But federal data and inspection reports show that some run by the dominant company, Encompass Health Corp., and other for-profit corporations have had rare but serious incidents of patient harm and perform below average on two key safety measures tracked by Medicare.

Yet even when inspections reveal grave cases of injury, federal health officials do not inform consumers or impose fines the way they do for nursing homes. And Medicare doesn’t provide easy-to-understand five-star ratings as it does for general hospitals.

In the most serious problems documented by regulators, rehab hospital errors involved patient deaths.

In Encompass Health’s hospital in Huntington, West Virginia, Elizabeth VanBibber, 73, was fatally poisoned by a carbon monoxide leak during construction at the facility.

At its hospital in Jackson, Tennessee, a patient, 68, was found dead overnight, lying on the floor in a “pool of blood” after an alarm that was supposed to alert nurses that he had gotten out of bed had been turned off.

In its hospital in Sioux Falls, South Dakota, a nurse gave Frederick Roufs, 73, the wrong drug, one of 26 medication errors the hospital made over six months. He died two days later at another hospital.

“I can still see Fred laying in the bed as they shut each little machine off,” said his widow, Susan Roufs. “They clicked four of them, and then the love of my life was gone.”

Encompass, which owns 168 hospitals and admitted 248,000 patients last year, has led the transformation of this niche industry. In 2023, stand-alone for-profit medical rehabilitation hospitals overtook nonprofits as the places where the majority of annual patient admissions occur, a KFF Health News and New York Times analysis found. A third of all admissions were to Encompass hospitals. Such facilities are required to provide three hours of therapy a day, five days a week.

Across the nation, there are now nearly 400 stand-alone rehab hospitals, the bulk of which are for-profit. These hospitals collectively generate profits of 10%, more than general hospitals, which earn about 6%, and far more than skilled nursing homes, which make less than 0.5%, according to the most recent data from the Medicare Payment Advisory Commission, an independent congressional agency.

At the same time, the number of small, specialized units within acute care hospitals — where most rehab used to be provided — has dwindled. There are now around 800 of those, and most are nonprofits.

In its latest annual report, Encompass, which is publicly traded, reported an 11% net profit in 2024, earning $597 million last year on revenues of $5.4 billion.

Federal data on the performance of about 1,100 of the rehab facilities show Encompass tends to be better at helping most patients return home and remain there. In a two-year period ending in September 2023, Medicare rated 233 rehab facilities as performing better than the national rate for this major metric, called “discharge to community.” Most rehabs with better community discharge rates are for-profit, and Encompass owns 79 of them.

But data from Medicare also reveals Encompass owns many of the rehabs with worse rates of potentially preventable, unplanned readmissions to general hospitals. Medicare evaluates how often patients are rehospitalized for conditions that might have been averted with proper care, including infections, bedsores, dehydration, and kidney failures.

Encompass accounts for about 1 in 7 rehab facilities nationally, but owned 34 of the 41 inpatient rehab facilities that Medicare rated as having statistically significantly worse rates of potentially preventable readmissions for discharged patients. (Overall, rates of readmission after discharge ranged from 7% to 12%, with a median of 9%.)

And it owned 28 of the 87 rehab facilities — 65 of which were for-profit — that had worse rates of potentially preventable readmissions to general hospitals during patient stays. (The median for these kinds of readmissions was 5%, and rates for individual rehabs ranged from 3% to 9%.)

Patrick Darby, the executive vice president and general counsel of Encompass, strongly defended the company’s record in written responses to questions. He dismissed Medicare’s readmissions ratings of “better,” “worse,” and “no different than the national rate” as “a crude scoring measure” and said “performance is so similar across the board.” He called the violations found during health inspections “rare occurrences” that “do not support an inference of widespread quality concerns.”

“The simplest and most accurate reason for EHC’s success is that our hospitals provide superior care to patients,” he said, referring to Encompass by its corporate initials.

Chih-Ying Li, an associate professor of occupational therapy at the University of Texas Medical Branch at Galveston School of Health Professions, said in an interview that a research study she conducted found the profit status of a rehab facility was the only characteristic associated with higher unplanned readmissions.

“The finding is pretty robust,” she said. “It’s not like huge, huge differences, but there are differences.”

Alarming Mistakes

VanBibber was admitted to Encompass’ Huntington hospital in 2021 for therapy to strengthen her lungs. At the time, the hospital was undergoing a $3 million expansion, and state regulators had warned the company that areas of the hospital occupied by patients had to be isolated from the construction “using airtight barriers,” according to a health inspection report.

In her room, which was about 66 feet from the construction zone, she began having trouble breathing, the report said. When she told the staff, they ignored her and shut her door, according to a lawsuit brought by her estate. Staff members eventually noticed that she was “lethargic and gasping for air,” and called 911.

When the emergency medical squad arrived, the carbon monoxide detectors they wore sounded. By that time, VanBibber’s blood oxygen levels were dangerously low, the inspection report said. She died three days later from respiratory failure and carbon monoxide poisoning, according to the inspection report and the lawsuit. A plumber had been using a gas-powered saw in the construction area, but there were no carbon monoxide detectors in the hallways, the report said.

In court papers, Encompass and its construction contractors denied negligence for VanBibber’s death. The case is pending.

Inspectors determined Encompass failed to maintain a safe environment for all patients during construction and didn’t properly evaluate other patients for signs of poisoning, the report said.

Since 2021, the federal Centers for Medicare and Medicaid Services, or CMS, which oversees health inspections, has found that 10 Encompass hospitals, including the one that cared for VanBibber, had immediate jeopardy violations, federal records show. Such violations — like the ones that Medicare also found in connection with the deaths of Roufs and the patient who fell after leaving his bed — mean a hospital’s failure to comply with federal rules has put patients at risk for serious injury, serious harm, serious impairment, or death.

Darby, the general counsel for Encompass, said the company regretted any clinical problems and had promptly addressed all such findings to the satisfaction of inspectors. He said Encompass that has an “excellent compliance record,” including superior results from its accreditation agency, and that its overall number of health citations was tiny given how many hospitals Encompass owns and how many patients it treats.

Six other corporate-operated for-profit hospitals were also cited, while none of the 31 stand-alone nonprofit rehab hospitals received such violations from 2021 to 2024. (Inspection reports for general hospitals do not systematically specify in which part of the building a violation occurred, so rehab unit violations cannot be identified.)

An alert called a bed alarm was at the root of immediate jeopardies at Encompass hospitals in Morgantown, West Virginia, and Jackson, Tennessee. The devices are pressure- and motion-sensitive and emit a sound and display a light to alert staff members that someone at a high risk of falls has left his or her bed.

In its Morgantown hospital, a nurse technician discovered a patient face down on the floor with a large gash on her head after a defective alarm did not go off, an inspection report said. After she died, the nurse told inspectors: “We are having a lot of problems with the bed alarms.”

Medicare is not authorized by law to fine rehab hospitals for safety rule violations, even ones involving deaths uncovered during inspections, as it has done with nearly 8,000 nursing homes during the last three years, imposing average fines of about $28,000.

The only option is to entirely cut off a rehab hospital’s reimbursement for all services by Medicare and Medicaid, which cover most patients. That step would most likely put it out of business and is almost never used because of its draconian consequences.

“Termination is typically a last resort after working with the provider to come back into compliance,” Catherine Howden, a CMS spokesperson, said in an email.

As a result, because there’s no graduated penalty, even the most serious — and rare — immediate jeopardy violations effectively carry no punishments so long as the hospital puts steps in place to avert future problems.

“Only having a nuclear weapon has really hurt patient safety,” said Michael Millenson, a medical quality advocate.

One immediate jeopardy incident did result in a punishment, but only because the hospital was in California, which allows its health department to issue penalties. Encompass’ Bakersfield hospital paid a $75,000 fine last year for failing to control the blood sugar of a patient who died after her heart stopped.

Rapid Growth and a Troubled History

Encompass has accelerated its expansion in recent years and now operates in 38 states and Puerto Rico. It plans to open 17 more hospitals in Arizona, Connecticut, Florida, Georgia, Maine, Pennsylvania, South Carolina, Texas, and Utah by the end of 2027, according to its latest report.

It frequently moves into new markets by persuading local nonprofit hospitals to shutter their rehab units in exchange for an equity stake in a newly built Encompass hospital, company executives have told investors.

The president of Encompass, Mark Tarr, calls it a “win-win proposition”: The local hospitals can use their emptied space for a more lucrative line of service and Encompass gets a “jump start” into a new market, with partner hospitals often referring patients.

Tarr, who was paid $9.3 million in compensation last year, told investors that Encompass requires that the existing hospitals sign a noncompete deal. Sixty-seven Encompass hospitals are joint ventures, mostly with nonprofit hospitals as investors, according to the company’s June financial filing, the most recent available.

Darby said the company’s profits allow it to build hospitals in areas that lack intensive inpatient rehabilitation and improve existing hospitals. “High-quality patient care is not only consistent with shareholder return, but quality and shareholder return are in fact critical to one another,” he said.

The success of Encompass is particularly notable given that it barely survived what experts said was one of the largest modern accounting scandals in 2003.

The Securities and Exchange Commission charged that the company, then known as HealthSouth, overstated earnings by $2.7 billion to meet Wall Street analyst quarterly expectations, leading to the ouster of its founder and directors. In 2004, the company agreed to pay the government $325 million to settle Medicare fraud allegations without admitting wrongdoing. Darby credited the company’s new leaders for obtaining a $2.9 billion judgment on behalf of shareholders against the company’s founder.

The company changed its name to Encompass in 2018 after acquiring Encompass Home Health and Hospice. In 2019, the Justice Department announced the company had agreed to pay $48 million to settle whistleblower lawsuit claims that it misdiagnosed patients to get higher Medicare reimbursements, and admitted patients who were too sick to benefit from therapy. The company denied any wrongdoing, blaming independent physicians who worked at its hospitals. Darby said Encompass settled the case only to “avoid more years of expense and disruption.” He said the Justice Department never filed a lawsuit despite years of investigation.

Medication Harms

Rehab hospital inspection reports are not posted on Care Compare, Medicare’s online search tool for consumers. KFF Health News had to sue CMS under the Freedom of Information Act to obtain all its inspection reports for rehab hospitals. In contrast, Care Compare publishes all nursing home inspection reports and assigns each facility a star rating for its adherence to health and safety rules.

So people now choosing a rehab hospital would not know that at the Encompass hospital in Sioux Falls, South Dakota, in 2021, a nurse accidentally gave Roufs a blood pressure drug called hydralazine instead of hydroxyzine, his prescribed anti-anxiety medication, according to an inspection report. Roufs went into cardiac arrest. This type of error, called a “look-alike/sound-alike,” is one hospitals and staff members are supposed to be especially alert to.

Months before, an internal safety committee had identified a trend of medication errors, including when a nurse accidentally gave a patient 10 times the prescribed amount of insulin, sending him to the hospital, the inspection report said. The nurse had misread four units as 40. Since Roufs’s death, inspectors have faulted the hospital six times for various lapses, most recently in April 2024 for improper wound care.

An Encompass hospital in Texarkana, Texas, misused antipsychotic medications to pacify patients, resulting in an immediate jeopardy finding from CMS, the report said. And the company’s hospital in Erie, Pennsylvania, was issued an immediate jeopardy violation for not keeping track of medication orders in 2023, when a patient had a cardiac arrest after not receiving all of his drugs, according to the inspection report.

The federal government’s overall quality oversight efforts are limited. Medicare docks payment to rehab facilities for patients readmitted to a general hospital during shorter-than-average rehab stays, but unlike at general hospitals, there are no financial penalties when recently discharged rehab patients are hospitalized for critical health issues.

The Biden administration announced last year it intended to develop a rating scale of 1 to 5 stars for rehab facilities. The industry’s trade association, the American Medical Rehabilitation Providers Association, requested a delay in the creation of star ratings until the current quality measures were refined. The Trump administration has not determined whether it will continue the effort to rate rehab facilities, according to a CMS spokesperson.

Deadly Bedsores

The family of Paul Webb Jr., 74, claimed in a lawsuit that the Encompass hospital in Erie left Webb unattended in a wheelchair for hours at a time, putting pressure on his tailbone, in 2021. His medical records, provided to reporters by the family, list a sitting tolerance of one hour.

Webb — who had been originally hospitalized after a brain bleed, a type of stroke — developed skin damage known as a pressure sore, or bedsore, on his bottom, the lawsuit said. The suit said the sore worsened after he was sent to a nursing home, which the family is also suing, then home, and he died later that year. In his final weeks, Webb was unable to stand, sit, or move much because of the injury, the lawsuit said.

In court papers, Encompass and the nursing home denied negligence, as Encompass has in some other pending and closed lawsuits that accused it of failing to prevent pressure sores because nurses and aides failed to regularly reposition patients, or notice and treat emerging sores. Darby said Webb’s death occurred three months after his Encompass stay and was not related to his care at Encompass. He said no hospital with long-term patients could prevent every new or worsening pressure sore, but that Encompass’ rates were similar to the 1% national average.

One of Webb’s sons, Darel Webb, recalled a warning given to the family as they left an appointment their father had with wound specialists: A doctor brought up Christopher Reeve, the actor who played Superman in movies in the 1970s and 1980s.

“He goes, ‘Remember, Superman was paralyzed from falling off the horse, but he died from a bedsore,’” he said.

Jordan Rau has been writing about hospital safety since 2008. Irena Hwang is a New York Times data reporter who uses computational tools to uncover hidden stories and illuminate the news.

METHODOLOGY

To examine the medical rehabilitation hospital industry, we obtained and analyzed a database of inspection reports of freestanding rehabilitation hospitals from the federal Centers for Medicare & Medicaid Services, or CMS. We also obtained inspection reports from several states through public records requests.

We analyzed inpatient rehabilitation facility characteristics and patient volume data contained in hospital data files from the Rand Corp., a nonprofit research organization. This dataset compiles cost reports all hospitals submit each year to CMS. For each facility for the years 2012 to 2023, we categorized annual discharges by facility type (freestanding rehabilitation hospital or unit within an acute care hospital); facility ownership status (for-profit, nonprofit, or government); and which hospitals were owned by Encompass Health under its current or prior name, HealthSouth.

Financial information about Encompass Health was obtained from the company’s Securities and Exchange Commission disclosure filings.

We examined the readmission rates for all inpatient rehabilitation facilities that CMS publishes in its quality data. CMS evaluates the frequency with which Medicare patients were readmitted for potentially preventable reasons to an acute care hospital during their rehab stay. Separately, CMS also evaluates the frequency of potentially preventable readmissions to an acute care hospital within 30 days of discharge from rehab. We also examined the rate of successful return to home or community. Figures for all three metrics were available for about 1,100 of the roughly 1,200 rehab facilities in the CMS data. The most recent readmission data covered Medicare discharges from October 2021 through September 2023.

We examined nursing home penalties from the last three years from CMS’ data on nursing homes.

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.

Early Thursday afternoon, the House approved a budget reconciliation bill that not only would make permanent many of President Donald Trump’s 2017 tax cuts, but also impose deep cuts to Medicaid, the Affordable Care Act, and, indirectly, Medicare.

Meanwhile, those appointed by Health and Human Services Secretary Robert F. Kennedy Jr. to a key vaccine advisory panel used their first official meeting to cast doubt on a preservative that has been used in flu vaccines for decades — with studies showing no evidence of its harm in low doses.

