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.

The Senate has passed — and sent back to the House — a bill that would allow the Trump administration to claw back some $9 billion in previously approved funding for foreign aid and public broadcasting. But first, senators removed from the bill a request to cut funding for the President’s Emergency Plan for AIDS Relief, President George W. Bush’s international AIDS/HIV program. The House has until Friday to approve the bill, or else the funding remains in place.

Meanwhile, a federal appeals court has ruled that West Virginia can ban the abortion pill mifepristone despite its approval by the Food and Drug Administration. If the ruling is upheld by the Supreme Court, it could allow states to limit access to other FDA-approved drugs.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

@joannekenen.bsky.social

Read Joanne's bio.

Shefali Luthra
The 19th

@shefali.bsky.social

Read Shefali's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

@SandhyaWrites.bsky.social

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• The Senate approved the Trump administration’s cuts to foreign aid and public broadcasting, a remarkable yielding of congressional spending power to the president. Before the vote, Senate GOP leaders removed President Donald Trump’s request to cut PEPFAR, sparing the funding for that global health effort, which has support from both parties.
• Next Congress will need to pass annual appropriations bills to keep the government funded, but that is expected to be a bigger challenge than the recent spending fights. Appropriations bills need 60 votes to pass in the Senate, meaning Republican leaders will have to make bipartisan compromises. House leaders are already delaying health spending bills until the fall, saying they need more time to work out deals — and those bills tend to attract culture-war issues that make it difficult to negotiate across the aisle.
• The Trump administration is planning to destroy — rather than distribute — food, medical supplies, contraceptives, and other items intended for foreign aid. The plan follows the removal of workers and dismantling of aid infrastructure around the world, but the waste of needed goods the U.S. government has already purchased is expected to further erode global trust.
• And soon after the passage of Trump’s tax and spending law, at least one Republican is proposing to reverse the cuts the party approved to health programs — specifically Medicaid. It’s hardly the first time lawmakers have tried to change course on their own policies, though time will tell whether it’s enough to mitigate any political (or actual) damage from the law.

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’ “UnitedHealth’s Campaign to Quiet Critics,” by David Enrich.

Joanne Kenen: The New Yorker’s “Can A.I. Find Cures for Untreatable Diseases — Using Drugs We Already Have?” by Dhruv Khullar.

Shefali Luthra: The New York Times’ “Trump Official Accused PEPFAR of Funding Abortions in Russia. It Wasn’t True,” by Apoorva Mandavilli.

Sandhya Raman: The Nation’s “‘We’re Creating Miscarriages With Medicine’: Abortion Lessons from Sweden,” by Cecilia Nowell.

Also mentioned in this week’s podcast:

• The Atlantic’s “The Trump Administration Is About To Incinerate 500 Tons of Emergency Food,” by Hana Kiros.
• KFF Health News’ “Vested Interests. Influence Muscle. At RFK Jr.’s HHS, It’s Not Pharma. It’s Wellness,” by Stephanie Armour.
• The Washington Post’s “A Clinic Blames Its Closing on Trump’s Medicaid Cuts. Patients Don’t Buy It,” by Hannah Knowles.

Click to open the transcript

Transcript: The Senate Saves PEPFAR Funding — For Now

[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 17, 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 Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Hello, everyone. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

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

Joanne Kenen: Hi, everybody. 

Rovner: No interview this week, but more than enough news. So we will get right to it. 

We’re going to start on Capitol Hill, where in the very wee hours of Thursday morning, the Senate approved the $9 billion package of rescissions of money already appropriated. It was largely for foreign aid and the Corporation for Public Broadcasting, which oversees NPR and PBS. Now, this bill represents pennies compared to the entire federal budget and even to the total of dollars that are appropriated every year, but it’s still a big deal because it’s basically Congress ceding more of its spending power back to the president. And even this small package was controversial. Before even bringing it to the floor, senators took out the rescission of funds for PEPFAR [the President’s Emergency Plan for AIDS Relief], the bipartisanly popular international AIDS/HIV program begun under President George W. Bush. So now it has to go back to the House, and the clock on this whole process runs out on Friday. Sandhya, what’s likely to happen next? 

Raman: I think that the House has been more amenable. They got this through quicker, but if you look— 

Rovner: By one vote. 

Raman: Yeah. But I think if you look at what else has been happening in the House this week that isn’t in the health sphere, they’ve been having issues getting other things done, because of some pushback from the Freedom Caucus, who’s been kind of stalling the votes and having them to go back. And other things that should have been smoother are taking a lot longer and having a lot more issues. So it’s more difficult to say without seeing how all of that plays out, if those folks are going to make a stink again about something here because some of this money was taken out. It’s a work in progress this week in the House. 

Rovner: Yeah, that’s a very kind way to put it. The House has basically been stalled for the last 24 hours over, as you say, many things, completely unrelated, but there is actually a clock ticking on this. They had 45 days from when the administration sent up this rescission request, and we’re now on Day 43 because Congress is the world’s largest group of high school students that never do anything until the last minute. So Democrats warned that this bill represents yet another dangerous precedent. They reached a bipartisan agreement on this year of spending bills in the spring, and this basically rolls at least some of that back using a straight party-line vote. What does this bode for the rest of Congress’ appropriations work for the fiscal year that starts in just a couple of months? 

Raman: I think that the sense has been that once this goes through, I think a lot of people have just been assuming that it’ll take time but that things will get passed on rescissions. It really puts a damper on the bipartisan appropriations process, and it’s going to make it a lot harder to get people to come to the table. So earlier this week we had the chair of the Appropriations Committee and the chair of the Labor, HHS [Health and Human Services], Education subcommittee in the House say that the health appropriations they were going to do next week for the House are going to get pushed back until September because they’re not ready. And I think that health is also one of the hardest ones to get through. There’s a lot more controversial stuff. It’s setting us up to go, kind of like usual at this point, for another CR [continuing resolution], because it’s going to be a really short timeline before the end of the fiscal year. But if you look at some— 

Rovner: Every year they say they’re going to do the spending bills separately, and every year they don’t. 

Raman: Yeah, and I think if you look at how they’ve been approaching some of the things that have been generally a little bit less controversial and how much pushback and how much more difficulties they’ve been having with that, even this week, I think that it’s going to be much more difficult to get that done. And the rescissions, pulling back on Congress’ power of the purse, is not going to make that any easier. 

Rovner: I think what people don’t appreciate, and I don’t think I appreciated it either until this came up, is that the rescissions process is part of the budget act, which is one of these things that Congress can do on an expedited basis in the Senate with just a straight majority. But the regular appropriations bills, unlike the budget reconciliation bill that we just did, need 60 votes. They can be filibustered. So the only way to get appropriations done is on a bipartisan basis, and yet they’re using this rather partisan process to take back some of the deal that they made. The Democrats keep saying it, and everybody’s like, Oh, process, process. But that actually could be a gigantic roadblock, to stopping everything in its tracks, right? 

Raman: I really think so. And if you look at who are the two Republicans in the Senate that voted against the rescissions, one of them is the Senate Appropriations chair, Susan Collins. And throughout this, one of her main concerns was when we still had the PEPFAR in there. But it just takes back her power as the highest-ranking appropriator in the Senate to do it through this process, especially when she wasn’t in favor of the rescissions package. 

So it’s going to make things, I think, a lot more complicated, and one of her concerns throughout has just been that there wasn’t enough information. She was pulling out examples of rescissions in the past and how it was kind of a different process. They were really briefed on why this was necessary. And it was just different now. So I think what happens with appropriations and how long it’ll take this year is going to be interesting to watch. 

Rovner: And it’s worth remembering that it’s when the appropriations don’t happen that the government shuts down. So, but that doesn’t happen until October. Well, separately we learned that — oh, go ahead, Joanne. 

Kenen: There’s also sort of a whole new wrinkle, is that rescissions is, if you’re a Republican and you don’t like something and you end up, to avoid a government shutdown or whatever reason, you end up having to vote for a bill, you just have the president put out a statement saying, If this goes through, I’m going to cut it afterwards. And then the Republican who doesn’t like it can give a floor speech saying, I’m voting for it because I like this in it and I know that the president’s going to take care of that. It really — appropriations is always messy, but there’s this whole unknown. The constitutional balance of who does what in the American government is shifting. And at the end of the day, the only thing we do know after both the first term and what’s happened so far even more so in the second term, is what [President Donald] Trump wants, Trump tends to get. 

