The Host

Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

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

@mayagoldman_

@maya-goldman.bsky.social

Read Maya's stories

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

@sarahkarlin-smith.bsky.social

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Among the takeaways from this week’s episode:

• 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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As summer ushers in peak mosquito season, health and vector control officials are bracing for the possibility of another year of historic rates of dengue. And with climate change, the lack of an effective vaccine, and federal research cuts, they worry the disease will become endemic to a larger swath of North America.

About 3,700 new dengue infections were reported last year in the contiguous United States, up from about 2,050 in 2023, according to the Centers for Disease Control and Prevention. All of last year’s cases were acquired abroad, except for 105 cases contracted in California, Florida, or Texas. The CDC issued a health alert in March warning of the ongoing risk of dengue infection.

“I think dengue is here with us to stay,” said infectious disease specialist Michael Ben-Aderet, associate medical director of hospital epidemiology at Cedars-Sinai in Los Angeles, about dengue becoming a new normal in the U.S. “These mosquitoes aren't going anywhere.”

Dengue is endemic — a label health officials assign when diseases appear consistently in a region — in many warmer parts of the world, including Latin America, India, and Southeast Asia. Dengue cases increased markedly last year in many of those places, especially in Central and South America.

The disease, which can spread when people are bitten by infected Aedes mosquitoes, was not common in the contiguous United States for much of the last century. Today, most locally acquired (meaning unrelated to travel) dengue cases in the U.S. happen in Puerto Rico, which saw a sharp increase in 2024, triggering a local public health emergency.

Most people who contract dengue don’t get sick. But in some people symptoms are severe: bleeding from the nose or mouth, intense stomach pain, vomiting, and swelling. Occasionally, dengue causes death.

California offers a case study in how dengue is spreading in the U.S. The Aedes aegypti and Aedes albopictus mosquitoes that transmit dengue weren’t known to be in the state 25 years ago. They are now found in 25 counties and more than 400 cities and unincorporated communities, mostly in Southern California and the Central Valley.

The spread of the mosquitoes is concerning because their presence increases the likelihood of disease transmission, said Steve Abshier, president of the Mosquito and Vector Control Association of California.

From 2016 through 2022, there were an average of 136 new dengue cases a year in California, each case most likely brought to the state by someone who had traveled and been infected elsewhere. In 2023, there were about 250 new cases, including two acquired locally.

In 2024, California saw 725 new dengue cases, including 18 acquired locally, state data shows.

Climate change could contribute to growth in the Aedes mosquitoes’ population, Ben-Aderet said. These mosquitoes survive best in warm urban areas, often biting during the daytime. Locally acquired infections often occur when someone catches dengue during travel, then comes home and is bitten by an Aedes mosquito that bites and infects another person.

“They've just been spreading like wildfire throughout California,” Ben-Aderet said.

Dengue presents a challenge to the many primary care doctors who have never seen it. Ben-Aderet said doctors who suspect dengue should obtain a detailed travel history from their patients, but confirming the diagnosis is not always quick.

“There's no easy test for it,” he said. “The only test that we have for dengue is antibody tests.” He added that “most labs probably aren't doing it commercially, so it's usually like a send-out test from most labs. So you really have to suspect someone has dengue.”

Best practices for avoiding dengue include eliminating any standing pools of water on a property — even small pools — and using mosquito repellent, Abshier said. Limiting activity at dusk and dawn, when mosquitoes bite most often, can also help.

Efforts to combat dengue in California became even more complicated this year after wildfires ripped through Los Angeles. The fires occurred in a hot spot for mosquito-borne illnesses. San Gabriel Valley Mosquito and Vector Control District officials have worked for months to treat more than 1,400 unmaintained swimming pools left in the wake of fire, removing potential breeding grounds for mosquitoes.

San Gabriel vector control officials have used local and state resources to treat the pools, said district spokesperson Anais Medina Diaz. They have applied for reimbursement from the Federal Emergency Management Agency, which has not historically paid for vector control efforts following wildfires.

In California, vector control agencies are often primarily funded by local taxes and fees on property owners.

Some officials are pursuing the novel method of releasing sterilized Aedes mosquitoes to reduce the problem. That may prove effective, but deploying the method in a large number of areas would be costly and would require a massive effort at the state level, Abshier said. Meanwhile, the federal government is pulling back on interventions: Several outlets have reported that the National Institutes of Health will stop funding new climate change-related research, which could include work on dengue.

This year, reported rates of dengue in much of the Americas have declined significantly from 2024. But the trend in the United States likely won’t be clear until later in the year, after the summer mosquito season ends.

Health and vector control researchers aren't sure how bad it will get in California. Some say there may be limited outbreaks, while others predict dengue could get much worse. Sujan Shresta, a professor and infectious disease researcher at the La Jolla Institute for Immunology, said other places, like Nepal, experienced relatively few cases of dengue in the recent past but now regularly see large outbreaks.

There is a vaccine for children, but it faces discontinuation from a lack of global demand. Two other dengue vaccines are unavailable in the United States. Shresta’s lab is hard at work on an effective, safe vaccine for dengue. She hopes to release results from animal testing in a year or so; if the results are positive, human trials could be possible in about two years.

“If there's no good vaccine, no good antivirals, this will be a dengue-endemic country,” she said.

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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The Host

Julie Rovner
KFF Health News

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Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

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

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

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

Panelists

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

Chris Sununu
Former governor of New Hampshire (R)

Roy Cooper
Former governor of North Carolina (D)

Among the takeaways from the discussion:

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

Video of this episode is available here on YouTube.

Click to open the transcript

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Gov. Cooper. 

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

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

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

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

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

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

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

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

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

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

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

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

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

Sebelius: Yeah. 

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

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

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

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

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

Sebelius: A big basket. 

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

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

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

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

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

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

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

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

Sebelius: Just a small addendum, too. 

Sununu: Sorry. I’m frustrated. 

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

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

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

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

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

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

Rovner: Next question. 

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

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

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

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

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

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

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

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

Cooper: Yeah, we are now. 

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

Sebelius: I think it’s almost 45. 

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

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

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

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

Sebelius: Regional. 

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

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

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

Sebelius: Maybe the next guys took it away. 

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

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

Sebelius: I was just— 

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

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

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

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

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

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

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

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

Sebelius: Can I just— 

Rovner: Yes. 

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

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

Sebelius: Or sending them on. 

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

Sebelius: It’s got to be earlier though. 

Sununu: Much earlier. 

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

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

Sebelius: No idea. 

Diaz: Why? 

Cooper: Save money. 

Sununu: Yeah, yeah. 

Cooper: Finding a way. 

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

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

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

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

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

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

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

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

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

Sununu: No, I hate hearing those words. 

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

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

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

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

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

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

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

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

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

Sebelius: I just wanted to clarify. 

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

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

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

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

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

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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.

Panelists

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

@SandhyaWrites.bsky.social

Read Sandhya's stories.

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 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
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 narrowly passing in the House in May, President Donald Trump’s “One Big Beautiful Bill” has now arrived in the Senate, where Republicans are struggling to decide whether to pass it, change it, or — as Elon Musk, who recently stepped back from advising Trump, is demanding — kill it. 

Adding fuel to the fire, the Congressional Budget Office estimates the bill as written would increase the number of Americans without health insurance by nearly 11 million over the next decade. That number would grow to approximately 16 million should Republicans also not extend additional subsidies for the Affordable Care Act, which expire at year’s end. 

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

@jessiehellmann.bsky.social

Read Jessie's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• Even before the CBO released estimates of how many Americans stand to lose health coverage under the House-passed budget reconciliation bill, Republicans in Washington were casting doubt on the nonpartisan office’s findings — as they did during their 2017 Affordable Care Act repeal effort.
• Responding to concerns about proposed Medicaid cuts, Iowa Sen. Joni Ernst, a Republican, this week stood behind her controversial rejoinder at a town hall that “we’re all going to die.” The remark and its public response illuminated the problematic politics Republicans face in reducing benefits on which their constituents rely — and may foreshadow campaign fights to come.
• Journalists revealed that Health and Human Services Secretary Robert F. Kennedy Jr.’s report on children’s health may have been generated at least in part by artificial intelligence. The telltale signs in the report of what are called “AI hallucinations” included citations to scientific studies that don’t exist and a garbled interpretation of the findings of other research, raising further questions about the validity of the report’s recommendations.
• And the Trump administration this week revoked Biden-era guidance on the Emergency Medical Treatment and Active Labor Act. Regardless, the underlying law instructing hospitals to care for those experiencing pregnancy emergencies still applies.

Also this week, Rovner interviews KFF Health News’ Arielle Zionts, who reported and wrote the latest “Bill of the Month” feature, about a Medicaid patient who had an emergency in another state and the big bill he got for his troubles. If you have an infuriating, outrageous, or baffling medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: KFF Health News’ “Native Americans Hurt by Federal Health Cuts, Despite RFK Jr.’s Promises of Protection,” by Katheryn Houghton, Jazmin Orozco Rodriguez, and Arielle Zionts.

Alice Miranda Ollstein: Politico’s “‘They’re the Backbone’: Trump’s Targeting of Legal Immigrants Threatens Health Sector,” by Alice Miranda Ollstein.

Lauren Weber: The New York Times’ “Take the Quiz: Could You Manage as a Poor American?” by Emily Badger and Margot Sanger-Katz.

Jessie Hellmann: The New York Times’ “A DNA Technique Is Finding Women Who Left Their Babies for Dead,” by Isabelle Taft.

Also mentioned in this week’s podcast:

• NOTUS.org’s “The MAHA Report Cites Studies That Don’t Exist,” by Emily Kennard and Margaret Manto.
• The Washington Post’s “White House MAHA Report May Have Garbled Science by Using AI, Experts Say,” by Lauren Weber and Caitlin Gilbert.

click to open the transcript

Transcript: Trump’s ‘One Big Beautiful Bill’ Lands in Senate. Our 400th Episode!

[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 5, 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: Lauren Weber of The Washington Post. 

Lauren Weber: Hello, hello. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Later in this episode we’ll have my interview with my colleague Arielle Zionts, who reported and wrote the KFF Health News “Bill of the Month,” about a Medicaid patient who had a medical emergency out of state and got a really big bill to boot. But first the news. And buckle up — there is a lot of it. 

We’ll start on Capitol Hill, where the Senate is back this week and turning its attention to that “Big Beautiful” budget reconciliation bill passed by the House last month, and we’ll get to the fights over it in a moment. But first, the Congressional Budget Office on Wednesday finished its analysis of the House-passed bill, and the final verdict is in. It would reduce federal health care spending by more than a trillion dollars, with a T, over the next decade. That’s largely from Medicaid but also significantly from the Affordable Care Act. And in a separate letter from CBO Wednesday afternoon, analysts projected that 10.9 million more people would be uninsured over the next decade as a result of the bill’s provisions. 

Additionally, 5.1 million more people would lose ACA coverage as a result of the bill, in combination with letting the Biden-era enhanced subsidies expire, for a grand total of 16 million more people uninsured as a result of Congress’ action and inaction. I don’t expect that number is going to help this bill get passed in the Senate, will it? 

Ollstein: We’re seeing a lot of what we saw during the Obamacare repeal fight in that, even before this report came out, Republicans were working to discredit the CBO in the eyes of the public and sow the seeds of mistrust ahead of time so that these pretty damaging numbers wouldn’t derail the effort. They did in that case, among other things. And so they could now, despite their protestations. 

But I think they’re saying a combination of true things about the CBO, like it’s based on guesses and estimates and models and you have to predict what human behavior is going to be. Are people going to just drop coverage altogether? Are they going to do this? Are they going to do that? But these are the experts we have. This is the nonpartisan body that Congress has chosen to rely on, so you’re not really seeing them present their own credible sources and data. They’re more just saying, Don’t believe these guys. 

Rovner: Yeah, and some of these things we know. We’ve seen. We’ve talked about the work requirement a million times, that when you have work requirements in Medicaid, the people who lose coverage are not people who refuse to work. It’s people who can’t navigate the bureaucracy. And when premiums go up, which they will for the Affordable Care Act, not just because they’re letting these extra subsidies expire but because they’re going back to the way premiums were calculated before 2017. The more expensive premiums get, the fewer people sign up. So it’s not exactly rocket science figuring out that you’re going to have a lot more people without health insurance as a result of this. 

Ollstein: Honestly, it seems from the reactions so far that Republicans on the Hill are more impacted by the CBO’s deficit increase estimates than they are by the number of uninsured-people increase estimates. 

Rovner: And that frankly feels a little more inexplicable to me that the Republicans are just saying, This won’t add to the deficit. And the CBO — it’s arithmetic. It’s not higher math. It’s like if you cut taxes this much so there’s less money coming in, there’s going to be less money and a bigger deficit. I’m not a math person, but I can do that part, at least in my head. 

Jessie, you’re on the Hill. What are you seeing over in the Senate? We don’t even have really a schedule for how this is going to go yet, right? We don’t know if the committees are going to do work, if they’re just going to plunk the House bill on the floor and amend it. It’s all sort of a big question mark. 

Hellmann: Yeah, we don’t have text yet from any of the committees that have health jurisdiction. There’s been a few bills from other committees, but obviously Senate Finance has a monumental task ahead of them. They are the ones that have jurisdiction over Medicaid. Their members said that they have met dozens of times already to work out the details. The members of the Finance Committee were at the White House yesterday with President [Donald] Trump to talk about the bill. 

It doesn’t seem like they got into the nitty-gritty policy details. And the message from the president seemed to mostly be, like, Just pass this bill and don’t make any major changes to it. Which is a tall order, I think, for some of the members like [Sens.] Lisa Murkowski of Alaska and Susan Collins of Maine, and even a few others that are starting to come out and raise concerns about some of the changes that the House made, like to the way that states finance their share of Medicaid spending through the provider tax. 

Lisa Murkowski has raised concerns about how soon the work requirements would take effect, because, she was saying, Alaska doesn’t have the infrastructure right now and that would take a little bit to work out. So there are clearly still a lot of details that need to be worked out. 

Rovner: Well, I would note that Senate Republicans were already having trouble communicating about this bill even before these latest CBO numbers came out. At a town hall meeting last weekend in Iowa, where nearly 1 in 5 residents are on Medicaid, Republican Sen. Joni Ernst had an unfortunate reaction to a heckler in the audience, and, rather than apologize — well, here’s what she posted on Instagram. 

Sen. Joni Ernst: Hello, everyone. I would like to take this opportunity to sincerely apologize for a statement that I made yesterday at my town hall. See, I was in the process of answering a question that had been asked by an audience member when a woman who was extremely distraught screamed out from the back corner of the auditorium, “People are going to die!” And I made an incorrect assumption that everyone in the auditorium understood that, yes, we are all going to perish from this earth. 

So I apologize. And I’m really, really glad that I did not have to bring up the subject of the tooth fairy as well. But for those that would like to see eternal and everlasting life, I encourage you to embrace my Lord and Savior, Jesus Christ. 

Rovner: And what you can’t see, just to add some emphasis, Ernst recorded this message in a cemetery with tombstones visible behind her. I know it is early in this debate, but I feel like we might look back on this moment later like [Sen. John] McCain’s famous thumbs-down in the 2017 repeal-and-replace debate. Or is it too soon? Lauren. 

Weber: For all the messaging they’ve tried to do around Medicaid cuts, for all the messaging, We’re all going to die I cannot imagine was on the list of approved talking points. And at the end of the day, I think it gets at how uncomfortable it is to face the reality of your constituents saying, I no longer have health care. This has been true since the beginning of time. Once you roll out an entitlement program, it’s very difficult to roll it back. 

So I think that this is just a preview of how poorly this will go for elected officials, because there will be plenty of people thrown off of Medicaid who are also Republicans. That could come back to bite them in the midterms and in general, I think, could lead — combine it with the anti-DOGE [Department of Government Efficiency] fervor— I think you could have a real recipe for quite the feedback. 

Rovner: Yes, and we’re going to talk about DOGE in a second. As we all now know, Elon Musk’s time as a government employee has come to an end, and we’ll talk about his legacy in a minute. But on his way out the door, he let loose a barrage of criticism of the bill, calling it, among other things, a, quote “disgusting abomination” that will saddle Americans with, quote, “crushingly unsustainable debt.” 

So basically we have a handful of Republicans threatening to oppose the bill because it adds to the deficit, another handful of Republicans worried about the health cuts — and then what? Any ideas how this battle plays out. I think in the House they managed to get it through by just saying, Keep the ball rolling and send it to the Senate. Now the Senate, it’s going to be harder, I think, for the Senate to say, Oh, we’ll keep the ball rolling and send it back to the House. 

Ollstein: Well, and to jump off Lauren’s point, I think the political blowback is really going to be because this is insult on top of injury in terms of not only are people going to lose Medicaid, Republicans, if this passes, but they’re being told that the only people who are going to lose Medicaid are undocumented immigrants and the undeserving. So not only do you lose Medicaid because of choices made by the people you elected, but then they turn around and imply or directly say you never deserved it in the first place. That’s pretty tough. 

Rovner: And we’re all going to die. 

Ollstein: And we’re all going to die. 

Weber: Just to add onto this, I do think it’s important to note that work requirements poll very popularly among the American people. A majority of Americans here “work requirements” and say, Gee, that sounds like a commonsense solution. What the reality that we’ve talked about in this podcast many, many times is, that it ends up kicking off people for bureaucratic reasons. It’s a way to reduce the rolls. It doesn’t necessarily encourage work. 

But to the average bear, it sounds great. Yes, absolutely. Why wouldn’t we want more people working? So I do think there is some messaging there, but at the end of the day, like Alice said, like I pointed out, they have not figured out the messaging enough, and it is going to add insult to injury to imply to some of these folks that they did not deserve their health care. 

Ollstein: And what’s really baffling is they are running around saying that Medicaid is going to people who should never have been on the program in the first place, able-bodied people without children who are not too young and not too old, sort of implying that these people are enrolling against the wishes of the program’s creators. 