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

Panelists

Maya Goldman
Axios

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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:

• This week the GOP steamrolled toward a major constriction of the nation’s social safety net, pushing through Trump’s tax and spending bill. The legislation contains significant changes to the way Medicaid is funded and delivered — in particular, through imposing the program’s first federal work requirement on many enrollees. Hospitals say the changes would be devastating, potentially resulting in the loss of services and facilities that could touch all patients, not only those on Medicaid.
• Some proposals in Trump’s bill were dropped during the Senate’s consideration, including a ban on Medicaid coverage for gender-affirming care and federal funding cuts for states that use their own Medicaid funds to cover immigrants without legal status. And for all the talk of not touching Medicare, the legislation’s repercussions for the deficit are expected to trigger spending cuts to the program that covers those over 65 and some with disabilities — potentially as soon as the next fiscal year.
• The newly reconstituted Advisory Committee on Immunization Practices met last week, and it looked pretty different from previous meetings: In addition to new members, there were fewer staffers on hand from the Centers for Disease Control and Prevention — and the notable presence of vaccine critics. The panel’s vote to reverse the recommendation of flu shots containing a mercury-based preservative — plus its plans to review the childhood vaccine schedule — hint at what’s to come.

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

Julie Rovner: The Lancet’s “Evaluating the Impact of Two Decades of USAID Interventions and Projecting the Effects of Defunding on Mortality up to 2030: A Retrospective Impact Evaluation and Forecasting Analysis,” by Daniella Medeiros Cavalcanti, et al.

Alice Miranda Ollstein: The New York Times’ “‘I Feel Like I’ve Been Lied To’: When a Measles Outbreak Hits Home,” by Eli Saslow.

Maya Goldman: Axios’ “New Docs Get Schooled in Old Diseases as Vax Rates Fall,” by Tina Reed.

Sarah Karlin-Smith: Wired’s “Snake Venom, Urine, and a Quest to Live Forever: Inside a Biohacking Conference Emboldened by MAHA,” by Will Bahr.

Also mentioned in this week’s episode:

• NBC News’ “Crisis Pregnancy Centers Told To Avoid Ultrasounds for Suspected Ectopic Pregnancies,” by Abigail Brooks.
• ProPublica’s “A ‘Striking’ Trend: After Texas Banned Abortion, More Women Nearly Bled to Death During Miscarriage,” by Kavitha Surana, Lizzie Presser, and Andrea Suozzo.
• The Washington Post’s “DOGE Loses Control Over Government Grants Website, Freeing Up Billions,” by Dan Diamond and Hannah Natanson.

click to open the transcript

Transcript: Trump’s Bill Reaches the Finish Line

[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, July 3, 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: Sarah Karlin-Smith at the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: And Maya Goldman of Axios News. 

Maya Goldman: Good to be here. 

Rovner: No interview this week, but more than enough news, so we will get right to it. So as we sit down to tape, the House is on the cusp of passing the biggest constriction of the federal social safety net ever, part of President [Donald] Trump’s, quote, “One Big Beautiful Bill,” which is technically no longer called that, because the name was ruled out of order when it went through the Senate. In an effort to get the bill to the president’s desk by the July Fourth holiday, aka tomorrow, the House had to swallow without changes the bill that passed the Senate on Tuesday morning after Vice President JD Vance broke a 50-50 tie. And the House has been in session continuously since Wednesday morning working to do just that, with lots of arm-twisting and threatening and cajoling to walk back the complaints from both conservative Republicans, who are objecting to the trillions of dollars the bill would add to the national debt, as well as moderates objecting to the Medicaid and food stamp cuts. 

There is a whole lot to unpack here, but let’s start with Medicaid, which would take the biggest hit of the health programs in this bill — ironically, just weeks before the program’s 60th anniversary. What does this bill do to Medicaid? 

Goldman: This bill makes some huge changes to the way that Medicaid is funded and delivered in the United States. One of the biggest changes is the first federal work requirement for Medicaid, which we’ve talked about at length. 

Rovner: Pretty much every week. 

Goldman: Pretty much every week. It’s going to be — it’s sort of death by paperwork for many people. They’re not necessarily forced to lose their coverage, but there are so many paperwork hurdles and barriers to making sure that you are reporting things correctly, that CBO [the Congressional Budget Office] expects millions of people are going to lose coverage. And we know from limited experiments with work requirements in Arkansas that it does not increase employment. So, that’s the biggie. 

Rovner: The House froze provider taxes, which is what most — all states but Alaska? — use to help pay their share of Medicaid. The Senate went even further, didn’t they? 

Goldman: Yeah. Hospitals are saying that it’s going to be absolutely devastating to them. When you cut funding, cut reimbursement in that way, cut the amount of money that’s available in that way, it trickles down to the patient, ultimately. 

Karlin-Smith: Especially things like the provider tax, but even just the loss to certain health systems of Medicaid patients end up having a spiral effect where it may impact people who are on other health insurance, because these facilities will no longer have that funding to operate the way they are. Particularly some facilities talked about how the Obamacare Medicaid expansion really allowed them to expand their services and beef up. And now if they lose that population, you actually end up with risks of facilities closing. The Senate tried to provide a little bit of money to alleviate that, but I think that’s generally seen as quite small compared to the long-term effects of this bill. 

Rovner: Yeah, there’s a $50 billion rural hospital slush fund, if you will, but that’s not going to offset $930 billion in cuts to Medicaid. And it’s important — I know we keep saying this, but it’s important to say again: It’s not just the people who will lose Medicaid who will be impacted, because if these facilities close — we’re talking about hospitals and rural clinics and other facilities that depend on Medicaid — people with all kinds of insurance are going to lack access. I see lots of nods going around. 

Goldman: Yeah. One salient example that somebody told me earlier this week was, think about ER wait times. It already takes so long to get seen if you go into the ER. And when people don’t have health insurance, they’re seeking care at the ER because it’s an emergency and they waited until it was an emergency, or that’s just where they feel they can go. But this is going to increase ER wait times for everybody. 

Rovner: And also, if nursing homes or other facilities close, people get backed up in the ER because they can’t move into the hospital when they need hospital care, because the hospital can’t discharge the people who are already there. I had sort of forgotten how that the crowded ERs are often a result of things other than too many people in the ER. 

Goldman: Right. 

Rovner: They’re a result of other strains on sort of the supply chain for care. 

Goldman: There’s so many ripple effects and dominoes that are going to fall, if you will. 

Rovner: So, there were some things that were in the House bill that, as predicted, didn’t make it into the Senate bill, because the parliamentarian said they violated the budget rules for reconciliation. That included the proposed Medicaid ban on all transgender care for minors and adults, and most of the cuts to states that use their own funds to cover undocumented people. But the parliamentarian ended up kind of splitting the difference on cutting funding to Planned Parenthood, which she had ruled in 2017 Congress couldn’t do in reconciliation. Alice, what happened here? 

Ollstein: She decided that one year of cuts was OK, when they had originally sought 10. And the only reason they originally sought 10 is that’s how these bills work. It’s a 10-year budget window. That’s how you calculate things. They sort of meant it to function like a permanent defund. So, the anti-abortion movement was really divided on this outcome, where some were declaring it a big victory and some were saying: Oh, only one year. This is such a disappointment and not what we were promised blah, blah, blah. And it’ll be really interesting to see if even one year does function like a sort of permanent defund. 

On the one hand, the anti-abortion movement is worried that because it’s one year, that means they’ll have to vote on it again next year right before the midterms, when people might get more squirrelly because of the politics of it, which obviously still exist now but would be more potent then. But clinics can’t survive without funding for long. We’re already seeing Planned Parenthoods around the country close because of Title X cuts, because of other budget instability. And so once a clinic closes, even if the funding comes back later, it can’t flip a switch and turn it back on. When things close, they close, the staff moves away, etc. 

Rovner: And we should emphasize Medicaid has not been used to pay for federal abortion funding ever. 

Ollstein: Yes. Yes. 

Rovner: That’s part of the Hyde Amendment. So we’re talking about non-abortion services here. We’re talking about contraception, and STD testing and treatment, and cancer screenings, and other types of primary care that almost every Planned Parenthood provides. They don’t all provide abortion, but they all provide these other ancillary services that lots of Medicaid patients use. 

Ollstein: Right. And so this will shut down clinics in states where abortion is legal, and it’ll shut down clinics in states where abortion is illegal and these clinics only are providing those other reproductive health services, which are already in scant supply and hard to come by. There’s massive maternity care deserts, contraceptive deserts around the country, and this is set to make that worse. 

Rovner: So, while this bill was not painted as a repeal of the Affordable Care Act, unlike the 2017 version, it does do a lot to scale that law back. This has kind of flown under the radar. Maya, you wrote about this. What does this bill do to the ACA? 

Goldman: Yeah. Well, so, there were a lot of changes that Congress was seeking to codify from rule that the Trump administration has finalized that really create a lot of extra barriers to enrolling in the ACA. A lot of those did not make it into the final bill that is being voted on, but there’s still more paperwork — death by paperwork. I think there’s preenrollment verification of eligibility, things like that. And I think just in general, the ACA has created massive gains in the insurer population in the United States over the last decade and a half. And there’s estimates that show that this would wipe out three-fourths of that gain. And so that’s just staggering to see that. 

Rovner: Yeah. I think people have underestimated the impact that this could have on the ACA. Of course, we’ve talked about this also a million times. This bill does not extend the additional subsidies that were created under the Biden administration, which has basically doubled the number of people who’ve been able to afford coverage and bought it on the marketplaces. But I’ve seen estimates that more than half of the people could actually end up dropping out of ACA coverage. 

Goldman: Yeah. And I think it’s important to talk about the timelines here. A lot of the work requirements in Medicaid won’t take effect for a couple of years, but people are going to lose their enhanced subsidies in January. And so we are going to see pretty immediate effects of this. 

Rovner: And they’re shortening the enrollment time. 

Goldman: Yeah. 

Rovner: And people won’t be able to be auto-reenrolled, which is how a lot of people continue on their ACA coverage. There are a lot of little things that I think together add up to a whole lot for the ACA. 

Goldman: Right. And Trump administration ACA enrollment barriers that were finalized might not be codified in this law, but they’re still finalized. 

Rovner: Yeah. 

Goldman: And so they will take effect for 2026 coverage. 

Rovner: And while President Trump has said repeatedly that he didn’t want to touch Medicare, this bill ironically is going to do exactly that, because the amount the tax cuts add to the deficit is likely to trigger a Medicare sequester under budget rules. That means there will be automatic cuts to Medicare, probably as soon as next year. 

All right, well, that is the moving bill, the One Big Beautiful Bill. One thing that has at least stopped moving for now is the Supreme Court, at least for the moment. The justices wrapped up their formal 2024-2025 term with some pretty significant health-related cases that impact two topics we’re talking about elsewhere in this episode, abortion and vaccines. 

First, abortion. The court ruled that Medicaid patients don’t have the right to sue to enforce the section of Medicaid law that ensures free choice of provider. In this case, it frees South Carolina to kick Planned Parenthood out of its Medicaid program. Now, this isn’t about abortion. This is about, as we said, other services that Planned Parenthood provides. But, Alice, what are the ramifications of this ruling? 

Ollstein: They could be very big. A lot of states have already tried and are likely to try to cut Planned Parenthood out of their Medicaid programs. And given this federal defund, this is now going after some of their remaining supports, which is state Medicaid programs, which is a separate revenue stream. And so this will just lead to even more clinic closures. And already, this kind of sexual health care is very hard to come by in a lot of places in the country. And that is set to be even more true in the future. And this is sort of the culmination of something that the right has worked towards for a long time. And so they had just a bunch of different strategies and tactics to go after Planned Parenthood in so many ways in the courts, and there’s still more shoes to drop. There’s still court cases pending. 

There’s one in Texas that’s accusing Planned Parenthood of defrauding the state, and so that judgment could wipe them out even more. This federal legislative effort, there’s the Supreme Court case — and they’ve really been effective at just throwing everything at the wall and seeing what sticks. And enough is sticking now that the organization is really — they were able to beat back a lot of these attempts before. They were able to rally in Congress. They were able to rally at the state level to push back on a lot of this. And that wasn’t true this time. And so I don’t know what conclusion to take from that. There’s, obviously, people are very overwhelmed. There’s a lot going on. There are organizations getting hit left and right, and maybe this just got lost in the noise this time. 

Rovner: Yeah, I think that may be. Well, the other big Supreme Court decision was one we’d talked about quite a bit, the so-called Braidwood case that was challenging the ability of the CDC’s [Center for Disease Control and Prevention’s] Preventive Services Task Force from recommending services that would then be covered by health insurance. This was arguably a win for the Biden administration. The court ruled that the task force members do not need to be confirmed by the Senate. But, Sarah, this also gives Secretary [Robert F.] Kennedy [Jr.] more power to do what he will with other advisory committees, right? 

Karlin-Smith: Right. By affirming the way the U.S. Preventive Services Task Force was set up, in that the HHS [Department of Health and Human Services] secretary is ultimately the authority for appointing the task force, which then makes recommendations around what coverage requirements under the ACA. It also sort of affirms the authority of the HHS secretary here. And I think people think it has implications for other bodies like CDC’s advisory committee on vaccines as well, where the secretary has a lot of authority. 

So, I think people who really support the coverage advantages that have come through the USPSTF and Obamacare have always pushed for this outcome in this case. But given our current HHS secretary, there are some worries that it might lead to rollbacks or changes in areas of the health care paradigm that he does not support. 

Rovner: Well, let us segue to that right now. That is, of course, as you mentioned, the other major CDC advisory committee, the one on immunization practices. When we left off, Secretary Kennedy had broken his promise to Senate health committee chairman Bill Cassidy and fired all 17 members of the committee, replacing them with vaccine skeptics and a couple of outright vaccine deniers. So last week, the newly reconstituted panel held its first meeting. How’d that go? 

Karlin-Smith: It was definitely an interesting meeting, different, I think, for people who have watched ACIP [the Advisory Committee on Immunization Practices] in the past. Besides just getting rid of the members of the advisory panel, Kennedy also removed a lot of the CDC staff who work on that topic as well. So the CDC staffers who were there and doing their typical presentations were much smaller in number. And for the most part, I think they did a really good job of sticking to the tried-and-true science around these products and really having to grapple with extremely, I think, unusual questions from many of the panelists. But the agenda got shrunk quite a bit, and one of the topics was quite controversial. Basically, they decided to review the ingredient thimerosal, which was largely taken out of vaccines in the late ’90s, early 2000s, but remains in certain larger vials of flu vaccines. 

Rovner: It’s a preservative, right? You need something in a multi-dose vaccine vial to keep it from getting contaminated. 

Karlin-Smith: And they had a presentation from Lyn Redwood, who was a former leader of the Children’s Health Defense, which is a very anti-vax organization started by Robert Kennedy. The presentation was generally seen as not based in science and evidence, and there was no other presentations, and the committee voted to not really allow flu vaccines with that ingredient. 

And the impact in the U.S. here is going to be pretty small because, I think, it’s about 4% of people get vaccines through those large-quantity vials, like if you’re in a nursing home or something like that. But what people are saying, and Scott Gottlieb [Food and Drug Administration commissioner in the first Trump administration] was talking a lot about this last week, was that this is really a hint of what is to come and the types of things they are going to take aim at. And he’s particularly concerned about another, what’s called an adjuvant, which is an ingredient added to vaccines to help make them work better, that’s in a lot of childhood vaccines, that Kennedy hinted at he wanted on the agenda for this meeting. It came off the agenda, but he presumes they will circle back to it. And if companies can’t use that ingredient in their vaccines, he’s not really clear they have anything else that is as good and as safe, and could force them out of the market. 

