KFF Health News' 'What the Health?': Nutrition Programs Face Their Own Shutdown
The Host
Julie Rovner
KFF Health News
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.
Health programs are feeling the pinch of the ongoing government shutdown. Funding for the Supplemental Nutrition Assistance Program, or SNAP, and the food program for women, infants, and children, WIC, is likely to run out in November, and cuts at the Centers for Disease Control and Prevention are keeping the agency from carrying out some of its primary public health functions.
Meanwhile, the Trump administration’s immigration crackdown is also leading to health consequences, and the Department of Homeland Security is trying to bolster its medical staff to cope with the large number of people in its custody.
This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Alice Miranda Ollstein of Politico, and Rachel Roubein of The Washington Post.
Panelists
Shefali Luthra
The 19th
Alice Miranda Ollstein
Politico
Rachel Roubein
The Washington Post
Among the takeaways from this week’s episode:
- As the federal shutdown continues, some are facing the startling possibility that their SNAP and WIC benefits soon will be cut off. Lawmakers remain in a stalemate over renewing the enhanced Affordable Care Act subsidies that are set to expire, and the roughly 24 million people with such plans — about 90% of whom benefit from the subsidies — are starting to learn what they will owe next year without them.
- With a key weekly government report on morbidity and mortality halted amid the shutdown, the New England Journal of Medicine and the Center for Infectious Disease Research and Policy announced they will team up to publish public health alerts. While others are stepping in to fill the gap left by the Trump administration’s pullback from public health, the federal government’s data and ability to access information are not easily replaced.
- It’s unclear whether the Trump administration’s plan to make in vitro fertilization more accessible will yield a substantial improvement in access to fertility treatments. Some employers already offer supplemental IVF benefits, and so far there are few details, such as how generous the Trump proposal would require coverage to be.
Also this week, Rovner interviews KFF Health News’ Katheryn Houghton, who wrote the latest “Bill of the Month” feature, about a broken elbow and a nearly six-figure bill.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: ProPublica’s “The Shadow President,” by Andy Kroll.
Shefali Luthra: The 19th’s “More People Are Freezing Their Eggs — But Most Will Never Use Them,” by Shalini Kathuria Narang, Rewire News Group.
Alice Miranda Ollstein: Brown University’s “New Study: AI Chatbots Systematically Violate Mental Health Ethics Standards.”
Rachel Roubein: The Washington Post’s “Errors in New Medicare Plan Portal Mislead Seniors on Coverage,” by Dan Diamond and Akilah Johnson.
Also mentioned in this week’s podcast:
- Politico’s “ICE Is Hiring Dozens of Health Workers as Lawsuits, Deaths in Custody Mount,” by Alice Miranda Ollstein and Ruth Reader.
- The 19th’s “ICE Keeps Detaining Pregnant Immigrants — Against Federal Policy,” by Shefali Luthra and Mel Leonor Barclay.
- The Associated Press’ “Anti-Science Bills Hit Statehouses, Stripping Away Public Health Protections Built Over A Century,” by Michelle R. Smith and Laura Ungar.
Click to open the transcript
Transcript: Nutrition Programs Face Their Own Shutdown
[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 reporters in Washington. We’re taping this week on Thursday, Oct. 23, 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 Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hi there.
Rovner: And Rachel Roubein of The Washington Post.
Rachel Roubein: Hi.
Rovner: Later in this episode we’ll have my interview with my KFF Health News colleague Katheryn Houghton, who reported and wrote the latest “Bill of the Month” about a broken elbow that cost nearly six figures to fix. But first, this week’s news.
So, today is Day 23 of the government shutdown, and there is still no discernible end in sight. But even though the Trump administration is playing fast and loose with the law that’s supposed to ban most spending without the consent of Congress, more ramifications to the shutdown are starting to be felt. It appears that both big federal nutrition programs — food stamps and WIC, which serves pregnant and breastfeeding women and the youngest children — will soon run out of money, which someone on social media pointed out would mean people going hungry on Thanksgiving, which is not a great look for the government. Yet both Republicans and Democrats still think they’re winning this fight. Really?
Ollstein: I feel like every week we’re like: Yep, still shut down. Yep, no real meaningful progress on negotiations. And we’re just in a “Groundhog Day” time loop here.
Rovner: And now the president’s off to Asia in addition to everything else.