So, Labor-H [the appropriations for Labor, HHS, Education and related agencies], like Sandhya just pointed out, the health bill is one of the hardest because there’s so much culture-war stuff in it. But, although, the Supreme Court has put some of that off the table. But I just don’t know how things play out in the current dynamic, which is unprecedented. 

Rovner: And of course, Labor-HHS also has the Department of Education in it. 

Kenen: The former Department of Education. 

Rovner: To say, which is in the process of being dismantled. So that’s going to make that even more controversial this year. Moving back to the present, separately we learned this week that the administration plans to spend hundreds of thousands of dollars of taxpayer money to destroy stocks of food and contraceptives and other medical devices rather than distribute them through some of the international aid programs that they’re canceling. Now, in the case of an estimated 500 tons of high-energy biscuits bought by USAID [the U.S. Agency for International Development] at the end of the Biden administration, you can almost understand it because they’re literally about to expire next week. According to The Atlantic, which first reported this story, this is only a small part of 60,000 metric tons of food already purchased from U.S. farmers and sitting in warehouses around the world, where the personnel who’d be in charge of distributing them would’ve been fired or transferred or called back to the U.S. 

At the same time, there are apparently also plans to destroy an estimated $12 million worth of HIV prevention supplies and contraceptives originally purchased as part of foreign aid programs rather than turn them over or even sell them to other countries or nonprofits. This feels like maybe the not most efficient use of taxpayer dollars? 

Luthra: I think this is something we’ve talked about before, but it really bears repeating. As a media ecosphere, we’ve sort of moved on from the really rapid dismantling of USAID. And it was not only without precedent. It was incredibly wasteful with the sudden way it was done, all of these things that were already purchased no longer able to be used, leases literally broken. And people had to pay more to break leases for offices set up in other countries, all these sorts of things that really could have already been used because they had been paid for. And instead, the money is simply lost. 

And I think the important thing for us to remember here is not only the immense waste financially to taxpayers but the real trust that has been lost, because these were promises made, things purchased, programs initiated, and when other countries see us pulling back in such a, again, I keep saying wasteful, but truly wasteful manner, it’s just really hard to ever imagine that the U.S. will be a reliable partner moving forward. 

Rovner: Yeah, absolutely. I understand the food thing to some extent because the food’s going to expire, but the medical supplies that could be distributed by somebody else? I’m still sort of searching for why that would make any sense in any universe, but yeah I guess this is the continuation of, We’re going to get rid of this aid and pretend that it never happened. 

Well, meanwhile, it’s only been a couple of weeks, but we’re starting to see the politics of that big Trump tax and spending measure play out. One big question is: Why didn’t Republicans listen to the usually very powerful hospital industry that usually gets its way but did not this time? And relatedly, will those Republicans who voted with Trump but against those powerful hospital interests do an about-face between now and when these Medicaid cuts are supposed to take effect? We’ve already seen Sen. Josh Hawley, the Republican from Missouri who loudly proclaimed his opposition to those Medicaid cuts before he voted for them anyway, introduce legislation to rescind them. So is this the new normal? I think, Joanne, you were sort of alluding to this, that you can now sort of vote for something and then immediately say: Didn’t mean to vote for that. Let’s undo it. 

Kenen: You could even do it before you vote for it, if they play it right. If Congress passes these things, we’re not going to pay attention. We’re already in that moment. But also, when I was working on a Medicaid piece, the magazine piece like four or five months ago, one of the most cynical people I know in Washington told me, he said, Oh, they’ll pass these huge cuts because they need the budget score to get the taxes through, and then they’ll start repealing it. And it seemed so cynical at the time, only he might’ve been right. 

So I don’t think they’re going to cut all of it. Republicans ideologically want a smaller Medicaid program. They want less spending. They want work requirements. You’re not going to see the whole thing go away. Could you see some retroactive tinkering or postponement or something? Yeah, you could. It’s too soon to know. Hospitals are the biggest employer in many, many congressional districts. This is a power— 

Rovner: Most of them. 

Kenen: Most, yeah. I don’t think it’s quite all, but like a lot. It’s the biggest single employer, and Medicaid is a big part of their income. And they still by law have to stabilize people who come in sick, and there’s emergency care and all sorts of other things, right? They do charity care. They do uninsured people. They do all sorts. They still treat people under certain circumstances even when they can’t pay. But right now, the threat of a primary opponent is more powerful than the threat of your local hospital being mad at you and harming health care access in your community. So much in the Republican world revolves around not getting the president mad enough that he threatens to get you beaten in a primary. We’ve seen that time and again already. 

Rovner: Right. And I will also say there’s precedent for this, for passing something and then unpassing it. Joanne and I covered in 19— 

Kenen: But it wasn’t the plan. 

Rovner: Yeah, I know. But remember, back in 1997 when they passed the Balanced Budget Act, every year for the next — was it three or four years? They did what we came to call “give back” bills. 

Kenen: Or punting, right? 

Rovner: Yeah, where they basically undid, they unspooled, some of those cuts, mostly because they’d cut more deeply than they’d intended to. And then we know with the Affordable Care Act, I’ve said this several times, they passed all of these financing mechanisms for it and then one by one repealed them. 

Kenen: And the individual mandate — I mean everything- 

Rovner: And the individual mandate, right. 

Kenen: They kept the dessert and they gave away everything. They undid everything that paid for the dessert, basically. 

Rovner: Right. Right. 

Kenen: And so it was the Cadillac — because people don’t remember anymore — the Cadillac tax, the insurance tax, the device tax. They all were like, One at a time! And they were repealed because lobbying works. 

Rovner: The tanning tax just went. 

Kenen: Right, right. So that dynamic existed, passing something unpopular and then redoing it, but the dynamic now really just comes — basically this is Donald Trump’s town. He has had a remarkable success in not only getting Congress to do what he wants but getting Congress to surrender some of its own powers, which have been around since Congress began. This is the way our government was set up. So there’s a very, very different dynamic, and it’s still unpredictable. None of us thought that the biggest crisis would be the [Jeffrey] Epstein case, right? Which is not a health story, and we don’t have to spend any time on it except to acknowledge— 

Rovner: Please. 

Kenen: —that there’s stuff going on in the background that people who had been extremely loyal to the president are now mad. And we don’t know how long. He’s very good at neutralizing things, too. He’s blaming it on the Democrats. 

But there is a different dynamic. Congress has less power because Congress gave up some of its power. Are they going to want to reassert themselves? There is no sign of it right now, but who knows what happens. I thought they would cut Medicaid. I thought they would do work requirements. I thought they would let the enhanced ACA subsidies expire. But I did not think the cuts would go this deep and this extensive — really transformationally pretty historic cuts. 

Rovner: Shefali, you wanted to say something? 

Kenen: Not pretty historic cuts, very historic cuts. Unprecedented. 

Luthra: I was thinking Joanne made such a good point about how, for all of the talk now about trying to mitigate that backlash, a lot of this is in line ideologically with what Republicans want. They do want a smaller Medicaid program. And I think a really interesting and still open question is whether they are willing and able to actually create policy that does reverse some of these cuts or not, and even if they do, if it’s sufficient to change voters’ perception, because we know that these cuts are very unpopular. Democrats are talking about them a lot. Hospitals are talking about them a lot. And just the failed attempt to repeal the ACA led to the 2018 midterms. And I think there is a real chance that this is the dominant topic when we head into next year’s elections. And it’s hard to say if Josh Hawley putting out a bill can undo that damage, so—. 

Rovner: Well, I’m so glad you mentioned that, because The Washington Post has a really interesting story about a clinic closing in rural Nebraska, with its owners publicly blaming the impending Medicaid cuts. Yet its Trump-supporting patients are just not buying it. Now in 2010, Republicans managed to hang the Affordable Care Act around Democrats’ necks well before the vast majority of the changes took place. Are Democrats going to be able to do that now? There’s a lot of people saying, Oh, well, they’re not going to be able to blame this on the Republicans, because most of it won’t have happened yet. This is really going to be a who-manages-to-push-their-narrative, right? 

Kenen: This really striking thing about that story is that the people who were losing access, they’re not losing their Medicaid yet, but they’re losing access to the only clinic within several — they have to drive hours now to get medical care. And when they were told this was because the Republican Congress and President Trump, they said, Oh no, it can’t be. First of all, a lot of people just don’t pay attention to the news. We know that. And then if you’re paying attention to news that never says anything negative about the president, that blames everything on Joe Biden no matter — if it rains yesterday, it was his fault, right? 