But Congress explicitly voted for these people to be eligible for the program. And then after the Supreme Court made it optional, all of these states, most states, voted either by a direct popular vote or through the legislature to extend Medicaid to this population. And now they’re turning around and saying they were never supposed to be on it in the first place. We didn’t get here by accident or fraud. 

Rovner: Or by executive order. 

Ollstein: Exactly. 

Rovner: Well, even before the Senate digs in, there’s still a lot of stuff that got packed into that House bill, some of it at the last minute that most people still aren’t aware of. And I’m not talking about [Rep.] Marjorie Taylor Greene and AI, although that, too, among other things. And shout out here to our podcast panelist Maya Goldman over at Axios. The bill would reduce the amount of money medical students could borrow, threatening the ability of people to train to become doctors, even while the nation is already suffering a doctor shortage. 

It would also make it harder for medical residents to pay their loans back and do a variety of other things. The idea behind this is apparently to force medical schools to lower their tuition, which would be nice, but this feels like a very indirect way of doing it. 

Weber: I just don’t think it’s very popular in an era in which we’re constantly talking about physician shortages and encouraging folks that are from minority communities or underserved communities to become primary care physicians or infectious disease physicians, to go to the communities that need them, that reflect them, to then say, Look, we’re going to cut your loans. And what that’s going to do — short of RFK [Robert F. Kennedy Jr.], who has toyed with playing with the code. So who knows? We could see. 

But as the current structure stands, here’s the deal: You have a lot of medical debt. You are incentivized to go into a more lucrative specialty. That means that you’re not going into primary care. You’re not going into infectious disease care. You’re not going to rural America, because they can’t pay you what it costs to repay all of your loans. So, I do think — and, it was interesting. I think the Guardian spoke to some of the folks from the study that said that this could change it. That study was based off of metrics from 2006, and for some reason they were like, The financial private pay loans are not really going to cut it today. 

I find it hard to believe this won’t get fixed, to be quite honest, just because I think hating on medical students is usually a losing battle in the current system. But who knows? 

Rovner: And hospitals have a lot of clout. 

Weber: Yeah. 

Rovner: Although there’s a lot of things in this bill that they would like to fix. And, I don’t know. Maybe— 

Weber: Well, and hospitals have a lot of financial incentive, because essentially they make medical residents indentured servants. So, yeah, they also would like them to have less loans. 

Rovner: As I mentioned earlier, Elon Musk has decamped from DOGE, but in his wake is a lot of disruption at the Department of Health and Human Services and not necessarily a lot of savings. Thousands of federal workers are still in limbo on administrative leave, to possibly be reinstated or possibly not, with no one doing their jobs in the meantime. Those who are still there are finding their hands tied by a raft of new rules, including the need to get a political-appointee sign-off for even the most routine tasks. 

And around the country, thousands of scientific grants and contracts have been summarily frozen or terminated for no stated cause, as the administration seeks to punish universities for a raft of supposed crimes that have nothing to do with what’s being studied. I know that it just happened, but how is DOGE going to be remembered? I imagine not for all of the efficiencies that it has wrung out of the health care system. 

Ollstein: Well, one, I wouldn’t be so sure things are over, either between Elon and the Trump administration or what the amorphous blob that is DOGE. I think that the overall slash-and-burn of government is going to continue in some form. They are trying to formalize it by sending a bill to Congress to make these cuts, that they already made without Congress’ permission, official. We’ll see where that goes, but I think that it’s not an ending. It’s just morphing into whatever its next iteration is. 

Rovner: I would note that the first rescission request that the administration has sent up formally includes getting rid of USAID [the U.S. Agency for International Development] and PEPFAR [the President’s Emergency Plan for AIDS Relief] and public broadcasting, which seems unlikely to garner a majority in both houses. 

Ollstein: Except, like I said, this is asking them to rubber-stamp something they’re already trying to do without them. Congress doesn’t like its power being infringed on, especially appropriators. They guard that power very jealously. Now, we have seen them a little quieter in this administration than maybe you would’ve thought, but I think there are some who, even if they agree on the substance of the cuts, might object to the process and just being asked to rubber-stamp it after the fact. 

Rovner: Well, meanwhile, Health and Human Services Secretary Kennedy continues to try to remake what’s left of HHS, although his big reorganization is currently blocked by a federal judge. And it turns out that his big MAHA, “Make America Healthy Again,” report may have been at least in part written by AI, which apparently became obvious when the folks at the news service NOTUS decided to do something that was never on my reporting bingo card, which is to check the footnotes in the report to see if they were real, which apparently many are not. Then, Lauren, you and your colleagues took that yet another step. So tell us about that. 

Weber: Yeah. NOTUS did a great job. They went through all the footnotes to find out that several of the studies didn’t exist, and my colleagues and I saw that and said, Hm, let’s look a little closer at these footnotes and see. And what we were able to do in speaking with AI experts is find telltale signs of AI. It’s basically a sign of artificial intelligence when things are hallucinated — which is what they call it — which is when it sounds right but isn’t completely factual, which is one of the dangers of using AI. 

And it appears that some of AI was used in the footnotes of this MAHA report, again, to, as NOTUS pointed out, create studies that don’t exist. It also kind of garbled some of the science on the other pieces of this. We found something called “oaicite,” which is a marker of OpenAI system, throughout the report. And at the end of the day, it casts a lot of questions on the report as a whole and: How exactly did it get made? What is the science behind this report? 

And even before anyone found any of these footnotes of any of this, a fair amount of these studies that this report cites to back up its thesis are a stretch. Even putting aside the fake studies and the garbled studies, I think it’s important to also note that a lot of the studies the report cites, a lot of what Kennedy does, take it a lot further than what they actually say. 

Rovner: So, this is all going well. Meanwhile, there is continuing confusion in vaccine land after Secretary Kennedy, flanked by FDA [Food and Drug Administration] Commissioner Marty Makary and NIH [National Institutes of Health] Director Jay Bhattacharya, announced in a video on X that the department would no longer recommend covid vaccines for pregnant women and healthy children, sidestepping the expert advice of the Centers for Disease Control and Prevention and its advisory committee of experts. 

The HHS officials say people who may still be at risk can discuss whether to get the vaccine with their doctors, but if the vaccines are no longer on the recommended list, then insurance is less likely to cover them and medical facilities are less likely to stock them. Paging Sen. [Bill] Cassidy, who still, as far as I can tell, hasn’t said anything about the secretary’s violation of his promise to the senator during his confirmation hearings that he wouldn’t mess with the vaccine schedule. Have we heard a peep from Sen. Cassidy about any of this? 

Ollstein: I have not, but a lot of the medical field has been very vocal and very upset. I was actually at the annual conference of the American College of Obstetricians and Gynecologists when this news broke, and they were just so confused and so upset. They had seen pregnant patients die of covid before the vaccines were available, or because there was so much misinformation and mistrust about the vaccines’ safety for pregnant people that a lot of people avoided it, and really suffered the consequences of avoiding it. 

A lot of the issue was that there were not good studies of the vaccine in pregnant people at the beginning of the rollout. There have since been, and those studies have since shown that it is safe and effective for pregnant people. But it was, in a lot of people’s minds, too late, because they already got it in their head that it was unsafe or untested. So the OB-GYNs at this conference were really, really worried about this. 

Rovner: And, confusingly, the CDC on its website amended its recommendations to leave children recommended but not pregnant women, which is kind of the opposite of, I think, what most of the medical experts were recommending. Jessie, you were about to add something. 

Hellmann: I just feel like the confusion is the point. I think Kennedy has made it a pattern now to get out ahead of an official agency decision and kind of set the narrative, even if it is completely opposite of what his agencies are recommending or are stating. He’s done this with a report that the CDC came out with autism, when he said rising autism cases aren’t because of more recognition and the CDC report said it’s a large part because of more recognition. 

He’s done this with food dyes. He said, We’re banning food dyes. And then it turns out they just asked manufacturers to stop putting food dyes into it. So I think it’s part of, he’s this figurehead of the agency and he likes to get out in front of it and just state something as fact, and that is what people are going to remember, not something on a CDC webpage that most people aren’t going to be able to find. 

Rovner: Yeah, it sounds like President Trump. It’s like, saying it is more important than doing it, in a lot of cases. So of course there’s abortion news this week, too. The Trump administration on Tuesday reversed the Biden administration guidance regarding EMTALA, the Emergency Medical Treatment and Active Labor Act. Biden officials, in the wake of the overturn of Roe v. Wade three years ago, had reminded hospitals that take Medicare and Medicaid, which is all of them, basically, that the requirement to provide emergency care includes abortion when warranted, regardless of state bans. Now, Alice, this wasn’t really unexpected. In fact, it’s happening later than I think a lot of people expected it to happen. How much impact is it going to have, beyond a giant barrage of press releases from both sides in the abortion debate? 

Ollstein: Yeah, so, OK, it’s important for people to remember that what the Biden administration, the guidance they put out was just sort of an interpretation of the underlying law. So the underlying law isn’t changing. The Biden administration was just saying: We are stressing that the underlying law means in the abortion context, in the post-Dobbs context, blah, blah, blah, blah, blah, that hospitals cannot turn away a pregnant woman who’s having a medical crisis. And if the necessary treatment to save her life or stabilize her is an abortion, then that’s what they have to do, regardless of the laws in the state. 

In a sense, nothing’s changed, because EMTALA itself is still in place, but it does send a signal that could make hospitals feel more comfortable turning people away or denying treatment, since the government is signaling that they don’t consider that a violation. Now, I will say, you’re totally right that this was expected. In the big lawsuit over this that is playing out now in Idaho, one of the state’s hospitals intervened as a plaintiff, basically in anticipation of this happening, saying, The Trump administration might not defend EMTALA in the abortion context, so we’re going to do it for them, basically, to keep this case alive. 

Rovner: And I would point out that ProPublica just won a Pulitzer for its series detailing the women who were turned away and then died because they were having pregnancy complications. So we do know that this is happening. Interestingly, the day before the administration’s announcement, the American College of Obstetricians and Gynecologists put out a new, quote, “practice advisory” on the treatment of preterm pre-labor rupture of membranes, which is one of the more common late-pregnancy complications that result in abortion, because of the risk of infection to the pregnant person. 

Reading from that guidance, quote, “the Practice Advisory affirms that ob-gyns and other clinicians must be able to intervene and, in cases of previable and periviable PPROM” — that’s the premature rupture of membranes — “provide abortion care before the patient becomes critically ill.” Meanwhile, this statement came out Wednesday from the American College of Emergency Physicians, quote, ,“Regardless of variances in the regulatory landscape from one administration to another, emergency physicians remain committed not just by law, but by their professional oath, to provide this care.” 

So on the one hand, professional organizations are speaking out more strongly than I think we’ve seen them do it before, but they’re not the ones that are in the emergency room facing potential jail time for, Do I obey the federal law or do I obey the state ban? 

Ollstein: And when I talk to doctors who are grappling with this, they say that even with the Biden administration’s interpretation of EMTALA, that didn’t solve the problem for them. It was some measure of protection and confidence. But still, exactly like you said, they’re still caught in between seemingly conflicting state and federal law. And really a lot of them, based on what they told me, were saying that the threat of the state law is more severe. It’s more immediate. 

It means being charged with a felony, being charged with a crime if they do provide the abortion, versus it’s a federal penalty, it’s not on the doctor itself. It’s on the institution. And it may or may not happen at some point. So when you have criminal charges on one side and maybe some federal regulation or an investigation on the other side, what are you going to choose? 

Rovner: And it’s hard to imagine this administration doing a lot of these investigations. They seem to be turning to other things. Well, we will watch this space, and obviously this is all still playing out in court. All right, that is this week’s news, or at least as much as we could squeeze in. Now we’ll play my “Bill of the Month” interview with Arielle Zionts, and then we’ll come back and do our extra credits. 

I am pleased to welcome back to the podcast KFF Health News’ Arielle Zionts, who reported and wrote the latest KFF Health News “Bill of the Month.” Arielle, welcome back. 

Arielle Zionts: Hi. Thanks for having me. 

Rovner: So this month’s patient has Medicaid as his health insurance, and he left his home state of Florida to visit family in South Dakota for the holidays, where he had a medical emergency. Tell us who he is and what happened that landed him in the hospital. 

Zionts: Sure. So I spoke with Hans Wirt. He was visiting family in the Black Hills. That’s where Mount Rushmore is and its beautiful outdoors. He was at a water park, following his son up and down the stairs and getting kind of winded. And at first he thought it might just be the elevation difference, because in Florida it’s like 33 feet above sea level. Here it’s above 3,000 in Rapid City. 

But then they got him back to the hotel room and he was getting a lot worse, his breathing, and then he turned pale. And his 12-year-old son is the one who called 911. And medics were like, Yep, you’re having a heart attack. And they took him to the hospital in town, and that is the only place to go. There’s just one hospital with an ER in Rapid City. 

Rovner: So the good news is that he was ultimately OK, but the bad news is that the hospital tried to stick them with the bill. How big was it? 

Zionts: It was nearly $78,000. 

Rovner: Wow. So let’s back up a bit. How did Mr. Wirt come to be on Medicaid? 

Zionts: Yeah. So it is significant that he is from Florida, because that is one of the 10 states that has not opted in to expand Medicaid. So in Florida, if you’re an adult, you can’t just be low-income. You have to also be disabled or caring for a minor child. And Hans says that’s his case. He works part time at a family business, but he also cares for his 12-year-old son, who is also on Medicaid. 

Rovner: So Medicaid patients, as we know, are not supposed to be charged even small copays for care in most cases. Is that still the case when they get care in other states? 

Zionts: So Medicaid will not pay for patient care if they are getting more of an elective or non-medically necessary kind of optional procedure or care in another state. But there are several exceptions, and one of the exceptions is if they have an emergency in another state. So federal law says that state Medicaid programs have to reimburse those hospitals if it was for emergency care. 

Rovner: And presumably a heart attack is an emergency. 

Zionts: Yes. 

Rovner: So why did the hospital try to bill him anyway? They should have billed Florida Medicaid, right? 

Zionts: So what’s interesting is while there’s a law that says the Medicaid program has to reimburse the hospital, there’s no law saying the hospital has to send the bill to Medicaid. And that was really interesting to learn. In this case, the hospital, it’s called Monument Health, and they said they only bill plans in South Dakota and four of our bordering states. So basically they said for them to bill for the Medicaid, they would have to enroll. 

And they say they don’t do that in every state, because there is a separate application process for each state. And their spokesperson described it as a burdensome process. So in this case, they billed Hans instead. 

Rovner: So what eventually happened with this bill? He presumably didn’t have $78,000 to spare. 

Zionts: Correct. Yeah. And he had told them that, and he said they only offered, Hey, you can set up a payment plan. But that would’ve still been really expensive, the monthly payments. So he reached out to KFF Health News, and I had sent my questions to the hospital, and then a few days later I get a text from Hans and he says, Hey, my balance is at zero now. He and I both eventually learned that that’s because the hospital paid for his care through a program called Charity Care. 

All nonprofit hospitals are required to have this program, which provides free or very discounted pricing for patients who are uninsured or very underinsured. And the hospital said that they screen everyone for this program before sending them to collections. But what that meant is that for months, Hans was under the impression that he was getting this bill. And he was, got a notice saying, This is your last warning before we send you to collection. 

Rovner: So, maybe they would’ve done it anyway, or maybe you gave them a nudge. 

Zionts: They say they would’ve done it anyways. 

Rovner: OK. So what’s the takeaway here? It can’t be that if you have Medicaid, you can’t travel to another state to visit family at Christmas. 

Zionts: Right. So Hans made that same joke. He said, quote, “If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state.” Obviously, he’s kidding. You can’t control when you have an emergency. So the takeaway is that you do risk being billed and that if you don’t know how to advocate yourself, you might get sent to collections. But I also learned that there’s things that you can do. 

So you could file a complaint with your state Medicaid program, and also, if you have a managed-care program, and they might have — you should ask for a caseworker, like, Hey, can you communicate with the hospital? Or you can contact an attorney. There’s free legal-aid ones. An attorney I spoke with said that she would’ve immediately sent a letter to the hospital saying, Look, you need to either register with Florida Medicaid and submit it. If not, you need to offer the Charity Care. So that’s the advice. 

Rovner: So, basically, be ready to advocate for yourself. 

Zionts: Yes. 

Rovner: OK. Arielle Zionts, thank you so much. 

Zionts: Thank you. 

Rovner: OK. We’re back, and 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. Jessie, why don’t you go first this week? 

Hellmann: My story is from The New York Times. It’s called “A [DNA] Technique Is Finding Women Who Left Their Babies for Dead,” which I don’t know how I feel about that headline, but the story was really interesting. It’s about how police departments are using DNA technology to find the mothers of infants that had been found dead years and years ago. And it gets a little bit into just the complicated situation. 

Some of these women have gone on to have families. They have successful careers. And now some of them are being charged with murder, and some who have been approached about this have unfortunately died by suicide. And it just gets into the ethics of the issue and what police and doctors, families, should be considering about the context around some of these situations, about what the circumstances were, in some cases, 40 years ago and what should be done with that. 

Rovner: Really thought-provoking story. Lauren. 

Weber: With credit to Julie, too, because she brought this up again, was brought back to a classic from The New York Times back in 2020, which is called “Take a Quiz: Could You Manage as a Poor American?” And here are the questions: I will read them for the group. 

Rovner: And I will point out that this is once again relevant. That’s why it was brought back. 

Weber: It’s once again relevant, and one of them is, “Do you have paper mail you plan to read that has been unopened for more than a week?” Yes. I’m looking at paper mail on my desk. “Have you forgotten to pay a utility bill on time?” If I didn’t set up auto pay, I probably would forget to pay a utility bill on time. “Have you received a government document in the mail that you did not understand?” Many times. “Have you missed a doctor’s appointment because you forgot you scheduled it or something came up?” 