Ollstein: Yes, but he wasn’t really super engaged on the shutdown and the reopening. Actually, some lawmakers in both parties have been begging him to get involved, saying it’s really the only way for this to work itself out and to strike some sort of deal on the Obamacare subsidies, is for President [Donald] Trump to be the leader of the Republican Party and tell them to get in line, basically. But that has not happened, and without that happening we haven’t seen a ton of real progress.
Roubein: I mean, I think one thing we’re all looking for is we’ve obviously started seeing rates in some states go up.
Rovner: For the ACA [Affordable Care Act]. Yeah.
Roubein: Yes, for the Obamacare exchanges, due to the impending expiration of the subsidies. But—
Rovner: And the impending open enrollment that starts Nov. 1.
Roubein: Exactly. And so we’ve not yet seen posted on HealthCare.gov, the federal site that some states use, those rates. So I think everyone’s also watching and waiting to see those rates, which are expected to go up.
Rovner: Well, we’ll get to the ACA in a minute, but first I want to talk a little bit more about some of the things that are actually happening because the government is shut down. Over at the CDC [Centers for Disease Control and Prevention], where furloughs have been followed by firings that may or may not be legal, remaining staff are unable to attend this week’s big international meetings on infectious diseases, which feels like something you’d want public health professionals to be kind of up to date on.
And with the so far temporary stoppage of the CDC’s Morbidity and Mortality Weekly Report, which is kind of the weekly bible of public health, now the New England Journal of Medicine and CIDRAP [the Center for Infectious Disease Research and Policy], the public health institute at the University of Minnesota, announced at that same infectious disease conference that they would begin publishing their own public health alerts to try and fill the void of the MMWR. It’s not clear to me if this is intended to be temporary and will stop if and when MMWR is back up and running. Or is RFK [Health and Human Services Secretary Robert F. Kennedy Jr.] actually succeeding in his quest to dismantle the CDC and leave public health up to states and private funders? Is this sort of the decline and fall of the federal role in public health?
Ollstein: I mean, I think it’s a step in a trajectory we’ve been seeing for a few years. It’s not brand-new. I mean, it reminds me of how during the peak of the covid pandemic, outside institutions, academic and otherwise, were setting up their own trackers and other data tools because they did not trust the federal government. And we’re sort of back in that same situation. It’s both a lack of trust in the federal government and the people running it, as well as this new slashing of resources and institutions and a desire to build sort of independent ones that can’t be sort of subject to these political whims in the future.
Although the idea was that the MMWR was protected from political whims, but that is maybe no longer the case. And so it’s tough because building these independent outside versions, they just won’t have the same resources. They won’t have the same access to data that the federal ones that they’re trying to replace had. So it’s not like a one-to-one. And again, seeing the splintering of trust. And so there’s a portion of the public that doesn’t trust the federal government right now, but there’s going to be a portion of the public that won’t trust this alternative setup, either. So it’s just very hard to have a gold standard fount of data that everyone can agree on.
Roubein: Just in sort of the public health space, we’re seeing this really particularly in vaccine policy. It’s starting to fracture along state and political lines. We’re seeing states in the Northeast and the West with their own coalitions to make shot recommendations. We’re seeing groups trying to, like major medical associations, putting out recommendations and saying that they don’t trust the new ACIP [Advisory Committee on Immunization Practices]. So that’s, I mean, I think a kind of tangible spot there.
Rovner: I would say, since I have all three of my abortion experts here, I mean one of the things that we’ve seen since the fall of Roe is that every state now has a completely different policy on reproductive health. Are we moving to the point where every state is also going to have a completely different policy on these public health issues?
Luthra: I think that’s really plausible, but just thinking about Rachel’s point about vaccines in particular, one of the most important differences there is that vaccines are effective when more people use them. And with abortion, we have seen these sort of patchworks take effect. People can travel. People can get pills mailed to them. And there’s a strain on this system. But if someone doesn’t get an abortion in Texas, that doesn’t necessarily affect the health of someone a few states over. But if we see some people have ready access to vaccines and trust in the system that enables them to get that kind of preventive health care and in other parts of the country we don’t, eventually what happens is that there is broader spread of disease and worse public health consequences for all of us.
Rovner: Which is kind of why we have a national public health infrastructure in the first place. We’ll clearly come back to this, but let’s move back to what’s driving this shutdown in the first place, as you mentioned, Rachel, which is the high and growing cost of health care. The Paragon Institute, which is providing what seems to be most of the Republicans’ talking points on health care these days, is pushing a new argument that the expiration of the additional Affordable Care Act tax credits are only a small piece of the increasing premiums for 2026. And that’s true. The CBO [Congressional Budget Office] said in its estimates that insurers are raising premiums slightly to make up for the loss of policyholders who are likely to drop their coverage, which will raise costs for everybody else. But the bigger reasons that premiums are going up are things like tariffs and industry consolidation and the general increase in health care cost.