So the sort of gap between — there are certain things that are matters of opinion and interpretation, and there are certain things that are matters of fact, but those facts are not getting through. And we do not know whether the Democrats will be able to get them through, because the resistance, it’s almost magical, right? My clinic closed because of a Republican Medicaid bill? Oh no, it’s hospital greed. They just don’t want to treat us anymore. They just, it doesn’t compute, because it doesn’t fit into what they have been reading and hearing, to the extent that they read and hear. 

Rovner: Sandhya, you want to add something? 

Raman: The one thing that as I’ve been asking around on Capitol Hill about the Hawley bill — and there was one from Sen. Rand Paul, and a House counterpart, from [Rep.] Greg Steube, does sort of the opposite — it wants to move up the timeline for one of the provisions. So one important thing to consider is neither of these bills have had a lot of buy-in from other members of Congress. They’ve been introduced, but the people that I’ve talked to have said, I’m not sure. 

And I think something interesting that Sen. Thom Tillis had said was: If Republicans had a problem with what some of the impacts would be, then why were they denying that there would be an effect on rural health or some of those things to begin with? And I think a lot of it will take some time to judge to see if people will move the needle, but if we’re going to change any of these deadlines through not reconciliation, you need 60 votes in the Senate and you’ll need Democrats on board as well as Republicans. And I think one interesting thing to watch there is that I think some of the Democrats are also looking at this in a political way. If there’s a Republican that has a bill that is trying to tamp down some of the effects of their signature reconciliation law, do they want to help them and sign on to that bill or kind of illustrate the effects of the bill before the midterms or whatever? 

Rovner: A lot more politics to come. 

Raman: Yeah. Yeah. 

Rovner: Meanwhile, over at HHS [the Department of Health and Human Services], there is also plenty of news. Many of the workers who’ve been basically in limbo since April when a judge temporarily halted the Trump administration’s efforts to downsize have now been formally let go after the Supreme Court last week lifted that injunction. What are we hearing about how things are going over at HHS? We’ve talked sort of every week about this sort of continuing chaos. I assume that the hammer falling is not helping. It’s not adding to things settling down. 

Kenen: No. And then Secretary [Robert F.] Kennedy [Jr.] just fired two top aides because — no one knows exactly the full story but it’s — and I certainly do not know the full story. But what I have read is that the personality conflict with his top aide — and that happens in offices, and he’s not the first person in the history of HHS to have people who don’t get along with one another. But it’s just more unsettled stuff in an agency already in flux, because now in addition to all these people being let go in all sorts of programs and programs being rolled back, you also have some leadership chaos at the top. 

Rovner: Well, meanwhile, HHS Secretary Kennedy took office with vows to eliminate the financial influence of Big Pharma, Big Food, and other industries with potential conflicts of interests. But shoutout here to my KFF Health News colleague Stephanie Armour, who has a story this week about how the new vested interests at HHS are the wellness industry. Kennedy and four top advisers, three of whom have been hired into the department, wrote Stephanie, quote, “earned at least $3.2 million in fees and salaries from their work opposing Big Pharma and promoting wellness in 2022 and 2023, according to a KFF Health News review of financial disclosure forms filed with the U.S. Office of Government Ethics and the Department of Health and Human Services; published media reports; and tax forms filed with the IRS. That total doesn’t include revenue from speaking fees, the sale of wellness products, or other income sources for which data is not publicly available.” Have we basically just traded one form of regulatory capture for another form of regulatory capture? 

Kenen: And one isn’t covered by insurance. Some of it is, but there’s a lot of stuff in the, quote, “wellness” industry that providers and so forth, certain services are covered if there’s licensed people and an evidence base for them, but a lot of it isn’t. And these providers charge a lot of money out-of-pocket, too. 

Rovner: And they make a lot of money. This is a totally — unlike Big Pharma, Big Food, and Big Medicine, which is regulated, Big Wellness is largely not regulated. 

Kenen: I think Stephanie — that was a really good piece — and I think Stephanie said it was, what, $6.3 trillion industry? Was that— 

Rovner: Yeah, it’s huge. 

Kenen: Am I remembering that number right? It’s largely unregulated. Many of the products have never gone through any review for safety or efficacy. And insurance doesn’t cover a lot of it. It doesn’t mean it’s all bad. There are certain things that are helpful, but as an industry overall, it leaves something for us to worry about. 

Rovner: Well, in HHS-adjacent breaking news that could turn out to be nothing or something really big, an appeals court in Richmond on Tuesday ruled 2-1 that West Virginia may in fact limit access to the abortion pill, even though it’s approved by the FDA [Food and Drug Administration]. It’s the first time a federal appeals court has basically said that states can effectively override the FDA’s nationwide drug approval authority. And it’s the question that the Supreme Court has already ducked once, in that case out of Texas last year where the justices ruled that the doctors who were suing didn’t have standing, so they didn’t have to get to that question. But, Shefali, this has implications well beyond abortion, right? 

Luthra: Oh, absolutely. We are seeing efforts across the country to restrict access to certain medications that are FDA-approved. Abortion pills are the obvious one, but, of course, we can think about gender-affirming care. We can think about access to all sorts of other therapeutics and even vaccines that are now sort of coming under political fire. And if FDA approval means less than state restrictions, as we are seeing in this case, as we very possibly could see as these kinds of arguments and challenges make their way to the Supreme Court. The case you alluded to earlier with the doctors who didn’t have standing is still alive, just with different plaintiffs now. And so these questions will probably come back. There are just such vast ramifications for any kind of medication that could be politicized, and it’s something that industry at large has been very worried about since this abortion pill became such a big question. And it is something that this decision is not going to alleviate. 

Rovner: Yes. Speaking of Big Pharma, they’re completely freaked out by this possibility because it does have implications for every FDA-approved drug. 

Luthra: And they invest so much money in trying to get products that have FDA approval. There’s a real promise that with this global gold standard, you will be able to keep a drug on the market and really make a lot of money on it. There’s also obviously concerns for birth control, which we aren’t seeing legally restricted in the same way as abortion yet, but it is something that is so deeply subject to politics and culture-war issues that that’s something that we could see coming down the line if trends continue the way they are. 

Rovner: Well, we will watch that space. Moving on. Wednesday was the third anniversary of the federal 988 federal crisis line, which has so far served an estimated 16 million people with mental health crises via call, text, or chat. An estimated 10% of those calls were routed through a special service for LGBTQ+ youth, which is being cut off today by the Trump administration, which accused the program, run by the Trevor Project, as, quote, “radical gender ideology.” Now, LGBTQ+ youth are among those at the highest risk for suicide, which is exactly what the 988 program was created to prevent. Yet there’s been very little coverage of this. I had to actually go searching to find out exactly what happened here. Is this just kind of another day in the Trump administration? 

Raman: I think a lot of it stems back to some of those initial executive orders related to gender ideology and DEI [diversity, equity, and inclusion] and things like that. The Trump administration’s kind of argument is that it shouldn’t be siloed. It should be all general. There shouldn’t be sort of special treatment, even though we do have specialized services for veterans who call in to these services and things. But I— 

Rovner: Although that was only saved when members of Congress complained. 

Raman: Yeah. But I do think that when we have so much happening in this space focused on LGBTQ issues, it’s easier for things to get missed. I think the one thing that I did notice was that California announced yesterday that they were going to step up to do a partnership with the Trevor Project to at least — the LGBTQ youth calling from California to any of those local 988 centers would be reaching people that have been trained a little bit more in cultural competency and dealing with LGBTQ youth. But that’s not going to be all the states and it’s going to take time. Yeah. 

Rovner: Yeah, we’re going to continue to see this cobbled together state by state. It feels like increasingly what services are available to you are going to be very much dependent on where you live. That’s always been true, but it feels like it’s getting more and more and more true. Shefali, I see you nodding. 

Luthra: Something you alluded to that I think bears making explicit is public health interventions are typically targeted toward people who are in greater danger or are at greater risk. That’s not discrimination — that’s public health efficiency. And suggesting that we shouldn’t have resources targeted toward people at higher risk of suicide is counter to what public health experts have been arguing for a very long time. And that’s just something that I think really bears noting and keeping in mind as we see what the impact of this is moving forward. 

Rovner: Yeah, I think that’s a very good point. Thank you. 

