people really need certain drugs covered by their plan, and so that might be the go-to question. Other people care very much about being able to see certain doctors or hospitals. So, for them, it’s a question of do they want to be in traditional Medicare, where they can see virtually any doctor and go to any hospital? Or if they want to be in a Medicare Advantage plan for a variety of reasons, the question is, are the doctors that they care most about covered by their plan? 

Rovner: There are big changes coming next year both for prescription drugs and for Medicare Advantage, right? 

Neuman: Absolutely. I mean, Medicare Advantage plans also cover prescription drugs, and what the big thing people need to know there is there’s a new out-of-pocket limit that’s coming. There’s not really much you have to do in order to get; it’s a Medicare benefit. So that’s really a huge change and it really is a change that helps people who take very expensive medications. I mean, I can tell you how helpful it would be to some family members of mine. I have a family member who is taking a drug, she had a Part D plan, and it was costing her $13,000 a year for this particular drug for her cancer treatment. With the new $2,000 out-of-pocket cap, her costs would drop from $13,000 to $2,000. Keep in mind that half of all people on Medicare live on an income of $36,000 or less, so this is a big deal. And not everybody is going to need this benefit in any given year, but over time, you never know. And so it’s a big change that will be helpful to people who take expensive medications. 

Rovner: Over the spring and summer, it looked like, because of this $2,000 cap, Part D plans were going to raise their premiums dramatically. That mostly didn’t happen. Why not? 

Neuman: The administration, the government put in place what they call a demonstration or a model, and essentially what it did is it limited premium increases. So no Part D plan will have a premium increase greater than $35 between 2024 and 2025. 

Rovner: … of $35 a month. 

Neuman: … of $35-a-month increase. Now that said, some will increase by $35, some will decrease. There are going to be changes, and that’s an important thing for people to keep an eye on as they consider their drug coverage for next year. 

Rovner: There are Republicans in Congress who say that what the administration did was sort of unfairly politically tinkering with Medicare, but this isn’t the first time this kind of thing has been put into place, right? 

Neuman: That’s absolutely true. I mean, I would agree that there was some concern that people in Medicare would see big increases in their drug premiums, and that was part of the concern that motivated the administration. But that was also a concern that motivated prior administrations. In fact, right after the drug benefit went into effect, and that was under the Bush administration, there were similar demonstrations that took effect. And at the time, nobody really complained because the main issue was protecting people from higher premiums. 

Rovner: But now everything is more political. 

Well, regular listeners to the podcast know that Medicare Advantage has become not just more popular among beneficiaries, but also much more controversial. Some companies are even using artificial intelligence to deny benefits and micromanaging doctors and other health care providers. Has the cost-benefit analysis for Medicare Advantage shifted over the past few years? 

Neuman: I think the focus on Medicare Advantage has changed. The way people are thinking about it is changing. Medicare Advantage is quite popular among people because plans, for a variety of reasons related to their payments, are able to offer extra benefits, and they are appealing. I mean, dental, vision, hearing. Now, the latest thing is “flex cards,” which is just kind of offering money for people to sign up for a plan. So it’s really appealing, particularly for people with fixed incomes. But the medical community has sort of surfaced and started raising concerns about what these prior authorizations and other cost-management tools mean for them and for their patients. 

So hospitals, for example, have expressed concerns about delayed payments. Doctors are now talking about prior authorization hassles. We recently did a study that documented 46 million prior-authorization requests, close to 2 million requests per enrollee. That’s a hassle for doctors. It also can delay or lead to no care for beneficiaries when it’s been prescribed by their doctor. It could, of course, limit inappropriate care, not necessary care, but I think the medical community now sees that Medicare Advantage is a big part of their patient profile and has some concerns. 

We’ve also been reading stories about some medical groups that are saying that we’re not going to take any more Medicare Advantage patients. So I think there’s a little bit more of an eye toward, gee, this has gotten really big. We know it’s really popular, but it might require a closer look. 

Rovner: Speaking of which, I mean, Medicare hasn’t really been a big campaign issue in 2024 when maybe it should have been. It doesn’t seem that safe to leave a program of its size and importance on autopilot, which is kind of what former President Trump is promising. What do we know about what Vice President Harris would do for Medicare if she were elected and what former President Trump would do if he was elected? 

Neuman: We actually know very little about what former President Trump would do. 

Rovner: He says he wouldn’t touch it. 

Neuman: He said he wouldn’t touch it. He said he’s concerned about drug costs, but we’re not really sure what more he would do there. He was for a proposal called Most Favored Nation, but he’s now withdrawn support for that. So it’s hard to know whether he would implement anything new or scale back what has already become the law of the land. For example, it’s not clear what he would do about government negotiations and whether or not there would be sufficient pressure in his caucus to scale back that pretty popular proposal that was included in the Inflation Reduction Act. 

Vice President Harris has talked about strengthening Medicare and improving the solvency, mostly through revenues on higher-income people. So that is one major proposal she has with regard to solvency. She has recently put out a proposal that would add a home care benefit to Medicare. This responds to a huge issue that you and I have talked about, that a lot of families across the country have talked about where people are really struggling to care for a family member. Family members are dropping out of the workforce in order to care for somebody because they cannot afford to get help at home. Medicare really does not currently provide a home care benefit except under limited circumstances. So this is recognizing a huge issue for families that are, it’s an economic issue if people, mostly women, have to step out of the workforce. It’s also an issue if you just cannot afford or you’re paying huge amounts for people to come into your home to help a parent, grandparent, spouse who’s unable to care for themselves. So that’s a big initiative on her part that would be funded primarily out of expanding Medicare’s ability to negotiate drugs. 

Rovner: So neither candidate is talking about solvency issues with Medicare, though, and that’s a long-term issue that somebody’s going to need to address, right? 

Neuman: Yes, that is absolutely true. It is an issue that is not going away. We have more and more people aging onto Medicare and the people who are on Medicare are getting older. And as people grow older, they tend to be more expensive. So this is not an imminent concern, but it is an issue that policymakers will have to deal with one way or the other in the years to come. 

Rovner: Well, we will keep talking about it. Tricia Neuman, thank you so much. 

Neuman: And thank you for having me, Julie. 

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it; we will put the links in our show notes, on your phone or other mobile device. Victoria, why don’t you go first this week? 