These are the basic facts that can derail someone from having access to health care or saddle them, because they lose access to health care and don’t realize it, with massive hospital bills. And this is a lot of what we could see in the coming months if some of these Medicaid changes come through. And I just, I think I would challenge a lot of people to think seriously about how much mail they leave unopened and what that could mean for them, especially if you are living in different homes, if you are moving frequently, etc. This paperwork burden is something to definitely be considered. 

Rovner: Yeah, I think we should sort of refloat this every time we have another one of these debates. Alice. 

Ollstein: So I wanted to recommend something I wrote [“‘They’re the Backbone’: Trump’s Targeting of Legal Immigrants Threatens Health Sector”]. It was my last story before taking some time off this summer. It is about the intersection of Trump’s immigration policies and our health care system. And so this is jumping off the Supreme Court allowing the Trump administration to strip legal status from hundreds of thousands of immigrants. Again, these are people who came legally through a designated program, and they are being made undocumented by the Trump administration, with the Supreme Court’s blessing. And tens of thousands of them are health care workers. 

And so I visited an elder care facility in Northern Virginia that was set to lose 65 staff members, and I talked to the residents and the other workers about how this would affect them, and the owner. And it was just a microcosm of the damage this could have on our health sector more broadly. Elder care is especially immigrant-heavy in its workforce, and everyone there was saying there just are not the people to replace these folks. 

And not only is that the case right now, but as the baby boomer generation ages and requires care, the shortages we see now are going to be nothing compared to what we could see down the road. With the lower birth rates here, we’re just not producing enough workers to do these jobs. The piece also looks into how public health and management of infectious diseases is also being worsened by these immigration raids and crackdowns and deportations. So, would love people to take a look. 

Rovner: I’m so glad you did this story, because it’s something that I keep running up and down screaming. And you can tell us why you’re taking some time off this summer, Alice. 

Ollstein: I’m writing a book. Hopefully it will be out next year, and I can’t wait to tell everyone more about it. 

Rovner: Excellent. All right. My extra credit this week is from my KFF Health News colleagues Katheryn Houghton, Jazmin Orozco Rodriguez, and Arielle Zionts, who you just heard talking about her “Bill of the Month,” and it’s called “Native Americans Hurt by Federal Health Cuts, Despite RFK Jr.’s Promises of Protection.” And that sums it up pretty well. The HHS secretary had a splashy photo op earlier this year out west, where he promised to prioritize Native American health. But while he did spare the Indian Health Service from personnel cuts, it turns out that the Native American population is also served by dozens of other HHS programs that were cut, some of them dramatically, everything from home energy assistance to programs that improve access to healthy food, to preventing overdoses. The Native community has been disproportionately hurt by the purging of DEI [diversity, equity, and inclusion] programs, because Native populations have systematically been subjected to unequal treatment over many generations. It’s a really good if somewhat infuriating story. 

OK. That is this week’s show. Before we go, if you will indulge me for a minute, this is our 400th episode of “What the Health?” We launched in 2017 during that year’s repeal-and-replace debate. I want to thank all of my panelists, current and former, for teaching me something new every single week. And everyone here at KFF Health News who makes this podcast possible. That includes not only my chief partners in crime, Francis Ying and Emmarie Huetteman, but also the copy desk and social media and web teams who do all the behind-the-scenes work that brings our podcast to you every week. And of course, big thanks to you, the listeners, who have stuck with us all these years. 

I won’t promise you 400 more episodes, but I will keep doing this as long as you keep wanting it. 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. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks these days? Jessie? 

Hellmann: @jessiehellmann on X and Bluesky, and LinkedIn. 

Rovner: Lauren. 

Weber: I’m @LaurenWeberHP on X and on Bluesky, shockingly, now. 

Rovner: Alice. 

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

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

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What do the KGB and the former CEO of Cincinnati Children’s Hospital have in common?

Eugene Litvak.

The Soviet intelligence agency and the children’s hospital have each separately looked to the Ukrainian émigré with a PhD in mathematics for help. He turned down the KGB, but Litvak saved Cincinnati Children’s Hospital more than $100 million a year. 

For decades, Litvak has been on a mission to save U.S. hospitals money and improve the lives of doctors, nurses, and patients. He says he has just the formula to do it.

Prominent experts vouch for his model, and he has documented impressive results so far: financial savings, fewer hospital-related deaths, lower staff turnover, and shorter wait times. Still, Litvak and his allies have struggled to persuade more hospitals to try his method.

Host Dan Weissmann speaks with Litvak about his unique life story, how he found the fix that he says could revolutionize American hospitals, and why he won’t stop fighting for it.

Dan Weissmann

@danweissmann

Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

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Transcript: A Mathematical Solution for US Hospitals?

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. Mark Taylor is a reporter, and when he started covering health care in the 1990s, the beat wasn’t his first choice.

Mark Taylor: I thought it was a punishment. I thought, I don’t know anything about healthcare. I was bad at science, I was bad at math. I didn’t understand any of this stuff, but I just was determined not to fail at it. And I dove into it head first and my wife said, you know, you used to read novels in bed and now you’re reading the CDCs mortality and morbidity report.

Dan: About twenty years in, he picked up some medical journals — like you do — and looked at some studies about work by a guy named Eugene Litvak.

Mark Taylor: I started reading these and going, wow, that’s a good story.

Dan: Litvak was a math PhD, with a background in operations management, systems engineering. He’d spent the first chunk of his career making telecommunications networks more efficient and reliable.

Many years later, One hospital that had implemented Litvak’s program had saved more than a hundred million dollars a year.

But the results were about more than money. Mark Taylor kept reading…

Mark Taylor: Reduces mortality rates in-hospital. That’s a good story. Improves nurse retention. We’ve got a nursing shortage. Reduces waiting times in ER and patient boarding.

Dan: Patient boarding sounds nerdy, but: We talked about this a couple of episodes ago, when we looked at the new HBO/Max medical drama “The Pitt.”

When hospital ERs get crowded — and way less effective — it’s generally because of crowding upstairs.

ER patients who need a bed upstairs can’t get one, so they wait in the ER. And clog it up. Wait times get longer. Medical mistakes happen. People die. 

On “The Pitt,” and in lots of hospitals, this gets treated as a fact of life.

Hospital administrators say they can’t afford to build the new wings or hire extra nurses to meet peak demands.

But Litvak’s work showed: They don’t need to.

Because — it turns out — random ER visits don’t cause those peaks.

Scheduled surgeries do. They get bunched up on certain days. Un-bunch them, and the peaks get smoother.

Nurses and doctors get less burned out. Fewer patients die. Hospitals waste less money.

In other words, Litvak’s work addressed some of the biggest problems Mark Taylor had been writing about for decades.

Mark Taylor: There’s a solution here. It’s been proven to work, and it’s been validated in the best medical journals in the country and in the world. How come this isn’t in every hospital?

Dan:  That was ten years ago. It’s still a good question. 

Mark wrote some newspaper stories about Litvak’s work, starting with one in the Chicago Tribune, and eventually started working on a book.

It came out in 2024, and it’s called “Hospital, Heal Thyself: One Brilliant Mathematician’s Proven Plan for Saving Hospitals, Many Lives and Billions of Dollars.”

By the time Eugene Litvak started working with hospitals, he was in his mid-40s. He had grown up in the Soviet Union, where he earned a PhD in math and worked as a systems engineer.

His career there came to a halt when he asked for an exit visa — and his request was refused for almost a decade. There was a word for people in that predicament, lots of them, like Litvak, Soviet Jews: refuseniks. 

Eventually he got to the U.S. — where he’s now spent decades trying to get hospitals to try his methods.

Eugene Litvak: I recently started telling people that I am a double refusenik, for 10 years refusing for the exit visa in Soviet Union, and now for 25 years in healthcare decision makers.

Dan: He’s not giving up any time soon. And he thinks eventually hospitals will come around. He thinks they’re gonna have to.

This is An Arm and a Leg– a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge, so the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering and useful.

Eugene Litvak was born in Kiev in 1949. Mark Taylor reports in his book that Eugene Litvak’s work in engineering and math attracted international attention in the 1970s.

Litvak also faced frustrating obstacles. A controlling boss. Semi-official antisemitism.

But what finally spurred him to try to leave the Soviet Union was an offer. From the secret police– the KGB. 

Eugene Litvak: And they were so nice, you know, like you’re talking to your long lost brother. They said, you have a lot of friends. You communicate with many people. How about you work for us?

Dan: Eugene says the offer terrified him. Because he knew immediately he couldn’t accept it.

Eugene Litvak: I would not be any longer in peace with myself. In addition to that,  I can tell you my father probably would stop talking to me if he would learn that I did something like that. So, these two factors –  look,  I didn’t think whether I should accept it or not. I didn’t think about that. The only thing that was immediately in my mind–  how can I avoid it to minimize the consequence for myself?

Dan: As he told Mark Taylor, he didn’t face immediate consequences for declining, but he knew he’d always be at risk. He and his wife decided to leave.

As they expected, they got fired from their jobs the day they applied for exit visas.

He says they were prepared to wait out a process that they figured would take months, maybe a year.

But their timing was bad. While they were waiting, in December 1979, the Soviet Union invaded Afghanistan. The Cold War got hotter, and exit visas basically stopped getting approved. 

Eugene Litvak: So we, and many thousands of others, became victims of that.

Dan: Eugene says for most of the next decade, police and the KGB called him in, searched his house, threatened him with prison — while he and his wife worked basic jobs: she washed floors in a factory. He delivered telegrams.

When they finally got to the U.S., in 1988, with Eugene’s parents in tow, Eugene’s job prospects weren’t much better.

He says he had contacts with well-known scientists, but not great English. He worked in a hotel gift shop, then behind the desk.

And practiced his English by cold-calling stores from the Yellow Pages.

Eugene Litvak: Like Home Depot. Asking may I buy, you know, the air conditioner? And then the supermarket. The CVS. I was doing that on a regular basis until people started understanding what I want from them.

Dan: He eventually got some consulting work. And he found his calling — his obsession — bringing his training as an operations engineer to U.S. hospitals — when his father’s health went downhill.

Eugene Litvak: I saw the failures in operations at the hospital by spending a lot of time with my father.

Dan: And his chutzpah — and his persistence — all of that, really shows itself in what he did next:

Eugene Litvak: I sent a letter actually to every hospital president in Massachusetts, offering my services to help. 

Dan: No takers. No responses. But in 1995, the vice president of a big local hospital, Mass General, gave a lecture about how new market conditions meant hospitals would need to get more efficient.

Afterwards, Litvak stepped up, introduced himself– and got an invitation to drop by for a chat. In that meeting, his new pal the Vice President gave him a small assignment — one that Eugene didn’t get to finish. 

Eugene Litvak: He interrupted me before even implementation. He said, we have a more important project and that is operating room.

Dan: Operating room. Surgeries.

Eugene Litvak: So that’s how it started.

Dan: A doctor named Mike Long, who ran logistics for the hospitals surgeries, had been pushing to get things more efficient.

Some days, surgical patients crowded the hospital, so doctors and nurses sweated through expensive overtime. Others, the place was quiet and the hospital lost money staffing empty beds. Nobody could figure out why. 

Long and Litvak became a team, with two big strengths: One, they were kindred spirits.

Eugene Litvak: As he described it, you know, long lost twins.

Dan: And two, they had complimentary expertise:

Eugene Litvak: He knew healthcare very well, which I didn’t, and I knew operations management, that he didn’t know.

Dan: They dove in together, pulling data, talking to people, and observing. The two of them worked and worked. For months, Litvak watched the weekly 6am meetings where surgeons would set their schedules.

They had a hypothesis: Sometimes more people just showed up in the ER: More broken legs, more burst appendixes. The ER got crowded, and so did the rest of the hospital.

So they searched their data for ways to predict or manage that problem.

And then one day, a totally different answer literally showed itself to them.

This was the 1990s, before PowerPoint. To share their data, they printed charts onto transparencies — plastic sheets for an overhead projector.

One day, in Mike Long’s office, they noticed a couple of these sheets sitting one on top of the other.

One had a line showing scheduled surgeries — more this day, fewer that day. The other had a line showing, day by day, how many hospital beds were full. 

Eugene Litvak: And we look. Wow, it’s almost the same. We put it against the light in the window and they almost coincided. That was an aha moment. 

Dan: When the line showing scheduled surgeries went up, so did  the line showing full beds — crowding. They went down together too. 

Eugene Litvak: It was clear message.

Dan: The question they’d been working on– why does the hospital get so jammed sometimes?

The answer wasn’t random at all. It had nothing to do with random surges in patients showing up in the ER.

The hospital got jammed — and the ER got backed up with patients waiting for a bed upstairs — when there were more surgeries scheduled.

And there was a definite pattern: There were a LOT more scheduled surgeries early in the week, on Mondays and Tuesdays.

He’s taken to calling it “weekday-related disease”

Eugene Litvak: Weekday related disease that manifests on a particular week days. 

Dan: On those days, there was no give in the operating-room schedule, a lot fewer open beds on the wards. When a normal day’s batch of emergency cases showed up– wham. Things got jammed.

I told Eugene: Hearing all this after the fact, it just seems — obvious. You schedule a bunch of surgeries, you’re gonna fill up the hospital, right? He was like, well, yeah.

Eugene Litvak: As one of the hospital’s chief medical officers said, Eugene pointed us to absolutely unexpected event that during the winter we have snow.

Dan: Right, but this hadn’t kind of occurred to anybody before.

Eugene Litvak: No. And the first people reaction was practically calling me names.

Dan: People in the hospital did not want to believe what Eugene’s data showed. 

Which is easier to understand given what Eugene had seen when he observed the surgeons doing their 6 a.m. scheduling meetings for those six months.

Each surgeon basically called dibs on a block of time for each week. And certain blocks were highly coveted: 

Eugene Litvak: Every surgeon wanted to do the surgery Monday morning.

Dan: The intensity of the scramble for those times had puzzled Eugene. He asked his partner Mike Long about it.

Eugene Litvak: I said, Mike, I hear they’re fighting for this morning, block times as they would fight for their spouses. And he said, Eugene, you don’t get it. He said they would rather give up their spouses than the morning, Monday, block time. 

Dan: Would rather give up their spouses than Monday morning block times. There were reasons– beyond just wanting the rest of the week clear.

Like: Surgeons wanted to come in and do their best work when they were fresh from the weekend.

They wanted the early-morning slot for the same reason frequent travelers want early flights: Later in the day, your schedule could get delayed because of some problems that happened earlier.

And if you operated on somebody later in the week, they might have to spend the weekend in the hospital. When, yeah, you might get called in to check on them.

But also: hospitals operate with skeleton crews on weekends. Fewer nurses, less staff around for services like physical therapy. 

Surgeons may have been looking out for themselves, Eugene says, but they were also trying to look out for their patients. And failing on both counts.

Eugene Litvak: They’re the first and foremost victim along with their patients of this mismanaged operation. They’re trying to do their best, but, but the system is screwed up.

Dan: And they did NOT want to hear some engineer telling them when they should operate.

Eugene Litvak: I talked to one of the prominent cardiac surgeon, really talented person. And, he told me, Eugene, how dare you are to teach me when I supposed to operate on my patients. Even my patients do not know when they should be operated on. How can you do that? And I said, okay, uh, your point is well taken. May look at your data, talk to your data people. He said, sure. So I talked to the data people. I came back and I said, look, I would like to be your student. As such, I would like to learn what kind of a disease your patients have that manifests itself every Tuesday 

Dan: And how did he respond?

Eugene Litvak: From that point, he avoided talking with me.

Dan: In his book, Mark Taylor reports that resistance like this from surgeons prevented Mass General from actually implementing Eugene Litvak and Mike Long’s recommendations.

Mike Long retired from Mass General in 2000, and Litvak’s consulting contract ended.

But by then they had compiled enough evidence to start publishing their findings in medical journals. And attracting allies in the field.

At Boston University, Litvak set up a tiny research center with big names in medicine on the advisory committee: Like the CEO of the organization that accredits most U.S. hospitals.

Hospitals brought Litvak in to consult — including the Mayo Clinic and Johns Hopkins. Mark Taylor’s book says they undertook limited projects that achieved impressive results –but never expanded.

And then in 2004 a couple of doctors from Cincinnati Children’s Hospital went to one of Litvak’s talks, and came away… impressed. Litvak ended up talking with the hospital’s CEO, Jim Anderson.

Jim Anderson CCH: And I thought this would be a fun adventure to pursue.

Dan: So he did. The adventure they undertook at Cincinnati Children’s remains Eugene Litvak’s biggest success to date. That’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News– that’s a nonprofit newsroom covering health issues in America. Their reporters do amazing work and win all kinds of awards every year. We’re honored to work with them.

As a first step, Cincinnati Children’s Hospital had Eugene Litvak do an evaluation and present recommendations to the lead medical staff.

Eugene Litvak: Vice president, chief of surgery, chief of anesthesia, et cetera, et cetera.

Dan: Eugene’s prescription: Change how you schedule surgeries, spread them out across the week. As he recalls, everybody seemed agreeable, and the CEO Jim Anderson made a proposal on the spot.

Eugene Litvak: So he asked me, Eugene, okay, would you do that for us now to implement what you are preaching for? And I said, no. And he said, how come? I said, because these very people who smile at me would create roadblocks, and I’m not sure I would overcome it. So he look around the room and said, okay, if you face any resistance, you call me directly. He looked at me again and said, would you do it now? I said, absolutely.

Dan: Jim Anderson recalls that part of the exchange a little differently.

Jim Anderson CCH: I remember telling them and said, look, we’re gonna do this anyway. We’d love to have you involved if you’re not. That’s fine. Go away. But, uh, we’re committed.

Dan: However that exchange went, the follow up was real.