So there were a bunch of hints of things concerning fights to come. The other big one was that they were saying they want to review the totality of the childhood vaccine schedule and the amount of vaccines kids get, which was really a red flag for people who followed the anti-vaccine movement, because anti-vaxxers have a lot of long-debunked claims that kids get too many vaccines, they get them too closer together. And scientists, again, have thoroughly debunked that, but they still push that. 

Rovner: And that was something else that Kennedy promised Cassidy he wouldn’t mess with, if I recall correctly, right? 

Karlin-Smith: You know, the nature of the agreement between Cassidy and Kennedy keeps getting more confusing to me. And I actually talked to both HHS’ secretary’s office and Cassidy’s office last week about that. And they both don’t actually agree on quite exactly what the terms were. But anyway, I looked at it in terms of the terms, like whether it’s to preserve the recommendations ACIP has made over time in the childhood schedule, whether it’s to preserve the committee members. I think it’s pretty clear that Kennedy has violated the sort of heart of the matter, which is he has gone after safe, effective vaccines and people’s access to vaccines in this country in ways that are likely to be problematic. And there are hints of more to come. He’s also cut off funding for vaccines globally. So, I don’t know. I almost just laugh thinking about what they actually agreed to, but there’s really no way Cassidy can say that Kennedy followed through on his promises. 

Rovner: Well, meanwhile, even while ACIP was meeting last week, the HHS secretary was informing the members of Gavi, that’s the Global Alliance for Vaccines and Immunizations, that he was canceling the U.S.’ scheduled billion-dollar contribution because, he said, the public-private partnership that has vaccinated more than a billion children over the past two and a half decades doesn’t take vaccine safety seriously enough. Really? 

Karlin-Smith: Yeah. Kennedy has these claims, again, that I think are, very clearly have been, debunked by experts, that Gavi is not thinking clearly about vaccine safety and offering vaccines they shouldn’t be, and the result is going to be huge gaps in what children can get around the globe to vaccines. And it comes on top of all the other cuts the U.S. has made recently to global health in terms of USAID [the U.S. Agency for International Development]. So I think these are going to be big impacts. And they may eventually trickle down to impact the U.S. in ways people don’t expect. 

If you think about a virus like covid, which continues to evolve, one of the fears that people have always had is we get a variant that is, as it evolves, that is more dangerous to people and we’re less able to protect with the vaccines we have. If you allow the virus to kind of spread through unvaccinated communities because, say you weren’t providing these vaccines abroad, that increases the risk that we get a bad variant going on. So obviously, we should be concerned, I think, just about the millions of deaths people are saying this could cause globally, but there’s also impacts to our country as well and our health. 

Rovner: I know there’s all this talk about soft-power humanitarian assistance and helping other countries, but as long as people can get on airplanes, it’s in our interest that people in other countries don’t get things that can be spread here, too, right? 

Goldman: Yeah. One very small comment that was made during the ACIP meeting this week from CDC staff was an update on the measles outbreak, which I just thought was interesting. They said that the outbreak in the South from earlier this year is mostly under control, but people are still bringing in measles from foreign countries. And so that’s very much a real, real threat. 

Rovner: Yeah. 

Ollstein: It’s the lesson that we just keep not learning again and again, which is if you allow diseases to spread anywhere, it’ll inevitably impact us here. We don’t live on an island. We have a very interconnected world. You can’t have a Well we’re going to only protect our people and nobody else mentality, because that’s just not how it works. And we’re reducing resources to vaccinate people here as well. 

Rovner: That’s right. Turning back to abortion, there was other news on that front this week. In Wisconsin, the state Supreme Court formally overturned that state’s 1849 abortion ban. That was the big issue in the Supreme Court election earlier this year. But a couple of other stories caught my eye. One is from NBC News about how crisis pregnancy centers, those anti-abortion facilities that draw women in by offering free pregnancy tests and ultrasounds, are actually advising clinics against offering ultrasounds in some cases after a clinic settled a lawsuit for misdiagnosing a woman’s ectopic pregnancy, thus endangering her life. Alice, if this is a big part of the centers’ draw with these ultrasounds, what’s going on here? 

Ollstein: I think it’s a good example. I want to stress that there’s a big variety of quality of medical care at these centers. Some have actual doctors and nurses on staff. Some don’t at all. Some offer good evidence-based care. Some do not. And I have heard from a lot of doctors that patients will come to them with ultrasounds that were incorrectly done or interpreted by crisis pregnancy centers. They were given wrong information about the gestation of their pregnancy, about the viability of their pregnancy. And so this doesn’t surprise me at all, based on what I’ve heard anecdotally. 

People should also remember that these centers are not regulated as much as health clinics are. And that goes for things like HIPAA [the Health Insurance Portability and Accountability Act] as well. They don’t have the same privacy protections for the information people share there. And so I think we should also keep in mind that women might be depending more and more on these going forward as Planned Parenthoods close, as other clinics close because of all the cuts we just talked about. These clinics are really proliferating and are trying to fill that vacuum. And so things like this should keep people questioning the quality of care they provide. 

Rovner: Yeah. And of course, layer on top of that the Medicaid cuts. There’s going to be an increased inability to get care, particularly in far-flung areas. You can sort of see how this can sort of all pile onto itself. 

Well, the other story that grabbed me this week comes from the Pulitzer Prize-winning team at ProPublica. It’s an analysis of hospital data from Texas that suggests that the state’s total abortion ban is making it more likely that women experiencing early miscarriages may not be getting timely care, and thus are more likely to need blood transfusions or experience other complications. Anti-abortion groups continue to maintain that these bans don’t impact women with pregnancy complications, which are super common, for those who don’t know, particularly early in pregnancy. But experience continues to suggest that that is not the case. 

Ollstein: Yeah. This is a follow-up to a lot of really good reporting ProPublica has done. They also showed that sepsis rates in Texas have gone way up in the wake of the abortion ban. And so anti-abortion groups like to point to the state’s report showing how many abortions are still happening in the state because of the medical emergency exceptions, and saying: See? It’s working. People are using the exceptions. And it is true that some people are, but I think that this kind of data shows that a lot of people are not. And again, if it’s with what I hear anecdotally, there’s just a lot of variety on the ground from hospital to hospital, even in the same city, interpreting the law differently. Their legal teams interpret what they can and can’t provide. It could depend on what resources they have. It could depend on whether they’re a public or private hospital, and whether they’re afraid of the state coming after them and their funding. 

And so I think this shows that one doctor could say, Yes, I do feel comfortable doing this procedure to save this woman’s life, and another doctor could say, I’m going to wait and see. And then you get the sepsis, the hemorrhage. These are very sensitive situations when even a short delay could really be life-and-death, or be long-term health consequences. People have lost the ability to have more children. We’ve seen stories about that. We’ve seen stories about people having to suffer a lot of health consequences while their doctors figure out what kind of care they can provide. 

Rovner: In the case of early miscarriage, the standard of care is to empty the uterus basically to make sure that the bleeding stops, which is either a D&C [dilation and curettage], which of course can also be an early abortion, or using the abortion pill mifepristone and misoprostol, which now apparently doctors are loath to use even in cases of miscarriage. I think that’s sort of the take-home of this story, which is a little bit scary because early miscarriage is really, really, really common. 

Ollstein: Absolutely. And this is about the hospital context, which is obviously very important, but I’m also hearing that this is an issue even for outpatient care. So if somebody is having a miscarriage, it’s not severe enough that they have to be hospitalized, but they do need this medication to help it along. And when they go to the pharmacy, their prescription says, “missed abortion” or “spontaneous abortion,” which are the technical terms for miscarriage. But a pharmacist who isn’t aware of that, isn’t used to it, it’s not something they see all the time, they see that and they freak out and they say, Oh, I don’t want to get sued, so they don’t dispense the medication. Or there are delays. They need to call and double-check. And that has been causing a lot of turmoil as well. 

Rovner: All right. Well, finally this week, Elon Musk is fighting with President Trump again over the budget reconciliation bill, but the long shadow of DOGE [the Department of Government Efficiency] still lives on in federal agencies. On the one hand, The Washington Post scooped this week that DOGE no longer has control over the Grants.gov website, which controls access to more than half a trillion dollars in federal grant funding. On the other hand, I’m still hearing that money is barely getting out and still has to get multiple approvals from political appointees before it can basically get to where it’s supposed to be going. NPR has a story this week with the ominous headline “‘Where’s Our Money?’ CDC Grant Funding Is Moving So Slowly Layoffs Are Happening.” 

I know there’s so much other news happening right now, it’s easy to overlook, but I feel like the public health and health research infrastructure are getting starved to death while the rest of us are looking at shinier objects. 

Goldman: Yeah. This the whole flood-the-zone strategy, right? There’s so many things going on that we can’t possibly keep up with all of them, but this is extremely important. I think if you talk to any research scientist that gets federal funding, they would tell you that things have not gotten back to normal. And there’s so much litigation moving through the courts that it’s going to take a really long time before this is settled, period. 

Rovner: Yeah. We did see yet another court decision this week warning that the layoffs at HHS were illegal. But a lot of these layoffs happened so long ago that these people have found other jobs or put their houses up for sale. You can’t quite put this toothpaste back in the tube. 

Goldman: Right. And also, with this particular ruling, this came from a Rhode Island federal judge, a Biden appointee, so it wasn’t very surprising. But it said that the reorganization plan of HHS was illegal. Or, not illegal, it was a temporary injunction on the reorganization plan and said HHS cannot place anyone else on administrative leave. But it doesn’t require them to rehire the employees that have been laid off, which is also interesting. 

Rovner: Yeah. Well, we will continue to monitor that. All right, that is as much as this week’s news as we have time for. 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 device. Sarah, you were first to choose this week. Why don’t you go first? 

Karlin-Smith: I took a look at a Wired piece from Will Bahr, “Snake Venom, Urine, and a Quest To Live Forever: Inside a Biohacking Conference Emboldened by MAHA.” And it is about a conference in Texas kind of designed to sell you products that they claim might help you live to 180 or more. A lot of what appears to be people essentially preying on people’s fears of mortality, aging, death to sell things that do not appear to be scientifically tested or validated by agencies like FDA. The founder even talks about using his own purified urine to treat his allergies. They’re microdosing snake venom. And it does seem like RFK is sort of emboldening this kind of way of thinking and behavior. 

One of the things I felt was really interesting about the story is the author can’t quite pin down what unites all of these people in their interests in this space. In many cases, they claim there are sort of — there’s not a political element to it. But since I cover the pharma industry very closely, they all seem disappointed with mainstream medical systems and the pharma industry with the U.S., and they are seeking other avenues. But it’s quite an interesting look at the types of things they are willing to try to extend their lives. 

Rovner: Yeah, it is quite the story. Maya, why don’t you go next? 

Goldman: My extra credit this week is from my Axios colleague Tina Reed. It’s called “New Docs Get Schooled in Old Diseases as Vaxx Rates Fall.” And it’s all about how medical schools are adjusting their curriculum to teach students to spend more time on measles and things that we have considered to be wiped out in the United States. And I think it just — it really goes to show that this is something that is real and that’s actually happening. People are coming to emergency rooms and hospitals with these illnesses, and young doctors need to learn about them. We already have so many things to learn in medical school that there’s certainly a trade-off there. 

Rovner: There is, indeed. And Alice, you have a related story. 

Ollstein: Yes, I do. So, this is from The New York Times. It’s called “‘I Feel I’ve Been Lied To’: When a Measles Outbreak Hits Home,” by Eli Saslow. And it’s about the measles outbreak that originated in Texas. But what I think it does a really good job at is, we’ve talked a lot about how people have played up the dangers of vaccines and exaggerated them and, in some cases, outright lied about them, and how that’s influencing people, fear of autism, etc., fear of these adverse reactions. But I think this piece really shows that the other side of that coin is how much some of those same voices have downplayed measles and covid. 

And so we have this situation where people are too afraid of the wrong things — vaccines — and not afraid enough of the right things — measles and these diseases. And so in the story people who are just, including people with some medical training, being shocked at how bad it is, at how healthy kids are really suffering and needing hospitalization and needing to be put on oxygen. And that really clashes with the message from this administration, which has really downplayed that and said it’s mainly hitting people who were already unhealthy or already had preexisting conditions, which is not true. It can hit other people. And so, yeah, I think it’s a very nuanced look at that. 

Rovner: Yeah, it’s a really extraordinary story. My extra credit this week is from the medical journal The Lancet. And I won’t read the entire title or its multiple authors, because that would take the rest of the podcast. But I will summarize it by noting that it finds that funding provided by the U.S. Agency for International Development, which officially closed up shop this week after being basically illegally dissolved by the Trump administration, has saved more than 90 million lives over the past two decades. And if the cuts made this year are not restored, an additional 14 million people will die who might not have otherwise. Far from the Trump administration’s claims that USAID has little to show for its work, this study suggests that the agency has had an enormous impact in reducing deaths from HIV and AIDS, from malaria and other tropical diseases, as well as those other diseases afflicting less developed nations. We’ll have to see how much if any of those services will be maintained or restored. 

OK. That’s this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. 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. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. You can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys these days? Sarah? 

Karlin-Smith: I’m a little bit on X, mostly on Bluesky, at @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice? 

Ollstein: Mostly on Bluesky, @alicemiranda. Still a little bit on X, @AliceOllstein. 

Rovner: Maya. 

Goldman: I am on X, @mayagoldman_, and also on LinkedIn. You can just find me under my name. 

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.

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

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

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

Panelists

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

Chris Sununu
Former governor of New Hampshire (R)

Roy Cooper
Former governor of North Carolina (D)

Among the takeaways from the discussion:

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

Video of this episode is available here on YouTube.

Click to open the transcript

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Gov. Cooper. 

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

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

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

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

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

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

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

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

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

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

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

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

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

Sebelius: Yeah. 

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

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

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

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

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

Sebelius: A big basket. 

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

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

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

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

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

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

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

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

Sebelius: Just a small addendum, too. 

Sununu: Sorry. I’m frustrated. 

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

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

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

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

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

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

Rovner: Next question. 

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

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

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

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

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

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

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

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

Cooper: Yeah, we are now. 

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

Sebelius: I think it’s almost 45. 

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

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

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

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

Sebelius: Regional. 

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

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

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

Sebelius: Maybe the next guys took it away. 

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

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

Sebelius: I was just— 

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

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

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

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

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

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

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

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

Sebelius: Can I just— 

Rovner: Yes. 

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

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

Sebelius: Or sending them on. 

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

Sebelius: It’s got to be earlier though. 

Sununu: Much earlier. 

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

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

Sebelius: No idea. 

Diaz: Why? 

Cooper: Save money. 

Sununu: Yeah, yeah. 

Cooper: Finding a way. 

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

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

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

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

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

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

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

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

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

Sununu: No, I hate hearing those words. 

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

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

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

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

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

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

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

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

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

Sebelius: I just wanted to clarify. 

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

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

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

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

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

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“We are full of people who come from other countries,” Goodness, 92, said about Goodwin House Alexandria’s staff. Without them, the retired Episcopal priest said, “I would be, and my building would be, desolate.”

The long-term health care industry is facing a double whammy from President Donald Trump’s crackdown on immigrants and the GOP’s proposals to reduce Medicaid spending. The industry is highly dependent on foreign workers: More than 800,000 immigrants and naturalized citizens comprise 28% of direct care employees at home care agencies, nursing homes, assisted living facilities, and other long-term care companies.

But in January, the Trump administration rescinded former President Joe Biden’s 2021 policy that protected health care facilities from Immigration and Customs Enforcement raids. The administration’s broad immigration crackdown threatens to drastically reduce the number of current and future workers for the industry. “People may be here on a green card, and they are afraid ICE is going to show up,” said Katie Smith Sloan, president of LeadingAge, an association of nonprofits that care for older adults.