But I’m wondering if that very semantic point, that the subsidy expiration is only a tiny part of the premium increase is going to make much difference to the people who are going to see their out-of-pocket costs double or more, because while the premium might only be going up a few percentage points, the expiring tax credit will dwarf that, because now they’re going to have to pay the whole premium instead of just a portion of the premium. It’s like your employer’s premiums are going up 5%, but your employer is cutting its contribution in half. That doesn’t seem like a very big solace to people who were — even though the expirations are a little bit of the premium increase, you’re still going to see a bill that says a thousand dollars a month instead of $200 a month, right?
Ollstein: I think we’re seeing that realization take hold. I mean, I know we’ve talked on the podcast before about a small handful of Republicans coming out and saying: Look, my kids’ premiums are going up. We really have to do something, people. Including some members you might not expect, like [Rep.] Marjorie Taylor Greene, very, very conservative folks who say: Look, I’m no fan of Obamacare, but we have to act. This is really bad. Meanwhile, you still have other lawmakers downplaying it, saying, Oh, those subsidies, that was a covid thing and covid’s over, so we don’t need that. But I think the more the plans and the costs start to solidify and people start getting these notifications, the political pressure will continue to build, but build towards what we’re not really sure at this point.
Rovner: Yeah, we’ve seen, I think we’re starting to actually see these premiums in a dozen states. And Rachel, as you mentioned, we will see the federal premiums soon and that might spur something. Meanwhile, the Democrats have a new talking point as well to counter the Republican complaints that the subsidies for the ACA coverage are exceedingly high. They point out that all other forms of health insurance coverage are also heavily subsidized by the government, Medicare and Medicaid by the federal and state governments and employer coverage by the tax exclusion that makes premiums tax-free for both employers and employees. So why, they say, should the individual market be the only one that is not highly subsidized? Effective or a little bit too complicated for this?
Roubein: I mean, I think in general, like at the sort of macro level, we tend to see this in health care. When there’s some benefit or there’s a new policy, it is hard to change that. A lot of things that are supposed to sort of, in Congress they’ll do for a few years, tend to just get extended on and on because it then becomes a pain point.
Rovner: So in the end, I mean, do these subsidies get extended or we still have to wait and see how painful this pain point gets?
Roubein: Who’s to say? I don’t like to always predict what Congress will do, so—
Rovner: Certainly not this year.
Luthra: One thing I will add in there is that we did some polling recently at The 19th just looking at broad economic concerns among other issues, and health care costs are a very serious concern for just a huge majority of Americans. It’s not even, I mean, across the board, this is true. It’s even more true for women. We know that the subsidies had and have had a really meaningful impact for a lot of specific demographics. Women are one of those, so are a lot of more conservative-leaning voters. And I just think that we may not know what will happen with the subsidies, but what we can say is that it’s a really big deal to a lot of people who will be affected, and it’s hard not to imagine that affecting how they think about their representation and ultimately whether government is working for them when they look at their health care getting more expensive.
Rovner: I don’t carry around a lot of numbers in my head, but the numbers that I carry around include 24 million people who are getting ACA coverage, 90% of whom are getting subsidies. So, it’s a lot of people, as we’ve said many times, in a lot of pretty Republican states. So we’ll see when the yelping really starts. Well, I want to talk a little bit about immigration and health because we have two excellent stories about health care and immigration this week, written or co-written by two of our panelists. How convenient. Alice, tell us about your story about ICE [Immigration and Customs Enforcement] hiring more health workers.
Ollstein: My co-worker and I noticed that all of these jobs were posted for doctors, nurses, pharmacists, therapists, health care workers to work specifically in ICE detention. And we were interested in, why go on this hiring spree? I mean, we’re in a government shutdown. It’s not exactly hiring season. But once we started looking into it — well, one, the federal government did not respond to our questions about why they’re hiring and what they hope to achieve. But we saw that the detainee population has exploded to record levels and the number of deaths has gone way up. We are approaching the number of deaths, just in 10 months this year, almost as much as occurred over the four years of the Biden administration. Now, the actual rate isn’t as high because there’s just so many more detainees, but it’s very troubling and people are dying of both sort of acute and chronic factors.