With Litvak’s guidance, the hospital reorganized the way it scheduled surgeries– and saved a hundred thirty-seven million dollars a year. They’d been planning to build a hundred-million dollar new tower to increase capacity, but with their new systems, they decided they didn’t need to.

Actually, Jim Anderson told another interviewer: without adding a single bed, the hospital took on more cases, AND wait times for patients went down by 28 percent. Nurses, surgeons, and anesthesiologists reported they were able to take better care of patients.

Jim Anderson says the hospital was making other changes too, but he gives Litvak lots of credit. 

Jim Anderson CCH: Eugene was a wonderful stimulus, to helping us, think outside the box and reorganize and really, uh, be more effective at what we did. 

Dan: And yet, almost twenty years later, he’s had clients here and there. But few institutions have gone as far as Cincinnati Children’s in following Litvak’s advice.

Jim Anderson CCH: It’s been a mystery to me for decades now. I’m astonished by the lack of response. 

Dan: That’s the mystery Mark Taylor stumbled across when he started reading about Eugene Litvak’s work years later. He started calling sources for a reality check.​

Mark Taylor: Most people in the hospital business knew nothing of him, hadn’t heard of him at all. But some of my best sources as a healthcare journalist, told me, you know, this guy is really onto something. and it was like, Jesus, this guy’s right. How come nobody else knows this?

Dan: He started reporting his first story on Litvak for the Chicago Tribune and basically asked Litvak himself: Who are your opponents?

Eugene Litvak: He said, Eugene, I’m health care reporter. I should be objective. You have the names of supporters and coauthors. I would like to know the names of naysayers so I can interview them, and I said, here is what I can do. If you find the one, I owe you a dinner.

Dan: He’s had a lot of time since then. Since that was like what, seven, eight years ago?

Eugene Litvak: Yeah.

Mark Taylor: I talked to well over a hundred sources and I called all kinds of hospital executives, consulting firms, and I couldn’t find anyone who said, a, this doesn’t work. B, his, algorithms are wrong. C this is a fraud. They’re making up details in that.

Dan: So what’s the holdup? In my first conversation with Eugene Litvak, we talked about why more hospitals don’t go with his recommendations– even after they hear about successes at institutions like Cincinnati Children’s.

Eugene Litvak: I’ve been told by other hospital leadership, those are special hospitals. Our hospital is different. Our patients are sicker. Uh, at one hospital, they asked me, it was in South Carolina. They asked me whether I ever implemented that in South Carolina.

Dan: Implemented his idea that by reorganizing surgeries, hospitals can save money and take better care of patients. 

Eugene Litvak: And I said, that’s a management law has nothing to do with the state. And they said, no, no, no, it does. Uh, and I said, then let, let me, I’m curious whether gravitation law works in South Carolina.

Dan: How did they respond to that? 

Eugene Litvak: Uh, people just get angry from some of my comments. 

Dan: Political maneuvering, may not be your strong suit, not to tell you anything you may not have heard before. 

Eugene Litvak: Yeah.

Dan: So I left that conversation with a hypothesis: Maybe this guy just doesn’t have the diplomatic skills for this kind of work.

But when I ran that hypothesis by Mark Taylor, he had a counter-example from Litvak’s work at Cincinnati Children’s Hospital.

The administration was backing him, but they said eventually the various department heads would vote his specific plan up or down– so he needed to secure *yes* votes.

Mark Taylor: He said, Mark, I, I lied a little bit. I would meet with these different constituencies, the orthopedic surgeons, the anesthesiologists, the nurses, the administration, and each one I would go to, I would tell now don’t tell anyone else, but your group is gonna benefit disproportionately from this

Dan: And then — as Eugene told me — the leaders met to vote on his plan.

Eugene Litvak:  So everybody raise his or her hand and look at his peers around with a slight smile. Say, oh guys, I know something you don’t, you know, I benefit more than you.

Dan: Eugene Litvak’s diplomatic skils — or lack thereof — maybe aren’t the whole issue. 

He and his supporters have another hypothesis. 

Namely: It’s hard to change institutions. 

Surgeons are trained to fight for those Monday morning block times– and in hospitals, they have a lot of clout. They bring in patients, and administrators are afraid to cross them.

Here’s one of Eugene Litvak’s most vocal allies

Peter Viccellio: My name is Peter Viccellio. I work at Stony Brook on Long Island, and I’m an. Emergency physician

Peter Viccellio:  and I am in my 48th year of practicing emergency medicine

Dan: Peter’s published big studies with Litvak, goes on conference panels with him.

And he’s got a very long view on medicine and hospitals. Not only has Peter himself been practicing for decades, his dad was a doctor.  Peter used to go with him on house calls when he was a kid. He says in those days

Peter Viccellio: If you had a stroke, you stayed at home. If you had heart attack, you stayed at home. ’cause the hospitals had nothing to offer you. So it made sense to have a hospital nine to five, Monday through Friday with a skeleton crew on evenings, nights, and weekends.

Dan: He’s seen the role of medicine and hospitals change dramatically

Peter Viccellio: When I was in medical school, if you had lupus, you died when you were 18 years old. Now I see 70 year olds with lupus. It’s amazing what I’ve seen. I think when I graduated from medical school, the only cancer that you could really cure was Hodgkin’s Lymphoma. That was it. And there are so many cancers now that can be cured, or at least can be substantially slowed down and contained. So it’s just a dramatic change.

Dan: But even though hospitals do so much more now, they haven’t changed their basic schedule.

Peter Viccellio: We have a seven day a week problem, and we’re still trying to solve it with a five day a week. Solution. And when I say five days a week, I mean eight hours each day of those five days a week. So that’s 24% of the week that we are running full fledged. 

Dan: And just changing the schedules for surgeons wouldn’t be enough– as Peter says a surgeon would tell you.

Peter Viccellio:If you wanna do a hip case on a Thursday or Friday, is there enough physical therapy present on weekends to get the patient up and walking around? Do you have the needed ancillary services and whatnot to get stuff done?

Dan: And he says hiring extra staff for weekends may sound expensive. But…

Peter Viccellio: if you’re doing more stuff on the weekends. But you have the same volume. It means you’re doing less somewhere else. So it’s called redistributing the load.

Dan:And people’s lives get more predictable — less emergency overtime. And according to Eugene Litvak’s modeling, you don’t necessarily need to go twenty-four seven. 

Peter Viccellio: if you went at this for six days a week, so that a Saturday was just like a Tuesday, then you’d get a huge gain.

Dan: But Peter says the old five-day-a-week schedule — and the problems that come with it– aren’t just U.S. phenomena.

Peter Viccellio: I’ve been to Italy and Korea and England and Scotland and all sorts of different places talking about the same exact problems that we have here. 

Dan: So while the capacity of medicine has exploded, the culture of hospitals is entrenched. 

Instead of asking, Why haven’t more hospitals done what Cincinnati Children’s did, it might have been smarter to ask: How did Cincinnati Children’s decide to jump in with both feet?

The answer turns out to be: Jim Anderson, the CEO, had taken a fairly unusual path. Before becoming the CEO, he had never worked for a hospital before.

He’d been a lawyer for most of his career — but had taken a few years out to run a local manufacturing company. While in that job, he joined the board at Children’s — and stayed on it for almost twenty years.

Jim Anderson: I ended up being chairman of the board and we needed a new CEO. And, um, we looked around and I lost control of the search committee and they turned on me and wanted me to do it. And so I agreed.

Dan: That was in 1996. By the time Eugene Litvak came to Children’s, Jim Anderson had been the CEO for ten years. He had been part of the organization’s leadership for a quarter century. 

Jim Anderson: I am much more comfortable, much more comfortable taking risks and pursuing adventures, than the typical medical community.

Dan: And even though he had that outsider’s perspective, he had the insiders’ trust.

Jim Anderson: The presumption was because we all knew each other and had worked together for so long that I wasn’t gonna do crazy things.

Dan: And to Jim Anderson, there was nothing crazy or unfamiliar about operations management. Because like Eugene Litvak — and, as far as he knows, unlike most health care executives — he had worked in industry, in manufacturing. 

Jim Anderson: I mean, if you went out and laid those out as criteria for your next CEO, you’d have a hard time filling it. It’s a lot, a lot of luck involved. 

Dan: Eugene Litvak has continued to attract clients one at a time — a hospital in Toronto, a clinic in New Orleans — and sometimes more. He says he’s currently working with the Canadian province of Alberta.

His ideas haven’t been adopted at that kind of scale in the U.S., but he thinks eventually hospitals will come around. Because they’ll have to. Many of them are in trouble financially. 

Litvak compares hospital CEOs to a guy falling from a skyscraper.

Eugene Litvak: And, in the middle of his fall, he said, oh, where I’m going, but touching his arms and legs are so far so good. 

Dan: Republicans in Congress are talking about cutting hundreds of billions of dollars from Medicaid. That’s a lot less money for hospitals.

Eugene Litvak says the government could save much more by offering hospitals technical support to adopt his program. He couldn’t do it all himself. 

Eugene Litvak: We are a small organization, but we can teach many other big sharks like Optum, Ernst & Young consulting company, Deloitte, McKinsey, how to do that. We could certify them and teach them how to do that. They have thousand, hundred thousand boots on the ground, so you can do that.

Dan: One way or another, he’ll keep at it. He tells me about an exchange with one of his advisory board members, a guy named Bill.

Eugene Litvak: At one of our board meetings, he told me, Eugene, I admire your persistence. And my answer was, Bill, if at one point, you feel like you want to call me an idiot, don’t mince your words.

Dan: If Eugene Litvak is an idiot, I would like to meet a lot more idiots like this.  

Meanwhile: We’ve been working hard on a two part series for next month.  About dealing with the high cost of drugs. 

A while back, we asked you to share your stories about sticker shock at the pharmacy

Listener:  The pharmacist would burst out laughing every time I showed up to pick up the prescription and he saw the charge.

Dan: And we asked you what you’d learned. You came through in a big way. Your responses taught us things we hadn’t understood before. And in our next two episodes, we’ll be sharing it all.

That starts in a few weeks.

Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. 

Our music is by Dave Weiner and Blue Dot Sessions. 

Bea Bosco is our consulting director of operations.

Lynne Johnson is our operations manager.

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America – and a core program at KFF:  an independent source of health policy research, polling, and journalism.

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW — Seattle’s NPR News station. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

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The Host

Julie Rovner
KFF Health News

@jrovner

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Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Cuts to health programs made by the second Trump administration in its first 100 days are already having an impact at the state and local level. And additional reductions under consideration in Congress could have even more far-reaching effects on the nation’s health care system writ large.

In this special episode of “KFF Health News’ ‘What the Health?’” national and local experts join host Julie Rovner for a live conversation at the Association of Health Care Journalists’ annual meeting in Los Angeles. This conversation was taped on Friday, May 30.

Joining Rovner are Rachel Nuzum, senior vice president for policy at The Commonwealth Fund; Berenice Núñez Constant, senior vice president of government relations and civic engagement at AltaMed Health Services; and Anish Mahajan, chief deputy director of the Los Angeles County Department of Public Health.

Panelists

Rachel Nuzum
The Commonwealth Fund

Berenice Núñez Constant
AltaMed Health Services

Anish Mahajan
Los Angeles County Department of Public Health

Click to open the transcript

Transcript: Live From AHCJ: Shock and Awe in Federal Health Policy

[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. We have a special episode today, direct from the annual meeting of the Association of Health Care Journalists in Los Angeles, where I moderated a panel called “Shock and Awe in Federal Health Policy,” featuring some pretty impressive guests. This was taped on Friday, May 30, at 1 p.m. Pacific time. As always, things might have happened by the time you hear this. So, here we go. 

Thank you all for joining us. We have a lot to cover, so I want to dive right in. I’m going to exercise a point of personal privilege for a moment, just to set the stage. In March, I started my 40th year of covering health policy in Washington, D.C. That was not supposed to be an applause line. I can safely say that what we’ve witnessed in terms of sweeping policy change these last four months is like nothing that I have ever seen or experienced before. I spend so much of my time telling editors and other reporters, “Yeah, that’s like what happened in 1993,” or, “Yeah, that’s like what happened in 2005.” But 2025 in terms of health policy is literally witnessing the dismantling of programs that I’ve spent my entire career chronicling the building of. It’s more than a little bit disorienting, to say the least. 

So that is my perspective, but you’re not here to see me. You’re here to see these very smart people around me. We are lucky to have a national expert and two local experts from Southern California. You have their full bios in the conference program, so I’ll just do the short versions. Our D.C. expert next to me here is Rachel Nuzum, senior vice president for policy at the Commonwealth Fund. And to help us get an idea of how this is all playing out on the ground here in Southern California, we’re also joined by Berenice Núñez Constant, senior vice president of government relations and external affairs at AltaMed Health Services, and Anish Mahajan, who’s the chief deputy director of the L.A. County Public Health Department. 

I thought we’d actually divide up this conversation into two parts — what’s happened so far and what the fallout has been from that, and what might happen in the coming weeks or months with the budget reconciliation bill and the rest of the federal budget. I know it’s really confusing with all the headlines about what’s been done and what’s being proposed, so let’s start with what has actually occurred. Rachel, give us the very short version. 

Rachel Nuzum: Sure. Thanks, Julie. Hi, everybody. Thanks so much for having us. Before we get started, I just want to say a little bit about the Commonwealth Fund. So we are a private foundation. We’re based in New York, and we also have an office in D.C. Our focus is making grants and doing our own research to really understand what the implications of some potential policy changes would be. So when we speak on behalf of the Commonwealth Fund, we’re talking about what we know from the evidence. Maybe that’s a state that’s tried a policy before, maybe it’s researchers that have modeled potential implications, but that we’re coming at it from an evidence-based perspective. It’s not an ideological kind of debate. So I just wanted to say that about the fund. A lot of the things that I’ll talk about today we have on our website, including state-by-state data, so that might be helpful for you all as you think about your pieces. 

But to get back to your question, Julie, I would just agree. I’ve also been in D.C. a long time, not quite 40 years, but I was on the Hill in several places. I’ve worked at the state level as well. And I think I would agree. I don’t think we were fully anticipating the sheer amount of the volume, right? We saw executive orders kind of at an unprecedented level. Those were then followed by litigation. So we’ve got, I think, an unprecedented number of cases that are happening right now, which just kind of puts a lot of uncertainty around some of the policies that have been proposed. We’ve seen pretty big HHS [Department of Health and Human Services] reorganizations. We talked a little bit about, in the last panel, a reduction of 20% of federal staff that run really important, critical programs. I think the effects are still being felt and sorted out, how that’s going to play out. 

Obviously, we knew that one of the top priorities would be the tax bill that is pending in Congress right now, and that’s really where a lot of the current policy conversations are happening in Congress. So that has been underway for the past three months, and it’s still going and gearing up for the summer. And a lot of uncertainty about funding and funding freezes. I think we’ve seen some stops and starts in terms of federal funding. So it hasn’t been that long. It’s been a lot of activity, a lot of people trying to get the lay of the land, letting new folks get settled in their positions, and really understanding: What can we take away from the executive orders in terms of policy direction? We’ve seen things like an outline for the skinny budget that also gives us a sense of administration priority, but we’re just over the first-hundred-days mark, and we’ve seen quite a lot of activity so far. 

Rovner: Berenice, how has what’s happened so far impacted your ability to provide the services that you provide? And why don’t you tell everybody what is it you do? 

Berenice Núñez Constant: Absolutely. Good afternoon, and great job on my name. We practiced. You did a great job. So AltaMed Health Services is the largest federally qualified health center in the nation. We serve about 700,000 patients in L.A. and Orange County, employ approaching 5,700-plus employees, providers, nurses, nurse practitioners, and predominantly serve a majority of Latino patients in Southern California on the primary care front, and bringing in a lot of the innovative models and really setting the best practice in a lot of spaces that we are in. 

We come at the work and have always come at the work from a social justice perspective and making sure that the most vulnerable have what they need in order to be successful and healthy. So for us, it has really been a moment of taking a look at how we speak about the programs that we administer and provide every single day. How do we make sure that patients continue to come into the clinic while there is activity happening in the communities and in the local surrounding areas that may be targeting them, their family, their community in a way that we haven’t seen in a while? 

And so what we actually do is really leverage our position as a trusted messenger. We are brick and mortar in these communities. I often say, regardless of what the issue is, whether it’s access to medical care, whether it’s an upcoming election, whether it’s a covid pandemic or a fire, as we had recently, we are that trusted voice and that trusted messenger. And I’m really proud that because of that, we’ve done so much work in this space, for some community health centers, more than 60 years — we’ve been around more than 57. So we thankfully are still not seeing a drastic decline for our appointments coming in, because we’ve done a lot of work to make sure that folks feel that they can come in and access their programs. 

But of course, for us, there are just so many questions. I know for you, there are also a lot of questions, but the questions that we’re hearing every single day from our patients, our communities, are: Am I going to lose my Medi-Cal? I don’t have Medi-Cal. I have Covered California. There’s a lack of understanding in terms of the programs that they qualify for. And then, of course, because we have made such progress here in California with innovative models using promotoras, or community health workers, for example, that started in the community health center as a position, we are also watching things like food benefits and social services and housing supports and all of that, all the way to the local level, while we are also facing a state deficit here in the state of California. And so together, that leaves me with sleepless nights and a lot of questions every single day. But thankfully, because of our role in the community, so far, so good. But we are obviously worried with what’s to come. 

Rovner: We heard early on about FQHCs [federally qualified health centers] not being able to draw down federal payments. Has that been an issue? And has it been resolved? 

Núñez Constant: Initially, right? Initially, I think, we were all in the same boat. We actually received notices that we were not going to be able to do that, so we initiated an immediate kind of emergency proactive drawdown. We were successful in doing that. We all had the same great idea — right? — to advance that request, and so we were able to do that, and we were really thankful for that. Then there have been a lot of questions around grants that we have, given the executive orders. Are they going to be canceled? So far, we really have only had one of our grants impacted out of the CDC [Centers for Disease Control and Prevention], but everything else, thankfully, is still in place, and so we are hopeful that those will stay in place. 