Well, speaking of popular things that are going away, a federal judge appointed by President Trump last week struck down the last-minute Biden administration rule from the Consumer Financial Protection Bureau that tried to bar medical debt from appearing on credit reports. This had been hailed as a major step for the 100 million Americans with medical debt, which is not exactly the same as buying a car or a TV that you really can’t afford. People don’t go into medical debt saying, Oh, I think I’m going to go run up a big medical bill that I can’t pay. But this strikes me as yet another way this administration is basically inflicting punishment on its own voters. Yes? 

Kenen: Yes, except we just don’t know. Some red states are so red that you don’t need every voter. We don’t know who actually votes, and we don’t know whether people make these connections, right? What we were talking about before with Medicaid — do they understand that this is something that President Trump not just urged but basically ordered Congress to do? So do people pay attention? How many people even know if their medical debt is or is not on their credit report? They know they have the medical debt, but I’m not sure everybody understands all the implication, particularly if you’re used to being in debt. You may be somebody who’s lost a job or couldn’t pay your mortgage or couldn’t pay your rent. Some of the people who have medical debt have so many other financial — not all — that it’s just part of a debt soup and it’s just one more ingredient. 

So how it plays out and how it’s perceived? It’s part of this unpredictable mix. Trump is openly talking about gerrymandering more, and so it won’t matter what voters do, because they’ll have more Republican seats. That’s just something he’s floating. We don’t know whether it’ll actually happen, but he floated it in public, so— 

Rovner: So much of this is flooding the zone, that people — there’s so much happening that people have no idea who’s responsible for what. There’s always the pollster question: Is your life better or worse than it was last year? Or four years ago, whatever. And I think that when you do so much so fast, it’s pretty hard to affix blame to anybody. 

Raman: And most people aren’t single-issue voters. They’re not going to the polls saying, My medical debt is back on my credit report. There’s so many other things, even if with the last election, health care was not the number one issue for most voters. So it’s difficult to say if it will be the top issue for the next election or the next one after that. 

And I guess just piggybacking that a lot of the times when there’s these big changes, they don’t take effect for a while. So it’s easier to rationalize, Oh, it may have been this person or that person or the senator then, or who was president at a different time, just because of how long it takes to see the effects in your daily life. 

Rovner: Politics is messy. All right, well, this is as much time for the news as we have this week? 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’ll put the links in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week? 

Luthra: Sure. My piece is from The New York Times, by Apoorva Mandavilli. The headline is “Trump Official Accused PEPFAR of Funding Abortions in Russia. It Wasn’t True.” And she takes a look at when the head of the OMB [Office of Management and Budget] told the Senate that PEPFAR had spent almost $10 million advising Russian doctors on abortions and gender analysis. And she goes through and says this isn’t true. PEPFAR hasn’t been in Russia. They cannot fund abortions. And she talks with people who were there and can say this simply isn’t true and this is very easy to disprove. And I like this piece because it’s just a reminder that a lot of things are being said about government spending that are not true. And it is a public service to remind readers that they are very easily disproven. 

Rovner: Yeah, and to go ahead and do that. Sandhya. 

Raman: My extra credit is “‘We’re Creating Miscarriages With Medicine’: Abortion Lessons From Sweden,” and it’s from Cecilia Nowell for The Nation, my co-fellow through AHCJ [the Association of Health Care Journalists] this year. Cecilia went to Kiruna, which is an Arctic village in Sweden, to look at how they’re using mifepristone for abortions up to 22 weeks in pregnancy, compared to up to 10 weeks in the U.S. And it’s a really interesting look at how they’re navigating rural access to abortion in very remote areas. Almost all abortions in Sweden are done through medication abortion, and while the majority here are in the 60% versus high 90s. So just interesting how they’re taking their approach there as rural access is limited here. 

Rovner: Really interesting story. Joanne. 

Kenen: This is a piece in The New Yorker by Dhruv Khullar, and it’s “Can A.I. Find Cures for Untreatable Diseases — Using Drugs We Already Have?” And what I found interesting, we’ve been hearing about: Can AI do this? It’s sort of been in the air since AI came around. But what was so interesting about this article is there’s a nonprofit that is actually doing it, and they have this sort of whole sort of hierarchy of why a drug may be promising and why a disease may be a good target. And then the AI look at genetics and diseases, and they have four or five factors they look at. And then there’s this just sort of hierarchy of which are the ones we can make accessible. 

So A, it’s actually happening. B, it has promise. It’s not a panacea, but there’s promise. And C, it’s being done by a nonprofit. It’s not a cocktail for an individual patient. It’s trying to figure out: What are the smartest drugs to be looking at and what can they treat? And they give examples of people who have gone into remission from rare diseases. And also it says there are 18,000 diseases and only 9,000 have treatment. So this is huge, right? Rare diseases may only affect a few people, but there are lots of rare diseases. So cumulatively some of the people they strike are young. So for someone who doesn’t always read about AI, I found this one interesting. 

Rovner: Also, we read somebody’s story about how AI is terrible for this, that, and the other thing. It is very promising for an awful lot of things. 

Kenen: No. Right. 

Rovner: There’s a reason that everybody’s looking at it. 

All right, my extra credit this week is also from The New York Times. It’s called “UnitedHealth’s Campaign to Quiet Critics,” by David Enrich, who’s The Times’ deputy investigations editor and, notably, author of a book on attacks on press freedoms. That’s because the story chronicles how UnitedHealth, the mega health company we have talked about a lot on this show, is taking a cue from President Trump and increasingly taking its critics to court, in part by claiming that critical reporting about the company risks inciting further violence like the Midtown Manhattan murder of United executive Brian Thompson last year. 

I hasten to add, this isn’t a matter of publications making stuff up. United, as we have pointed out, is a subject of myriad civil and criminal investigations into potential Medicare fraud as well as antitrust violations. This is still another chapter unfolding in the big United story. 

OK, that is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us to 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 hanging these days? Shefali? 

Raman: I’m at Bluesky, @shefali. 

Rovner: Sandhya. 

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

Rovner: Joanne? 

Kenen: I’m mostly at Bluesky, @joannekenen.bsky, and I’ve been posting things more on LinkedIn, and there are more health people hanging out there. 

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

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On his way to an Ultimate Fighting Championship event, Health and Human Services Secretary Robert F. Kennedy Jr. stopped by the home of podcaster Gary Brecka. The two spent time in a hyperbaric oxygen chamber and tried some intravenous nutrition drips that Brecka, a self-avowed longevity and wellness maven, sells and promotes on his show, “The Ultimate Human.”

Then the podcast taping started, and Kennedy — who was also on the mic — took aim at Big Pharma’s influence on federal health policy.

“We have a sick-care system in our country, and the etiology ultimately of all that disease is corruption,” Kennedy said before the show cut away to an ad for vitamin chips. “And it’s the capture of these agencies by the industries they are supposed to regulate.”

While Kennedy lambastes federal agencies he says are overly influenced by the pharmaceutical industry, he and some other figures of the “Make America Healthy Again,” or MAHA, movement — such as siblings Calley and Casey Means, Robert Malone, and Peter McCullough — have their own financial ties to a vast and largely unregulated $6.3 trillion global wellness industry they also support and promote.

Kennedy and those four advisers — three of whom have been tapped for official government roles — earned at least $3.2 million in fees and salaries from their work opposing Big Pharma and promoting wellness in 2022 and 2023, according to a KFF Health News review of financial disclosure forms filed with the U.S. Office of Government Ethics and the Department of Health and Human Services; published media reports; and tax forms filed with the IRS.

The total doesn’t include revenue from speaking fees, the sale of wellness products, or other income sources for which data isn’t publicly available.

The Means siblings have launched wellness companies that have raised more than $99 million from investors, according to company news releases as well as information from Clay, a customer research data company, and Tracxn, an information technology firm that provides access to a database of companies, funding rounds, and investor information.

“Secretary Kennedy, and all HHS officials, fully comply with all ethics and financial disclosure laws,” agency spokesperson Emily Hilliard said in an email. “Any attempt to suggest impropriety is reckless and politically motivated.”

Some public health leaders and ethicists say the financial ties raise red flags, with the potential for personal profits to shape decision-making at the highest levels of federal health agencies.

“It’s becoming completely corrupted,” said Arthur Caplan, founding head of the medical ethics division at New York University’s Grossman School of Medicine. “You shouldn’t have a vested interest in making recommendations on wellness or supplements or health. It opens the door to all kinds of shenanigans. Big Wellness is no different than Big Pharma. They’re a well-organized political force.”