Existing staffing shortages and quality-of-care problems would be compounded by other policies pushed by Trump and the Republican-led Congress, according to nursing home officials, resident advocates, and academic experts. Federal spending cuts under negotiation may strip nursing homes of some of their largest revenue sources by limiting ways states leverage Medicaid money and making it harder for new nursing home residents to retroactively qualify for Medicaid. Care for 6 in 10 residents is paid for by Medicaid, the state-federal health program for poor or disabled Americans.

“We are facing the collision of two policies here that could further erode staffing in nursing homes and present health outcome challenges,” said Eric Roberts, an associate professor of internal medicine at the University of Pennsylvania.

The industry hasn’t recovered from covid-19, which killed more than 200,000 long-term care facility residents and workers and led to massive staff attrition and turnover. Nursing homes have struggled to replace licensed nurses, who can find better-paying jobs at hospitals and doctors’ offices, as well as nursing assistants, who can earn more working at big-box stores or fast-food joints. Quality issues that preceded the pandemic have expanded: The percentage of nursing homes that federal health inspectors cited for putting residents in jeopardy of immediate harm or death has risen alarmingly from 17% in 2015 to 28% in 2024.

In addition to seeking to reduce Medicaid spending, congressional Republicans have proposed shelving the biggest nursing home reform in decades: a Biden-era rule mandating minimum staffing levels that would require most of the nation’s nearly 15,000 nursing homes to hire more workers.

The long-term care industry expects demand for direct care workers to burgeon with an influx of aging baby boomers needing professional care. The Census Bureau has projected the number of people 65 and older would grow from 63 million this year to 82 million in 2050.

In an email, Vianca Rodriguez Feliciano, a spokesperson for the Department of Health and Human Services, said the agency “is committed to supporting a strong, stable long-term care workforce” and “continues to work with states and providers to ensure quality care for older adults and individuals with disabilities.” In a separate email, Tricia McLaughlin, a Department of Homeland Security spokesperson, said foreigners wanting to work as caregivers “need to do that by coming here the legal way” but did not address the effect on the long-term care workforce of deportations of classes of authorized immigrants.

Goodwin Living, a faith-based nonprofit, runs three retirement communities in northern Virginia for people who live independently, need a little assistance each day, have memory issues, or require the availability of around-the-clock nurses. It also operates a retirement community in Washington, D.C. Medicare rates Goodwin House Alexandria as one of the best-staffed nursing homes in the country. Forty percent of the organization’s 1,450 employees are foreign-born and are either seeking citizenship or are already naturalized, according to Lindsay Hutter, a Goodwin spokesperson.

“As an employer, we see they stay on with us, they have longer tenure, they are more committed to the organization,” said Rob Liebreich, Goodwin’s president and CEO.

Jackline Conteh spent much of her youth shuttling between Sierra Leone, Liberia, and Ghana to avoid wars and tribal conflicts. Her mother was killed by a stray bullet in her home country of Liberia, Conteh said. “She was sitting outside,” Conteh, 56, recalled in an interview.

Conteh was working as a nurse in a hospital in Sierra Leone in 2009 when she learned of a lottery for visas to come to the United States. She won, though she couldn’t afford to bring her husband and two children along at the time. After she got a nursing assistant certification, Goodwin hired her in 2012.

Conteh said taking care of elders is embedded in the culture of African families. When she was 9, she helped feed and dress her grandmother, a job that rotated among her and her sisters. She washed her father when he was dying of prostate cancer. Her husband joined her in the United States in 2017; she cares for him because he has heart failure.

“Nearly every one of us from Africa, we know how to care for older adults,” she said.

Her daughter is now in the United States, while her son is still in Africa. Conteh said she sends money to him, her mother-in-law, and one of her sisters.

In the nursing home where Goodness and 89 other residents live, Conteh helps with daily tasks like dressing and eating, checks residents’ skin for signs of swelling or sores, and tries to help them avoid falling or getting disoriented. Of 102 employees in the building, broken up into eight residential wings called “small houses” and a wing for memory care, at least 72 were born abroad, Hutter said.

Donald Goodness grew up in Rochester, New York, and spent 25 years as rector of The Church of the Ascension in New York City, retiring in 1997. He and his late wife moved to Alexandria to be closer to their daughter, and in 2011 they moved into independent living at the Goodwin House. In 2023 he moved into one of the skilled nursing small houses, where Conteh started caring for him.

“I have a bad leg and I can’t stand on it very much, or I’d fall over,” he said. “She’s in there at 7:30 in the morning, and she helps me bathe.” Goodness said Conteh is exacting about cleanliness and will tell the housekeepers if his room is not kept properly.

Conteh said Goodness was withdrawn when he first arrived. “He don’t want to come out, he want to eat in his room,” she said. “He don’t want to be with the other people in the dining room, so I start making friends with him.”

She showed him a photo of Sierra Leone on her phone and told him of the weather there. He told her about his work at the church and how his wife did laundry for the choir. The breakthrough, she said, came one day when he agreed to lunch with her in the dining room. Long out of his shell, Goodness now sits on the community’s resident council and enjoys distributing the mail to other residents on his floor.

“The people that work in my building become so important to us,” Goodness said.

While Trump’s 2024 election campaign focused on foreigners here without authorization, his administration has broadened to target those legally here, including refugees who fled countries beset by wars or natural disasters. This month, the Department of Homeland Security revoked the work permits for migrants and refugees from Cuba, Haiti, Nicaragua, and Venezuela who arrived under a Biden-era program.

“I’ve just spent my morning firing good, honest people because the federal government told us that we had to,” Rachel Blumberg, president of the Toby & Leon Cooperman Sinai Residences of Boca Raton, a Florida retirement community, said in a video posted on LinkedIn. “I am so sick of people saying that we are deporting people because they are criminals. Let me tell you, they are not all criminals.”

At Goodwin House, Conteh is fearful for her fellow immigrants. Foreign workers at Goodwin rarely talk about their backgrounds. “They’re scared,” she said. “Nobody trusts anybody.” Her neighbors in her apartment complex fled the U.S. in December and returned to Sierra Leone after Trump won the election, leaving their children with relatives.

“If all these people leave the United States, they go back to Africa or to their various countries, what will become of our residents?” Conteh asked. “What will become of our old people that we’re taking care of?”

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 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.

The Supreme Court this week ruled in favor of Tennessee’s law banning most gender-affirming care for minors — a law similar to those in two dozen other states.

Meanwhile, the Senate is still hoping to complete work on its version of President Donald Trump’s huge budget reconciliation bill before the July Fourth break. But deeper cuts to the Medicaid program than those included in the House-passed bill could prove difficult to swallow for moderate senators.

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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Among the takeaways from this week’s episode:

• The Supreme Court’s ruling on gender-affirming care for transgender minors was relatively limited in its scope. The majority did not address the broader question about whether transgender individuals are protected under federal anti-discrimination laws and, as with the court’s decision overturning the constitutional right to an abortion, left states the power to determine what care trans youths may receive.
• The Senate GOP unveiled its version of the budget reconciliation bill this week. Defying expectations that senators would soften the bill’s impact on health care, the proposal would make deeper cuts to Medicaid, largely at the expense of hospitals and other providers. Republican senators say those cuts would allow them more flexibility to renew and extend many of Trump’s tax cuts.
• The Medicare trustees are out this week with a new forecast for the program that covers primarily those over age 65, predicting insolvency by 2033 — even sooner than expected. There was bipartisan support for including a crackdown on a provider practice known as upcoding in the reconciliation bill, a move that could have saved a bundle in government spending. But no substantive cuts to Medicare spending ultimately made it into the legislation.
• With the third anniversary of the Supreme Court decision overturning Roe v. Wade approaching, the movement to end abortion has largely coalesced around one goal: stopping people from accessing the abortion pill mifepristone.

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

Julie Rovner: The New York Times’ “The Bureaucrat and the Billionaire: Inside DOGE’s Chaotic Takeover of Social Security,” by Alexandra Berzon, Nicholas Nehamas, and Tara Siegel Bernard.  

Victoria Knight: The New York Times’ “They Asked an A.I. Chatbot Questions. The Answers Sent Them Spiraling,” by Kashmir Hill.  

Alice Miranda Ollstein: Wired’s “What Tear Gas and Rubber Bullets Do to the Human Body,” by Emily Mullin.  

Sandhya Raman: North Carolina Health News and The Charlotte Ledger’s “Ambulance Companies Collect Millions by Seizing Wages, State Tax Refunds,” by Michelle Crouch.  

Also mentioned in this week’s podcast:

• KFF’s “KFF Health Tracking Poll: Views of the One Big Beautiful Bill,” by Ashley Kirzinger, Lunna Lopes, Marley Presiado, Julian Montalvo III, and Mollyann Brodie.
• The Associated Press’ “Trump Administration Gives Personal Data of Immigrant Medicaid Enrollees to Deportation Officials,” by Kimberly Kindy and Amanda Seitz.
• The Guardian’s “VA Hospitals Remove Politics and Marital Status From Guidelines Protecting Patients From Discrimination,” by Aaron Glantz.

click to open the transcript

Transcript: Supreme Court Upholds Bans on Gender-Affirming Care

[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, June 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 Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning. 

Rovner: And Victoria Knight of Axios News. 

Victoria Knight: Hello, everyone. 

Rovner: No interview this week but more than enough news to make up for it, so we will go right to it. It is June. That means it is time for the Supreme Court to release its biggest opinions of the term. On Wednesday, the justices upheld Tennessee’s law banning gender-affirming medical care for trans minors. And presumably that means similar laws in two dozen other states can stand as well. Alice, what does this mean in real-world terms? 

Ollstein: So, this is a blow to people’s ability to access gender-affirming care as minors, even if their parents support them transitioning. But it’s not necessarily as restrictive a ruling as it could have been. The court could have gone farther. And so supporters of access to gender-affirming care see a silver lining in that the court didn’t go far enough to rule that all laws discriminating against transgender people are fine and constitutional. A few justices more or less said that in their separate opinions, but the majority opinion just stuck with upholding this law, basically saying that it doesn’t discriminate based on gender or transgender status. 

Rovner: Which feels a little odd. 

Ollstein: Yes. So, obviously, many people have said, How can you say that laws that only apply to transgender people are not discriminatory? So, been some back-and-forth about that. But the majority opinion said, Well, we don’t have to reach this far and decide right now if laws that discriminate against transgender people are constitutional, because this law doesn’t. They said it discriminates based on diagnosis — so anyone of any gender who has the diagnosis of gender dysphoria for medications, hormones, that’s not a gender discrimination. But obviously the only people who do have those diagnoses are transgender, and so it was a logic that the dissenters, the three progressive dissenters, really ripped into. 

Rovner: And just to be clear, we’ve heard about, there are a lot of laws that ban sort of not-reversible types of treatments for minors, but you could take hormones or puberty blockers. This Tennessee law covers basically everything for trans care, right? 

Ollstein: That’s right, but only the piece about medications was challenged up to the Supreme Court, not the procedures and surgeries, which are much more rare for minors anyways. But it is important to note that some of the conservatives on the court said they would’ve gone further, and they basically said, This law does discriminate against transgender kids, and that is fine with us. And they said the court should have gone further and made that additional argument, which they did not at this time. 

Rovner: Well, I’m sure the court will get another chance sometime in the future. While we’re on the subject of gender-affirming care in the courts, in Texas on Wednesday, conservative federal district judge Matthew Kacsmaryk — that’s the same judge who unsuccessfully tried to repeal the FDA’s [Food and Drug Administration’s] approval of the abortion pill a couple of years ago — has now ruled that the Biden administration’s expansion of the HIPAA [Health Insurance Portability and Accountability Act] medical privacy rules to protect records on abortion and gender-affirming care from being used for fishing expeditions by conservative prosecutors was an overreach, and he slapped a nationwide injunction on those rules. What could this mean if it’s ultimately upheld? 

Ollstein: I kind of see this in some ways like the Trump administration getting rid of the EMTALA [Emergency Medical Treatment and Labor Act] guidance, where the underlying law is still there. This is sort of an interpretation and a guidance that was put out on top of it, saying, We interpret HIPAA, which has been around a long time, to apply in these contexts, because we’re in this brave new world where we don’t have Roe v. Wade anymore and states are seeking records from other states to try to prosecute people for circumventing abortion bans. And so, that wasn’t written into statute before, because that never happened before. 

And so the Biden administration was attempting to respond to things like that by putting out this rule, which has now been blocked nationwide. I’m sure litigation will continue. There are also efforts in the courts to challenge HIPAA more broadly. And so, I would be interested in tracking how this plays into that. 

Rovner: Yeah. There’s plenty of efforts sort of on this front. And certainly, with the advent of AI [artificial intelligence], I think that medical privacy is going to play a bigger role sort of as we go forward. All right. Moving on. While the Supreme Court is preparing to wrap up for the term, Congress is just getting revved up. Next up for the Senate is the budget reconciliation, quote, “Big Beautiful Bill,” with most of President [Donald] Trump’s agenda in it. This week, the Senate Finance Committee unveiled its changes to the House-passed bill, and rather than easing back on the Medicaid cuts, as many had expected in a chamber where just a few moderates can tank the entire bill, the Finance version makes the cuts even larger. Do we have any idea what’s going on here? 

Knight: Well, I think mostly they want to give themselves more flexibility in order to pursue some of the tax policies that President Trump really wants. And so they need more savings, basically, to be able to do that and be able to do it for a longer amount of years. And so that’s kind of what I’ve heard, is they wanted to give themselves more room to play around with the policy, see what fits where. But a lot of people were surprised because the Senate is usually more moderate on things, but in this case I think it’s partially because they specifically looked at a provision called provider taxes. It’s a way that states can help fund their Medicaid programs, and so it’s a tax levied on providers. So I think they see that as maybe — it could still affect people’s benefits, but it’s aimed at providers — and so maybe that’s part of it as well. 

Rovner: Well, of course aiming at providers is not doing them very much good, because hospitals are basically freaking out over this. Now there is talk of creating a rural hospital slush fund to maybe try to quell some of the complaints from hospitals and make some of those moderates feel better about voting for a bill that the Congressional Budget Office still says takes health insurance and food aid from the poor to give tax cuts to the rich. But if the Senate makes a slush fund big enough to really protect those hospitals, wouldn’t that just eliminate the Medicaid savings that they need to pay for those tax cuts, Victoria? That’s what you were just saying. That’s why they made the Medicaid cuts bigger. 

Knight: Yeah. I think there’s quite a few solutions that people are throwing around and proposing. Yeah, but, exactly. Depending on if they do a provider relief fund, yeah, then the savings may need to go to that. I’ve also heard — I was talking to senators last week, and some of them were like, I’d rather just go back to the House’s version. So the House’s version of the bill put a freeze on states’ ability to raise the provider tax, but the Senate version incrementally lowers the amount of provider tax they can levy over years. The House just freezes it and doesn’t allow new ones to go higher. Some senators are like: Actually, can we just do that, go back to that? And we could live with that. 