And so there’s all these lawsuits right now about medical neglect and poor access to medical care in ICE detention. There are multiple hunger strikes going on in multiple states related to We’re being denied access to health care. And so all of this is sort of building to a crisis point. And people are being held in facilities that weren’t meant to hold people, let alone this many people, these sort of tent cities they’re standing up very quickly. Facilities are overcrowded, which makes it hard to control the spread of disease. Just a lot of issues going on. And so we talk to people about what could hiring some new medical personnel, what could that help address and what is it not likely to address in terms of the conditions.
Rovner: Yeah, I mean it seems when you have that many people in detention, hiring a couple of dozen of health workers is going to not really solve the problem.
Ollstein: Right. So, one, we don’t know if and when these people will be hired, but even so, again, a few dozen compared to they’re trying to grow the population of detainees by tens of thousands. The numbers don’t really add up.
Rovner: Well, Shefali, you have a story that kind of follows onto that, about women who are pregnant or nursing being taken into immigration custody, which is a change from prior practice, and the sometimes tragic outcomes of that. What did you find?
Luthra: So this story came because we just kept seeing individual lawsuits and single reports of someone saying: I was detained while I was pregnant. Here are the conditions I was held in. Some people reported miscarriages. Some people just reported really substandard care. And it came to become clear to us that this appeared to be somewhat of a trend, is these women were being detained, sometimes for short periods, sometimes for longer periods, and they were having adverse health consequences.
And so we did some digging. We learned that there actually was a policy put in place that said you are not supposed to detain people who are pregnant, who are nursing, who are a year postpartum, unless there are really extenuating circumstances. We looked everywhere to see: Had this been rescinded anywhere? And it hadn’t been. And that was just so striking to us because this policy is technically still in place. ICE is not supposed to be detaining these people, and every doctor you speak to will say: Well, we can’t study. There’s no randomized control trial of being detained versus not and pregnant and what happens to you.
But we know what is good for pregnancy and what is not, and we can say that the best practices are you shouldn’t detain people where access to prenatal care is sporadic at best, maybe not in the language that you speak. The food will not work for you, especially if you have these strong aversions. You may not be able to talk to someone right away if you suspect you are miscarrying. There’s a lot of psychological and physical stress. And then at the same time, the government has stopped reporting just how many of these cases there are.
And so there’s a lot of efforts underway to try and figure out as detention gets broader and broader, they try and, as Alice said, really increase the number of people being detained. We are seeing more women in particular, more pregnant, postpartum nursing women, being detained, and the numbers will just not be able to give us that clear sense of who they are or also what the health consequences can be.
Rovner: We’ll try to keep an eye on it there. I will post links obviously to both of your stories. I want to talk about MAHA, Make America Healthy Again. The AP [Associated Press] has a series out this week tracking the organized campaign by those with financial interest in the MAHA movement to, in the words of the story, quote, “strip away protections that have been built over a century” in public health. The reporters, including KFF Health News alum Laura Ungar, tracked 420 anti-science bills introduced in 43 state legislatures around the country focusing on vaccines, fluoride, and raw milk. They also tracked back those pushing the legislation to the supplement and wellness product sellers, raw milk farmers, and others who stand to profit from focusing on the MAHA priorities. For all of Secretary Kennedy’s accusations about the health care industry being in the pocket of Big Pharma or Big Food, can’t it also be said that many of his allies are in the pocket of Big Wellness?
Ollstein: I think that it has been fascinating that the wellness industry, the supplements industry, these aren’t being seen as the big capitalist forces that they really have become. And they’re far less regulated than the industries that the movement rails against, like food and like the pharmaceutical industry. And yet it sort of has this sheen of virtue that is — it’s gotten a lot less scrutiny and a lot less questioning. And so I wonder if that changes as this power shift happens at the state and federal level.
Rovner: Yeah. I think the raw milk producers I think really probably shocked me the most, maybe because I knew about the other ones, but sort of the power of the burgeoning raw milk industry. By the way, if you don’t pasteurize milk, you can get all kinds of bacteria and viruses and other bad things from drinking raw milk. It’s one of those things, like many of these things, that sounds great until you actually look into it. Rachel, you wanted to add something?