Unlike any other previous administration, President Donald Trump’s administration has elevated anti-vaccine and wellness leaders to positions at HHS from which they can steer federal policy. Adherents to the MAHA movement say the change is long overdue, arguing that previous administrations haven’t devoted sufficient attention to the potential harms of traditional medical approaches.

Critics including health policy leaders and physicians say they worry the revamped HHS and its agencies are now harming public health. For example, they point to a recent Kennedy decision to remove and replace all the members of a vaccine advisory group, a move the American Medical Association criticized as lacking transparency and proper vetting. Two of Kennedy’s newly named panel members — Malone and Martin Kulldorff — previously earned money as paid experts in vaccine lawsuits against Merck, as first reported by Reuters and the life-sciences news outlet BioSpace.

Calley Means, who has criticized the recommended U.S. vaccine schedule for youths and has no medical training, is a special government employee and a top health adviser to Kennedy. He also co-founded the wellness company Truemed.

The company enables people to spend pretax dollars from Flexible Spending Accounts and Health Savings Accounts to pay for wellness products, health food, and SoulCycle classes.

Truemed’s website says it can provide customers with a “Letter of Medical Necessity” for the items.

The IRS has warned consumers about companies that misrepresent wellness items like food as FSA-eligible when they are not, in fact, permitted medical expenses.

The IRS did not respond to questions about the status of that policy under the Trump administration.

In 2024, when Kennedy was running for president as an independent, he promoted Means’ company on his own podcast. Means also promoted his close connection with Kennedy last year on podcasts and on Instagram while also using social media to advance Truemed. And while working for the public as a special government employee since March, Means has used social and new media to promote podcasters who make money selling wellness products, to criticize specific pharmaceutical drugs, and to tout the wellness book he co-wrote, “Good Energy,” according to a KFF Health News review of social media posts and podcasts.

Means has also used podcasts and social media to rail against new injectable weight loss drugs. The Trump administration in April decided not to finalize a rule that would have allowed Medicaid and Medicare to cover the injectable drugs, putting them out of reach for millions of potential users.

Hilliard, the HHS spokesperson, didn’t respond to questions about whether Means, as a Kennedy adviser, has recused himself from decisions that could affect his business. Neither HHS nor the White House responded to requests to speak with him.

His sister, Casey Means, is Trump’s pick for surgeon general and was also an adviser to Kennedy during his 2024 presidential run. She co-founded Levels, a company valued at $300 million in 2022 that promotes glucose monitoring for nondiabetic, healthy individuals. Consumers pay $199 for a one-month supply of continuous glucose monitors.

She has used social media to call for public policy that would encourage blood sugar monitoring for healthy individuals, saying “tips to stabilize glucose should be on every billboard in America.” Research has found little evidence that such monitoring provides health benefits for people without diabetes.

Her company stands to benefit under the Trump administration. Kennedy said in April that he was considering a regulatory framework for federal health programs’ coverage of injectable weight loss drugs that would first require patients to try glucose monitoring or other options.

“And if they don’t work, then you would be entitled to the drug,” he told CBS News.

Casey Means isn’t a practicing doctor and doesn’t hold an active medical license, according to records from the Oregon Medical Board. And, as an online influencer, she “failed to disclose that she could profit” from sales of products she recommends, according to The Associated Press.

HHS spokesperson Hilliard didn’t answer questions about whether Casey Means would recuse herself from working on anything that would directly benefit her company, or why she didn’t disclose that she could profit from sales of products she recommends. HHS didn’t respond to questions about Means’ ties to Kennedy or agency support for glucose monitoring, nor did the agency respond to a request to speak directly to the Trump surgeon general pick.

Outside Advisers

McCullough, a former cardiac doctor who has financial ties to the wellness industry, has been part of Kennedy’s circle of informal advisers, according to people close to the secretary. He also has enough sway with some GOP lawmakers that they’ve had him testify before Congress. In May, he told a Senate subcommittee that mRNA covid-19 vaccines can lead to deaths that have been underreported. But the FDA says the covid vaccines are safe, with fewer than 1 in 200,000 vaccinated individuals experiencing a severe allergic reaction or heart problems like myocarditis or pericarditis.

He profits from his anti-covid-vaccine message. McCullough devised a protocol he says helps people detox from covid mRNA shots, selling the products through The Wellness Co. McCullough is the company’s chief scientific officer, draws a partial salary, and holds an equity stake.

For $89.99, consumers can purchase Ultimate Spike Detox supplements containing nattokinase, an enzyme from fermented soybeans. A two-month supply of Spike Support supplements sells on Amazon for about $62. More than 900 bottles have sold in the past month.

McCullough didn’t respond to an email seeking comment. HHS also didn’t respond to questions about his relationship with Kennedy.

Some health policy leaders and doctors say the financial connections federal health officials and advisers have to the wellness industry raise concerns.

“It’s exactly the problem RFK has taken up with the FDA, saying it’s too beholden to pharma,” said Pieter Cohen, an associate professor of medicine at Harvard University.

“When you’re in bed with supplement manufacturers, you are creating the same kinds of conflicts of interest, whether or not you directly profit,” he said. “You should be independently advocating for public health, not cheerleading for any particular industry.”

The wellness sector includes personal care, weight loss, health, nutrition, and wellness tourism.

Its lobbying influence is markedly smaller than the lobbying reach of pharmaceutical companies, according to OpenSecrets, a research organization that tracks money in U.S. politics. The nutritional and dietary supplements industry spent about $3.7 million on lobbying in 2024, for example, compared with the $387 million the pharmaceutical industry spent the same year.

It’s also gotten far less scrutiny. The industry is a growing political force with its own lobbyists, celebrities, and industry-backed advocacy groups, and research shows that public interest in wellness has grown since the pandemic. Eighty-four percent of U.S. consumers say wellness is a “top” or “important” priority, according to a survey released this year by McKinsey & Co.

Unlike with Big Pharma, there’s scant regulation of the industry. Companies can sell supplements and other products without notifying the FDA, and there’s little oversight by the Federal Trade Commission of their product claims.

“The wellness industry profiteers by undermining and creating distrust in science and regulated products,” said Andrea Love, an immunologist and microbiologist who founded ImmunoLogic, a science and health education organization. “They are messaging that the government and Big Pharma are hiding information and treatments or cures to keep us weak and vulnerable.”

Ethics and Disclosures

People on both sides of the issue say the industry has found its captain in Kennedy, an anti-vaccine activist with deep ties to the MAHA and wellness movements.

He has profited by referring people to law firms that are suing over alleged vaccine injury. For example, he gets a fee for referring potential clients to a Los Angeles personal injury firm, according to a January ethics statement to HHS and his financial disclosures. One of his adult sons works at the personal injury law firm.

When his nomination to the HHS secretary post was under consideration, Kennedy indicated in his ethics disclosure that he intended to continue profiting from lawsuits over Gardasil, a Merck vaccine that protects against HPV. After Democrats raised concerns with the financial relationship, he told Congress he would divest his interest and sign over the financial stake to one of his adult sons.

Federal ethics rules bar government employees from participating in matters in which they, their spouse, or their minor child has a financial stake. It doesn’t include adult children such as Kennedy’s sons.

“There are a lot of loopholes, and that is one of them,” said Cynthia Brown, senior ethics counsel at the Citizens for Responsibility and Ethics in Washington, a watchdog organization focused on U.S. government ethics and accountability. “It certainly is an appearance problem. Even if it’s not a technical violation, it is an ethical problem in terms of influence.”

Some lawmakers and ethics leaders weren’t mollified by Kennedy’s planned divestiture. Sen. Elizabeth Warren (D-Mass.) called on Kennedy to agree to a four-year, post-employment ban on accepting any compensation from lawsuits involving any entity regulated by HHS.

“It would be insufficient for RFK Jr. to only divest his interest in the Gardasil case while leaving the window open to profit from other anti-vax lawsuits, including future cases he could bring after leaving office,” she said in a statement.

Kennedy also made money on the MAHA name by applying in September to register it as a trademark. He transferred trademark ownership to a limited liability company led by friend and MAHA ally Del Bigtree after making about $100,000 off the phrase, according to his financial disclosure.