Knight: Sure. My extra credit is a story on NPR, it’s called “Why Catholic Bishops Are Donating Less To Oppose Abortion Rights Measures This Year.” It was on Weekend Edition, and it is by Rosemary Westwood and Jack Jenkins, basically detailing that in the past, the Catholic Church and bishops have been really big in the anti-abortion movement and that has also translated to donating a lot of money to anti-abortion campaigns. But this year, they’re kind of seeing almost a historic low in how little they’re donating to anti-abortion campaigns. And they didn’t really have a clear answer of what the reason for that was, except that maybe they’re just acknowledging the reality of the situation. When you look at particularly the ballot measures in states and how popular those have been — we’ve seen since 2022 that the ballot measures, even in more conservative-leaning states, that protect abortion access, and those vary depending on the state, what they look like, they’ve been really, really popular. And they really have been really overwhelmingly approved, even if there’s Republicans running on the same ballot with them and that people are voting for. People still really support abortion rights mostly. 

So that seems to be the reason — they didn’t really have a clear reason, but it was an interesting marker in the trend of just kind of following where abortion rights are going, as well as where the Catholic Church is moving as well. It seems to be becoming somewhat more progressive over time. 

Rovner: I was fascinated by this story, which I just heard on the radio as I was driving, because the Catholic Church is the originator of the right-to-life movement in the United States. And for a long time, it was almost exclusively the Catholic Church that was pushing this, and now it seems to have moved sort of into other places. So this is sort of the exclamation point on that, that it’s broadened and changed, but it’s no longer being driven as much by the Catholic Church as it used to be. Rachel, why don’t you go next? 

Cohrs Zhang: Sure. So my piece is in The Atlantic, and the headline is “The Perverse Consequences of Tuition-Free Medical School,” by Rose Horowitch. And I just love this story because it’s a look back on this policy that seemed like a good idea at the time, where these really wealthy benefactors are donating to elite, often elite medical schools to make tuition free. And the whole idea was that more doctors will go into primary care if they don’t have debt, and it might open medical school to a more diverse cohort of students. And the opposite has almost happened, where they’re not seeing any more doctors going into primary care and their student body has actually gotten more wealthy than it was before. So I mean, it’s just a great check-in, because I feel like so often we’re just looking forward with the news that we don’t take a moment to question whether some of these policies or stories that we’ve covered, how they’ve worked out a couple of years later. So, I thought it was a great look back. 

Rovner: Yes, in health care, so many things go in, we try things with so much promise, and sometimes they don’t work. So it’s good to notice when they don’t work. Sarah? 

Karlin-Smith: I took a look at a Vanity Fair piece by Katherine Eban: “Inside the Bungled Bird Flu Response, Where Profits Collide With Public Health.” And it’s a fascinating deep dive to the challenges the U.S. has faced in containing what is, right now at least, mostly just an epidemic in animals, but certainly has public health folks worried about the potential for a human spillover pandemic, if not properly contained. And it’s just a really great story that shows you all of the tensions, and how it has a lot of these flashbacks to early days of covid, where you had different parts of the government with different responsibilities, not quite working together well, and not quite knowing how to play together well. Because you have the USDA in this case, which in many ways has the economics of farmers and the dairy industry in mind more than perhaps broader health concerns. You have FDA, which regulates milk; CDC, which comes in and does the human health; and then you have states, which don’t necessarily always have to answer to everything the federal government would like them to be doing here. 

And the biggest, I think, crisis we face now is just we don’t have a lot of data. We don’t have enough information to truly know the scope of this outbreak. And without knowing that, I think you risk something bad happening before we are on top of it. And that’s really what people are really concerned about now, particularly with seasonal flu season coming up, is if you mix this virus and a human being with seasonal flu or even in an animal, you could develop an even more dangerous virus. So, it’s a warning to everybody in the public health space that this is something we need to be paying attention to because, obviously, the best thing to do is contain it and tamp it out and not have to deal with a much larger human pandemic. 

Rovner: Yes, that would be nice. Something else to keep us awake at night. 

My story this week is from NBC News, it’s called “Crisis Pregnancy Center’s Forms Give Rare Insight Into Anti-Abortion Practices,” by Abigail Brooks. She got a hold of the intake forms of a pregnancy center in Idaho, which included not just the typical medical questions, but also questions about religious and financial status. And one asking, “What decision would the father like you to make, regarding the outcome of your pregnancy?” The answers, which are not protected by HIPAA, because crisis pregnancy centers are not technically medical providers, allow the staff to score whether a patient is “abortion-vulnerable,” which would lead them to try to talk her out of ending the pregnancy. 

It also includes a story of one patient who was strung along so long waiting for test results from this crisis pregnancy center that she ended up needing a second-trimester abortion. It’s quite the look at what goes on behind the scenes at some of these centers, and I strongly recommend it. 

OK, that’s all the time we have today. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, I’m @jrovner. Sarah, where are you hanging these days? 

Karlin-Smith: A little bit on X, a little bit on Bluesky, at @SarahKarlin or @sarahkarlin-smith. 

Rovner: Rachel? 

Cohrs Zhang: I’m on X @rachelcohrs and also spending some time on LinkedIn, so feel free to follow me there. 

Rovner: Great. Victoria? 

Knight: I am @victoriaregisk still on X. I am trying to post more on LinkedIn, too. 

Rovner: OK, well, we will be back in your feed next week. Until then, be healthy. 

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Julie Rovner
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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.

As part of a media blitz aimed at women voters, Vice President Kamala Harris this week rolled out a plan for Medicare to provide in-home long-term care services. It’s popular, particularly for families struggling to care for both young children and older relatives, but its enormous expense has prevented similar plans from being implemented for decades.

Meanwhile, President Joe Biden called out former President Donald Trump by name for having “led the onslaught of lies” about the federal efforts to help people affected by hurricanes Helene and Milton. Even some Republican officials say the misinformation about hurricane relief efforts is threatening public health.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's stories.

Shefali Luthra
The 19th

@shefalil

Read Shefali's stories.