Even Sen. Josh Hawley, who has been one of the biggest vocal voices on concern for rural hospitals and concern for Medicaid cuts, he told me, Freeze would be OK with me. And so, I don’t know. I could see them maybe doing that, but we’ll see. There’s probably more negotiations going on over the weekend, and they’re also going to start the “Byrd bath” procedure, which basically determines whether provisions in the bill are related to the budget or not and can stay in the bill. And so, there’s actually gender-affirming care and abortion provisions in the bill that may get thrown out because of that. So— 

Rovner: Yeah, this is just for those who don’t follow reconciliation the way we do, the “Byrd bath,” named for the former Sen. [Robert] Byrd, who put this rule in that said, Look, if you’re going to do this big budget bill with only 50 votes, it’s got to be related to the budget. So basically, the parliamentarian makes those determinations. And what we call the “Byrd bath” is when those on both sides of a provision that’s controversial go to the parliamentarian in advance and make their case. And the parliamentarian basically tells them in private what she’s going to do — like, This can stay in, or, This will have to go out. If the parliamentarian rules it has to go out, then it needs to overcome a budget point of order that needs 60 votes. So basically, that’s why stuff gets thrown out, unless they think it’s popular enough that it could get 60 votes. And sorry, that’s my little civics lesson for the day. Finish what you were saying, Victoria. 

Knight: No, that was a perfect explanation. Thank you. But I was just saying, yeah, I think that there are still some negotiations going on for the Medicaid stuff. And where also, you have to remember, this has to go back to the House. And so it passed the House with the provider tax freeze, and that still required negotiations with some of the more moderate members of House Republicans. And some of them started expressing their concern about the Senate going further. And so they still need to — it has to go back through the House again, so they need to make these Senate moderates happy and House moderates happy. There’s also the fiscal conservatives that want deeper cuts. So there’s a lot of people within the caucus that they need to strike a balance. And so, I don’t know if this will be the final way the bill looks yet. 

Rovner: Although, I think I say this every week, we have all of these Republicans saying: I won’t vote for this bill. I won’t vote for this bill. And then they inevitably turn around and vote for this bill. Do we believe that any of these people really would tank this bill? 

Knight: That’s a great point. Yeah. Sandhya, go ahead. 

Raman: There are at least a couple that I don’t think, anything that we do, they’re not going to change their mind. There is no courting of Rep. [Thomas] Massie in the House, because he’s not going to vote for it. I feel like in the Senate it’s going to be really hard to get Rand Paul on board, just because he does not want to raise the deficit. I think the others, it’s a little bit more squishy, depends kind of what the parliamentarian pulls out. And I guess also one thing I’m thinking about is if the things they pull out are big cost-savers and they have to go back to the drawing board to generate more savings. We’ve only had a few of the things that they’ve advised on so far, but it’s not health, and we still need to see — health are the big points. So, I think— 

Rovner: Well, they haven’t started the “Byrd bath” on the Finance provisions— 

Raman: Yes, or— 

Rovner: —which is where all the health stuff is. 

Raman: Yeah. 

Knight: But that is supposed to be over the weekend. It’s supposed to start over the weekend. 

Raman: Yes. 

Rovner: Right. 

Raman: Yeah. So, I think, depending on that, we will see. Historically, we have had people kind of go back and forth. And even with the House, there were people that voted for it that then now said, Well, I actually don’t support that anymore. So I think just going back to just what the House said might not be the solution, either. They have to find some sort of in-between before their July Fourth deadline. 

Rovner: I was just going to say, so does this thing happen before July Fourth? I noticed that that Susie Wiles, the White House chief of staff said: Continue. It needs to be on the president’s desk by July Fourth. Which seems pretty nigh impossible. But I could see it getting through the Senate by July Fourth. I’m seeing some nods. Is that still the goal? 

Knight: Yeah. I think that’s the goal. That’s what Senate Majority Leader [John] Thune has been telling people. He wants to try to pass it by mid-, or I think start the process by, midweek. And then it’s going to have to go through a “vote-a-rama.” So Democrats will be able to offer a ton of amendments. It’ll probably go through the night, and that’ll last a while. And so, I saw some estimate, maybe it’ll get passed next weekend through the Senate, but that’s probably if everything goes as it’s supposed to go. So, something could mess that up. 

But, yeah, I think the factor here that has — I think everyone’s kind of been like: They’re not going to be able to do it. They’re not going to be able to do it. With the House, especially — the House is so rowdy. But then, when Trump calls people and tells them to vote for it, they do it. There’s a few, yeah, like Rand Paul and Massie — they’re basically the only ones that will not vote when Trump tells them to. But other than that — so if he wants it done, I do think he can help push to get it done. 

Rovner: Yeah. I noticed one change, as I was going through, in the Senate bill from the House bill is that they would raise the debt ceiling to $5 trillion. It’s like, that’s a pretty big number. Yeah. I’m thinking that alone is what says Rand Paul is a no. Before we move on, one more thing I feel like we can’t repeat enough: This bill doesn’t just cut Medicaid spending. It also takes aim at the Affordable Care Act and even Medicare. And a bunch of new polls this week show that even Republicans aren’t super excited about this bill. Are Republican members of Congress going to notice this at some point? Yeah, the president is popular, but this bill certainly isn’t. 

Raman: When you look at some of the town halls that they’ve had — or tried to have — over the last couple months and then scaled back because there was a lot of pushback directly on this, the Medicaid provisions, they have to be aware. But I think if you look at that polling, if you look at the people that identify as MAGA within Republicans, it’s popular for them. It’s just more broadly less popular. So I think that’s part of it, but— 

Ollstein: I think that people are very opposed to the policies in the bill, but I also think people are very overwhelmed and distracted right now. There’s a lot going on, and so I’m not sure there will be the same national focus on this the way there was in 2017 when people really rallied in huge ways to protect the Affordable Care Act and push Congress not to overturn it. And so I think maybe that could be a factor in that outrage not manifesting as much. I also think that’s a reason they’re trying to do this quickly, that July Fourth deadline, before those protest movements have an opportunity to sort of organize and coalesce. 

Just real quickly on the rural hospital slush fund, I saw some smart people comparing it to a throwback, the high-risk pools model, in that unless you pour a ton of funding into it, it’s not going to solve the problem. And if you pour a ton of funding into it, you don’t have the savings that created the problem in the first place, the cuts. And all that is to say also, how do we define rural? A lot of suburban and urban hospitals are also really struggling currently and would be subject to close. And so now you get into the pitting members and districts against each other, because some people’s hospitals might be saved and others might be left out in the cold. And so I just think it’s going to be messy going forward. 

Rovner: I spent a good part of the late ’80s and early ’90s pulling out of bills little tiny provisions that would get tucked in to reclassify hospitals as rural so they could qualify, because there are already a lot of programs that give more money to rural hospitals to keep them open. Sorry, Victoria, we should move on, but you wanted to say one more thing? 

Knight: Oh, yeah. No. I was just going to say, going back to the unpopularity of the bill based on polling, and I think that we’ll see at least Democrats — if Republicans get this done and they have the work requirements and the other cuts to Medicaid in the bill, cuts to ACA, no renewal of premium tax credits — I think Democrats will really try to make the midterms about this, right? We already are seeing them messaging about it really hardcore, and obviously the Democrats are trying to find their way right now post-[Joe] Biden, post-[Kamala] Harris. So I think they’ll at least try to make this bill the thing and see if it’s unpopular with the general public, what Republicans did with health care on this. So we’ll see if that works for them, but I think they’re going to try. 

Rovner: Yeah, I think you’re right. Well, speaking of Medicare, we got the annual trustees report this week, and the insolvency date for Medicare’s Hospital Insurance Trust Fund has moved up to 2033. That’s three years sooner than predicted last year. Yet there’s nothing in the budget reconciliation bill that would address that, not even a potentially bipartisan effort to go after upcoding in Medicare Advantage that we thought the Finance Committee might do, that would save money for Medicare that insurers are basically overcharging the government for. What happened to the idea of going after Medicare Advantage overpayments? 

Knight: My general vibe I got from asking senators was that Trump said, We’re not touching Medicare in this bill. He did not want that to happen. And I think, again, maybe potentially thinking about the midterms, just the messaging on that, touching Medicare, it kind of always goes where they don’t want to touch Medicare, because it’s older people, but Medicaid is OK, even though it’s poor people. 

Rovner: And older people. 

Ollstein: And they are touching Medicare in the bill anyway. 

Rovner: Thank you. I know. I think that’s the part that makes my head swim. It’s like, really? There are several things that actually touch Medicare in this bill, but the thing that they could probably save a good chunk of money on and that both parties agree on is the thing that they’re not doing. 

Knight: Exactly. It was very bipartisan. 

Rovner: Yes. It was very bipartisan, and it’s not there. All right. Moving on. Elon Musk has gone back to watching his SpaceX rockets blow up on the launchpad, which feels like a fitting metaphor for what’s been left behind at the Department of Health and Human Services following some of the DOGE [Department of Government Efficiency] cuts. On Monday, a federal judge in Massachusetts ruled that billions of dollars in cuts to about 800 NIH [National Institutes of Health] research grants due to DEI [diversity, equity, and inclusion] were, quote, “arbitrary and capricious” and wrote, quote, “I’ve never seen government racial discrimination like this.” And mind you, this was a judge who was appointed by [President] Ronald Reagan. So what happens now? It’s been months since these grants were terminated, and even though the judge has ordered the funding restored, this obviously isn’t the last word, and one would expect the administration’s going to appeal, right? So these people are just supposed to hang out and wait to see if their research gets to continue? 

Raman: This has been a big thing that has come up in all of the appropriations hearings we’ve had so far this year, that even though the gist of that is to look forward at the next year’s appropriations, it’s been a big topic of just: There is funding that we as Congress have already appropriated for this. Why isn’t it getting distributed? So I think that will definitely be something that they push back up on the next ones of those. Some of the different senators have said that they’ve been looking into it and how it’s been affecting their districts. So I would say that. But I think the White House in response to that called the decision political, which I thought was interesting given, like you said, it was a Reagan appointee that said this. So it’ll definitely be something that I think will be appealed and be a major issue. 

Ollstein: Yeah, and the folks I’ve talked to who’ve been impacted by this stress that you can’t flip funding on and off like a switch and expect research to continue just fine. Once things are halted, they’re halted. And in a lot of cases, it is irreversible. Samples are thrown out. People are laid off. Labs are shut down. Even if there’s a ruling that reverses the policy, that often comes too late to make a difference. And at the same time, people are not waiting around to see how this back-and-forth plays out. People are getting actively recruited by universities and other countries saying: Hey, we’re not going to defund you suddenly. Come here. And they’re moving to the private sector. And so I think this is really going to have a long impact no matter what happens, a long tail. 

Rovner: And yet we got another reminder this week of the major advances that federally funded research can produce, with the FDA approval of a twice-a-year shot that can basically prevent HIV infection. Will this be able to make up maybe for the huge cuts to HIV programs that this administration is making? 

Raman: It’s only one drug, and we have to see what the price is, what cost— 

Rovner: So far the price is huge. I think I saw it was going to be like $14,000 a shot. 

Raman: Which means that something like PrEP [pre-exposure prophylaxis] is still going to be a lot more affordable for different groups, for states, for relief efforts. So I think that it’s a good step on the research front, but until the price comes down, the other tools in the toolbox are going to be a lot more feasible to do. 

Rovner: Yeah. So much for President Trump’s goal to end HIV. So very first-term. All right. Well, turning to abortion, it’s been almost exactly three years since the Supreme Court overturned the nationwide right to abortion in the Dobbs case. In that time we’ve seen abortion outlawed in nearly half the states but abortions overall rise due to the expanded use of abortion medication. We’ve seen doctors leaving states with bans, for fear of not being able to provide needed care for patients with pregnancy complications. And we’ve seen graduating medical students avoiding taking residencies in those states for the same reason. Alice, what’s the next front in the battle over abortion in the U.S.? 

Ollstein: It’s been one of the main fronts, even before Dobbs, but it’s just all about the pills right now. That’s really where all of the attention is. So whether that’s efforts ongoing in the courts back before our friend Kacsmaryk to try to challenge the FDA’s policies around the pills and impose restrictions nationwide, there’s efforts at the state level. There’s agitation for Congress to do something, although I think that’s the least likely option. I think it’s much more likely that it’s going to come from agency regulation or from the courts or from states. So I would put Congress last on the list of actors here. But I think that’s really it. And I think we’re also seeing the same pattern that we see in gender-affirming care battles, where there’s a lot of focus on what minors can access, what children can access, and that then expands to be a policy targeting people of any age. 

So I think it’s going to be a factor. One thing I think is going to slow down significantly are these ballot initiatives in the states. There’s only a tiny handful of states left that haven’t done it yet and have the ability to do it. A lot of states, it’s not even an option. So I would look at Idaho for next year, and Nevada. But I don’t think you’re going to see the same storm of them that you have seen the last few years. And part of that is, like I said, there’s just fewer left that have the ability. But also some people have soured on that as a tactic and feel that they haven’t gotten the bang for the buck, because those campaigns are extremely expensive, extremely resource-intensive. And there’s been frustration that, in Missouri, for instance, it’s sort of been — the will of the people has sort of been overturned by the state government, and that’s being attempted in other states as well. And so it has seemed to people like a very expensive and not reliable protection, although I’m not sure in some states what the other option would even be. 

Rovner: Of course the one thing that is happening on Capitol Hill is that the House Judiciary Committee last week voted to repeal the 1994 Freedom of Access to Clinic Entrances Act, or FACE. Now this law doesn’t just protect abortion clinics but also anti-abortion crisis pregnancy centers. This feels like maybe not the best timing for this sort of thing, especially in light of the shootings of lawmakers in Minnesota last weekend, where the shooter reportedly had in his car a list of abortion providers and abortion rights supporters. Might that slow down this FACE repeal effort? 

Ollstein: I think it already was going to be an uphill battle in the Senate and even maybe passing the full House, because even some conservatives say, Well, I don’t know if we should get rid of the FACE Act, because the FACE Act also applies to conservative crisis pregnancy centers. And lest we forget, only a few short weeks ago, an IVF [in vitro fertilization] clinic was bombed, and it would’ve applied in that situation, too. And so some conservatives are divided on whether or not to get rid of the FACE Act. And so I don’t know where it is going forward, but I think these recent instances of violence certainly are not helping the efforts, and the Trump administration has already said they’re not really going to enforce FACE against people who protest outside of abortion clinics. And so that takes some of the heat off of the conservatives who want to get rid of it. Of course, they say it shouldn’t be left for a future administration to enforce, as the Biden administration did. 

Raman: It also applies to churches, which I think if you are deeply religious that could also be a point of contention for you. But, yeah, I think just also with so much else going on and the fact that they’ve kind of slowed down on taking some of these things up for the whole chamber to vote on outside of in January, I don’t really see it coming up in the immediate future for a vote. 

Rovner: Well, at the same time, there are efforts in the other direction, although the progress on that front seems to be happening in other countries. The British Parliament this week voted to decriminalize basically all abortions in England and Wales, changing an 1861 law. And here on this side of the Atlantic, four states are petitioning the FDA to lift the remaining restrictions on the abortion pill, mifepristone, even as — Alice, as you mentioned — abortion foes argue for its approval to be revoked. You said that the abortion rights groups are shying away from these ballot measures even if they could do it. What is going to be their focus? 

Ollstein: Yeah, and I wouldn’t say they’re shying away from it. I’ve just heard a more divided view as a tactic and whether it’s worth it or not. But I do think that these court battles are really going to be where a lot is decided. That’s how we got to where we are now in the first place. And so the effort to get rid of the remaining restrictions on the abortion pill, the sort of back-and-forth tug here, that’s also been going on for years and years, and so I think we’re going to see that continue as well. And I think there’s also going to be, parallel to that, a sort of PR war. And I think we saw that recently with anti-abortion groups putting out their own not-peer-reviewed research to sort of bolster their argument that abortion pills are dangerous. And so I think you’re going to see more things like that attempting to — as one effort goes on in court, another effort in parallel in the court of public opinion to make people view abortion pills as something to fear and to want to restrict. 