HHS’ Hilliard didn’t answer questions about whether Kennedy had signed over his interest in fees from legal referrals to his son, the money he made by registering MAHA as a trademark, or whether he agreed with Warren’s request that upon leaving office he accept a four-year ban on accepting money from lawsuits involving entities regulated by HHS.

Bigtree is executive director of the Informed Consent Action Network, or ICAN, an anti-vaccination group. He was communications director for Kennedy’s failed presidential campaign, and as an informal adviser to the secretary he helped vet candidates for HHS jobs. Bigtree’s salary at the nonprofit was $234,000 for the 2023 fiscal year, according to documents filed with the IRS. ICAN paid $6 million in legal fees to Siri & Glimstad in 2023. The firm’s managing partner, Aaron Siri, focuses on vaccine injury. He has been Kennedy’s personal lawyer and adviser, and also helped vet candidates for the secretary.

Brown, an ethics counselor, said the transfer and ongoing advisory relationship could raise questions about who is influencing Kennedy. Bigtree, at a Politico event in February, called on Kennedy to recruit scientists to HHS who believe vaccines cause autism, for example. One of Kennedy’s early actions at HHS was the launch of a study on the causes of autism.

ICAN didn’t respond to an email seeking comment. HHS also didn’t respond to questions about Kennedy’s transfer of the MAHA trademark to Bigtree.

“This is the type of Washington wheeling and dealing that raises questions about integrity in government,” Brown said. “If it was trademarked before he became a public official, there may be no law broken. But by transferring it to someone he knows, it illustrates the constant trickle of influence among those in power.”

Past administrations have faced similar criticism over health regulators’ ties to Big Pharma. Alex Azar, who led HHS during the previous Trump administration, worked for drugmaker Eli Lilly before entering public office. Robert Califf, FDA commissioner during the Biden administration, was a consultant to drug companies.

Scott Gottlieb, who was FDA commissioner from 2017 to 2019 and an adviser to Trump’s presidential campaign, stepped down to join the board of the drugmaker Pfizer.

“Big Pharma is well off. But, in general, financial conflicts don’t depend on how much the organizations are spending,” said Zeke Emanuel, a bioethicist who served on a covid advisory board under President Joe Biden. “The question is, is there a reasonable concern that financial or other concerns are affecting their judgment?”

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

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

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

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

Panelists

Maya Goldman
Axios

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Sarah Karlin-Smith
Pink Sheet

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Alice Miranda Ollstein
Politico

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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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USE OUR CONTENT

This story can be republished for free (details).

The Trump administration has declared that it will aggressively combat chronic disease in America.

Yet in its feverish purge of federal health programs, it has proposed eliminating the National Center for Chronic Disease Prevention and Health Promotion and its annual funding of $1.4 billion.

That’s one of many disconnects between what the administration says about health — notably, in the “MAHA Report” that President Donald Trump recently presented at the White House — and what it’s actually doing, scientists and public health advocates say.

Among other contradictions:

• The report says more research is needed on health-related topics such as chronic diseases and the cumulative effects of chemicals in the environment. But the Trump administration’s mass cancellation of federal research grants to scientists at universities, including Harvard, has derailed studies on those subjects.
• The report denounces industry-funded research on chemicals and health as widespread and unreliable. But the administration is seeking to cut government funding that could serve as a counterweight.
• The report calls for “fearless gold-standard science.” But the administration has sowed widespread fear in the scientific world that it is out to stifle or skew research that challenges its desired conclusions.

“There are many inconsistencies between rhetoric and action,” said Alonzo Plough, chief science officer at the Robert Wood Johnson Foundation, a philanthropy focused on health.

The report, a cornerstone of President Donald Trump’s “Make America Healthy Again” agenda, was issued by a commission that includes Secretary of Health and Human Services Robert F. Kennedy Jr. and other top administration officials.

News organizations found that it footnoted nonexistent sources and contained signs that it was produced with help from artificial intelligence. White House Press Secretary Karoline Leavitt described the problems as “formatting issues,” and the administration revised the report.

Trump ordered the report to assess causes of a “childhood chronic disease crisis.” His commission is now working on a plan of action.

Spokespeople for the White House and Department of Health and Human Services did not respond to questions for this article.

Studies Derailed

The MAHA report says environmental chemicals may pose risks to children’s health. Citing the National Institutes of Health, it said there’s a “need for continued studies from the public and private sectors, especially the NIH, to better understand the cumulative load of multiple exposures and how it may impact children’s health.”

Meanwhile, the administration has cut funding for related studies.

For example, in 2020 the Environmental Protection Agency asked scientists to propose ways of researching children’s exposure to chemicals from soil and dust. It said that, for kids ages 6 months to 6 years, ingesting particulates — by putting their hands on the ground or floor then in their mouths — could be a significant means of exposure to contaminants such as herbicides, pesticides, and a group of chemicals known as PFAS.

One of the grants — for almost $1.4 million over several years — went to a team of scientists at Johns Hopkins University and the University of California-San Francisco. Researchers gained permission to collect samples from people’s homes, including dust and diapers.

But, beyond a small test run, they didn’t get to analyze the urine and stool samples because the grant was terminated this spring, said study leader Keeve Nachman, a professor of environmental health and engineering at Hopkins.

“The objectives of the award are no longer consistent with EPA funding priorities,” the agency said in a May 10 termination notice.

Another EPA solicitation from 2020 addressed many of the issues the MAHA report highlighted: cumulative exposures to chemicals and developmental problems such as attention-deficit/hyperactivity disorder, obesity, anxiety, and depression. One of the resulting grants funded the Center for Early Life Exposures and Neurotoxicity at the University of North Carolina-Chapel Hill. That grant was ended weeks early in May, said the center’s director, Stephanie Engel, a UNC professor of epidemiology.

In a statement, EPA press secretary Brigit Hirsch said the agency “is continuing to invest in research and labs to advance the mission of protecting human health and the environment.” Due to an agency reorganization, “the way these grants are administered will be different going forward,” said Hirsch, who did not otherwise answer questions about specific grants.

In its battle with Harvard, the Trump administration has stopped paying for research the NIH had commissioned on topics such as how autism might be related to paternal exposure to air pollution.

The loss of millions of dollars of NIH funding has also undermined data-gathering for long-term research on chronic diseases, Harvard researchers said. A series of projects with names like Nurses’ Health Study II and Nurses’ Health Study 3 have been tracking thousands of people for decades and aimed to keep tracking them as long as possible as well as enrolling new participants, even across generations.

The work has included periodically surveying participants — mainly nurses and other health professionals who enrolled to support science — and collecting biological samples such as blood, urine, stool, or toenail clippings.

Researchers studying health problems such as autism, ADHD, or cancer could tap the data and samples to trace potential contributing factors, said Francine Laden, an environmental epidemiologist at Harvard’s T.H. Chan School of Public Health. The information could retrospectively reveal exposures before people were born — when they were still in utero — and exposures their parents experienced before they were conceived.

Harvard expected that some of the grants wouldn’t be renewed, but the Trump administration brought ongoing funding to an abrupt end, said Walter Willett, a professor of epidemiology and nutrition at the Chan school.

As a result, researchers are scrambling to find money to keep following more than 200,000 people who enrolled in studies beginning in the 1980s — including children of participants who are now adults themselves — and to preserve about 2 million samples, Willett said.

“So now our ability to do exactly what the administration wants to do is jeopardized,” said Jorge Chavarro, a professor of nutrition and epidemiology at the Chan school. “And there’s not an equivalent resource. It’s not like you can magically recreate these resources without having to wait 20 or 30 years to be able to answer the questions” that the Trump administration “wants answered now.”

Over the past few months, the administration has fired or pushed out almost 5,000 NIH employees, blocked almost $3 billion in grant funding from being awarded, and terminated almost 2,500 grants totaling almost $5 billion, said Sen. Patty Murray (D-Wash.), vice chair of the Senate Appropriations Committee, at a June 10 hearing on the NIH budget.

In addition, research institutions have been waiting months to receive money under grants they’ve already been awarded, Murray said.

In canceling hundreds of grants with race, gender, or sexuality dimensions, the administration engaged in blatant discrimination, a federal judge ruled on June 16.

Cutting Funding

After issuing the MAHA report, the administration published budget proposals to cut funding for the NIH by $17.0 billion, or 38%, the Centers for Disease Control and Prevention by $550 million, or 12%, and the EPA by $5 billion, or 54%.