Among the takeaways from this week’s episode:

• Vice President Kamala Harris’ plan to expand Medicare to cover more long-term care is popular but not new, and in the past has proved prohibitively expensive.
• Former President Donald Trump has abandoned support for a drug price policy he pursued during his first term. The idea, which would lower drug prices in the U.S. to their levels in other industrialized countries, is vehemently opposed by the drug industry, raising the question of whether Trump is softening his hard line on the issue.
• Abortion continues to be the biggest health policy issue of 2024, as Republican candidates — in what seems to be a replay of 2022 — try to distance themselves from their support of abortion bans and other limits. Voters continue to favor reproductive rights, which creates a brand problem for the GOP. Trump’s going back and forth on his abortion positions is an exception to the tack other candidates have taken.
• The Supreme Court returned from its summer break and immediately declined to hear two abortion-related cases. One case pits Texas’ near-total abortion ban against a federal law that requires emergency abortions to be performed in certain cases. The other challenges a ruling earlier this year from the Alabama Supreme Court finding that embryos frozen for in vitro fertilization have the same legal rights as born humans.
• The 2024 KFF annual employer health benefits survey, released this week, showed a roughly 7% increase in premiums, with average family premiums now topping $25,000 per year. And that’s with most employers not covering two popular but expensive medical interventions: GLP-1 drugs for weight loss and IVF.

Also this week, excerpts from a KFF lunch with “Shark Tank” panelist and generic drug discounter Mark Cuban, who has been consulting with the Harris campaign about health care issues.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Julie Rovner: KFF Health News’ “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly.

Shefali Luthra: The 19th’s “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” by Mel Leonor Barclay.

Jessie Hellmann: The Assembly’s “Helene Left Some NC Elder-Care Homes Without Power,” by Carli Brosseau.

Joanne Kenen: The New York Times’ “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It,” by Kate Morgan.

Also mentioned on this week’s podcast:

• The New York Times’ “Biden Accuses Trump of ‘Outright Lies’ About Hurricane Response,” by Michael D. Shear.
• The Miami Herald’s “Florida Threatens To Prosecute TV Stations Over Abortion Ad. FCC Head Calls It ‘Dangerous,’” by Claire Healy and Ana Ceballos.
• KFF’s “2024 Employer Health Benefits Survey.”

Click to open the Transcript

Transcript: Yet Another Promise for Long-Term Care Coverage

[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, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, October 10th, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go. 

Today we are joined via teleconference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Jesse Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: And Joanne Kenen of the Johns Hopkins Schools of Public Health and Nursing and Politico magazine. 

Joanne Kenen: Hi everybody. 

Rovner: Later in this episode, we’ll have some excerpts from the Newsmaker lunch we had here at KFF this week with Mark Cuban — “Shark Tank” star, part-owner of the Dallas Mavericks NBA team, and, for the purposes of our discussion, co-founder of the industry-disrupting pharmaceutical company Cost Plus Drugs. But first, this week’s news. 

We’re going to start this week with Vice President [Kamala] Harris, who’s been making the media rounds on women-focused podcasts and TV shows like “The View.” To go along with that, she’s released a proposal to expand Medicare to include home-based long-term care, to be paid for in part by expanding the number of drugs whose price Medicare can negotiate. Sounds simple and really popular. Why has no one else ever proposed something like that? she asks, knowing full well the answer. Joanne, tell us! 

Kenen: As the one full-fledged member of the sandwich generation here, who has lived the experience of being a family caregiver while raising children and working full time, long-term care is the unfulfillable, extremely expensive, but incredibly important missing link in our health care system. We do not have a system for long-term care, and people do not realize that. Many people think Medicare will, in fact, cover it, where Medicare covers it in a very limited, short-term basis. So the estimates of what families spend both in terms of lost work hours and what they put out-of-pockets is in, I think it’s something like $400 billion. It’s extraordinarily high. But the reason it’s been hard to fix is it’s extraordinarily expensive. And although Harris put out a plan to pay for this, that plan is going to have to be vetted by economists and budget scorers and skeptical Republicans. And probably some skeptical Democrats. It’s really expensive. It’s really hard to do. Julie has covered this for years, too. It’s just— 

Rovner: I would say this is where I get to say one of my favorite things, which is that I started covering health care in 1986, and in 1986 my first big feature was: Why don’t we have a long-term care policy in this country? Thirty-eight years later, and we still don’t, and not that people have not tried. There, in fact, was a long-term-care-in-the-home piece of the Affordable Care Act that passed Congress, and HHS [the Department of Health and Human Services] discovered that they could not implement it in the way it was written, because only the people who would’ve needed it would’ve signed up for it. It would’ve been too expensive. And there it went. So this is the continuing promise of something that everybody agrees that we need and nobody has ever been able to figure out how to do. Shefali, I see you nodding here. 

Luthra: I mean, I’m just thinking again about the pay-fors in here, which are largely the savings from Medicare negotiating drug prices. And what Harris says in her plan is that they’re going to get more savings by expanding the list of drugs that get lower prices. But that also feels very politically suspect when we have already heard congressional Republicans say that they would like to weaken some of those drug negotiation price provisions. And we also know that Democrats, even if they win the presidency, are not likely to have Congress. It really takes me back to 2020, when we are just talking about ideas that Democrats would love to do if they had full power of Congress, while all of us in Washington kind of know that that is just not going to happen. 

Rovner: Yes, I love that one of the pay-fors for this is cutting Medicare fraud. It’s like, where have we heard that before? Oh, yes. In every Medicare proposal for the last 45 years. 

Kenen: And it also involves closing some kind of international tax loopholes, and that also sounds easy on paper, and nothing with taxes is ever easy. The Democrats probably are not going to have the Senate. Nobody really knows about the House. It looks like the Democrats may have a narrow edge in that, but we’re going to have more years of gridlock unless something really changes politically, like something extraordinary changes politically. The Republicans are not going to give a President Harris, if she is in fact President Harris, her wish list on a golden platter. On the other hand there’s need for this. 

Rovner: But in fairness, this is what the campaign is for. 

Kenen: Right. There is a need for something on long-term care. 

Rovner: And everybody’s complaining: Well, what would she do? What would she do if she was elected? Well, here’s something she said she would do if she could, if she was elected. Well, meanwhile, former President [Donald] Trump has apparently abandoned a proposal that he made during his first term to require drugmakers to lower their prices for Medicare to no more than they charge in other developed countries where their prices are government-regulated. Is Trump going soft on the drug industry? Trump has been, what, the Republican, I think, who’s been most hostile towards the drug industry until now. 