Rovner: All right. Well, finally this week, a couple of stories that just kind of jumped out at me. First, the AP [Associated Press] is reporting that Medicaid officials, over the objections of some at the agency, have turned over to the Department of Homeland Security personal data on millions of Medicaid beneficiaries, including those in states that allow noncitizens to enroll even if they’re not eligible for federal matching funds, so states that use their own money to provide insurance to these people. That of course raises the prospect of DHS using that information to track down and deport said individuals. But on a broader level, one of the reasons Medicaid has been expanded for emergencies and in some cases for noncitizens is because those people live here and they get sick. And not only should they be able to get medical care because, you know, humanity, but also because they may get communicable diseases that they can spread to their citizen neighbors and co-workers. Is this sort of the classic case of cutting off your nose despite your face? 

Ollstein: I think we saw very clearly during covid and during mpox and measles, yes. What impacts one part of the population impacts the whole population, and we’re already seeing that these immigration crackdowns are deterring people, even people who are legally eligible for benefits and services staying away from that. We saw that during Trump’s first term with the public charge rule that led to people disenrolling in health programs and avoiding services. And that effect continued. There’s research out of UCLA showing that effect continued even after the Biden administration got rid of the policy. And so fear and the chilling effect can really linger and have an impact and deter people who are citizens, are legal immigrants, from using that as well. It’s a widespread impact. 

Rovner: And of course, now we see the Trump administration revoking the status of people who came here legally and basically declaring them illegal after the fact. Some of this chilling effect is reasonable for people to assume. Like the research being cut off, even if these things are ultimately reversed, there’s a lot of — depends whether you consider it damage or not — but a lot of the stuff is going to be hard. You’re not going to be able to just resume, pick up from where you were. 

Ollstein: And one concern I’ve been hearing particularly is around management of bird flu, since a lot of legal and undocumented workers work in agriculture and have a higher likelihood of being exposed. And so if they’re deterred from seeking testing, seeking treatment, that could really be dangerous for the whole population. 

Rovner: Yeah. It is all about health. It is always all about health. All right. Well, the last story this week is from The Guardian, and it’s called “VA Hospitals Remove Politics and Marital Status From Guidelines Protecting Patients From Discrimination.” And it’s yet another example of how purging DEI language can at least theoretically get you in trouble. It’s not clear if VA [Department of Veterans Affairs] personnel can now actually discriminate against people because of their political party or because they’re married or not married. The administration says other safeguards are still in place, but it is another example of how sweeping changes can shake people’s confidence in government programs. I imagine the idea here is to make people worried about discrimination and therefore less likely to seek care, right? 

Raman: It’s also just so unusual. I have not heard of anything like this before in anything that we’ve been reporting, where your political party is pulled into this. It just seems so out of the realm of what a provider would need to know about you to give you care. And then I could see the chilling effect in the same way, where if someone might want to be active on some issue or share their views, they might be more reluctant to do so, because they know they have to get care. And if that could affect their ability to do so, if they would have to travel farther to a different VA hospital, even if they aren’t actually denying people because of this, that chilling effect is going to be something to watch. 

Rovner: And this is, these are not sort of theoretical things. There was a case some years ago about a doctor, I think he was in Kentucky, who wouldn’t prescribe birth control to women who weren’t married. So there was reason for having these protections in there, even though they are not part of federal anti-discrimination law, which is what the Trump administration said. Why are these things in there? They’re not required, so we’re going to take them out. That’s basically what this fight is over. But it’s sort of an — I’m sure there are other places where this is happening. We just haven’t seen it yet. 

All right, well, that is this week’s news. 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. Victoria, why don’t you go first this week? 

Knight: Sure thing. My extra credit, it’s from The New York Times. The title is, “They Asked an A.I. Chatbot Questions. The Answers Sent Them Spiraling,” by Kashmir Hill, who covers technology at The Times. I had seen screenshots of this article being shared on X a bunch last week, and I was like, “I need to read this.” 

Basically it shows that different people who, they may be going through something, they may have a lot of stress, or they may already have a mental health condition, and they start messaging ChatGPT different things, then ChatGPT can kind of feed into their own delusions and their own misaligned thinking. That’s because that’s kind of how ChatGPT is built. It’s built to be, like, they call it in the story, like a sycophant. Is that how you say it? So it kind of is supposed to react positively to what you’re saying and kind of reinforce what you’re saying. And so if you’re feeding it delusions, it will feed delusions back. And so it was really scary because real-life people were impacted by this. There was one individual who thought he was talking to — had found an entity inside of ChatGPT named Juliet, and then he thought that OpenAI killed her. And so then he ended up basically being killed by police that came to his house. It was just — yeah, there was a lot of real-life effects from talking to ChatGPT and having your own delusions reinforced. So, and so it was just an effect of ChatGPT on real-life people that I don’t know if we’ve seen illustrated in a news story yet. And so it was very illuminating, yeah. 

Rovner: Yeah. Not scary much. Sandhya. 

Raman: My extra credit was “Ambulance Companies Collect Millions by Seizing Wages, State Tax Refunds.” It’s by Michelle Crouch for The Charlotte Ledger [and North Carolina Health News]. It’s a story about how some different ambulance patients from North Carolina are finding out that their income gets tapped for debt collection by the state’s EMS agencies, which are government entities, mostly. So the state can take through the EMS up to 10% of your monthly paycheck, or pull from your bank account higher than that, or pull from your tax refunds or lottery winnings. And it’s taking some people a little bit by surprise after they’ve tried to pay off this care and having to face this, but something that the agencies are also saying is necessary to prevent insurers from underpaying them. 

Rovner: Oh, sigh. 

Raman: Yeah. 

Rovner: The endless stream of really good stories on this subject. Alice. 

Ollstein: So I chose this piece in Wired by Emily Mullin called “What Tear Gas and Rubber Bullets Do to the Human Body,” thinking a lot about my hometown of Los Angeles, which is under heavy ICE [Immigration and Customs Enforcement] enforcement and National Guard and Marines and who knows who else. So this article is talking about the health impacts of so-called less-lethal police tactics like rubber bullets, like tear gas. And it is about how not only are they sometimes actually lethal — they can kill people and have — but also they have a lot of lingering impacts, especially tear gas. It can exacerbate respiratory problems and even cause brain damage. And so it’s being used very widely and, in some people’s view, indiscriminately right now. And there should be more attention on this, as it can impact completely innocent bystanders and press and who knows who else. 

Rovner: Yeah. There’s a long distance between nonlethal and harmless, which I think this story illustrates very well. My extra credit this week is also from The New York Times. It’s called “The Bureaucrat and the Billionaire: Inside DOGE’s Chaotic Takeover of Social Security,” by Alexandra Berzon, Nicholas Nehamas, and Tara Siegel Bernard. It’s about how the White House basically forced Social Security officials to peddle a false narrative that said 40% of calls to the agency’s customer service lines were from scammers — they were not — how DOGE misinterpreted Social Security data and gave a 21-year-old intern access to basically everyone’s personal Social Security information, and how the administration shut down some Social Security offices to punish lawmakers who criticized the president. This is stuff we pretty much knew was happening at the time, and not just in Social Security. But The New York Times now has the receipts. It’s definitely worth reading. 

OK. That is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. Also, 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. You can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me still on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Sandhya. 

Raman: @SandhyaWrites on X and the same on Bluesky. 

Rovner: Alice. 

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

Rovner: Victoria. 

Knight: I am @victoriaregisk on X. 

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

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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.

After explicitly promising senators during his confirmation hearing that he would not interfere in scientific policy over which Americans should receive which vaccines, Health and Human Services Secretary Robert F. Kennedy Jr. this week fired every member of the Advisory Committee on Immunization Practices, the group of experts who help the Centers for Disease Control and Prevention make those evidence-based judgments. Kennedy then appointed new members, including vaccine skeptics, prompting alarm from the broader medical community.

Meanwhile, over at the National Institutes of Health, some 300 employees — many using their full names — sent a letter of dissent to the agency’s director, Jay Bhattacharya, saying the administration’s policies “undermine the NIH mission, waste our public resources, and harm the health of Americans and people across the globe.”

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.

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.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

@joannekenen.bsky.social

Read Joanne's bio.

Among the takeaways from this week’s episode:

• After removing all 17 members of the vaccine advisory committee, Kennedy on Wednesday announced eight picks to replace them — several of whom lack the expertise to vet vaccine research and at least a couple who have spoken out against vaccines. Meanwhile, Sen. Bill Cassidy of Louisiana, the Republican head of the chamber’s health committee, has said little, despite the fact that Kennedy’s actions violate a promise he made to Cassidy during his confirmation hearing not to touch the vaccine panel.
• In other vaccine news, the Department of Health and Human Services has canceled private-sector contracts exploring the use of mRNA technology in developing vaccines for bird flu and HIV. The move raises concerns about the nation’s readiness against developing and potentially devastating health threats.
• Hundreds of NIH employees took the striking step of signing a letter known as the “Bethesda Declaration,” protesting Trump administration policies that they say undermine the agency’s resources and mission. It is rare for federal workers to use their own names to voice public objections to an administration, let alone President Donald Trump’s, signaling the seriousness of their concerns.
• Lawmakers have been considering adding Medicare changes to the tax-and-spend budget reconciliation legislation now before the Senate — specifically, targeting the use of what’s known as “upcoding.” Curtailing the practice, through which medical providers effectively inflate diagnoses and procedures to charge more, has bipartisan support and could increase the savings by reducing the amount the government pays for care.

Also this week, Rovner interviews Douglas Holtz-Eakin, president of the American Action Forum and former director of the Congressional Budget Office, to discuss how the CBO works and why it’s so controversial.

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

Julie Rovner: Stat’s “Lawmakers Lobby Doctors To Keep Quiet — or Speak Up — on Medicaid Cuts in Trump’s Tax Bill,” by Daniel Payne.  

Anna Edney: KFF Health News’ “Two Patients Faced Chemo. The One Who Survived Demanded a Test To See if It Was Safe,” by Arthur Allen.  

Sarah Karlin-Smith: Wired’s “The Bleach Community Is Ready for RFK Jr. To Make Their Dreams Come True,” by David Gilbert.  

Joanne Kenen: ProPublica’s “DOGE Developed Error-Prone AI Tool To ‘Munch’ Veterans Affairs Contracts,” by Brandon Roberts, Vernal Coleman, and Eric Umansky.  

Also mentioned in this week’s podcast:

• The Hill’s “Cassidy in a Bind as RFK Jr. Blows Up Vaccine Policy,” by Nathaniel Weixel.
• JAMA Pediatrics’ “Firearm Laws and Pediatric Mortality in the US,” by Jeremy Samuel Faust, Ji Chen, and Shriya Bhat.

Click to open the transcript

Transcript: RFK Jr. Upends Vaccine Policy, After Promising He Wouldn’t

[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, June 12, 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 Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

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

Joanne Kenen: Hi, everybody. 

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

Sarah Karlin-Smith: Hello, everybody. 

Rovner: Later in this episode we’ll have my interview with Douglas Holtz-Eakin, head of the American Action Forum and former head of the Congressional Budget Office. Doug will talk about what it is that CBO actually does and why it’s the subject of so many slings and arrows. But first, this week’s news. 

The biggest health news this week is out of the Department of Health and Human Services, where Secretary Robert F. Kennedy Jr. on Monday summarily fired all 17 members of the CDC’s [Centers for Disease Control and Prevention’s] vaccine advisory committee, something he expressly promised Republican Sen. Bill Cassidy he wouldn’t do, in exchange for Cassidy’s vote to confirm him last winter. Sarah, remind us what this committee does and why it matters who’s on it? 

Karlin-Smith: So, they’re a committee that advises CDC on who should use various vaccines approved in the U.S., and their recommendations translate, assuming they’re accepted by the CDC, to whether vaccines are covered by most insurance plans and also reimbursed. There’s various laws that we have that set out, that require coverage of vaccines recommended by the ACIP [Advisory Committee on Immunization Practices] and so forth. So without ACIP recommendations, you may — vaccines could be available in the U.S. but extremely unaffordable for many people. 

Rovner: Right, because they’ll be uncovered. 

Karlin-Smith: Correct. Your insurance company may choose not to reimburse them. 

Rovner: And just to be clear, this is separate from the FDA’s [Food and Drug Administration’s] actual approval of the vaccines and the acknowledgment it’s safe and effective. Right, Anna? 

Edney: Yeah, there are two different roles here. So the FDA looks at all the safety and effectiveness data and decides whether it’s safe to come to market. And with ACIP, they are deciding whether these are things that children or adults or pregnant women, different categories of people, should be getting on a regular basis. 

Rovner: So Wednesday afternoon, Secretary Kennedy named eight replacements to the committee, including several with known anti-vaccine views. I suppose that’s what we all expected, kind of? 

Kenen: He also shrunk it, so there are fewer voices. The old panel, I believe, had 17. And the law says it has to have at least eight, and he appointed eight. As far as we know, that’s all he’s appointing. But who knows? A couple of more could straggle in. But as of now, it means there’s less viewpoints, less voices, which may or might not turn out to be a good thing. But it is a different committee in every respect. 

Edney: And I think it is a bit of what we expected in the sense that these are people who either are outright vaccine critics or, in a case or two, have actually said vaccines do horrible things to people. One of them had said before that the covid vaccine caused an AIDS-like virus in people. And there is a nurse that is part of the committee now that said her son was harmed by vaccines. And not saying that is or isn’t true — her concerns could be valid — but that she very much has worked to question vaccines. 

So I think it is the committee that we maybe would’ve expected from a sense of, I think he’s trying to bring in people who are a little bit mainstream, in the sense if you looked at where they worked or things like that, you might not say, like: Oh, Georgetown University. I get it. But they are people who have taken kind of the more of a fringe approach within maybe kind of a mainstream world. 

Karlin-Smith: I was going to say there’s also many people on the list that it’s just not even clear to me why you would look at their expertise and think, Oh, this is a committee they should serve on. One of the people is an MIT [Massachusetts Institute of Technology], essentially, like, business school professor who tangentially I think has worked on health policy to some extent. But, right, this is not somebody who has extreme expertise in vaccinology, immunology, and so forth. You have a psychiatrist whose expertise seems to be on nutrition and brain health. 

And one thing I think people don’t always appreciate about this committee at CDC is, you see them in these public meetings that happen a few times a year, but they do a lot of work behind the scenes to actually go through data and make these recommendations. And so having less people and having people that don’t actually have the expertise to do this work seems like it could cause a big problem just from that point of view. 

Edney: And that can be the issue that comes up when Kennedy has said, I don’t want anyone with any conflicts of interest. Well, we’ve talked about this. Certainly you don’t want a legit conflict of interest, but a lot of people who are going to have the expertise you need may have a perceived conflict that he doesn’t want on there. So you end up maybe with somebody who works in operations instead of on vaccines. 

Rovner: You mean maybe we’ll have people who actually have researched vaccines. 

Edney: Right. Exactly. Yeah. 

Kenen: The MIT guy is an expert in supply chains. None of us know who the best supply chain business school professor is in the world. Maybe it’s him, but it’s a very odd placement. 

Rovner: Well, so far Sen. Cassidy hasn’t said very much other than to kind of communicate that he’s not happy right now. Has anybody heard anything further? The secretary has been sort of walking up to the line of things he told the senator he wouldn’t do, but this clearly is over the line of things he told the senator he wouldn’t do. And now it’s done. 