Rovner: Dr. Mahajan, public health has not been so lucky in this, have they? 

Anish Mahajan: Yeah, that’s right, Julie. Thanks so much. It’s a pleasure and honor to represent public health here and the L.A .County Department of Public Health, which works to ensure the health of 10 million Angelenos every day. I’m going to start by saying public health work is nonpartisan, but it’s also not well understood by the public, and I’m so delighted to have a room full of journalists to try to help tell the story. I want to just say a couple words about what public health is. Public health works to keep entire populations healthy. It focuses on things that you think of, like acute infectious diseases, but it also focuses on chronic diseases. It works on preventing heart disease and diabetes and cancer. It looks at environmental toxins, ocean water safety. If you’re going to go for a swim today out in the ocean, you’re glad that we’re testing the ocean water right now to make sure it doesn’t have bacterial overgrowth or other problems. Lots of surfers in L.A. are looking at our reports every single day. 

Public health has a gamut of programs, which is why it’s a hard story to tell. But we have not been fortunate so far, and Julie started with saying: What have the impacts been so far? In public health, unfortunately, we’ve already had some impacts. And I’m going to also say that public health is an essential upstream component of what we spend a lot of our time focusing on, which is health care delivery. All of us go to the doctor, but our goal is to try to stay out of the doctor’s office and work on prevention. And so it’s easier to cut prevention than it is to cut care, and so we’re facing that. 

And so what have we faced so far? We have faced a sort of chaotic immediate rescission of key public health grants nationwide. Example: HIV prevention and STD prevention. The CDC center, division for HIV prevention is proposed to be eliminated. Many of the people who work there no longer, they may be still on the books, but they don’t work anymore. For example, we have a five-year cooperative grant agreement with the CDC for HIV prevention going back decades, and our most recent five-year grant, we’re about to enter our second year starting — day after tomorrow is the start of the second year of this grant. It’s $19 million that comes to us, the local health department, each year, and we use that money to give to our community partners, as we heard from Berenice and many of them out there, who mount HIV testing, education, biomedical kinds of HIV prevention like pre-exposure prophylaxis. I’m sure you’ve heard of this. This is where antiretroviral drugs help prevent the acquisition of HIV among high-risk groups. This funding is critical to do all of this work. 

We simply never received the notice of award for June 1. We still haven’t. We can still hope that over the next 24 to 48 hours we will, but we know we won’t. There was never a notification from the government as to whether we would in fact receive anything or if the program is over. It’s left the entire infrastructure for HIV prevention, not just here in L.A. but across the nation, with a giant question mark of: What are we supposed to do beginning June 1? This is a massive dismantling. Another thing that’s occurred, back in late March, jurisdictions around the country received notices that their CDC grants for Epidemiological and Laboratory Capacity grants, these are called ELC grants, are immediately terminated midstream during their grant period. This meant about $45 million of potential loss to us at L.A. County Department of Public Health. 

We used this money from these grants to pay for outbreak response for infectious diseases in places like jails and schools and other congregate care settings. This money was being used to improve the laboratory capacity of public health so that we could do genomic sequencing better and faster. It was also being used to modernize our data systems so that data could transfer more quickly from the field to the hospital and to other entities that need it so that we can respond timely. The immediate rescission fortunately was taken to court, and there’s currently a preliminary injunction, so the money is still flowing. But it’s sort of senseless to have these kind of immediate rescissions, because so much money has gone into creating these projects of infrastructure, laboratory modernization, computer system modernization, that if you pull the rug out from underneath, you end up having a lot of sunk costs, let alone the lack of those services. And so this has been very difficult and challenging for us. 

Rovner: I want you to talk about — obviously administrations change, administration priorities change, but we’ve never seen this kind of, sort of wholesale, We don’t agree with this so we’re going to stop spending the money, right? 

Núñez Constant: No. Oh my gosh. I’ve realized that, probably, laughing and smiling has become a little bit of a coping mechanism. But, no, we have not. In fact, for the last few decades we’ve really, in this space, have enjoyed really a growth trajectory, right? We’ve been able to expand the benefit model, making it a lot more comprehensive. We’ve been able to put forth innovation, right? When the community health center was once small — the free clinic is what everybody remembers it as a local community free clinic — now there are a lot of us that are really sophisticated, Medi-Cal health care delivery systems. We have become that at AltaMed — right? — because the system has sustained that level of innovation and growth, and so, though, I think it was really kind of more rose-colored glasses at the beginning. 

We got one of our grants canceled immediately out of the CDC. We are expecting that, as of now — right? — no HIV funding coming, and hopefully the state will do something about it in the May revise. I know we will get there, but it is really alarming. We have built this very sophisticated system that is actually producing the outcomes that we have all been working so hard to produce. Our folks are getting healthier. Our folks who didn’t have access to care in a sustainable, consistent way, now they do, all the way from birth to earth as they say, right? And so it has been really amazing, and that is slipping through our fingers as we speak. 

Rovner: So that’s a wonderful segue to actually what I wanted to talk about next, which is what’s potentially coming down the pike. We have this skinny budget for HHS that we’ve seen that proposes pretty dramatic cuts. We keep being told of a possibility of a rescissions package to officially take back some of the money that’s been appropriated. And then of course we have the tax bill. So Rachel, why don’t you sort of give us an idea of what’s on the horizon? 

Nuzum: The tax bill is real. The tax bill is happening, and the tax bill’s concrete. So where we are in the process right now is the House last week passed a piece of legislation that has about a $880 billion cut to Medicaid. I will say that again. It’s an $880 billion cut to Medicaid. Because we just saw some recent polling that showed that 40% of voters, if they know about the bill, they don’t know that there’s Medicaid cuts in there, and there are. It would be the largest reduction of resources, federal resources, for the Medicaid program since its inception. So that’s kind of one key thing to know. 

I think the other thing is there’s a lot of implications for Medicaid, for the beneficiaries, for the families, but a tremendous amount of implications for state and local economies. There’s job loss associated with cuts of this magnitude, and it just kind of goes on and on. We’re talking about community health centers. Forty-five percent of community health centers’ revenue, on average — in some places it’s higher, some places it’s lower — comes from Medicaid, right? So you can’t really talk about these issues in isolation. We’re dealing with rescissions. We’re dealing with changes to the way the Health Resources and Services Administration office that oversees community health centers, how they’re staffed, and we’re also potentially talking about a pretty major cut to the Medicaid program. 

So at the fund, we focus a lot on people’s ability to access care and to afford care. So one of the first things we look at when we’re looking at potential policy implications is: Will this expand or contract access to health care? And with the policies in this bill, we could see as many as 13.7 million people losing coverage. That could take us back to kind of pre-ACA-level cuts. So what I would say is that there is still time. This is going to the Senate next week. The Senate will go through their exercise. They will think about what they need to do to kind of get a bill across the finish line, and then if there are major differences with the House bill, the House will have to vote on it again. So we are maybe in the fifth inning, maybe rounding home and getting ready to start the sixth inning, but there are a lot of implications in this bill. It’s a thousand pages. It came together pretty quickly. So there’s just a lot to kind of … 

Rovner: Those who listened to last week’s “What the Health?” will know that at the last minute there were a lot of changes inserted for the Affordable Care Act [ACA], too. At first it was just this matter of, well, they’re not going to extend these additional subsidies and that will cause a lot of people to be priced out of their coverage. But it’s more than that, right? 

Nuzum: I think we just saw an estimate — we put out a piece last week — 24 million people that have marketplace coverage could see major changes to their plans. That’s above and beyond the people that may lose coverage under the bill. So in general, there is nothing in the reconciliation bill or the budget bill that changes how we’re delivering care, or it doesn’t make health care more affordable. What it does is it shifts costs to the states or to beneficiaries or their families. It is primarily an exercise to reduce the federal resources we’re spending on these programs. The need doesn’t go away. These programs are designed to grow when the economy has a downturn. That’s why they’re called entitlement programs. They grow as they’re needed. And so this is really about reducing the federal share. So again, a much bigger proportion going to states and states feeling that hit as well. 

Rovner: So I want to hear from both of you about what this level of reduction could mean to your ability to continue to do what you do. 

Núñez Constant: So stating the obvious, right? We don’t pay it up front. We will pay it times 10 on the back end. We all understand that, and it really frustrates me when I hear the conversation about savings up front, because it’s not going to be that, and we’ve seen that and we’ve been there before, for community health centers that serve 32 million patients nationally, about 8 million patients here in California. And even though, for example, children — right? — are thankfully not included, we understand that families enroll together, right? We know that there are mixed-status families. We know that if someone is fearful, they’re not going to go, and go access the care regularly as we need them to, as we think about population health and public health and the strides that we need to make. 

But in a very real way, clinics will close. Hospitals, emergency rooms will fill up. Folks will go to the ER for a flu instead of accessing it at a provider, because they no longer have care. Things like a dental benefit here in California that’s being eliminated for the folks with unsatisfactory immigration status, is the new term that we are using, that can lead to what it leads to. We’ve done so much work to make sure that dental care is included as a person’s overall health. And so clinic doors will close. It will shutter the health care delivery system across the country, and we will see folks showing up in the ER for services that they do not need to show up for. And more generally, and I will hand it over to my colleague, there will be implications to public health, and the public health of the most vulnerable communities more disproportionately. 

Mahajan: Yeah, thanks so much. I’ll just mention that Medicaid changes certainly could impact our ability to effectively treat those who are suffering from substance use disorders as well. But in public health, apart from Medicaid we’re looking at the skinny budget and the budget proposal from Congress and the reorganization that was noted at HHS, and the tea leaves are very concerning, extremely concerning. I’m going to give a few examples. Something that’s not in the proposed budget from Congress is the Public Health Emergency Preparedness grant. This is a national grant that supports the emergency preparedness of communities around the country to be ready for things like emerging infectious diseases, things like mpox, Ebola, covid. They also help jurisdictions deal with weather-related events, wildfire like we had here in L.A., earthquakes, floods, and also acts of terrorism, bioterrorism specifically, in medical countermeasures or having the coordinated response you would need in the event of a biological attack to access the stockpiles of medications to help prevent the fallout from the deployment of such things. 

And so, for example, here, these are over $20-, $25 million worth of grants to this jurisdiction here in L.A. County annually. It’s eliminated. It’s not in the budget proposal. There has been rhetoric about it being something called a state’s responsibility. If this were to be eliminated, our ability to coordinate on things like the BioWatch system, which is a system set up by the Department of Homeland Security that monitors the air at major events like the Olympics or the Super Bowl, which we in public health deploy as well as in certain jurisdictions including this one. There are 30 around the nation, but one here in L.A., where there are 30 locations around the city where BioWatch is deployed. And it looks for these things like anthrax, tularemia, and other dangerous biological weapons, and it’s constantly monitored in our public health lab daily. We test for it. This is what the Public Health Emergency Preparedness grant funds, and so it’s an immediate risk to public safety with what we’re seeing in the budget. 

I also want to mention there’s a lot of discussion about cutting the Vaccines for Children’s program and generally support for vaccination in the president’s proposed skinny budget and in Congress’ budget. I just want to remind folks that back in the late ’80s we had a large measles outbreak in the United States. We had 55,000 people infected, some 11,000 hospitalizations, 123 children lost their lives. And what we’ve learned from that in history is that there were mainly Black and brown populations that were having trouble accessing care. The cost of vaccines were too high. Even individuals who were going see the doctor couldn’t get the vaccine. There was vaccine hesitancy. And it led to the Vaccines for Children’s program. And here we are now, and we’re looking at the situation and the sort of undermining of potential funding streams to continue to support the deployment of vaccination, and we are going to see more and more outbreaks. 

At the end of the day, what we see in the proposed budget is a complete decrease in our ability to fund outbreak response. A single person who flies into LAX here, just a few yards from here, who’s discovered to have measles results in hundreds of contact tracing that’s needed. We have specialized experts who go out into the community and figure out who might’ve come into contact with that individual who’s now tested positive for something like measles, and we deploy the testing and the medications and the connection to care. All of this is at risk in what’s being proposed. 

Rovner: So a lot of people think, Well, I’m not on Medicaid, or, I’m not on a marketplace plan, so this isn’t really relevant to me. But what happens to those programs impacts the rest of the health care delivery system. You’ve just given such a wonderful example of how it impacts a public health system. What would it mean to the rest of the health care delivery system if we see cuts of this magnitude? 

Nuzum: I think this is where it just illustrates what a web this all is. If you have safety net hospitals or hospitals in rural areas that are disproportionately dependent on Medicaid and we blow a hole through those budgets, they are more likely to close. We see hospital closures, and I know a lot of you are writing about these issues all across the country, especially in rural areas. Or maybe the hospital’s not closing but the OB wards are closing and you can’t find a place to have a baby in states like Kansas that have lost 17 rural hospitals in the last decade. Those changes will be felt by everyone living in that area kind of regardless of your ability to pay or who your coverage source is. So if a hospital closes, the hospital closes. If providers say, I can’t make it work here, I can’t pay my bills and raise my family, that’s a loss for the entire community. And so I think keeping in mind how connected these pieces are is really critical. 

We also know that programs like Medicaid, direct cuts to those don’t just impact Medicaid families. Thirty percent of Medicaid resources are directed towards Medicare beneficiaries because there are cost-sharing expectations that happen in the Medicare program and Medicaid steps in to be able to help low-income seniors pay for out-of-pocket costs, pay for long-term care. Most of us know it is the default long-term care program in our country, Medicaid, and it’s our default behavioral health, mental health, addiction program in our country. It’s the number one payer for inpatient mental health stays. Everybody knows, I think, how much of a shortage and how difficult it is to find an inpatient bed for mental health services, so just imagine if the largest payer is no longer able to kind of step up. So those are things that are going to be felt by every single person here. We already talked about how these changes in the marketplace and uncertainty around those policies would impact commercial pricing and plans. So it’s just a kind of a domino effect. 

Mahajan: Yeah, I just want to quickly add to that. I think there’s things that Congress has the power to do, and there are things that we just heard from the previous acting CMS [Centers for Medicare & Medicaid Services] administrator on Medicaid waivers. Just to pick up on a point Rachel’s making, we in California rely on a Medicaid waiver for substance use residential treatment that allows us to be paid by Medicaid for institutions that have more than 16 beds, and we’re able to get paid by Medicaid to put a substance use sufferer into those beds, because of a Medicaid waiver. If CMS decides not to continue that waiver when it’s due in 2026 or decides to rescind it, we will suddenly have a sudden drop in the ability to actually house people that are needing housing while they’re receiving substance use care. 

Nuzum: Can I just say one other thing on the waiver point? Even if the waivers are allowed to continue, we have to ask ourselves what will happen and what will states be able to continue to do, again, if we have cuts of this magnitude. So even without kind of ending waivers that have been approved, I’m very worried about some of those voluntary, optional activities that states have taken on through the waiver process. 

Núñez Constant: So my add would be that folks say, I don’t, I’m not impacted. You don’t need Medicaid, but you don’t need Medicaid now. I think it’s important because it’s a safety net program for a reason. And so any changes in any formulas for federal funding or federal matches that states receive, obviously, if there’s a big cut it’s going to cause a budget hole. That will have economic implications to jobs. Those folks that are, and we are already seeing major deficits — city of Los Angeles, monumental deficit. We’re seeing layoffs in different industries already happening, starting with the federal level. So these folks will eventually qualify for Medicaid and really need this program. 

The other thing that I will say is, health care, we produce jobs in communities, very well-paying jobs — nurses, doctors, behavioral health specialists, but even folks like me on the administrative side as well. And we have also done so much work to train the next generation of doctors and nurses and done so much work to get them to come to the community health center, because that’s a whole other conversation. And so we’re going to lose that. All of that infrastructure that is now in place, we’re going to lose. And so when something changes in the future, we’re going to have to rebuild all of that. But also all the investments that we made to date are just going to go away, and that’s really a frustrating part. 

Rovner: It’s obviously not just health care that’s getting shaken up right now in terms of policy. Immigration is a gigantic priority for this administration, both in terms of stopping the inflow and ejecting immigrants already here, including those here legally. That really impacts both health care delivery and public health, right? 

Mahajan: Yeah. No, I think when we think about sort of the approaches that are being taken at the moment, it started with executive orders and it sort of has flown down into policy perspectives about ensuring that federal dollars are not utilized on folks who are — what’s the new— 

Núñez Constant: Unsatisfactory immigration status. 

Mahajan: Thank you. Unsatisfactory immigration status. And I think this is going to be a huge challenge nationwide for us to understand how we maintain continuity of services for people in need to prevent the fallout on individual health, and then certainly the implications on population and public health. 

Núñez Constant: For us, we are in the business of taking care of anyone and everyone who needs care. That is why federally qualified health centers started, received the designation, receive the funding that they do, because we are located in all of the high-need communities across the country to care for some of the most complex patients. And so for us, a health care provider, that is not our business to really get into the status of someone. Where I really worry is where there are proposals now being proposed in this last bill that penalize states who have expanded programs to cover the UIS [unsatisfactory immigration status] population and penalizing and bringing down that federal match. That’s going to be from 90% to 80%, and obviously that’s going to cause another budget hole that we’re going to have to solve for. 

Rovner: All right. Well, I’m sitting here in a room full of health reporters, so I know you guys have questions. If you want to start lining up, there’s a microphone right here. I will ask you to please tell us who you are and where you’re from, and while you’re sort of getting yourselves together, I’m going to ask one more question. Reproductive health hasn’t gotten the headlines that it did before [President Donald] Trump came back to office, but that doesn’t mean it’s not still being affected in a big way. What have we maybe missed looking at all of these other things on the reproductive health front? 