Hellmann: I would say maybe. I think the “most favored nation” proposal is something that the pharmaceutical industry has feared even more than the Democrats’ Medicare negotiation program. And it’s something that Trump really pursued in his first term but wasn’t able to get done. In such a tight race, I think he’s really worried about angering pharmaceutical companies, especially after they were just kind of dealt this loss with Medicare price negotiation. And if he does win reelection, he’s going to be kind of limited in his ability to weaken that program. It’s going to be hard to repeal it. It’s extremely popular, and he may be able to weaken it. 

Rovner: “It” meaning price negotiation, not the “most favored nations” prices. 

Hellmann: Yeah. It’s going to be really hard to repeal that, and he may be able to weaken it through the negotiation process with drug companies. It’s definitely an interesting turn. 

Rovner: Joanne, you want to add something? 

Kenen: Trump rhetorically was very harsh on the drug companies right around the time of his inauguration. I think it was the week before, if I remember correctly. Said a lot of very tough stuff on drugs. Put out a list of something like dozens of potential steps. The drug companies have lots of allies in both parties, and more in one than the other, but they have allies on the Hill, and nothing revolutionary happened on drug pricing under Trump. 

Rovner: And his HHS secretary was a former drug company executive. 

Kenen: Yes, Eli Lilly. So we also pointed out here that former President Trump is not consistent in policy proposals. He says one thing, and then he says another thing, and it’s very hard to know where he’s going to come down. So Trump and drug pricing is an open question. 

Rovner: Yes, we will see. All right, well, moving on. Drug prices and Medicare aside, the biggest health issue of Campaign 2024 continues to be abortion and other reproductive health issues. And it’s not just Trump trying to back away from his anti-abortion record. We’ve had a spate of stories over the past week or so of Republicans running for the House, the Senate, and governorships who are trying to literally reinvent themselves as, if not actually supportive of abortion rights, at least anti abortion bans. And that includes Republicans who have not just voted for and advocated for bans but who have been outspokenly supportive of the anti-abortion effort, people like North Carolina Republican gubernatorial candidate Mark Robinson, New Hampshire Republican gubernatorial candidate and former U.S. Senator Kelly Ayotte, along with former Michigan Republican representative and now Senate candidate Mike Rogers. Donald Trump has gotten away repeatedly, as Joanne just said, with changing his positions, even on hot-button issues like abortion. Are these candidates going to be able to get away with doing the same thing, Shefali? 

Luthra: I think it’s just so much tougher when your name is not Donald Trump. And that’s because we know from focus group after focus group, and survey after survey, that voters kind of give Trump more leeway on abortion. Especially independent voters will look at him and say, Well, I don’t think he actually opposes abortion, because I’m sure he’s paid for them. And they don’t have that same grace that they give to Republican lawmakers and Republican candidates, because the party has a bad brand on abortion at large, and Trump is seen as this kind of maverick figure. But voters know that Republicans have a history of opposing abortion, of supporting restrictions. 

When you look at surveys, when you talk to voters, what they say is, Well, I don’t trust Republicans to represent my interests on this issue, because they largely support access. And one thing that I do think is really interesting is, once again, what we’re seeing is kind of a repeat of the 2022 elections when we saw some very brazen efforts by Republican candidates for the House and Senate try and scrub references to abortion and to fetal personhood from their websites. And it didn’t work, because people have eyes and people have memories, and, also, campaigns have access to the internet archive and are able to show people that, even a few weeks ago, Republican candidates were saying something very different from what they are saying now. I don’t think Mark Robinson can really escape from his relatively recent and very public comments about abortion. 

Rovner: Well, on the other hand, there’s some things that don’t change. Republican vice presidential candidate JD Vance told RealClearPolitics last week that if Trump is elected again, their administration would cut off funding to Planned Parenthood because, he said, and I quote, “We don’t think that taxpayers should fund late-term abortions.” Notwithstanding, of course, that even before the overturn of Roe, less than half of all Planned Parenthoods even performed abortions and almost none of those who did perform them later in pregnancy. Is it fair to say that Vance’s anti-abortion slip is showing? 

Luthra: I think it might be. And I will say, Julie, when I saw that he said that, I could hear you in my head just yelling about the Hyde Amendment, because we know that Planned Parenthood does not use taxpayer money to pay for abortions. But we also know that JD Vance has seen that he and his ticket are kind of in a tough corner talking about abortion. He has said many times, We need to rebrand — he’s very honest about that, at least — and trying to focus instead on this nonmedical term of “late term” abortions. 

It’s a gamble. It’s hoping that voters will be more sympathetic to that because they’ll think, Oh, well, that sounds very extreme. And they’re trying to shift back who is seen as credible and who is not, by focusing on something that historically was less popular. But again, it’s again tricky because when we look at the polling, voters’ understanding of abortion has shifted and they are now more likely to understand that when you have an abortion later in pregnancy, it is often for very medically complex reasons. And someone very high-profile who recently said that is Melania Trump in her new memoir, talking about how she supports abortion at all stages of pregnancy because often these are very heart-wrenching cases and not sort of the murder that Republicans have tried to characterize them as. 

Rovner: I think you’re right. I think this is the continuation of the 2022 campaign, except that we’ve had so many more women come forward. We’ve seen actual cases. It used to be anti-abortion forces would say, Oh, well, this never happened. I mean, these are wrenching, awful things that happened to a lot of these patients with pregnancy complications late in pregnancy. And it is, I know, because I’ve talked to them. It’s very hard to get them to talk publicly, because then they get trolled. Why should they step forward? 

Well, now we’ve seen a lot of these women stepping forward. So we now see a public that knows that this happens, because they’re hearing from the people that it’s happened to and they’re hearing from their doctors. I do know also from the polling that there are people who are going to vote in these 10 states where abortion is on the ballot. Many of them are going to vote for abortion access and then turn around and vote for Republicans who support restrictions, because they’re Republicans. It may or may not be their most important issue, but I still think it’s a big question mark where that happens and how it shakes out. Joanne, did you want to add something? 

Kenen: You’re seeing two competing things at the same time. You have a number of Republicans trying to moderate their stance or at least sound like they’re moderating their stance. At the same time, you also have the whole, where the Republican Party is on abortion has shifted to the right. They are talking about personhood at the moment of conception, the embryo — which is, scientifically put, a small ball of cells still at that point — that they actually have the same legal rights as any other post-birth person. 