Kenen: It’s like over the line and he set fire to it. And Cassidy has been pretty quiet. And in fact, when Kennedy testified before Cassidy — Cassidy is the chairman of the health committee — a couple of weeks ago, he gave him a really warm greeting and thanked him for coming and didn’t say: You’re a month late. I wanted you here last month. The questions were very soft. And things have only gotten more heated since then, with the dissolution of the ACIP committee and this reconstitution of it. And he’s been very quiet for somebody who publicly justified, who publicly wrestled with this, the confirmation, was the deciding vote, and then has been really soft since then — in public. 

Rovner: I sent around a story this morning to the panelists, from The Hill, which I will link to in the show notes, that quotes a political science professor in Louisiana pointing out that perhaps it would be better for Cassidy politically not to say anything, that perhaps public opinion among Republicans who will vote in a primary is more on the side of Secretary Kennedy than Sen. Cassidy, which raises some interesting questions. 

Edney: Yeah. And I think that, at least for me, I’m at the point of wondering if Cassidy didn’t know that all along, that there’s a point he was willing to go up to but a line that he is never going to have been willing to cross, and that is actually coming out against Kennedy and, therefore, [President Donald] Trump. He doesn’t want to lose his reelection. I am starting to wonder if he just hoped it wouldn’t come to this and so was able to say those things that got him to vote for Kennedy and then hope that it wouldn’t happen. 

And I think that was a lot of people. They weren’t on the line like Cassidy was, but I think a lot of people thought, Oh, nothing’s ever going to happen on this. And I think another thing I’m learning as I cover this administration and the Kennedy HHS is when they say, Don’t worry about it, look away, we’re not doing anything that big of a deal, that’s when you have to worry about it. And when they make a big deal about some policy they’re bringing up, it actually means they’re not really doing a lot on it. So I think we’re seeing that with vaccines for sure. 

Rovner: Yes, classic watch what they do not what they say. 

Kenen: But if you’re Cassidy and you already voted to impeach President Trump, which means you already have a target from the right — he’s a conservative, but it’s from the more conservative, though, the more MAGA [Make America Great Again] — if you do something mavericky, sometimes the best political line is to continue doing it. But they’ve also changed the voting rules, my understanding is, in Louisiana so that independents are — they used to be able to cross party lines in the primaries, and I believe you can’t do that anymore. So that also changed, and that’s recent, so that might have been what he thought might save him. 

Rovner: Well, it’s not just ACIP where Secretary Kennedy is insinuating himself directly into vaccine policy. HHS has also canceled a huge contract with vaccine maker Moderna, which was working on an mRNA-based bird flu vaccine, which we might well need in the near future, and they’ve also canceled trials of potential HIV vaccines. What do we know about what this HHS is doing in terms of vaccine policy? 

Karlin-Smith: The bird flu contract I think is very concerning because it seems to go along the lines of many people in this administration and Kennedy’s orbit who sometimes might seem a little bit OK with vaccines, more OK than Kennedy’s record, is they are very anti the newer mRNA technology, which we know proved very effective in saving tens of millions of lives. I was looking at some data just even the first year they rolled out after covid. So we know they work. Obviously, like all medical interventions, there are some side effects. But again, the benefits outweigh the risks. And this is the only, really, technology that we have that could really get us vaccines really quickly in a pandemic and bird flu. 

Really, the fear there is that if it were to jump to humans and really spread from human-to-human transmission — we have had some cases recently — it could be much more devastating than a pandemic like covid. And so not having the government have these relationships with companies who could produce products at a particular speed would be probably incredibly devastating, given the other technologies we have to invest in. 

Edney: I think Kennedy has also showed us that he, and spoken about this, is that he is much more interested in a cure for anything. He has talked about measles and Why can’t we just treat it better? And we’re seeing that with the HIV vaccine that won’t be going forward in the same way, is that the administration has basically said: We have the tools to deal with it if somebody gets it. We’re just not going to worry about vaccinating as much. And so I think that this is a little bit in that vein as well. 

Rovner: So the heck with prevention, basically. 

Edney: Exactly. 

Rovner: Well, in related news, some 300 employees of the National Institutes of Health, including several institute directors, this week sent an open letter of dissent to NIH Director Jay Bhattacharya that they are calling the “Bethesda Declaration.” That’s a reference to the “Great Barrington Declaration” that the NIH director helped spearhead back in 2020 that protested covid lockdowns and NIH’s handling of the science. 

The Bethesda Declaration protests policies that the signatories say, quote, “undermine the NIH mission, waste our public resources, and harm the health of Americans and people across the globe.” Here’s how one of the signers, Jenna Norton of the National Institute of Diabetes and Digestive and Kidney Diseases, put it in a YouTube video. 

Jenna Norton: And the NIH that I’m working in now is unrecognizable to me. Every day I go into the office and I wonder what ethical boundary I’m going to be asked to violate, what probably illegal action am I going to be asked to take. And it’s just soul-crushing. And that’s one of the reasons that I’m signing this letter. One of my co-signers said this, but I’m going to quote them because I thought it was so powerful: “You get another job, but you cannot get another soul.” 

Rovner: I’ve been covering NIH for a lot of years. I can’t remember pushback like this against an administration by its own scientists, even during the height of the AIDS crisis in the 1980s. How serious is this? And is it likely to have any impact on policy going forward? 

Edney: I think if you’re seeing a good amount of these signers who sign their actual names and if you’re seeing that in the government, something is very serious and there are huge concerns, I think, because, as a journalist, I try to reach people who work in the government all the time. And if they’re not in the press office, if they speak to me, which is rare, even they do not want me to use their name. They do not want to be identified in any way, because there are repercussions for that. 

And especially with this administration, I’m sure that there is some fear for people’s jobs and in some instances maybe even beyond. But I think that whether there will be any policy changes, that is a little less clear, how this administration might take that to heart or listen to what they’re saying. 

Rovner: Bhattacharya was in front of a Senate Appropriations subcommittee this week and was asked about it, but only sort of tangentially. I was a little bit surprised that — obviously, Republicans, we just talked about Sen. Cassidy, they are afraid to go up against the Trump administration’s choices for some of these jobs — but I was surprised that even some of the Democrats seemed a little bit hands-off. 

Edney: Yeah, no one ever asks the questions I want asked at hearings, I have to say. I’m always screaming. Yeah, exactly. I’m always like: No. What are you doing? 

Rovner: That’s exactly how I was, like: No, ask him this. 

Edney: Right. 

Rovner: Don’t ask him that. 

Edney: Exactly. 

Rovner: Well, moving on to the Big Budget Bill, which is my new name for it. Everybody else seems to have a different one. It’s still not clear when the Senate will actually take up its parts, particularly those related to health, but it is clear that it’s not just Medicaid and the Affordable Care Act on the table but now Medicare, too. Ironically, it feels like lawmakers could more easily squeeze savings out of Medicare without hurting beneficiaries than either Medicaid or the ACA, or is that just me being too simplistic about this whole thing? 

Kenen: The Medicare bill is targeted at upcoding, which means insurers or providers sort of describing a symptom or an illness in the most severe terms possible and they get paid more. And everybody in government is actually against that. Everybody ends up paying more. I don’t know what else the small —this has just bubbled up — but I don’t know if there’s other small print. 

This alone, if it wasn’t tied to all the politics of everything else in this bill, this is the kind of thing, if you really do a bill that attacks inflated medical bills, you could probably get bipartisan support for. But because — and, again, I don’t know what else is in, and I know that’s the top line. There may be something that I’m not aware of that is more of a poison pill. But that issue you could get bipartisan consensus on. 

But it’s folded into this horrendously contentious thing. And it’s easy to say, Oh, they’re trying to cut Medicare, which in this case maybe they’re trying to cut it in a way that is smart, but it just makes it more complicated. If they do go for it, if they do decide that this goes in there, it could create a little more wiggle room to not cut some other things quite as deeply. 

But again, they’re calling everything waste, fraud, and abuse. None of us would say there is no waste, fraud, and abuse in government or in health care. We all know there is waste, fraud, and abuse, but that doesn’t mean that what they’re cutting here is waste, fraud, and abuse in other aspects of that bill. 

Rovner: Although, as you say, I think there’s bipartisan consensus, including from Mehmet Oz, who runs Medicare, that upcoding is waste and fraud. 

Kenen: Right. But other things in the bill are being called waste, fraud, and abuse that are not, right? That there’s things in Medicaid that are not waste, fraud, and abuse. They’re just changing the rules. But I agree with you, Julie. I think that in a bill that is not so fraught, it would’ve been easier to get consensus on this particular item, assuming it’s a clean upcoding bill, if you did it in a different way. 

Rovner: And also, there’s already a bipartisan bill on pharmacy benefit managers kicking around. There are a lot of things that Congress could do on a bipartisan basis to reduce the cost of Medicare and make the program better and shore it up, and that doesn’t seem to be what’s happening, for the most part. 

Well, we continue to learn things about the House-passed bill that we didn’t know before, and one thing we learned this week that I think bears discussing comes from a new poll from our KFF polling unit that found that nearly half those who purchased Affordable Care Act coverage from the marketplaces are Republicans, including a significant percentage who identify themselves as MAGA Republicans. 

So it’s not just Republicans in the Medicaid expansion population who’d be impacted. Millions of Trump supporters could end up losing or being priced out of their ACA insurance, too, particularly in non-Medicaid-expansion states like Florida and Texas. A separate poll from Quinnipiac this week finds that only 27% of respondents think Congress should pass the big budget reconciliation bill. Could either of these things change some Republican perceptions of things in this bill, or is it just too far down the train tracks at this point? 

Karlin-Smith: We saw a few weeks ago [Sen.] Joni Ernst seemed to be really highly critical of her own supporters who were pushing back on her support for the bill. Even when Republicans failed to get rid of the ACA and [Sen.] John McCain gave it the thumbs-down, he was the one. It wasn’t like everyone else was coming to help him with that. 

And again, I think there was the same dynamic where a lot of people who, if you had asked them did they support Obamacare while it was being written in law, in early days before they saw any benefit of it, would have said no and politically align themselves with the Republican Party, and their views have come to realize, once you get a benefit, that it may actually be more desirable, perhaps, than you initially thought. 

I think it could become a problem for them, but I don’t think it’s going to be a mass group of Republicans are going to change their minds over this. 

Rovner: Or are they going to figure out that that’s why they’re losing their coverage? 

Kenen: Right. Many things in this bill, if it goes into effect, are actually after the 2026 elections. The ACA stuff is earlier. And someone correct me if I’m wrong, but I’m pretty sure it expires in time for the next enrollment season. 

Rovner: Yeah, and we’ve talked about this before. The expanded credits, which are not sort of quote-unquote— 

Kenen: No, they’re separate. 

Rovner: —“in this bill,” but it’s the expiration of those that’s going to cause— 

Kenen: In September. And so those— 

Rovner: Right. 

Kenen: —people would— 

Rovner: In December. No, at the end of the year they expire. 

Kenen: Right. So that in 2026, people getting the expanded benefit. And there’s also somewhat of a misunderstanding that that legislation opened Obamacare subsidies to people further up the eligibility roof, so more people who had more money but still couldn’t afford insurance do get subsidies. That goes away, but it cascades down. It affects lower-income people. It affects other people. It’s not just that income bracket. 

There are sort of ripple effects through the entire subsidized population. So people will lose their coverage. There’s really no dispute about that. The reason it was sunsetted is because it costs money. Congress does that a lot. If we do it for five years, we can get it on the score that we need out of the CBO. But if we do it for 10 years, we can’t. So that is not an unusual practice in Congress for Republicans and Democrats, but that happens before the election. 

It’s just whether people connect the dots and whether there are enough of them to make a difference in an election, right? Millions of people across the country. But does it change how people vote in a specific race in a state that’s already red? If it’s a very red state, it may not make people get mad, but it may not affect who gets elected to House or the Senate in 2026. 

Rovner: We will see. So Sarah, I was glad you mentioned Sen. Ernst, because last week we talked about her comment that we’re all going to die, in response to complaints at a town hall meeting about the Medicaid cuts. Well, Medicare and Medicaid chief Mehmet Oz says to Sen. Ernst, Hold my beer. Speaking on Fox Business, Oz said people should only get Medicaid if they, quote, “prove that they matter.” 

Now, this was in the context of saying that if you want Medicaid, you should work or go to school. Of course, most people on Medicaid do work or care-give for someone who can’t work or do go to school — they just have jobs that don’t come with private health insurance. I can’t help but think this is kind of a big hole in the Republican talking points that we keep seeing. These members keep suggesting that all working people or people going to school get health insurance, and that’s just not the case. 

Kenen: But it sounds good. 

Karlin-Smith: I was going to say, there are small employers that don’t have to provide coverage under the ACA. There are people that have sort of churned because they work part time or can’t quite get enough hours to qualify, and these are often lower-income people. And I think the other thing I’ve seen people, especially in the disability committee and so forth, raises — there’s an underlying rhetoric here that to get health care, you have to be deserving and to be working. 

That, I think, is starting to raise concerns, because even though they kind of say they’re not attacking that population that gets Medicaid, I think there is some concern about the language that they’re using is placing a value on people’s lives that just sort of undermines those that legitimately cannot work, for no fault of their own. 

Kenen: It’s how the Republicans have begun talking about Medicaid again. Public opinion, and KFF has had some really interesting polls on this over the last few years, really interesting changes in public attitudes toward Medicaid, much more popular. And it’s thought of even by many Republicans as a health care program, not a welfare program. What you have seen — and that’s a change. 

What you’ve seen in the last couple of months is Republican leaders, notably Speaker [Mike] Johnson, really talking about this as welfare. And it’s very reminiscent of the Reagan years, the concept of the deserving poor that goes back decades. But we haven’t heard it as much that these are the people who deserve our help and these are the lazy bums or the cheats. 

Speaker Johnson didn’t call them lazy bums and cheats, but there’s this concept of some people deserve our help and the rest of them, tough luck. They don’t deserve it. And so that’s a change in the rhetoric. And talking about waste and talking about fraud and talking about abuse is creating the impression that it’s rampant, that there’s this huge abuse, and that’s not the case. People are vetted for Medicaid and they do qualify for Medicaid. 

States have their own money and their own enrollment systems. They have every incentive to not cover people who don’t deserve to be covered. Again, none of us are saying there’s zero waste. We would never say that. None of us are saying there’s zero abuse. But it’s not like that’s the defining characteristic of Medicaid is that it’s all fraud and abuse, and that you can cut hundreds of millions of dollars out of it without anybody feeling any pain. 

Rovner: And there were a lot of Republican states that expanded Medicaid, even when they didn’t have to, that are going to feel this. That’s a whole other issue that I think we will talk about probably in the weeks to come. I want to move to DOGE [the Department of Government Efficiency]. Elon Musk is back in California, having had a very ugly breakup with President Trump and possibly a partial reconciliation. But the impact of DOGE continues across the federal government, as well as at HHS. 

The latest news is apparently hundreds of CDC employees who were told that they were being laid off who are now being told: Never mind. Come back to work. Of course, this news comes weeks after they were told they were being fired, and it’s unclear how many of them have upended their work and family lives in the interim. 

But at the same time, much of the money that’s supposed to be flowing, appropriations for the current fiscal year that were passed by Congress and signed by President Trump — apparently still being held up. What are you guys hearing about how things at HHS are or aren’t going in the wake of the DOGE cutbacks? Go ahead, Sarah. 

Karlin-Smith: It still seems like people at the federal government that I talked to are incredibly unhappy. At other agencies, as well, there have been groups of people called back to work, including at FDA. But still, I think the general sense is there’s a lot of chaos. People aren’t comfortable that their job will be there long-term. Many people even who were called back are saying they’re still looking for work other places. 