Nuzum: I’m going to sound like a broken record, but Medicaid is a major payer of women’s health services. It’s the number one payer for live births, for births, in this country, and it’s a major cover source for newborns. So again, any changes to Medicaid is going to really impact that. We’ve seen, I think we’re up to 40 states that have decided to move forward and extend Medicaid coverage for women after birth, so the postpartum extension up to 12 months. Again, that’s all through a waiver, which is great. It’s really exciting to see kind of the evidence be reflected in the fact that blue states, red states, purple states, everyone is kind of recognizing that the time for complications or for death, it doesn’t just happen in those first few weeks but it can really extend into that first year. That’s one of those other programs that I am worried about as an optional program for states to take on and do through waivers, again, that if they don’t have the ability and the resources to do that. 

Rovner: In other words, so if the federal government makes them pay a larger share of other Medicaid costs, they’re going to have to cut back on the option. 

Nuzum: Right, and I think there’s a lot of uncertainty around: Where does this leave Title X safety net family planning clinics and services? Again, we still haven’t seen the full skinny budget. So we’ve seen outlines, but what we’ve seen so far is not really encouraging in terms of what would be available for contraceptive coverage or cervical cancer screenings across the country. 

Núñez Constant: I would just add, just one of the callouts were on essential health benefits. We got that out of the Affordable Care Act. Women’s reproductive health became something that we didn’t have to pay copays for, really kind of provided some equity and access there for many women, and so that’s concerning that the “essential health benefit” term is starting to come back up. And then just here in California, we constitutionalized a women’s reproductive right to choose, and some of the proposals that we’re now starting to see here in California are defunding that. We do not provide abortion services. We provide women’s services, reproductive health support, at federally qualified health centers at AltaMed. However, there obviously will be implications just more generally. 

Mahajan: Well, the first thing that came to mind, Julie, with your question was the Women’s Health Initiative and the cancellation for one day by NIH [the National Institutes of Health]. And I’m glad it was only one day. And I think that it raises for us the question of the focus on DEI [diversity, equity, and inclusion], as it were, and the executive orders around it and sort of the policy approaches that are being sort of embedded in the budget proposals around DEI. DEI doesn’t feel really well explained. And when we think about health inequities, my argument would be DEI doesn’t have anything to say about health inequities. Health inequities are a fact, and we see health inequities in Black and brown perinatal morbidity and mortality, and that needs to remain a focus even if federal dollars are utilized for it, and I hope that we can continue to do that. 

Rovner: We have a long line, so please tell us who you are, and please make your question a question. 

Christine Herman: I’m Christine Herman with Illinois Public Media, and I’m on the board of AHCJ. Thank you for being here. We got a little pushback on a question that we had to our former speaker, CMS Deputy Administrator Stephanie Carlton, about Medicaid cuts. And she said it’s not cuts — it’s a reduction in the rate of growth of Medicaid expenses. Is it wrong for us to talk about this in terms of Medicaid cuts? Is that the accurate phrasing? And is there any conceivable way that you see the proposed changes to Medicaid leading to improvements to Medicaid in part or in whole? I’d love to hear your thoughts. Thank you. 

Nuzum: I would say that I think it’s hard to argue with the Congressional Budget Office that shows the reduction in federal spending. We have direct savings mapped to the changes in Medicaid, and it’s about $880 billion in savings over 10 years, and we see the coverage loss associated with that. So I think it’s fair to say that on the federal side we are talking about a pretty massive reduction in resources towards the program. They have to make assumptions about what states do in response, right? And we could have a long conversation about, well, a state could fill the hole or a state could do this or that. It’s hard to see any state being in the position to kind of fully fill that hole, which is why I think it’s more realistic to talk about it as a reduction of federal resources and a shift to the states to really make that determination. 

Núñez Constant: I would add also just the fact that it puts more rigid requirements on things like provider taxes, for example, and how a state utilizes those dollars is also going to be limiting. We use a lot. We receive some, what we call wraparound payments, or some additional payments for quality programs. And so there will be implications if there are reductions to funds, if there are reductions to provider taxes and how we can — or limitations on how we can use them, restrictions. And then penalizing states for certain expansions that they have put in place and literally bringing a match rate from 90 to 80%, for example. And then ultimately whatever happens on women’s health and reproductive health and changes to maybe essential health benefits, programs like HIV services and funding for that. For me, I also agree it’s hard to argue that that’s not a cut when we will see it as less funding ultimately at the state level and local level. 

Mahajan: Yeah, I’ll just quickly add that clearly coverage reductions means a reduction in spending, which is — you can call it a cut, but it’s a reduction in spending. I do want to say, or at least the rhetoric is that it’s about reducing waste, fraud, and abuse at Medicaid. I’m also a primary care doctor, and I took care of patients for 10 years in primary care, many in, basically, in the safety net, in Medicaid and uninsured people. These are working people. Many of them are working people, and those who weren’t working, I can tell you, at least in my experience, were unable to work, for good reasons. I think about the administrative cost of trying to ascertain and document everybody’s work requirements is a cost and just adds to the administrative burden of our insurance programs rather than actually doing what it needs to do, which is expand access to care. 

Nuzum: Can I add one more thing on work requirements? So this is an example of where we have seen states give this a try, so we have real experience and ability to kind of look and see what happened. So Georgia’s a great example. Georgia’s the most recent state to roll out the Georgia Pathways program, which was unique because it both expanded Medicaid and brought the work requirement with it at the same time, right? And so the projections for the Georgia Pathways program was that they were going to enroll a hundred thousand people in the first year and 250,000 total. They spent $26 million to implement the program and to staff up, to put the processes in place. They enrolled 4,500 people in Georgia in the first year. We see in Michigan — they invested $30 million — that they only had the program around for two years before it was struck down. 

But we have real data from states and from folks who have been trying to follow the law and implement some of these programs, and so hopefully as we kind of see some of these policies come back, taking those earlier experiences into consideration, thinking about: If a policy is to move forward, what resources do states and local economies and providers need to actually make this work? States have to balance their budget every year. The federal government does not. So it is not an option for them to take action in these spaces. 

Rovner: So I stayed up all night last week watching the House Rules Committee and then the House itself work through this bill, and I heard from any number of Republicans: But we’re not cutting Medicaid for kids or for pregnant women or for elderly people. It’s just the people who should be working and aren’t. But as you were saying with the maternal health part, that’s not how the Medicaid budget works, right? 

Nuzum: It’s just more interrelated than that. What we know from decades of research, of studying what happens when you give a child continuous Medicaid coverage, is that not only are their childhood health outcomes improved, their educational attainments improved, but their health status in their adult years is better and their earning potential is better, right? So this is the upstream points you were making before that investing in kids — you asked what was different. Medicaid coverage for kids never used to be political, right? We all remember the stories, the Democratic and Republican senators hanging out together talking about the CHIP program [the Children’s Health Insurance Program]. Community health center funding never used to be political. That could be something that you could join hands on, and no one wanted to see this— 

Rovner: NIH funding never used to be political. 

Nuzum: Right? We could go on and on. And so, but the reality is when you start pulling dollars out of the system, you start seeing how fragile these connections are and how connected. 

Mahajan: I just want to add one quick point to the sort of hard-to-reach folks, folks who are homebound and groups that have trouble accessing care in a traditional way. We have funding from the CDC that we hope persists that we’re very worried about, which we’ve dedicated to an experiment here in L.A. called Community Public Health Teams. We’ve taken eight census or eight locations where we see the worst inequities in health outcomes and where people have the hardest access, for a variety of reasons, hardest ability to access health care, even if they’re insured, and we’ve created teams of a federally qualified health center, a community-based organization, and public health professionals, along with community health workers, to really use a Costa Rica public health model to go out there and know the community, engage them, connect them to the services. These other upstream strategies, these strategies to try to get at folks who are really being left behind, the funding for that is even, is clearly, at risk when we’re talking about Medicaid being at risk. 

Maia Anderson: Hi, my name is Maia Anderson. I’m a reporter at Morning Brew. My question is for Dr. Mahajan specifically. With so many of your grants being canceled, I’m curious: What is your department doing to combat that? Are you looking for other sources of funding? Or what kind of work are you doing to combat that? 

Mahajan: Thanks so much for the question. I really appreciate it. I do want to say, the CDC’s budget prior to its proposed cuts, nearly 80% of it goes to state and local health jurisdictions like us. Public health is local, and local health jurisdictions and states have the authority and statute to do public health. At L.A. County Department of Public Health, 50% of our budget is federal dollars. Some jurisdictions it’s as high as 70, 80%. Other jurisdictions may be less, a little less than that. But as we see a closure of funding or reductions, major reductions of funding for public health, there doesn’t appear to be any other places to look to fill the gap. There is a budget crisis here in L.A. city and county. There’s a budget crisis at the state-of-California level, and we are now looking at strategically downsizing our services. It will likely mean workforce reductions and certainly program closures and slower responses to an outbreak of measles coming through LAX, as an example. We may not be able to test the ocean water if these cuts come to pass. 

And so these are very real things that we want our community to know. How are we doing it? We are engaging our community and our stakeholders and explaining to them what we are facing and asking them for their input about what’s most important to do with the limited dollars that we’ll have left. We’re looking at what are the criteria with which we can downsize and reserve whatever money that is in federal to continue it. These are extremely hard choices, and I fear for the public health outcomes that we’re going to see as a result. 

Cassie McGrath: Hi. Good afternoon. My name’s Cassie McGrath. I also work with the Morning Brew. We’re a curious bunch. My question is asking a response to the CMS chief of staff’s proposal that some of the programs that Medicaid currently covers could go to other departments, like the Department of Education funding student loan repayment, things like that. So I’m wondering what your response is to that. How possible is it to reallocate those Medicaid dollars in your eyes and that sort of restructuring? 

Nuzum: There’s a number of places where agencies have been proposed to be cut. The Administration for Children and Families said, We can deliver these services in other areas. I don’t think anyone is arguing that there aren’t any efficiencies in the way the federal government is organized. I do think the Medicaid program is uniquely complicated, with all of the populations that we’ve talked about — from there’s Medicaid in schools, there’s Medicaid for moms and babies, there’s Medicaid for the dual-eligibles. It’s just a very complicated program. And in general, pulling pieces of programs apart and spreading them out doesn’t usually provide a more coordinated, kind of thoughtful response. So that said, I’m sure there are efficiencies within HHS and the rest of the federal government, but thinking about the complexity of the Medicaid program and the populations that all have very different needs, that seems concerning to start pulling it apart. 

Nathan O’Hara: Hi. I’m Nathan O’Hara. I’m a researcher at the University of Maryland. Thank you very much for a very insightful discussion. As a researcher, I’m very concerned about reductions in federal research funding, and you’ve highlighted a number of major health shocks that have started or are potentially coming. I’m curious on your comments on how these reductions in health care research funding are going to influence our ability to understand the magnitude of these changes. 

Nuzum: I think that’s a really great question. My colleague Dave Radley did a workshop this morning, too, on data availability and how important that is. We do a number of our own kind of intramural research pieces at the Commonwealth Fund, too, and we’re very reliant on publicly reported, regularly updated, trustworthy data at the federal level. So first off, I would just say that could and should be a bipartisan place for us all to agree on how important it is to have that data, to know: Are we moving in the right direction on things like maternal mortality? Are we getting in on top of emerging infections before it kind of gets out of hand? So just a major plug for kind of the need for data and really maintaining that, and I know there’s a lot of efforts underway to kind of push on that. 

I think the other signals that are going to universities in terms of research, we also see that as a foundation. A lot of these universities are our research partners. Several of them have research areas that are on pause, or they’re having to kind of halt the work. And so I think it’s going to take some time for us to kind of fully grasp and see the results of some of these reductions. And they’re not all concrete endings of research priorities. There’s a lot of kind of fear about getting it wrong, kind of given some of the executive orders are kind of overstepping. And so it’s a hard time to be doing research, whether you’re at NIH, whether you’re at a university. So I sympathize. I think it’s going to take some time for us to figure out kind where everything lands. 

Rovner: I want to piggyback on that question because it was a question I wanted to ask, which is there seems to be sort of a war on expertise, if you will, both in terms of medical research, in terms of public health, in terms of just health care in general. How much of that is going to influence sort of what happens going forward, just a rejection of evidence? 

Mahajan: Well, I was surprised and shocked at the secretary’s notion that the major medical journals that we look to for the top-line, highest-quality research may not be something he would want to see federal-dollar research being published in, and it was very surprising to me. I look at the MAHA [Make America Healthy Again] report on children’s health that just came out, and there’s a lot in there that’s good that we want to have related to children’s nutrition. Yet we’re looking at SNAP [the Supplemental Nutrition Assistance Program] being ended, and we’re looking at SNAP-Ed, which is a small component of SNAP which is around how we do the education component to vulnerable groups who are behind on nutrition, especially children, on how to eat healthy. And so there is sort of these mixed signals coming, and there’s great research just to know SNAP-Ed works, peer-reviewed research, but I’m not sure that that’s going to win the day anymore, because there doesn’t seem to be an appreciation, widely, about the importance of that expertise. 

Núñez Constant: I would add that on the federally qualified health center front, we really rely on data that designates certain areas as medically underserved or health professional shortage areas, and so that’s where we’re located. And so we are also in the business of the social determinants of health, and we really leverage a lot of the public health data that’s available. And as we look at innovations and opportunities to build out new programs, we really are relying on a lot of these reports that are coming from the federal level. And obviously we’re administered by these federal departments, HRSA being our administrator. And so we need correct data, but also we need to make sure that that data is also reflecting the actual communities and the actual local picture in a very accurate way. 

Lisa Aliferis: Hi. I’m Lisa Aliferis. I’m a longtime former health journalist and now at the California Health Care Foundation. So you talked about the lessons we have from states that instituted work requirements, yet we also heard Stephanie Carlton say that we’ve learned from the experience from those states and the feds will help the states put together better systems so that will be, I guess, easier for people to demonstrate that they’re working. Can you talk about how realistic it is that these better systems can come to pass in the next two to three years that the feds are talking about instituting work requirements? 

Nuzum: What I will say is that if anyone has worked at the state level, you know the state of their IT systems. 

Unidentified speaker: That’s very kind. 

Nuzum: Right? And so they’ve been working with these systems for decades, and regardless of if the resources do materialize, it will take time, to your point. And it’s not just: Do we have an infrastructure for getting the word out? Someone made the analogy a couple days ago — I forget now who, I’ve talked to so many people. What we’re potentially asking Medicaid beneficiaries to do is the equivalent of doing your taxes twice a month. Who of us have access to those documents or the time or the kind of wherewithal? And then, so there’s a really great piece on a man in Georgia who was really excited to get on. He lost his coverage three times in nine months, just from administrative hurdles. They had a system, but he kept getting kicked off the system. So it’s not just having a system in place. That’s a big part of it. But also, how do the beneficiaries interact with that system? Because we know that a lot of the people that are losing coverage or are projected to lose coverage under the work requirements, they’re still eligible, but they’re losing coverage because of the administrative burden. 

Mahajan: Yeah, I’ll just quickly add, leaving even the institution of work requirements out of it, just annually the redetermination, or when somebody’s on Medicaid, or Medi-Cal in California, and they come up on their year and they have to renew, we see such a churn and a loss of people falling off. And then suddenly they can’t get their meds and then they realize. It’s administratively extremely challenging with our systems in place currently, and for a variety of reasons, to maintain these kinds of things for the people who need it most. 

Drew Hawkins: Hello. My name is Drew Hawkins. I cover public health in the Gulf States Newsroom, so I cover Louisiana, Mississippi, and Alabama. Mississippi, Alabama — two non-expansion. Louisiana, an expansion state. I was in [Louisiana’s] District 4 last weekend, Speaker Mike Johnson’s district, and I was talking to a lot of people who are on Medicaid, many of them who didn’t work or worked part time —hairdressers, did some mechanic work — a lot of people I think that could lose coverage. I heard several times Medicaid is really important to them. It’s all they have, some people said. But not this connection that these cuts are happening or could impact them. I’m curious to get y’all’s perspective on what or why that disconnect might exist between a lot of people who have Medicaid coverage but maybe aren’t realizing that this is coming down the line for them. 

Nuzum: Well, that’s why we’re here talking to all of you. We want your help telling the stories. But one of the things we were talking about in the hall, Medicaid can be called something different in every state depending on where you are. So it’s BadgerCare in Wisconsin. It’s Medi-Cal here in California. So one of the easiest things to do, or kind of the low-hanging fruit, is just make sure people know. You can still have Medicaid and have a card that says Aetna, right? So a lot of people don’t potentially know. And then I think just being able to put those real stories in front of them and talk about: What is it that you need? How do you use your benefits? Oh, actually, those are safe because you’re disabled. Or, Those are safe because you are a mom and baby. Or, Those are potentially at risk. So again, just the nature of the complexity of the program, there’s so many different coverage eligibility categories depending on the population. I think just getting really specific and having those conversations like you were doing, just keeping it up. 

Núñez Constant: I would add that there’s a lot of — y’all are doing a really great job at talking about the cuts that are to come. How that’s being translated and, I think, absorbed at a patient level is: Oh no, I’m going to lose my Medicaid. And it’s happened already, right? And so just reminding folks as well that these are proposals, that this is coming maybe, right? It’s being worked out. But also we keep reminding our patients — and our workforce, by the way, because they ask us also: Am I going to lose my job? Is there going to be a reduction in workforce? And we just keep reminding them when something happens that it is a proposal and ultimately that we will let them know. 

But also, I do a lot of work in these communities. Obviously you’ve heard that. Sometimes — right? —these folks need one, two, three, four, five times hearing the same message for them to begin to understand. We all know that these folks are vulnerable. They’re left out of the systems, right? And so these systems are built essentially to lock out sometimes. It’s so complex. There’s language issues. There are cultural issues. And so we continue to do the work, and we understand that when we are serving our patients that it is a much heavier lift and we are going to have to invest resources to get the — make sure it’s in language, make sure they’re getting it one, two, three, four, five times, and make sure that they’re hearing from a trusted messenger. 