So that’s become a fairly common view in the Republican Party, as opposed to something that just five or six years ago was seen as the fringe. And Trump is going around saying that Democrats allow babies to be executed after birth, which is not true. And they’re particularly saying this is true in Minnesota because of [Gov.] Tim Walz, and some voters must believe it, right? Because they keep saying it. So you have this trend that Shefali just described and that you’ve described, Julie, about this sort of attempting to win back trust, as Vance said. And it sounded more moderate, and at the same time as you’re hearing this rhetoric about personhood and execution. So I don’t think the Republicans have yet solved their own whiplash post-Roe. 

Rovner: Meanwhile, the abortion debate is getting mired in the free-speech debate. In Florida, Republican governor Ron DeSantis is threatening legal action against TV stations airing an ad in support of the ballot measure that would overturn the state’s six-week abortion ban. That has in turn triggered a rebuke from the head of the Federal Communications Commission warning that political speech is still protected here in the United States. Shefali, this is really kind of out there, isn’t it? 

Luthra: It’s just so fascinating, and it’s really part of a bigger effort by Ron DeSantis to try and leverage anything that he can politically or, frankly, in his capacity as head of the state to try and weaken the campaign for the ballot measure. They have used the health department in other ways to try and send out material suggesting that the campaign’s talking points, which are largely focused on the futility of exceptions to the abortion ban, they’re trying to argue that that is misinformation, and that’s not true. And they’re using the state health department to make that argument, which is something we don’t really see very often, because usually health departments are supposed to be nonpartisan. And what I will say is, in this case, at least to your point, Julie, the FCC has weighed in and said: You can’t do this. You can’t stop a TV station from airing a political ad that was bought and paid for. And the ads haven’t stopped showing at this point. I just heard from family yesterday in Florida who are seeing the ads in question on their TV, and it’s still— 

Rovner: And I will post a link to the ad just so you can see it. It’s about a woman who’s pregnant and had cancer and needed cancer treatment and needed to terminate the pregnancy in order to get the cancer treatment. It said that the exception would not allow her to, which the state says isn’t true and which is clearly one of these things that is debatable. That’s why we’re having a political debate. 

Luthra: Exactly. And one thing that I think is worth adding in here is, I mean, this really intense effort from Governor DeSantis and his administration comes at a time when already this ballot measure faces probably the toughest fight of any abortion rights measure. And we have seen abortion rights win again and again at the ballot, but in Florida you need 60% to pass. And if you look across the country at every abortion rights measure that has been voted on since Roe v. Wade was overturned, only two have cleared 60, and they are in California and they are in Vermont. So these more conservative-leaning states, and Florida is one of them, it’s just, it’s really, really hard to see how you get to that number. And we even saw this week there’s polling that suggests that the campaign has a lot of work to do if they’re hoping to clear that threshold. 

Rovner: And, of course, now they have two hurricanes to deal with, which we will deal with in a few minutes. But first, the Supreme Court is back in session here in Washington, and even though there’s no big abortion case on its official docket as of now this term, the court quickly declined to hear two cases on its first day back, one involving whether the abortion ban in Texas can override the federal emergency treatment law that’s supposed to guarantee abortion access in medical emergencies threatening the pregnant woman’s life or health. The court also declined to overrule the Alabama Supreme Court’s ruling that frozen embryos can be considered legally as unborn children. That’s what Joanne was just talking about. Where do these two decisions leave us? Neither one actually resolved either of these questions, right? 

Luthra: I mean, the EMTALA [Emergency Medical Treatment and Labor Act] question is still ongoing, not because of the Texas case but because of the Idaho case that is asking very similar questions that we’ve talked about previously on this podcast. And the end of last term, the court kicked that back down to the lower courts to continue making its way through. We anticipate it will eventually come back to the Supreme Court. So this is a question that we will, in fact, be hearing on at some point. 

Rovner: Although, the irony here is that in Idaho, the ban is on hold because there was a court stay. And in Texas, the ban is not on hold, even though we’re talking about exactly the same question: Does the federal law overrule the state’s ban? 

Luthra: And what that kind of highlights — right? — is just how much access to abortion, even under states with similar laws or legislatures, really does depend on so many factors, including what circuit court you fall into or the makeup of your state Supreme Court and how judges are appointed or whether they are elected. There is just so much at play that makes access so variable. And I think the other thing that one could speculate that maybe the court didn’t want headlines around reproductive health so soon into an election, but it’s not as if this is an issue that they’re going to be avoiding in the medium- or long-term future. These are questions that are just too pressing, and they will be coming back to the Supreme Court in some form. 

Rovner: Yes, I would say in the IVF [in vitro fertilization] case, they simply basically said, Go away for now. Right? 

Luthra: Yeah. And, I mean, right now in Alabama, people are largely able to get IVF because of the state law that was passed, even if it didn’t touch the substance of that state court’s ruling. This is something, for now, people can sort of think is maybe uninterrupted, even as we all know that the ideological and political groundwork is being laid for a much longer and more intense fight over this. 

Rovner: Well, remember back last week when we predicted that the judge’s decision overturning Georgia’s six-week ban was unlikely to be the last word? Well, sure enough, the Georgia Supreme Court this week overturned the immediate overturning of the ban, which officially went back into effect on Monday. Like these other cases, this one continues, right? 

Luthra: Yes, this continues. The Georgia case continued for a while, and it just sort of underscores again what we’ve been talking about, just how much access really changes back and forth. And I was talking to an abortion clinic provider who has clinics in North Carolina and Georgia. She literally found out about the decision both times and changed her plans for the next day because I texted her asking her for comment. And providers and patients are being tasked with keeping up with so much. And it’s just very, very difficult, because Georgia also has a 24-hour waiting period for abortions, which means that every time the decision around access has changed — and we know it very well could change again as this case progresses — people will have to scramble very quickly. And in Georgia, they have also been trying to do that on top of navigating the fallout of a hurricane. 