There’s just so many changes in both, I think, in their day-to-day lives and how they do their job, but then also philosophically in terms of policy and what they are allowed to do, that I think a lot of people are becoming kind of demoralized and trying to figure out: Can they do what they signed up to do in their job, or is it better just to move on? And I think there’s going to be long-term consequences for a lot of these government agencies. 

Rovner: You mean being fired and unfired and refired doesn’t make for a happy workplace? 

Karlin-Smith: I was going to say a lot of them were called back to offices that they didn’t always have to come to. They’ve lost people who have been working and never lost their jobs, have lost close colleagues, support staff they rely on to do their jobs. So it’s really complicated even if you’re in the best-case scenario, I think, at a lot of these agencies. 

Kenen: And a loss of institutional memory, too, because nobody knows everything in your office. And in an office that functions, it’s collaborative. I know this, you know that. We work together, and we come out with a better product. So that’s been eviscerated. And then — we’re all in a part of an industry that’s seen a lot of downsizing and chaos, in journalism, and the outcome is worse. When things get beaten up and battered and kicked out, things are harmed. And it’s true of any industry, since we haven’t been AI-replaced yet. 

Rovner: Yet. So it’s been a while since we had a, quote, “This Week in Private Equity in Health Care,” but this week the governor of Oregon signed into law a pretty serious ban on private equity ownership of physician practices. Apparently, this was prompted by the purchase by Optum — that’s the arm of UnitedHealth that is now the largest owner of physician practices in the U.S. — of a multi-specialty group in Eugene, Oregon, that caused significant dislocation for patients and was charged by the state with impermissibly raising prices. Hospitals are not included in Oregon’s ban, but I wonder if this is the start of a trend. Or is this a one-off in a pretty blue state, which Oregon is? 

Edney: I think that it could be. I don’t know, certainly, but I think to watch how it plays out might be quite interesting. The problem with private equity ownership of these doctors’ offices is then the doctors don’t feel that they can actually give good care. They’ve got to move people through. It’s all about how much money can they make or save so that private equity can get its reward. And so I think that people certainly are frustrated by it, as in people who get the care, also people who are doing legislating and things like that. So I wouldn’t be surprised to see some other attempts at this pop up now that we’ve seen one. 

Kenen: But Oregon is uniquely placed to get something like this through. They are a very blue state. They’ve got a history of some health reform stuff that’s progressive. I don’t think you’ll see this domino-ing through every state legislature in the short term. 

Rovner: But I will also say that even in Oregon, it took a while to get this through. There was a lot of pushback because there is concern that without private equity, maybe some of these practices are going to go belly up. This is the continuing fight about the future of the health care workforce and who’s going to underwrite it. 

Well, finally this week, I want to give a shoutout to the biggest cause of childhood death and injury that is not being currently addressed by HHS, which is gun violence. According to a new study in JAMA Pediatrics, firearms deaths among children and teens grew significantly in states that loosened gun laws following a major Supreme Court decision in 2010. And it wasn’t just accidents. The increase in deaths included homicides and suicides, too. Yet gun violence seems to have kind of disappeared from the national agenda for both parties. 

Edney: Yeah, you don’t hear as much about it. I don’t know why. I don’t know if it’s because we’re inundated every day with a million things. And currently at the moment, that just hasn’t come up again, as far as a tragedy. That often tends to bring it back to people’s front of mind. And I think that there is, on the Republican side at least, we’re seeing tax cuts for gun silencers and things like that. So I think they’re emboldened on the side of NRA [the National Rifle Association]. I don’t know if Democrats are seeing that and thinking it’s a losing battle. What else can I focus my attention on? 

Kenen: Well, it’s in the news when there’s a mass killing. Society has just sort of become inured or shut its eyes to the day to day to day to day to day. The accidents, the murders. Don’t forget, a lot of our suicide problem is guns, including older white men in rural states who are very pro-gun. Those who kill themselves, it is how they kill themselves. It’s just something we have let happen. 

Rovner: Plus, we’re now back to arguing about whether or not vaccines are worthwhile. So, a lot of the oxygen is being taken up with other issues at the moment. 

Kenen: There’s a very overcrowded bandwidth these days. Yes. 

Rovner: There is. I think that’s fair. All right, well, that is this week’s news, or as much as we could squeeze in. Now we will play my interview with Doug Holtz-Eakin, and then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Douglas Holtz-Eakin, president of the American Action Forum, a center-right think tank, and former head of the Congressional Budget Office during the George W. Bush administration, when Republicans also controlled both Houses of Congress. Doug, thank you so much for being here. 

Douglas Holtz-Eakin: My pleasure. Thank you. 

Rovner: I mostly asked you here to talk about CBO and what it does and why it’s so controversial. But first, tell us about the American Action Forum and what it is you do now. 

Holtz-Eakin: So the American Action Forum is, on paper, a center-right think tank, a 501(c)(3) entity that does public education on policy issues, but it’s modeled on my experiences at working at the White House twice, running the Congressional Budget Office, and I was also director of domestic and economic policy on the John McCain campaign. And in those jobs, you worked on policy issues. You did policy education, issues, options, advice, but you worked on whatever was happening that day. 

You didn’t have the luxury of saying: Yeah, that’s not what I do. Get back to me when something interests you. And you had to convey your results in English to nonspecialists. So there was a sort of a premium on the communications function, and you also had to understand the politics. On a campaign you had to make good policy good politics, and at the White House you worried about the president’s program. 

No matter who was in Congress, that was all they thought about. And in Congress, the CBO is nonpartisan by law, and so obviously you have to care about that. And I just decided I like that work, and that’s what AAF does. We do domestic and economic policy on the issues that are going on in Congress or the agencies, with an emphasis on providing material that is readable to nonspecialists so they can understand what’s going on. 

Rovner: You’re a professional policy nerd, in other words. 

Holtz-Eakin: Pretty much, yeah. 

Rovner: As am I. So I don’t mean that in any way to be derogatory. I plead guilty myself. 

Holtz-Eakin: These bills, who knew? 

Rovner: Exactly. Well, let’s talk about the CBO, which, people may or may not know, was created along with the rest of the congressional budget process overhaul in 1974. What is CBO’s actual job? What is it that CBO is tasked to do? 

Holtz-Eakin: It has two jobs. Job number one, the one we’re hearing so much about now, is to estimate the budgetary impact of pieces of legislation being considered on the floor of the House or the Senate. So they call this scoring, and it is: How much will the bill change the flow of revenues into the Treasury and the flow of spending out of the Treasury year by year over what is currently 10 years? 

And you compare that to what would happen if you didn’t pass law, which is to say, leave the laws of land on autopilot and check out what happened to the budget then. So that’s what it’s doing now, and you get a lot of disagreement on the nature of that analysis. It also spends a lot of time doing studies for members of Congress on policies that Congress may have to be looking at in the future. 

And so anticipating the needs of Congress, studying things like Social Security reforms, which are coming, or different ways to do Medicaid reform if we decide to go down that route, and things that will prepare the Congress for future debates. 

Rovner: Obviously these scores are best guesses of people who spend a lot of time studying economic models. How accurate are CBO’s estimates? 

Holtz-Eakin: They’re wrong all the time, but that’s because predicting the future is really hard, and because when CBO does its estimates, it’s not permitted by law to anticipate future actions of Congress, and Congress is always doing something. That often changes the outcome down the road. Sometimes there are just unexpected events in the world. The pandemic was not something that was in the CBO baseline in 2019. And so, obviously, the numbers changed dramatically because of that. 

And also, because CBO is not really just trying to forecast. If that was all it was being asked to do, it might get closer sometimes, but what it’s really being asked to do is to be able to compare pieces of legislation. What’s the House bill look like compared to the Senate bill? And to do that, you have to keep the point of comparison, the so-called baseline, the same for as long as you’re doing this legislation. 

In some cases, that’s quite a long time. It was over two years for the Affordable Care Act. And by the time you’re at the end, the forecast is way out of date. But for consistency, you have to hold on to it. And then people say, Oh, you got the forecast wrong. But it’s the nature of what they’re being asked to do, which is to provide consistent scores that rank things appropriately, that can interfere with the just pure forecasting aspect. 

Rovner: And basically they’re the referee. It’s hard to imagine being able to do this process without having someone who acts as a referee, right? 

Holtz-Eakin: Well, yes. And in fact, sometimes you see them rush through and ignore CBO. And generally, that’s a sign that it’s not going well, because they really should take the time to understand the consequences of what they’re up to. 

Rovner: And how does that work? CBO, people get frustrated because this stuff doesn’t happen, like, overnight. They write a bill and there should be a CBO score the next day. But it’s not just fed into an AI algorithm, right? 

Holtz-Eakin: No. That’s a great misconception about CBO. People think there’s a model. You just put it in the model. You drop the legislation and out comes the numbers. And there are some things for which we have a very good feel because they’ve been done a lot. So change the matching rate in Medicaid and see what happens to spending — been done a lot. We understand that pretty well. 

Pass a Terrorism Risk Insurance Act, where the federal government provides a backstop to the private property and casualty insurance companies in the event there’s a terrorist attack at an unknown time in the future using an unknown weapon in an unknown location — there’s no model for that. You just have to read about extreme events, look at their financial consequences, imagine how much money the insurance companies would have, when they would round up money, and how much the federal government would be on the hook for. It’s not modeling. You’re asking CBO’s professionals to make informed budgetary judgments, and we pay them for their judgment. And I think that’s poorly understood. 

Rovner: So I’ve been at this since the late 1980s. I’ve seen a lot of CBO directors, Republican and Democrats, and my impression is that, to a person, they have tried very hard to play things as much down the middle as possible. Do you guys have strategy sessions to come up with ways to be as nonpartisan as you can? 

Holtz-Eakin: The truth is you just listen to the staff. I say this and I’m not sure people will fully appreciate it: Nonpartisanship is in the DNA of CBO, and I attribute this to the very first director, Alice Rivlin, and some of her immediate successors. They were interested in establishing the budget office, which had been invented in 1974, really got up and running a couple of years later, and they wanted to establish this credibility. 

And regardless of their own political leanings, they worked hard to put in place procedures and training of the staff that emphasized: There’s a research literature out there, go look at it. What’s the consensus in that research literature? Regardless of what you might think, what is it telling you about the impact of this program or this tax or whatever it might be? Bring that back. That’s what we’re going to do. 

Now we’ve done an estimate. Let’s go out at the end of the year and look at all our baseline estimates and look at what actually happened, compare the before and after. Oh my God. We’re really off. Why? What can we learn from that? And it’s a constant repetition of that. It’s been going on for a long time now and with just outstanding results, I think. CBO is a very professional place that has a very specialized job and does it real well. 

Rovner: So obviously, lawmakers have always complained about the CBO, because you always complain about the referee, particularly if they say something you don’t like or you disagree with. I feel like the criticism has gotten more heated in the last couple of years and that there’s been more of an effort to really undermine what it is that CBO does. 

Holtz-Eakin: I don’t know if I agree with that. That comes up a lot. It is certainly more pointed. I lay a lot of this at the feet of the president, who, when he first ran, introduced a very personal style campaigning. Everything is personal. He doesn’t have abstract policy arguments. He makes it about him versus someone else and usually gives that person a nickname, like “Rocket Boy” for the leader of North Korea, and sort of diminishes the virtues and skills of his opponent, in this case. 

So he says, like, that CBO is horrible. It’s a terrible place. That is more personal. That isn’t the nature of the attacks I receive, for example. But other than that, it’s the same, right? When CBO delivers good news, Congress says, God, we did a good job. When CBO delivers bad news, they say, God, CBO is terrible. And that’s been true for a long time. 

Rovner: And I imagine it will in the future. Doug Holtz-Eakin, thank you so much for being here and explaining all this. 

Holtz-Eakin: Thank you. 

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 device. Sarah, why don’t you go first this week? 

Karlin-Smith: I took a look at a story in Wired by David Gilbert, “The Bleach Community Is Ready for RFK Jr. To Make Their Dreams Come True.” It’s a story about Kennedy’s past references to the use of chlorine dioxide and groups of people who were pushing for this use as kind of a cure-all for almost any condition you can think of. And one thing the author of this piece picked up on is that some of the FDA warnings not to do this, because it’s incredibly dangerous and can kill you — it is not going to cure any of the ailments described — have been taken off of the agency’s website recently, which seems a bit concerning. 

Now, FDA seems to suggest they did it because it’s just a few years old and they tend to archive posts after that. But if you read what happens to people who try and use bleach — or really it’s like even more concentrated product, essentially — it would be hard for me to understand why you would want to try this. But it is incredibly concerning to see these just really dangerous, unscientifically supported cures come back and get sort of more of a platform. 

Rovner: Yes. I guess we can’t talk about gun violence because we’re talking about drinking bleach. Anna. 

Edney: So mine is from KFF Health News, by Arthur Allen. It’s “Two Patients Faced Chemo. The One Who Survived Demanded a Test To See if It Was Safe.” And I found this starts off with a woman who needed chemo, and she got it and she started getting sores in her mouth and swelling around her eyes. And eventually she died a really painful, awful death, not from the cancer but from not being able to swallow or talk. And it was from the chemo. It was a reaction to the chemo, which I didn’t realize until I read this can, is a rare side effect that can happen. 

And there is a test for it. You can tell who might respond this way to chemo. And it doesn’t necessarily mean you wouldn’t get any chemo. You would instead maybe get lower doses, maybe different days of the week, things like that to try to help you not end up like this woman. And he also was able to talk to someone who knew about this and insisted on the test. And those were some of the calibrations that they made for her treatment. So I think it’s a great piece of public service journalism. It helps a lot of people be aware. 

Rovner: Super interesting. I had no idea until I read it, either. Joanne. 

Kenen: ProPublica, Brandon Roberts, Vernal Coleman, and Eric Umansky did a story called “DOGE Developed Error-Prone AI Tool to ‘Munch’ Veterans Affairs Contract.” And they had a related story that Julie can post that actually shows the code and the AI prompts, and you do not have to be very technically sophisticated to understand that there were some problems with those prompts. Basically, they had somebody who had no government experience and no health care experience writing really bad code and bad prompts. 

And we don’t know how many of the contracts were actually canceled, as opposed to flagged for canceling. There were things that they said were worth $34 million that weren’t needed. They were actually $35,000 and essential things that really pertain to patient care, including programs to improve nursing care were targeted. They were “munched,” which is not a word I had come across. So yes, it was everything you suspected and ProPublica documented it. 

Rovner: Yeah, it’s a very vivid story. Well, my extra credit this week is from Stat, and it’s called “Lawmakers Lobby Doctors To Keep Quiet — or Speak Up — on Medicaid Cuts in Trump’s Tax Bill,” by Daniel Payne. And it’s about something called reverse lobbying, lawmakers lobbying the lobbyists — in this case, in hopes of getting them to speak out or not about the budget reconciliation bill and its possible impact. Both sides know the public trusts health groups more than they trust lawmakers at this point. 

And so Democrats are hoping doctor and hospital groups will speak out in opposition to the cuts to Medicaid and the Affordable Care Act, while Republicans hope they will at least keep quiet. And Republicans, because it’s their bill, have added some sweeteners — a long-desired pay increase for doctors in Medicare. So we will have to wait to see how this all shakes out. 

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

Edney: X or Bluesky, @annaedney. 

Rovner: Joanne 

Kenen: Bluesky or LinkedIn, @joannekenen. 

Rovner: Sarah. 

Karlin-Smith: All of the above, @SarahKarlin or @sarahkarlin-smith. 

Rovner: 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.

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.

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Anna Edney
Bloomberg News

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Sarah Karlin-Smith
Pink Sheet

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Alice Miranda Ollstein
Politico

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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.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

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Alice Miranda Ollstein
Politico

@AliceOllstein

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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