“This budget reflects the President’s vision of making Americans the healthiest in the world while achieving his goal of transforming the bureaucracy,” the HHS “Budget in Brief” document says. Elements of Trump’s proposed budget for the 2026 fiscal year clash with priorities laid out in the MAHA report.

Kennedy has cited diabetes as part of a crisis in children’s health. The $1.4 billion unit the White House has proposed to eliminate at the CDC — the National Center for Chronic Disease Prevention and Health Promotion — has housed a program to track diabetes in children, adolescents, and young adults.

“To say that you want to focus on chronic diseases” and then “to, for all practical purposes, eliminate the entity at the Centers for Disease Control and Prevention which does chronic diseases,” said Georges Benjamin, executive director of the American Public Health Association, “obviously doesn’t make a lot of sense.”

In a May letter, Office of Management and Budget Director Russell Vought listed the chronic disease center as “duplicative, DEI, or simply unnecessary,” using an abbreviation for diversity, equity, and inclusion programs.

Within the NIH, the White House has proposed cutting $320 million from the National Institute of Environmental Health Sciences, a reduction of 35%. That unit funds or conducts a wide array of research on issues such as chronic disease.

Trump’s budget proposes spending $500 million “to tackle priority activities to Make America Healthy Again,” including $260 million for his new Administration for a Healthy America to address the “chronic illness epidemic.”

Ceding Ground to Industry

The MAHA report argues that corporate influence has compromised government agencies and public health through “corporate capture.”

It alleges that most research on chronic childhood diseases is funded by the food, pharmaceutical, and chemical industries, as well as special interest organizations and professional associations. It says, for example, that a “significant portion of environmental toxicology and epidemiology studies are conducted by private corporations,” including pesticide manufacturers, and it cites “potential biases in industry-funded research.”

It’s “self-evident that cutbacks in federal funding leave the field open to the very corporate funding RFK has decried,” said Peter Lurie, president of the Center for Science in the Public Interest, a watchdog group focused on food and health.

Lurie shared the report’s concern about industry-funded research but said ceding ground to industry won’t help. “Industry will tend to fund those studies that look to them like they will yield results beneficial to industry,” he said.

In search of new funding sources, Harvard’s school of public health “is now ramping up targeted outreach to potential corporate partners, with careful review to ensure the science meets the highest standards of research integrity,” Andrea Baccarelli, dean of the school’s faculty, wrote in a June 11 letter to students, faculty, and others.

“It’s just simple math that if you devastate governmental funding by tens of billions of dollars, then the percentage of industry funding dollars will go up,” said Plough, who is also a clinical professor at the University of Washington School of Public Health.

“So therefore, what they claim to fear more,” he said, will “become even more influential.”

The MAHA report says “the U.S. government is committed to fostering radical transparency and gold-standard science.”

But many scientists and other scholars see the Trump administration waging a war on science that conflicts with its agenda.

In March, members of the National Academies of Sciences, Engineering, and Medicine accused the administration of “destroying” scientific independence, “engaging in censorship,” and “pressuring researchers to alter or abandon their work on ideological grounds.”

In May, NIH employees wrote that the administration was politicizing research — for example, by halting or censoring work on health disparities, health impacts of climate change, gender identity, and immunizations.

Recent comments by Kennedy pose another threat to transparency, researchers and health advocates say.

Kennedy said on a podcast that he would probably create in-house government journals and stop NIH scientists from publishing their research in The Lancet, The New England Journal of Medicine, The Journal of the American Medical Association, and others.

Creating new government outlets for research would be a plus, said Dariush Mozaffarian, director of the Food is Medicine Institute at the Friedman School of Nutrition Science and Policy at Tufts University.

But confining government scientists to government journals, he said, “would be a disaster” and “would basically amount to censorship.”

“That’s just not a good idea for science,” Mozaffarian said.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

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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CLARKESVILLE, Ga. — Last September, Alton Fry went to the doctor concerned he had high blood pressure. The trip would result in a prostate cancer diagnosis.

So began the stress of trying to pay for tens of thousands of dollars in treatment — without health insurance.

“I’ve never been sick in my life, so I’ve never needed insurance before,” said Fry, a 54-year-old self-employed masonry contractor who restores old buildings in the rural Appalachian community he’s called home nearly all his life.

Making sure he had insurance was the last thing on his mind, until recently, Fry said. He had been rebuilding his life after a prison stay, maintaining his sobriety, restarting his business, and remarrying his wife. “Things got busy,” he said.

Now, with a household income of about $48,000, Fry and his wife earn too much to qualify for Georgia’s limited Medicaid expansion. And he said he found that the health plans sold on the state’s Affordable Care Act exchange were too expensive or the coverage too limited.

In late April, a friend launched a crowdfunding campaign to help Fry cover some of the costs. To save money, Fry said, he’s taking a less aggressive treatment route than his doctor recommended.

“There is no help for middle-class America,” he said.

More than 26 million Americans lacked health insurance in the first six months of 2024, according to the Centers for Disease Control and Prevention.

The uninsured are mostly low-income adults under age 65, and people of color, and most live in the South and West. The uninsured rate in the 10 states that, like Georgia, have not expanded Medicaid to nearly all low-income adults was 14.1% in 2023, compared with 7.6% in expansion states, according to KFF, a health information nonprofit that includes KFF Health News.

Health policy researchers expect the number of uninsured to swell as the second Trump administration and a GOP-controlled Congress try to enact policies that explicitly roll back health coverage for the first time since the advent of the modern U.S. health system in the early 20th century.

Under the “One Big Beautiful Bill Act” — budget legislation that would achieve some of President Donald Trump’s priorities, like extending tax cuts mainly benefiting the wealthy — some 10.9 million Americans would lose health insurance by 2034, according to estimates by the nonpartisan Congressional Budget Office based on a House version of the budget bill.

A Senate version of the bill could result in more people losing Medicaid coverage, with reductions in federal spending and rules that would make it harder for people to qualify. But that bill suffered a major blow June 26 when the Senate parliamentarian, a nonpartisan official who enforces the chamber’s rules, rejected several health provisions — including the proposal to gradually reduce provider taxes, a mechanism that nearly every state uses to increase its federal Medicaid funding.

The number could rise to 16 million if proposed rule changes to the ACA take effect and tax credits that help people pay for ACA plans expire at the end of the year, according to the CBO. In KFF poll results released in June, nearly two-thirds of people surveyed viewed the bill unfavorably and more than half said they were worried federal funding cuts would hurt their family’s ability to obtain and afford health care.

Like Fry, more people would be forced to pay for health expenses out-of-pocket, leading to delays in care, lost access to needed doctors and medications, and poorer physical and financial health.

“The effects could be catastrophic,” said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured.

The House-passed bill would represent the largest reduction in federal support for Medicaid and health coverage in history, she said. If the Senate approves it, it would be the first time Congress moved to eliminate coverage for millions of people.

“This would take us back,” Tolbert said.

A Patchwork System

The United States is the only wealthy country where a substantial number of citizens lack health insurance, due to nearly a century of pushback against universal coverage from doctors, insurance companies, and elected officials.

“The complexity is everywhere throughout the system,” said Sherry Glied, dean of New York University’s Wagner School of Public Service, who worked in the George H.W. Bush, Clinton, and Obama administrations. “The big bug is that people fall between the cracks.”

This year, KFF Health News is speaking to Americans about the challenges they face in finding health insurance and the effects on their ability to get care; to providers who serve the uninsured; and to policy experts about why, even when the nation hit its lowest recorded uninsured rate in 2023, nearly a tenth of the U.S. population still lacked health coverage.

So far, the reporting has found that despite decades of policies designed to increase access to care, the very structure of the nation’s health insurance system creates the opposite effect.

Government-backed universal coverage has eluded U.S. policymakers for decades.

After lobbying from physician groups, President Franklin D. Roosevelt abandoned plans to include universal health coverage in the Social Security Act of 1935. Then, because of a wage and salary cap used to control inflation during World War II, more employers offered health insurance to lure workers. In 1954, health coverage was formally exempted from income tax requirements, which led more employers to offer the benefit as part of compensation packages.

Insurance coverage offered by employers came to form the foundation of the U.S. health system. But eventually, problems with linking health insurance to employment emerged.

“We realized, well, wait, not everybody is working,” said Heidi Allen, an associate professor at the Columbia School of Social Work who studies the impact of social policies on access to care. “Children aren’t working. People who are elderly are not working. People with disabilities are not working.”