Rovner: Yeah. And as we pointed out a couple of weeks ago when the court overturned the North Dakota ban, there are no abortion providers left in North Dakota. Now that there’s no ban, it’s only in theory that abortion is now once again allowed in North Dakota. Well, before we leave abortion for this week, we have two new studies showing how abortion bans are impacting the health care workforce. In one survey, more than half of oncologists, cancer doctors, who were completing their fellowships, so people ready to go into practice, said they would consider the impact of abortion restrictions in their decisions about where to set up their practice. And a third said abortion restrictions hindered their ability to provide care. 

Meanwhile, a survey of OBGYNs in Texas by the consulting group Manatt Health found “a significant majority of practicing OB/GYN physicians … believe that the Texas abortion laws have inhibited their ability to provide highest-quality and medically necessary care to their patients,” and that many have already made or are considering making changes to their practice that would “reduce the availability of OB/GYN care in the state.” What’s the anti-abortion reaction to this growing body of evidence that abortion bans are having deleterious effects on the availability of other kinds of health care, too? I mean, I was particularly taken by the oncologists, the idea that you might not be able to get cancer care because cancer doctors are worried about treating pregnant women with cancer. 

Luthra: They’re blaming the doctors. And we saw this in Texas when the Zurawski case was argued and women patients and doctors in the state said that they had not been able to get essential, lifesaving medical care because of the state’s abortion ban and lack of clarity around what was actually permitted. And the state argued, and we have heard this talking point again and again, that actually the doctors are just not willing to do the hard work of practicing medicine and trying to interpret, Well, obviously this qualifies. That’s something we’ve seen in the Florida arguments. They say: Our exceptions are so clear, and if you aren’t able to navigate these exceptions, well, that’s your problem, because you are being risk-averse, and patients should really take this up with their doctors, who are just irresponsible. 

Rovner: Yes, this is obviously an issue that’s going to continue. Well, moving on. The cost of health care continues to grow, which is not really news, but this week we have more hard evidence, courtesy of my KFF colleagues via the annual 2024 Employer Health Benefit Survey, which finds the average family premium rose 7% this year to $25,572, with workers contributing an average of $6,296 towards that cost. And that’s with a distinct minority of firms covering two very popular but very expensive medical interventions, GLP-1 [glucagon-like peptide-1] drugs for obesity and IVF, which we’ve just been talking about. Anything else in this survey jump out at anybody? 

Hellmann: I mean, that’s just a massive amount of money. And the employer is really paying the majority of that, but that doesn’t mean it doesn’t have an impact on people. That means it’s going to limit how much your wages go up. And something I thought of when I read this study is these lawsuits that we’re beginning to see, accusing employers of not doing enough to make sure that they’re limiting health care costs. They’re not playing enough of a role in what their benefits look like. They’re kind of outsourcing this to consultants. And so when you look at this data and you see $25,000 they’re spending per year per family on health care premiums, you wonder, what are they doing? 

Health care, yes, it’s obviously very expensive, but you just kind of question, what role are employers actually playing in trying to drive down health care costs? Are they just taking what they get from consultants? And another thing that kind of stood out to me from this is, I think it’s said in there, employers are having a hard time lately of passing these costs on to employees, which is really interesting. It’s because of the tight labor market. But obviously health care is still very expensive for employees — $6,000 a year in premiums for family coverage is not a small amount of money. So employers are just continuing to absorb that, and it does really impact everyone. 

Rovner: It’s funny. Before the Affordable Care Act, it was employers who were sort of driving the, You must do something about the cost of health care, because inflation was so fast. And then, of course, we saw health care inflation, at least, slow down for several years. Now it’s picking up again. Are we going to see employers sort of getting back into this jumping up and down and saying, “We’ve got to do something about health care costs”? 

Hellmann: I feel like we are seeing more of that. You’re beginning to hear more from employers about it. I don’t know. It’s just such a hard issue to solve, and I’ve seen more and more interest from Congress about this, but they really struggle to regulate the commercial market. So … 

Rovner: Yes, as we talk about at length every week. But it’s still important, and they will still go for it. Well, finally, this week in health misinformation. Let us talk about hurricanes — the public health misinformation that’s being spread both about Hurricane Helene that hit the Southeast two weeks ago, and Hurricane Milton that’s exiting Florida even as we are taping this morning. President [Joe] Biden addressed the press yesterday from the White House, calling out former President Trump by name along with Georgia Republican congresswoman Marjorie Taylor Greene for spreading deliberate misinformation that’s not just undermining efforts at storm relief but actually putting people in more danger. Now, I remember Hurricane Katrina and all the criticism that was heaped, mostly deservedly, on George W. Bush and his administration, but I don’t remember deliberate misinformation like this. I mean, Joanne, have you ever seen anything like this? You lived in Florida for a while. 

Kenen: I went through Andrew, and there’s always a certain — there’s confusion and chaos after a big storm. But there’s a difference between stuff being wrong that can be corrected and stuff being intentionally said that then in this sort of divided, suspicious, two-realities world we’re now living in, that’s being repeated and perpetuated and amplified. It damages public health. It damages people economically trying to recover from this disastrous storm or in some cases storms. I don’t know how many people actually believe that Marjorie Taylor asserted that the Democrats are controlling the weather and sending storms to suppress Republican voters. She still has a following, right? But other things … 

Rovner: She still gets reelected. 

Kenen: … being told that if you go to FEMA [the Federal Emergency Management Agency] for help, your property will be confiscated and taken away from you. I mean, that’s all over the place, and it’s not true. Even a number of Republican lawmakers in the affected states have been on social media and making statements on local TV and whatever, saying: This is not true. Please, FEMA is there to help you. Let’s get through this. Stop the lies. A number of Republicans have actually been quite blunt about the misinformation coming from their colleagues and urging their constituents to seek and take the help that’s available. 

This is the public health crisis. We don’t know how many people have been killed. I don’t think we have an accurate total final count from Helene, and we sure don’t have from Milton. I mean, the people did seem to take this storm seriously and evacuated, but it also spawned something like three dozen tornadoes in places where people hadn’t been told, there’s normally no need to evacuate. There’s flooding. It’s a devastating storm. So when people are flooding, power outages, electricity, hard to get access to health care, you can’t refrigerate your insulin. All these— 

Rovner: Toxic floodwaters, I mean, the one thing … 

Kenen: Toxic, yeah. 

Rovner: … we know about hurricanes is that they’re more dangerous in the aftermath than during the actual storm in terms of public health. 