So figuring out how you bring the community health center voice forward, the promotoras, the community health workers, the folks who are in the community, in addition to the patients themselves, to share their story. That goes really far for engaging and really educating the communities that we are in. But they won’t open the door, they won’t come and show up, if they really don’t have that trust. So the trusted messengers are really key to any messaging. 

Rovner: All right, well, we are out of time. I want to ask you one very quick question before we go, because this has been so heavy. Is there something, briefly, that keeps you optimistic? OK. 

Nuzum: Man. So what I will say that keeps me optimistic about just kind of what’s happening in Congress is that it feels like every day there’s more understanding and appreciation of kind of what’s in the bill, what’s at stake. We’re finding different ways to talk to different communities about it. And again, this isn’t to kind of raise up one provision over the other, but at the end of the day we want people to understand what’s in the bill, what the potential implications are, and then make informed choices. And I do think there’s an effort going on, in large part thanks to the stories that you all are writing and the data that has been collected, to help shift that narrative. 

Núñez Constant: People are talking about Medicaid, right? When this all started, we were like: Oh no, we are going to be left behind. This is going to be — that voice is not going to emerge in the conversation. And it has become front and center. So the advocacy work that we are doing together is working. Folks are asking the questions, and so I’m really excited about that. And it is actually getting to community, because we receive the questions all the time. And oftentimes, even in our own workforces, folks don’t really understand policy and the implications. And so as these things have rolled out, doctors are engaged. They want to know more. Our nurses want to advocate. Folks want to get involved. 

And to me — right? — I am in the business. In order to do my job every single day, I have to remain hopeful. And it really does give me a lot of hope that we’ve done the work to engage folks that are typically left out, and that folks are seeing this work as meaningful, and that Medicaid has really emerged as a priority program and a safety net program and something that we are all trying to protect and preserve. 

Mahajan: Yeah, I’ll say I am encouraged, maybe not optimistic, but I’m encouraged by advocacy for sure, and I’m also encouraged by the actions that are being taken in court to ensure that we follow a process in how we make decisions about budget in the United States of America. 

Rovner: Well, I want to thank the panel, and I want to thank the audience for your great questions, and thank you, AHCJ. 

OK, that’s our special show for this week. As always, if you have comments or questions, you can write us at whatthehealth@kff.org. Or hit me up on social media, @jrovner on X or @julierovner on Bluesky. We’ll be back in your feed later this week with all the regular news. 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.

Panelists

Anna Edney
Bloomberg News

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Read Anna's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

@sarahkarlin-smith.bsky.social

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned in this week’s podcast:

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

click to open the transcript

Transcript: Bill With Billions in Health Program Cuts Passes House

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

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

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

Alice Miranda Ollstein: Hello. 

Rovner: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

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

Sarah Karlin-Smith: Hello there. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Edney: Right, right. 

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

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

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

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

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

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

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

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

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

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

Rovner: Yeah, California, most notably. 

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

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

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

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

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

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

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

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

Edney: Right. 

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

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

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

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

Ollstein: Multiple nights. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Correct. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mary Ziegler, thanks for joining us again. 

Mary Ziegler: Thanks for having me. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ziegler: Yeah, exactly. 

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

Ziegler: Thanks for having me. 

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Sarah. 

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

Rovner: Alice. 

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

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

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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 narrowly passing a budget resolution this spring foreshadowing major Medicaid cuts, Republicans in Congress are having trouble agreeing on specific ways to save billions of dollars from a pool of funding that pays for the program without cutting benefits on which millions of Americans rely. Moderates resist changes they say would harm their constituents, while fiscal conservatives say they won’t vote for smaller cuts than those called for in the budget resolution. The fate of President Donald Trump’s “one big, beautiful bill” containing renewed tax cuts and boosted immigration enforcement could hang on a Medicaid deal.

Meanwhile, the Trump administration surprised those on both sides of the abortion debate by agreeing with the Biden administration that a Texas case challenging the FDA’s approval of the abortion pill mifepristone should be dropped. It’s clear the administration’s request is purely technical, though, and has no bearing on whether officials plan to protect the abortion pill’s availability.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Maya Goldman of Axios, and Sandhya Raman of CQ Roll Call.

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Anna Edney
Bloomberg News

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Maya Goldman
Axios

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Read Maya's stories

Sandhya Raman
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Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Congressional Republicans are making halting progress on negotiations over government spending cuts. As hard-line House conservatives push for deeper cuts to the Medicaid program, their GOP colleagues representing districts that heavily depend on Medicaid coverage are pushing back. House Republican leaders are eying a Memorial Day deadline, and key committees are scheduled to review the legislation next week — but first, Republicans need to agree on what that legislation says.
• Trump withdrew his nomination of Janette Nesheiwat for U.S. surgeon general amid accusations she misrepresented her academic credentials and criticism from the far right. In her place, he nominated Casey Means, a physician who is an ally of HHS Secretary Robert F. Kennedy Jr.’s and a prominent advocate of the “Make America Healthy Again” movement.
• The pharmaceutical industry is on alert as Trump prepares to sign an executive order directing agencies to look into “most-favored-nation” pricing, a policy that would set U.S. drug prices to the lowest level paid by similar countries. The president explored that policy during his first administration, and the drug industry sued to stop it. Drugmakers are already on edge over Trump’s plan to impose tariffs on drugs and their ingredients.
• And Kennedy is scheduled to appear before the Senate’s Health, Education, Labor and Pensions Committee next week. The hearing would be the first time the secretary of Health and Human Services has appeared before the HELP Committee since his confirmation hearings — and all eyes are on the committee’s GOP chairman, Sen. Bill Cassidy of Louisiana, a physician who expressed deep concerns at the time, including about Kennedy’s stances on vaccines.

Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who co-reported and co-wrote the latest KFF Health News’ “Bill of the Month” installment, about an unexpected bill for what seemed like preventive care. If you have an outrageous, baffling, or infuriating medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: NPR’s “Fired, Rehired, and Fired Again: Some Federal Workers Find They’re Suddenly Uninsured,” by Andrea Hsu. 

Maya Goldman: Stat’s “Europe Unveils $565 Million Package To Retain Scientists, and Attract New Ones,” by Andrew Joseph. 

Anna Edney: Bloomberg News’ “A Former TV Writer Found a Health-Care Loophole That Threatens To Blow Up Obamacare,” by Zachary R. Mider and Zeke Faux. 

Sandhya Raman: The Louisiana Illuminator’s “In the Deep South, Health Care Fights Echo Civil Rights Battles,” by Anna Claire Vollers. 

Also mentioned in this week’s podcast:

• ProPublica’s series “Life of the Mother: How Abortion Bans Lead to Preventable Deaths,” by Kavitha Surana, Lizzie Presser, Cassandra Jaramillo, and Stacy Kranitz, and the winner of the 2025 Pulitzer Prize for public service journalism.
• The New York Times’ “G.O.P. Targets a Medicaid Loophole Used by 49 States To Grab Federal Money,” by Margot Sanger-Katz and Sarah Kliff.
• KFF Health News’ “Seeking Spending Cuts, GOP Lawmakers Target a Tax Hospitals Love to Pay,” by Phil Galewitz.
• Axios’ “Out-of-Pocket Drug Spending Hit $98B in 2024: Report,” by Maya Goldman.

click to open the transcript

Transcript: Cutting Medicaid Is Hard — Even for the GOP

[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 8, 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 a videoconference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Great to be here. 

Rovner: And Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

Rovner: Later in this episode we’ll have my “Bill of the Month” interview with my KFF Health News colleague Lauren Sausser. This month’s patient got preventive care they assumed would be covered by their Affordable Care Act health plan, except it wasn’t. But first, this week’s news. 

We’re going to start on Capitol Hill, where Sandhya is coming directly from, where regular listeners to this podcast will be not one bit surprised that Republicans working on President [Donald] Trump’s one “big, beautiful” budget reconciliation bill are at an impasse over how and how deeply to cut the Medicaid program. Originally, the House Energy and Commerce Committee was supposed to mark up its portion of the bill this week, but that turned out to be too optimistic. Now they’re shooting for next week, apparently Tuesday or so, they’re saying, and apparently that Memorial Day goal to finish the bill is shifting to maybe the Fourth of July? But given what’s leaking out of the closed Republican meetings on this, even that might be too soon. Where are we with these Medicaid negotiations? 

Raman: I would say a lot has been happening, but also a lot has not been happening. I think that anytime we’ve gotten any little progress on knowing what exactly is at the top of the list, it gets walked back. So earlier this week we had a meeting with a lot of the moderates in Speaker [Mike] Johnson’s office and trying to get them on board with some of the things that they were hesitant about, and following the meeting, Speaker Johnson had said that two of the things that have been a little bit more contentious — changing the federal match for the expansion population and instituting per capita caps for states — were off the table. But the way that he phrased it is kind of interesting in that he said stay tuned and that it possibly could change. 

And so then yesterday when we were hearing from the Energy and Commerce Committee, it seemed like these things are still on the table. And then Speaker Johnson has kind of gone back on that and said, I said it was likely. So every time we kind of have any sort of change, it’s really unclear if these things are in the mix, outside the mix. When we pulled them off the table, we had a lot of the hard-line conservatives get really upset about this because it’s not enough savings. So I think any way that you push it with such narrow margins, it’s been difficult to make any progress, even though they’ve been having a lot of meetings this week. 

Rovner: One of the things that surprised me was apparently the Senate Republicans are weighing in. The Senate Republicans who aren’t even set to make Medicaid cuts under their version of the budget resolution are saying that the House needs to go further. Where did that come from? 

Raman: It’s just been a difficult process to get anything across. I mean, in the House side, a lot of it has been, I think, election-driven. You see the people that are not willing to make as many concessions are in competitive districts. The people that want to go a little bit more extreme on what they’re thinking are in much more safe districts. And then in the Senate, I think there’s a lot more at play just because they have longer terms, they have more to work with. So some of the pushback has been from people that it would directly affect their states or if the governors have weighed in. But I think that there are so many things that they do want to get done, since there is much stronger agreement on some of the immigration stuff and the taxes that they want to find the savings somewhere. If they don’t find it, then the whole thing is moot. 

Rovner: So meanwhile, the Congressional Budget Office at the request of Democrats is out with estimates of what some of these Medicaid options would mean for coverage, and it gives lie to some of these Republican claims that they can cut nearly a trillion dollars from Medicaid without touching benefits, right? I mean all of these — and Maya, your nodding. 

Goldman: Yeah. 

Rovner: All of these things would come with coverage losses. 

Goldman: Yeah, I think it’s important to think about things like work requirements, which has gotten a lot of support from moderate Republicans. The only way that that produces savings is if people come off Medicaid as a result. Work requirements in and of themselves are not saving any money. So I know advocates are very concerned about any level of cuts. I talked to somebody from a nursing home association who said: We can’t pick and choose. We’re not in a position to pick and choose which are better or worse, because at this point, everything on the table is bad for us. So I think people are definitely waiting with bated breath there. 

Rovner: Yeah, I’ve heard a lot of Republicans over the last week or so with the talking points. If we’re just going after fraud and abuse then we’re not going to cut anybody’s benefits. And it’s like — um, good luck with that. 

Goldman: And President Trump has said that as well. 

Rovner: That’s right. Well, one place Congress could recoup a lot of money from Medicaid is by cracking down on provider taxes, which 49 of the 50 states use to plump up their federal Medicaid match, if you will. Basically the state levies a tax on hospitals or nursing homes or some other group of providers, claims that money as their state share to draw down additional federal matching Medicaid funds, then returns it to the providers in the form of increased reimbursement while pocketing the difference. You can call it money laundering as some do, or creative financing as others do, or just another way to provide health care to low-income people. 

But one thing it definitely is, at least right now, is legal. Congress has occasionally tried to crack down on it since the late 1980s. I have spent way more time covering this fight than I wish I had, but the combination of state and health provider pushback has always prevented it from being eliminated entirely. If you want a really good backgrounder, I point you to the excellent piece in The New York Times this week by our podcast pals Margot Sanger-Katz and Sarah Kliff. What are you guys hearing about provider taxes and other forms of state contributions and their future in all of this? Is this where they’re finally going to look to get a pot of money? 

Raman: It’s still in the mix. The tricky thing is how narrow the margins are, and when you have certain moderates having a hard line saying, I don’t want to cut more than $500 billion or $600 billion, or something like that. And then you have others that don’t want to dip below the $880 billion set for the Energy and Commerce Committee. And then there are others that have said it’s not about a specific number, it’s what is being cut. So I think once we have some more numbers for some of the other things, it’ll provide a better idea of what else can fit in. Because right now for work requirements, we’re going based on some older CBO [Congressional Budget Office] numbers. We have the CBO numbers that the Democrats asked for, but it doesn’t include everything. And piecing that together is the puzzle, will illuminate some of that, if there are things that people are a little bit more on board with. But it’s still kind of soon to figure out if we’re not going to see draft text until early next week. 

Goldman: I think the tricky thing with provider taxes is that it’s so baked into the way that Medicaid functions in each state. And I think I totally co-sign on the New York Times article. It was a really helpful explanation of all of this, and I would bet that you’ll see a lot of pushback from state governments, including Republicans, on a proposal that makes severe changes to that. 

Rovner: Someday, but not today, I will tell the story of the 1991 fight over this in which there was basically a bizarre dealmaking with individual senators to keep this legal. That was a year when the Democrats were trying to get rid of it. So it’s a bipartisan thing. All right, well, moving on. 

It wouldn’t be a Thursday morning if we didn’t have breaking federal health personnel news. Today was supposed to be the confirmation hearing for surgeon general nominee and Fox News contributor Janette Nesheiwat. But now her nomination has been pulled over some questions about whether she was misrepresenting her medical education credentials, and she’s already been replaced with the nomination of Casey Means, the sister of top [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] aide Calley Means, who are both leaders in the MAHA [“Make America Healthy Again”] movement. This feels like a lot of science deniers moving in at one time. Or is it just me? 

Edney: Yeah, I think that the Meanses have been in this circle, names floated for various things at various times, and this was a place where Casey Means fit in. And certainly she espouses a lot of the views on, like, functional medicine and things that this administration, at least RFK Jr., seems to also subscribe to. But the one thing I’m not as clear on her is where she stands with vaccines, because obviously Nesheiwat had fudged on her school a little bit, and— 

Rovner: Yeah, I think she did her residency at the University of Arkansas— 

Edney: That’s where. 

Rovner: —and she implied that she’d graduated from the University of Arkansas medical school when in fact she graduated from an accredited Caribbean medical school, which lots of doctors go to. It’s not a sin— 

Edney: Right. 

Rovner: —and it’s a perfectly, as I say, accredited medical school. That was basically — but she did fudge it on her resume. 

Edney: Yeah. 

Rovner: So apparently that was one of the things that got her pulled. 

Edney: Right. And the other, kind of, that we’ve seen in recent days, again, is Laura Loomer coming out against her because she thinks she’s not anti-vaccine enough. So what the question I think to maybe be looking into today and after is: Is Casey Means anti-vaccine enough for them? I don’t know exactly the answer to that and whether she’ll make it through as well. 

Rovner: Well, we also learned this week that Vinay Prasad, a controversial figure in the covid movement and even before that, has been named to head the FDA [Food and Drug Administration] Center for Biologics and Evaluation Research, making him the nation’s lead vaccine regulator, among other things. Now he does have research bona fides but is a known skeptic of things like accelerated approval of new drugs, and apparently the biotech industry, less than thrilled with this pick, Anna? 

Edney: Yeah, they are quite afraid of this pick. You could see it in the stocks for a lot of vaccine companies, for some other companies particularly. He was quite vocal and quite against the covid vaccines during covid and even compared them to the Nazi regime. So we know that there could be a lot of trouble where, already, you know, FDA has said that they’re going to require placebo-controlled trials for new vaccines and imply that any update to a covid vaccine makes it a new vaccine. So this just spells more trouble for getting vaccines to market and quickly to people. He also—you mentioned accelerated approval. This is a way that the FDA uses to try to get promising medicines to people faster. There are issues with it, and people have written about the fact that they rely on what are called surrogate endpoints. So not Did you live longer? but Did your tumor shrink? 

And you would think that that would make you live longer, but it actually turns out a lot of times it doesn’t. So you maybe went through a very strong medication and felt more terrible than you might have and didn’t extend your life. So there’s a lot of that discussion, and so that. There are other drugs. Like this Sarepta drug for Duchenne muscular dystrophy is a big one that Vinay Prasad has come out against, saying that should have never been approved, because it was using these kind of surrogate endpoints. So I think biotech’s pretty — thinking they’re going to have a lot tougher road ahead to bring stuff to market. 

Rovner: And I should point out that over the very long term, this has been the continuing struggle at FDA. It’s like, do you protect the public but make people wait longer for drugs or do you get the drugs out and make sure that people who have no other treatments available have something available? And it’s been a constant push and pull. It’s not really been partisan. Sometimes you get one side pushing and the other side pushing back. It’s really nothing new. It’s just the sort of latest iteration of this. 

Edney: Right. Yeah. This is the pendulum swing, back to the Maybe we need to be slowing it down side. It’s also interesting because there are other discussions from RFK Jr. that, like, We need to be speeding up approvals and Trump wants to speed up approvals. So I don’t know where any of this will actually come down when the rubber meets the road, I guess. 

Rovner: Sandhya and Maya, I see you both nodding. Do you want to add something? 