Yet subsequent efforts to expand coverage to all Americans were met with backlash from unions who wanted health insurance as a bargaining chip, providers who didn’t want government oversight, and those who had coverage through their employers.

That led policymakers to add programs piecemeal to make health insurance accessible to more Americans.

There’s Medicare for older adults and Medicaid for people with low incomes and disabilities, both created in 1965; the Children’s Health Insurance Program, created in 1997; the ACA’s exchange plans and Medicaid expansion for people who can’t access job-based coverage, created in 2010.

As a result, the U.S. has a patchwork of health insurance programs with numerous interest groups vying for dollars, rather than a cohesive system, health policy researchers say.

Falling Through the Cracks

The lack of a cohesive system means that, even though Americans are eligible for health insurance, they struggle to access it, said Mark Shepard, an associate professor of public policy at the Harvard Kennedy School of Government. No central entity exists in the U.S. to ensure that all people have a plan, he said.

Over half of the uninsured might qualify for Medicaid or subsidies that can help cover the costs of an ACA plan, according to KFF. But many people aren’t aware of their options or can’t navigate overlapping programs — and even subsidized coverage can be unaffordable.

Those who have fallen through the cracks said it feels like the system has failed them.

Yorjeny Almonte of Allentown, Pennsylvania, earns about $2,600 a month as an inspector in a cabinet warehouse. When she started her job in December 2023, she didn’t want to spend nearly 10% of her income on health insurance.

But, last year, her uninsured mom chose to fly to the Dominican Republic to get care for a health concern. So Almonte, 23, who also needed to see a doctor, investigated her employer’s health offerings. By then she had missed the deadline to sign up.

“Now I have to wait another year,” she said.

In January, Camden, Alabama, resident Kiana George, who’s uninsured, landed in an intensive care unit months after she stopped seeing a nurse practitioner and taking blood pressure medications — an ordeal that saddled her with nearly $7,000 in medical bills.

George, 30, was kicked off Medicaid in 2023 after she got hired by an after-school program. It pays $800 a month, an income too high to qualify her for Medicaid in Alabama, which hasn’t expanded to cover most low-income adults. She also doesn’t make enough for a free or reduced-cost ACA plan.

George, who has a 9-year-old daughter, said she “has no idea” how she can repay the debt from the emergency room visit. And because she fears more bills, she has given up on treatment for ovarian cysts.

“It hurts, but I’m just gonna take my chances,” she said.

Widening the Gaps

Health insurance is fundamentally a financial product, intended to protect the policyholder’s pocketbook from accidents or illnesses.

Researchers have known for decades that a lack of insurance coverage leads to poor access to health care, said Tom Buchmueller, a health economist at the University of Michigan Ross School of Business.

“It’s only more recently we’ve had really good, strong evidence that shows that health insurance really does improve health outcomes,” Buchmueller said.

Research released this spring by the National Bureau of Economic Research found that expanding Medicaid reduced low-income adults’ chances of dying by 2.5%. In 2019, a separate study published by that nonpartisan think tank provided experimental evidence that health insurance coverage reduced mortality among middle-aged adults.

In late May, the House narrowly advanced the budget legislation that independent government analysts said would result in millions of Americans losing health insurance coverage and reduce federal spending on programs like Medicaid by billions of dollars.

A key provision would require some Medicaid enrollees to work, volunteer, or complete other qualifying activities for 80 hours a month, starting at the end of 2026. Most Medicaid enrollees already work or have some reason they can’t, such as a disability, according to KFF.

House Speaker Mike Johnson has defended the requirement as “moral.”

“If you are able to work and you refuse to do so, you are defrauding the system. You’re cheating the system,” he told CBS News in the wake of the bill’s passage.

A Senate version of the bill also includes work requirements and more frequent eligibility checks for Medicaid recipients.

Fiscal conservatives argue a solution is needed to curb health care’s rising costs.

The U.S. spends about twice as much per capita on health care as other wealthy nations, and that spending would grow under the GOP’s budget bill, said Michael Cannon, director of health policy studies at the Cato Institute, a think tank that supports less government spending on health care.

But the bill doesn’t address the root causes of administrative complexity or unaffordable care, Cannon said. To do that would entail, for instance, doing away with the tax break for employer-sponsored care, which he said fuels excessive spending, raises prices, and ties health insurance to employment. He said the bill should cut federal funding for Medicaid, not just limit its growth.

The bill would throw more people into a high-cost health care landscape with little protection, said Aaron Carroll, president and CEO of AcademyHealth, a nonpartisan health policy research nonprofit.

“There’s a ton of evidence that shows that if you make people pay more for health care, they get less health care,” he said. “There’s lots of evidence that shows that disproportionately affects poor, sicker people.”

Labon McKenzie, 45, lives in Georgia, the only state that requires some Medicaid enrollees to work or complete other qualifying activities to obtain coverage.

He hasn’t been able to work since he broke multiple bones after he fell through a skylight while on the job three years ago. He got fired from a county road and bridge crew after the accident and hasn’t been approved for Social Security or disability benefits.

“I can’t stand up too long,” he said. “I can’t sit down too long.”

In February, McKenzie started seeing double, but canceled an appointment with an ophthalmologist because he couldn’t come up with the $300 the doctor wanted in advance. His cousin gave him an eye patch to tide him over, and, in desperation, he took expired eye drops his daughter gave him. “I had to try something,” he said.

McKenzie, who lives in rural Fort Gaines, wants to work again. But without benefits, he can’t get the care he needs to become well enough.

“I just want my body fixed,” he said.

Have you recently lost your health insurance coverage? Have you been uninsured for a while? Click here to contact KFF Health News and share your story.

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

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

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

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

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

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

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

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

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

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

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

Employer-Sponsored Health Insurance: The Basics

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

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

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

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

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

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

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

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

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

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

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

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

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

So Who Isn’t Insured Through Workplace Insurance?

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

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

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

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

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

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

Cost and Quality — And Therefore Access to Care — Vary

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

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

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

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

Our Ruling

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

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

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

We rate this statement Half True.

Sources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The Host

Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

Read Julie's stories.

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

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

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

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

Panelists

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

Chris Sununu
Former governor of New Hampshire (R)

Roy Cooper
Former governor of North Carolina (D)

Among the takeaways from the discussion:

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

Video of this episode is available here on YouTube.

Click to open the transcript

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Gov. Cooper. 

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

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

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

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

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

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

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

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

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

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

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

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

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

Sebelius: Yeah. 

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

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

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

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

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

Sebelius: A big basket. 

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

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

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

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

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

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

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

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

Sebelius: Just a small addendum, too. 

Sununu: Sorry. I’m frustrated. 

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

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

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

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

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

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

Rovner: Next question. 

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

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

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

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

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

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

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

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

Cooper: Yeah, we are now. 

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

Sebelius: I think it’s almost 45. 

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

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

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

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

Sebelius: Regional. 

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

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

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

Sebelius: Maybe the next guys took it away. 

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

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

Sebelius: I was just— 

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

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

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

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

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

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

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

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

Sebelius: Can I just— 

Rovner: Yes. 

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

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

Sebelius: Or sending them on. 

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

Sebelius: It’s got to be earlier though. 

Sununu: Much earlier. 

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

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

Sebelius: No idea. 

Diaz: Why? 

Cooper: Save money. 

Sununu: Yeah, yeah. 

Cooper: Finding a way. 

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

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

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

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

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

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

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

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

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

Sununu: No, I hate hearing those words. 

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

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

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

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

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

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

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

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

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

Sebelius: I just wanted to clarify. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Among the takeaways from this week’s episode:

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

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

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

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

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

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

Also mentioned in this week’s podcast:

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

click to open the transcript

Transcript: Supreme Court Upholds Bans on Gender-Affirming Care

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, June 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning. 

Rovner: And Victoria Knight of Axios News. 

Victoria Knight: Hello, everyone. 

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

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

Rovner: Which feels a little odd. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Raman: Yes, or— 

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

Raman: Yeah. 

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

Raman: Yes. 

Rovner: Right. 

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: And older people. 

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

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

Knight: Exactly. It was very bipartisan. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

All right, well, that is this week’s news. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week? 

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

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

Rovner: Yeah. Not scary much. Sandhya. 

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

Rovner: Oh, sigh. 

Raman: Yeah. 

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

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

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

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

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

Rovner: Alice. 

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

Rovner: Victoria. 

Knight: I am @victoriaregisk on X. 

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

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Julie Rovner 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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