Kenen: Right. This is a life-threatening public health emergency to really millions of people. And misinformation, not just getting something wrong and then trying to correct it, but intentional disinformation, is something we haven’t seen before in a natural disaster. And we’re only going to have more natural disasters. And it was really — I mean, Julie, you already pointed this out — but it was really unusual how precise Biden was yesterday in calling out Trump by name, and I believe at two different times yesterday. So I heard one, but I think I read about what I think was the second one really saying, laying it at his feet that this is harming people. 

Rovner: Yeah, like I said, I remember Katrina vividly, and that was obviously a really devastating storm. I do also remember Democrats and Republicans, even while they were criticizing the federal government reaction to it, not spreading things that were obviously untrue. All right. Well, that is the news for this week. Now we will play a segment from our Newsmaker interview with Mark Cuban, and then we will be back with our extra credits. 

On Tuesday, October 8th, Mark Cuban met with a group of reporters for a Newsmaker lunch at KFF’s offices in Washington, D.C. Cuban, a billionaire best known as a panelist on the ABC TV show “Shark Tank,” has taken an interest in health policy in the past several years. He’s been consulting with the campaign of Vice President Harris, although he says he’s definitely not interested in a government post if she wins. Cuban started out talking about how, as he sees it, the biggest problem with drug prices in the U.S. is that no one knows what anyone else is paying. 

Mark Cuban: I mean, when I talk to corporations and I’ve tried to explain to them how they’re getting ripped off, the biggest of the biggest said, Well, so-and-so PBM [pharmacy benefit manager] is passing through all of their rebates to us. 

And I’m like: Does that include the subsidiary in Scotland or Japan? Is that where the other one is? 

I don’t know. 

And it doesn’t. By definition, you’re passing through all the rebates with the company you contracted with, but they’re not passing through all the rebates that they get or that they’re keeping in their subsidiary. And so, yeah, I truly, truly believe from there everybody can argue about the best way. Where do you use artificial intelligence? Where do you do this? What’s the EHR [electronic health record? What’s this? We can all argue about best practices there. But without a foundation of information that’s available to everybody, the market’s not efficient and there’s no place to go. 

Rovner: He says his online generic drug marketplace, costplusdrugs.com, is already addressing that problem. 

Cuban: The crazy thing about costplusdrugs.com, the greatest impact we had wasn’t the markup we chose or the way we approach it. It’s publishing our price list. That changed the game more than anything. So when you saw the FTC [Federal Trade Commission] go after the PBMs, they used a lot of our pricing for all the non-insulin stuff. When you saw these articles written by the Times and others, or even better yet, there was research from Vanderbilt, I think it was, that says nine oncology drugs, if they were purchased by Medicare through Cost Plus, would save $3.6 billion. These 15, whatever drugs would save six-point-whatever billion. All because we published our price list, people are starting to realize that things are really out of whack. And so that’s why I put the emphasis on transparency, because whether it’s inside of government or inside companies that self-insure, in particular, they’re going to be able to see. The number one rule of health care contracts, particularly PBM contracts, is you can’t talk about PBM contracts. 

Rovner: Cuban also says that more transparency can address problems in the rest of the health care system, not just for drug prices. Here’s how he responded to a question I asked describing his next big plan for health care. 

We’ve had, obviously, issues with the system being run by the government not very efficiently and being run by the private sector not very efficiently. 

Cuban: Very efficiently, yeah. 

Rovner: And right now we seem to have this sort of working at cross-purposes. If you could design a system from the ground up, which would you let do it? The government or— 

Cuban: I don’t think that’s really the issue. I think the issue is a lack of transparency. And you see that in any organization. The more communication and the more the culture is open and transparent, the more people hold each other responsible. And I think you get fiefdoms in private industry and you get fiefdoms in government, as well, because they know that if no one can see the results of their work, it doesn’t matter. I can say my deal was the best and I did the best and our outcomes are the best, but there’s no way to question it. And so talking to the Harris campaign, it’s like if you introduce transparency, even to the point of requiring PBMs and insurers to publish their contracts publicly, then you start to introduce an efficient market. And once you have an efficient market, then people are better able to make decisions and then you can hold them more accountable. 

And I think that’s going to spill over beyond pharm. We’re working on — it’s not a company — but we’re working on something called Cost Plus Wellness, where we’re eating our own dog food. And it’s not a company that’s going to be a for-profit or even a nonprofit, for that matter, just for the lives that I cover for my companies, that we self-insure. We’re doing direct contracting with providers, and we’re going to publish those contracts. And part and parcel to that is going through the — and I apologize if I’m stumbling here. I haven’t slept in two days, so bear with me. But going through the hierarchy of care and following the money, if you think about when we talk to CFOs and CEOs of providers, one of the things that was stunning to me that I never imagined is the relationship between deductibles for self-insured companies and payers, and the risk associated with collecting those deductibles to providers. 

And I think people don’t really realize the connection there. So whoever does Ann’s care [KFF Chief Communications Officer Ann DeFabio, who was present] — well, Kaiser’s a little bit different, but let’s just say you’re employed at The Washington Post or whoever and you have a $2,500 deductible. And something happens. Your kid breaks their leg and goes to the hospital, and you’re out of market, and it’s out of network. Well, whatever hospital you go to there, you might give your insurance card, but you’re responsible for that first $2,500. And that provider, depending on where it’s located, might have collection — bad debt, rather — of 50% or more. 

So what does that mean in terms of how they have to set their pricing? Obviously, that pricing goes up. So there’s literally a relationship between, particularly on pharmacy, if my company takes a bigger rebate, which in turn means I have a higher deductible because there’s less responsibility for the PBM-slash-insurance company. My higher deductible also means that my sickest employees are the ones paying that deductible, because they’re the ones that have to use it. And my older employees who have ongoing health issues and have chronic illnesses and need medication, they’re paying higher copays. But when they have to go to the hospital with that same deductible, because I took more of a rebate, the hospital is taking more of a credit risk for me. That’s insane. That makes absolutely no sense. 

And so what I’ve said is as part of our wellness program and what we’re doing to — Project Alpo is what we call it, eating our own dog food. What I’ve said is, we’ve gone to the providers and said: Look, we know you’re taking this deductible risk. We’ll pay you cash to eliminate that. But wait, there’s more. We also know that when you go through a typical insurer, even if it’s a self-insured employer using that insurer and you’re just using the insurance company not for insurance services but as a TPA [third-party administrator], the TPA still plays games with the provider, and they underpay them all the time. 