Raman: I think this was kind of a theme that I also heard this week in the — we had the Senate Finance hearing for some of the HHS [Department of Health and Human Services] nominees, and Jim O’Neill, who’s one of the nominees, that was something that was brought up by Finance ranking member Ron Wyden, that some of his past remarks when he was originally considered to be on the short list for FDA commissioner last Trump administration is that he basically said as long as it’s safe, it should go ahead regardless of efficacy. So those comments were kind of brought back again, and he’s in another hearing now, so that might come up as an issue in HELP [the Senate Committee on Health, Education, Labor and Pensions] today. 

Rovner: And he’s the nominee for deputy secretary, right? Have to make sure I keep all these things straight. Maya, you wanting to add something? 

Goldman: Yeah, I was just going to say, I think there is a divide between these two philosophies on pharmaceuticals, and my sense is that the selection of Prasad is kind of showing that the anti-accelerated-approval side is winning out. But I think Anna is correct that we still don’t know where it’s going to land. 

Rovner: Yes, and I will point out that accelerated approval first started during AIDS when there was no treatments and basically people were storming the — literally physically storming — the FDA, demanding access to AIDS drugs, which they did finally get. But that’s where accelerated approval came from. This is not a new fight, and it will continue. 

Turning to abortion, the Trump administration surprised a lot of people this week when it continued the Biden administration’s position asking for that case in Texas challenging the abortion pill to be dropped. For those who’ve forgotten, this was a case originally filed by a bunch of Texas medical providers demanding the judge overrule the FDA’s approval of the abortion pill mifepristone in the year 2000. The Supreme Court ruled the original plaintiff lacked standing to sue, but in the meantime, three states —Missouri, Idaho, and Kansas — have taken their place as plaintiffs. But now the Trump administration points out that those states have no business suing in the Northern District of Texas, which kind of seems true on its face. But we should not mistake this to think that the Trump administration now supports the current approval status of the abortion bill. Right, Sandhya? 

Raman: Yeah, I think you’re exactly right. It doesn’t surprise me. If they had allowed these three states, none of which are Texas — they shouldn’t have standing. And if they did allow them to, that would open a whole new can of worms for so many other cases where the other side on so many issues could cherry-pick in the same way. And so I think, I assume, that this will come up in future cases for them and they will continue with the positions they’ve had before. But this was probably in their best interest not to in this specific one. 

Rovner: Yeah. There are also those who point out that this could be a way of the administration protecting itself. If it wants to roll back or reimpose restrictions on the abortion pill, it would help prevent blue states from suing to stop that. So it serves a double purpose here, right? 

Raman: Yeah. I couldn’t see them doing it another way. And even if you go through the ruling, the language they use, it’s very careful. It’s not dipping into talking fully about abortion. It’s going purely on standing. Yeah. 

Rovner: There’s nothing that says, We think the abortion pill is fine the way it is. It clearly does not say that, although they did get the headlines — and I’m sure the president wanted — that makes it look like they’re towing this middle ground on abortion, which they may be but not necessarily in this case. 

Well, before we move off of reproductive health, a shoutout here to the incredible work of ProPublica, which was awarded the Pulitzer Prize for public service this week for its stories on women who died due to abortion bans that prevented them from getting care for their pregnancy complications. Regular listeners of the podcast will remember that we talked about these stories as they came out last year, but I will post another link to them in the show notes today. 

OK, moving on. There’s even more drug price news this week, starting with the return of, quote, “most favored nation” drug pricing. Anna, remind us what this is and why it’s controversial. 

Edney: Yeah. So the idea of most favored nation, this is something President Trump has brought up before in his first administration, but it creates a basket, essentially, of different prices that nations pay. And we’re going to base ours on the lowest price that is paid for— 

Rovner: We’re importing other countries’— 

Edney: —prices. 

Rovner: —price limits. 

Edney: Yeah. Essentially, yes. We can’t import their drugs, but we can import their prices. And so the goal is to just basically piggyback off of whoever is paying the lowest price and to base ours off of that. And clearly the drug industry does not like this and, I think, has faced a number of kind of hits this week where things are looming that could really come after them. So Politico broke that news that Trump is going to sign or expected to sign an executive order that will direct his agencies to look into this most-favored-nation effort. And it feels very much like 2.0, like we were here before. And it didn’t exactly work out, obviously. 

Rovner: They sued, didn’t they? The drug industry sued, as I recall. 

Edney: Yeah, I think you’re right. Yes. 

Goldman: If I’m remembering— 

Rovner: But I think they won. 

Goldman: If I’m remembering correctly, it was an Administrative Procedure Act lawsuit though, right? So— 

Rovner: It was. Yes. It was about a regulation. Yes. 

Goldman: —who knows what would happen if they go through a different procedure this time. 

Rovner: So the other thing, obviously, that the drug industry is freaked out about right now are tariffs, which have been on again, off again, on again, off again. Where are we with tariffs on — and it’s not just tariffs on drugs being imported. It’s tariffs on drug ingredients being imported, right? 

Edney: Yeah. And that’s a particularly rough one because many ingredients are imported, and then some of the drugs are then finished here, just like a car. All the pieces are brought in and then put together in one place. And so this is something the Trump administration has began the process of investigating. And PhRMA [Pharmaceutical Research and Manufacturers of America], the trade group for the drug industry, has come out officially, as you would expect, against the tariffs, saying that: This will reduce our ability to do R&D. It will raise the price of drugs that Americans pay, because we’re just going to pass this on to everyone. And so we’re still in this waiting zone of seeing when or exactly how much and all of that for the tariffs for pharma. 

Rovner: And yet Americans are paying — already paying — more than they ever have. Maya, you have a story just about that. Tell us. 

Goldman: Yeah, there was a really interesting report from an analytics data firm that showed the price that Americans are paying for prescriptions is continuing to climb. Also, the number of prescriptions that Americans are taking is continuing to climb. It certainly will be interesting to see if this administration can be any more successful. That report, I don’t think this made it into the article that I ended up writing, but it did show that the cost of insulin is down. And that’s something that has been a federal policy intervention. We haven’t seen a lot of the effects yet of the Medicare drug price negotiations, but I think there are signs that that could lower the prices that people are paying. So I think it’s interesting to just see the evolution of all of this. It’s very much in flux. 

Rovner: A continuing effort. Well, we are now well into the second hundred days of Trump 2.0, and we’re still learning about the cuts to health and health-related programs the administration is making. Just in this week’s rundown are stories about hundreds more people being laid off at the National Cancer Institute, a stop-work order at the National Institute of Allergy and Infectious Diseases research lab at Fort Detrick, Maryland, that studies Ebola and other deadly infectious diseases, and the layoff of most of the remaining staff at the National Institute for Occupational Safety and Health. 

A reminder that this is all separate from the discretionary-spending budget request that the administration sent up to lawmakers last week. That document calls for a 26% cut in non-mandatory funding at HHS, meaning just about everything other than Medicare and Medicaid. And it includes a proposed $18 billion cut to the NIH [National Institutes of Health] and elimination of the $4 billion Low Income Home Energy Assistance Program, which helps millions of low-income Americans pay their heating and air conditioning bills. Now, this is normally the part of the federal budget that’s deemed dead on arrival. The president sends up his budget request, and Congress says, Yeah, we’re not doing that. But this at least does give us an idea of what direction the administration wants to take at HHS, right? What’s the likelihood of Congress endorsing any of these really huge, deep cuts? 

Raman: From both sides— 

Rovner: Go ahead, Sandhya. 

Raman: It’s not going to happen, and they need 60 votes in the Senate to pass the appropriations bills. I think that when we’re looking in the House in particular, there are a lot of things in what we know from this so-called skinny budget document that they could take up and put in their bill for Labor, HHS, and Education. But I think the Senate’s going to be a different story, just because the Senate Appropriations chair is Susan Collins and she, as soon as this came out, had some pretty sharp words about the big cuts to NIH. They’ve had one in a series of two hearings on biomedical research. Concerned about some of these kinds of things. So I cannot necessarily see that sharp of a cut coming to fruition for NIH, but they might need to make some concessions on some other things. 

This is also just a not full document. It has some things and others. I didn’t see any to FDA in there at all. So that was a question mark, even though they had some more information in some of the documents that had leaked kind of earlier on a larger version of this budget request. So I think we’ll see more about how people are feeling next week when we start having Secretary Kennedy testify on some of these. But I would not expect most of this to make it into whatever appropriations law we get. 

Goldman: I was just going to say that. You take it seriously but not literally, is what I’ve been hearing from people. 

Edney: We don’t have a full picture of what has already been cut. So to go in and then endorse cutting some more, maybe a little bit too early for that, because even at this point they’re still bringing people back that they cut. They’re finding out, Oh, this is actually something that is really important and that we need, so to do even more doesn’t seem to make a lot of sense right now. 

Rovner: Yeah, that state of disarray is purposeful, I would guess, and doing a really good job at sort of clouding things up. 

Goldman: One note on the cuts. I talked to someone at HHS this week who said as they’re bringing back some of these specialized people, in order to maintain the legality of, what they see as the legality of, the RIF [reduction in force], they need to lay off additional people to keep that number consistent. So I think that is very much in flux still and interesting to watch. 

Rovner: Yeah, and I think that’s part of what we were seeing this week is that the groups that got spared are now getting cut because they’ve had to bring back other people. And as I point out, I guess, every week, pretty much all of this is illegal. And as it goes to courts, judges say, You can’t do this. So everything is in flux and will continue. 

All right, finally this week, Health and Human Services Secretary Robert F. Kennedy Jr., who as of now is scheduled to appear before the Senate Health, Education, Labor, and Pensions Committee next week to talk about the department’s proposed budget, is asking CDC [the Centers for Disease Control and Prevention] to develop new guidance for treating measles with drugs and vitamins. This comes a week after he ordered a change in vaccine policy you already mentioned, Anna, so that new vaccines would have to be tested against placebos rather than older versions of the vaccine. These are all exactly the kinds of things that Kennedy promised health committee chairman Bill Cassidy he wouldn’t do. And yet we’ve heard almost nothing from Cassidy about anything the secretary has said or done since he’s been in office. So what do we expect to happen when they come face-to-face with each other in front of the cameras next week, assuming that it happens? 

Edney: I’m very curious. I don’t know. Do I expect a senator to take a stand? I don’t necessarily, but this— 

Rovner: He hasn’t yet. 

Edney: Yeah, he hasn’t yet. But this is maybe about face-saving too for him. So I don’t know. 

Rovner: Face-saving for Kennedy or for Cassidy? 

Edney: For Cassidy, given he said: I’m going to keep an eye on him. We’re going to talk all the time, and he is not going to do this thing without my input. I’m not sure how Cassidy will approach that. I think it’ll be a really interesting hearing that we’ll all be watching. 

Rovner: Yes. And just little announcement, if it does happen, that we are going to do sort of a special Wednesday afternoon after the hearing with some of our KFF Health News colleagues. So we are looking forward to that hearing. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast KFF Health News’ Lauren Sausser, who co-reported and wrote the latest KFF Health News “Bill of the Month.” Lauren, welcome back. 

Lauren Sausser: Thank you. Thanks for having me. 

Rovner: So this month’s patient got preventive care, which the Affordable Care Act was supposed to incentivize by making it cost-free at the point of service — except it wasn’t. Tell us who the patient is and what kind of care they got. 

Sausser: Carmen Aiken is from Chicago. Carmen uses they/them pronouns. And Carmen made an appointment in the summer of 2023 for an annual checkup. This is just like a wellness check that you are very familiar with. You get your vaccines updated. You get your weight checked. You talk to your doctor about your physical activity and your family history. You might get some blood work done. Standard stuff. 

Rovner: And how big was the bill? 

Sausser: The bill ended up being more than $1,400 when it should, in Carmen’s mind, have been free. 

Rovner: Which is a lot. 

Sausser: A lot. 

Rovner: I assume that there was a complaint to the health plan and the health plan said, Nope, not covered. Why did they say that? 

Sausser: It turns out that alongside with some blood work that was preventive, Carmen also had some blood work done to monitor an ongoing prescription. Because that blood test is not considered a standard preventive service, the entire appointment was categorized as diagnostic and not preventive. So all of these services that would’ve been free to them, available at no cost, all of a sudden Carmen became responsible for. 

Rovner: So even if the care was diagnostic rather than strictly preventive — obviously debatable — that sounds like a lot of money for a vaccine and some blood test. Why was the bill so high? 

Sausser: Part of the reason the bill was so high was because Carmen’s blood work was sent to a hospital for processing, and hospitals, as you know, can charge a lot more for the same services. So under Carmen’s health plan, they were responsible for, I believe it was, 50% of the cost of services performed in an outpatient hospital setting. And that’s what that blood work fell under. So the charges were high. 

Rovner: So we’ve talked a lot on the podcast about this fight in Congress to create site-neutral payments. This is a case where that probably would’ve made a big difference. 

Sausser: Yeah, it would. And there’s discussion, there’s bipartisan support for it. The idea is that you should not have to pay more for the same services that are delivered at different places. But right now there’s no legislation to protect patients like Carmen from incurring higher charges. 

Rovner: So what eventually happened with this bill? 

Sausser: Carmen ended up paying it. They put it on a credit card. This was of course after they tried appealing it to their insurance company. Their insurance company decided that they agreed with the provider that these services were diagnostic, not preventive. And so, yeah, Carmen was losing sleep over this and decided ultimately that they were just going to pay it. 

Rovner: And at least it was a four-figure bill and not a five-figure bill. 

Sausser: Right. 

Rovner: What’s the takeaway here? I imagine it is not that you should skip needed preventive/diagnostic care. Some drugs, when you’re on them, they say that you should have blood work done periodically to make sure you’re not having side effects. 

Sausser: Right. You should not skip preventive services. And that’s the whole intent behind this in the ACA. It catches stuff early so that it becomes more treatable. I think you have to be really, really careful and specific when you’re making appointments, and about your intention for the appointment, so that you don’t incur charges like this. I think that you can also be really careful about where you get your blood work conducted. A lot of times you’ll see these signs in the doctor’s office like: We use this lab. If this isn’t in-network with you, you need to let us know. Because the charges that you can face really vary depending on where those labs are processed. So you can be really careful about that, too. 

Rovner: And adding to all of this, there’s the pending Supreme Court case that could change it, right? 

Sausser: Right. The Supreme Court heard oral arguments. It was in April. I think it was on the 21st. And it is a case that originated out in Texas. There is a group of Christian businesses that are challenging the mandate in the ACA that requires health insurers to cover a lot of these preventive services. So obviously we don’t have a decision in the case yet, but we’ll see. 

Rovner: We will, and we will cover it on the podcast. Lauren Sausser, thank you so much. 

Sausser: Thank you. 

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

Goldman: My extra credit is from Stat. It’s called “Europe Unveils $565 Million Package To Retain Scientists, and Attract New Ones,” by Andrew Joseph. And I just think it’s a really interesting evidence point to the United States’ losses, other countries’ gain. The U.S. has long been the pinnacle of research science, and people flock to this country to do research. And I think we’re already seeing a reversal of that as cuts to NIH funding and other scientific enterprises is reduced. 

Rovner: Yep. A lot of stories about this, too. Anna. 

Edney: So mine is from a couple of my colleagues that they did earlier this week. “A Former TV Writer Found a Health-Care Loophole That Threatens To Blow Up Obamacare.” And I thought it was really interesting because it had brought me back to these cheap, bare-bones plans that people were allowed to start selling that don’t meet any of the Obamacare requirements. And so this guy who used to, in the ’80s and ’90s, wrote for sitcoms — “Coach” or “Night Court,” if anyone goes to watch those on reruns. But he did a series of random things after that and has sort of now landed on selling these junk plans, but doing it in a really weird way that signs people up for a job that they don’t know they’re being signed up for. And I think it’s just, it’s an interesting read because we knew when these things were coming online that this was shady and people weren’t going to get the coverage they needed. And this takes it to an extra level. They’re still around, and they’re still ripping people off. 

Rovner: Or as I’d like to subhead this story: Creative people think of creative things. 

Edney: “Creative” is a nice word. 

Rovner: Sandhya. 

Raman: So my pick is “In the Deep South, Health Care Fights Echo Civil Rights Battles,” and it’s from Anna Claire Vollers at the Louisiana Illuminator. And her story looks at some of the ties between civil rights and health. So 2025 is the 70th anniversary of the bus boycott, the 60th anniversary of Selma-to-Montgomery marches, the Voting Rights Act. And it’s also the 60th anniversary of Medicaid. And she goes into, Medicaid isn’t something you usually consider a civil rights win, but health as a human right was part of the civil rights movement. And I think it’s an interesting piece. 

Rovner: It is an interesting piece, and we should point out Medicare was also a huge civil rights, important piece of law because it desegregated all the hospitals in the South. All right, my extra credit this week is a truly infuriating story from NPR by Andrea Hsu. It’s called “Fired, Rehired, and Fired Again: Some Federal Workers Find They’re Suddenly Uninsured.” And it’s a situation that if a private employer did it, Congress would be all over them and it would be making huge headlines. These are federal workers who are trying to do the right thing for themselves and their families but who are being jerked around in impossible ways and have no idea not just whether they have jobs but whether they have health insurance, and whether the medical care that they’re getting while this all gets sorted out will be covered. It’s one thing to shrink the federal workforce, but there is some basic human decency for people who haven’t done anything wrong, and a lot of now-former federal workers are not getting it at the moment. 

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 if you left us a review. That helps other people find us, too. Thanks as always to our editor, Emmarie Huetteman, and our producer, Francis Ying. Also, as always, you can email us your comments or questions, We’re at whatthehealth@kff.org, or you can still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Sandhya? 

Raman: I’m on X, @SandhyaWrites, and also on Bluesky, @SandhyaWrites at Bluesky. 

Rovner: Anna. 

Edney: X and Bluesky, @annaedney. 

Rovner: Maya. 

Goldman: I am on X, @mayagoldman_. Same on Bluesky and also increasingly on LinkedIn. 

Rovner: All right, we’ll be back in your feed next week. Until then, be healthy. 

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