And so what happens as a result of the underpayment is that provider has to have offices and offices full of administrative assistants and lawyers, and they have to not only pay for those people, but they have the associated overhead and burden and the time. And then talking to them, to a big hospital system, they said that’s about 2% of their revenue. So because of that, that’s 2%. Then, wait, there’s more. You have the pre-ops, and you have the TPAs who fight you on the pre-ops. But the downstream economic impacts are enormous because, first, the doctor has to ask for the pre-op. That’s eating doctor’s time, and so they see fewer patients. And then not only does the doctor have to deal with them, they go to HR at the company who self-insures and says, Wait, my employee can’t come to work, because their child is sick, and you won’t approve this process or, whatever, this procedure, because it has to go through this pre-op. 

Or if it’s on medications, it’s you want to go through the step-up process or you want to go through a different utilization because you get more rebates. All these pieces are intertwined, and we don’t look at it holistically. And so what we’re saying with Cost Plus Wellness is, we’re going to do this all in a cash basis. We’re going to trust doctors so that we’re not going to go through a pre-op. Now we’ll trust but verify. So as we go through our population and we look at all of our claims, because we’ll own all of our claims, we’re going to look to see if there are repetitive issues with somebody who’s just trying to —there’s lots of back surgeries or there’s lots of this or there’s lots of that — to see if somebody’s abusing us. And because there’s no deductible, we pay it, and we pay it right when the procedure happens or right when the medication is prescribed. Because of all that, we want Medicare pricing. Nobody’s saying no. And in some cases I’m getting lower than Medicare pricing for primary care stuff. 

Rovner: OK, we are back. Now it’s time for our extra credits. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We will include the links to all these stories in our show notes on your phone or other device. Joanne, why don’t you go first this week. 

Kenen: There was a fascinating story in The New York Times by Kate Morgan. The headline was “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It.” So I knew nothing about this, and it was so interesting. Placentas have amazing healing properties for wound care, burns, infections, pain control, regenerating skin tissue, just many, many things. And it’s been well known for years, and it’s not widely used. This is a story specifically about a really severe burn victim in a gas explosion and how her face was totally restored. We don’t use this, partly because placenta — every childbirth, there’s a placenta. There are lots of them around. There’s I think three and a half million births a year, or that’s the estimate I read in the Times. One of the reasons they weren’t being used is, during the AIDS crisis, there was some development toward using them, and then the AIDS crisis, there was a fear of contamination and spreading the virus, and it stopped decades later. 

We have a lot more ways of detecting, controlling, figuring out whether something’s contaminated by AIDS or whether a patient has been exposed. It is being used again on a limited basis after C-sections, but it seems to have pretty astonishing — think about all the wound care for just diabetes. I’m not a scientist, but I just looked at the story and said, it seems like a lot of people could be healed quicker and more safely and earlier if this was developed. They’re thrown away now. They’re sent to hospital waste incinerators and biohazard waste. They’re garbage, and they’re actually medicine. 

Rovner: Definitely a scientist’s cool story. Shefali. 

Luthra: My story is from my brilliant colleague Mel Leonor Barclay. The headline is “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” and as part of this really tremendous series that she has running this week, looking at how Latinas as a much more influential and growingly influential voter group could shape gun violence, abortion rights, and housing. And in this story, which I really love, she went to Arizona and spent time talking to folks on all sides of the issue to better understand how Latinas are affected by abortion rights and also how they’ll be voting on this. 

And she really challenges the narrative that has existed for so long, which is that Latinas are largely Catholic, largely more conservative on abortion. And she finds something much more complex, which is that actually polls really show that a large share of Latina voters in Arizona and similar states support abortion rights and will be voting in favor of measures like the Arizona constitutional amendment. But at the same time, there are real divides within the community, and people talk about their faith in a different way and how it connects their stance on abortion. They talk about their relationships with family in different ways, and I think it just underscores how rarely Latina voters are treated with real nuance and care and thoughtfulness when talking about something as complex as abortion and abortion politics. And I really love the way that she approaches this piece. 

Rovner: It was a super-interesting story. Jesse. 

Hellmann: My story is from The Assembly. It’s an outlet in North Carolina. It’s called “Helene Left Some North Carolina Elder-Care Homes Without Power.” Some assisted living facilities have been without power and water since the hurricane hit. Several facilities had to evacuate residents, and the story just kind of gets into how North Carolina has more lax rules around emergency preparedness. While they do require nursing homes be prepared to provide backup power, the same requirements don’t apply to assisted living facilities. And it’s because there’s been industry pushback against that because of the cost. But as we see some more of these extreme weather events, it seems like something has to be done. We cannot just allow vulnerable people living in these facilities to go hours and hours without power and water. And I saw that there was a facility where they evacuated dozens of people who had dementia, and that’s just something that’s really upsetting and traumatizing for people. 

Rovner: Yeah, once again, now we are seeing these extreme weather events in places that, unlike Florida and Texas, are not set up and used to extreme weather events. And it is something I think that a lot of people are starting to think about. Well, my story this week is from our KFF Health News public health project called Health Beat, and it’s called “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly. And it’s one of those stories you never really think about until it’s pointed out that in areas, particularly those that had been redlined, in particular, the lack of safety infrastructure that most of us take for granted — crosswalks, sidewalks, traffic lights are not really there. And that’s a public health crisis of its own, and it’s one that rarely gets addressed, and it’s a really infuriating but a really good story. 

All right, that is our show. Next week, for my birthday, we’re doing a live election preview show here at KFF in D.C., because I have a slightly warped idea of fun. And you’re all invited to join us. I will put a link to the RSVP in the show notes. I am promised there will be cake. 

As always, if you enjoy 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. Thanks as always to our technical guru, Francis Ying, and our fill-in editor this week, Stephanie Stapleton. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me for the moment at X. I’m @jrovner. Joanne, where are you? 

Kenen: @JoanneKenen sometimes on Twitter and @joannekenen1 on Threads.

Rovner: Jessie.

Hellmann: @jessiehellmann on Twitter.

Rovner: Shefali.

Luthra: @shefalil on Twitter.

Rovner: We will be back in your feed next week. Until then, be healthy.

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