Roubein: Oh yeah, I was just going to say that I think in general, this push from the Make America Healthy Again movement, its allies into state legislatures, has been very coordinated. This is a big goal of the MAHA movement. Allies aligned with Kennedy are pushing a range of bills. They’re also pushing bills around food that did pass the state legislatures last year, such as barring SNAP [Supplemental Nutrition Assistance Program] recipients from using their benefits to buy soda or cracking down on artificial dyes in the food supply. But in general, Kennedy has not put sort of sweeping regulations, new regulations, around food, around pesticides, etc. And instead, a lot of allies are seeking to use the states, particularly when it comes to food, to sort of pressure companies and then be able to kind of pressure into a sort of federal, a more kind of national push.
Rovner: That’s kind of this administration’s theme, right? It’s: We’re not going to regulate, because we don’t like regulation. We’re just going to do individual deals with individual companies. I mean, certainly that’s what Trump’s doing with tariffs and other things, and it looks like that’s what Kennedy’s doing too, right? Seeing nodding.
Well, moving on. Like pretty much every week, there is news on the reproductive health front. Late last week, President Trump unveiled his plan to improve access to IVF [in vitro fertilization] for people hoping to get pregnant. During the 2024 campaign, he very specifically promised to make IVF free, either by having the government pay for it or requiring insurers to cover it, quote, “because we want more babies,” he said. But his plan doesn’t really do either of those things, right? It doesn’t make it free. I’m seeing shaking heads. Someone explain what it actually does do.
Ollstein: So there’s two pieces of this. One is a voluntary agreement with a pharmaceutical company to lower the cost of one fertility drug. It’s not a drug that every single person who goes through the process uses, but a lot of people do use it. I will also note that out of the total cost of IVF, the cost of these drugs is just like a fraction of it. Less than a quarter is what I was told when I talked to experts. So this doesn’t do anything to lower the cost of the consultations, the egg retrievals, the egg storage, the embryo implantation. All of those costs are unchanged. So there’s the drug crisis — yeah.
Rovner: I would say basically if you don’t have coverage for IVF and you can’t afford it on your own, lowering the cost of the drug is nice but it’s not going to make you able to afford it. Right?
Ollstein: Likely not. Likely not. But the other piece of it is we’re still waiting for the exact text of what this guidance and regulation will consist of, but just going off of what they’ve said, they want to make it easier for employers to offer supplemental IVF coverage that’s separate from the regular health plan. Now, I’ve talked to some experts who are really skeptical that that will make a difference. One, employers can already do that. Politico offers supplemental IVF coverage.
Rovner: So does KFF Health News.
Ollstein: There you go. And so it’s not clear what this guidance, which comes with no funding, no incentives, no mandates, why an employer that didn’t already offer it would choose to offer it now. It’s not totally clear. But also making it this separate supplemental thing, you get into this adverse selection situation where the only people who are going to sign up for it are the people who plan to use it, and that doesn’t spread the cost around and bring it down like regular insurance does.
Luthra: And I think it’s worth noting, if we even — to Alice’s point, we don’t have a lot of details yet about how these plans would work — but going off of everything they said in their remarks, looking through what documentation has been put out so far, one thing we keep hearing about from administration officials is the flexibility within these plans and the ideas that employers could offer benefits that match their values.
Which I think is really interesting because when you talk about fertility benefits, some people do have moral objections to IVF, and when you talk about matching their values, there’s a real question there: Are these plans actually required to cover IVF with multiple embryos, created with embryos discarded? We also heard a lot of chatter about offering benefits that would address the root causes of infertility. And this has become somewhat of an allusion to other forms, regimens, ideas of what fertility treatment can be that conservatives call restorative reproductive medicine.
And I think as we get more details, a really important question to see is, how generous do these plans have to be, or are they in practice? Do they actually cover IVF in a way that is meaningful and actually addresses people’s needs? Or do they instead offer limited coverage of something that is less effective, maybe already covered, and certainly already affordable for a lot of Americans?
Rovner: So one would assume that this plan is sort of meek because the administration is trying to be sensitive to the portion of the anti-abortion movement that opposes IVF because, as you say, you often create multiple embryos and then don’t end up using them and they end up getting destroyed. So is the politics of this going to satisfy both sides or going to dissatisfy both sides of this fight?
Luthra: The anti-abortion movement seems to understand that it could have been worse for them, but they are not thrilled about it, either. You mentioned, when we were discussing this part of the show, the Vox article, which I thought had a really great headline, by Rachel Cohen Booth, which was “Trump Manages To Disappoint Nearly Everyone With His New IVF Plan,” which I think is about right. I mean, this is not what people who want broad access to IVF would actually hope for, and this is certainly not what conservatives who oppose IVF would hope for, either, because they want something that is more sweeping in its criticism of IVF as it’s practiced. They want something that more full-throatedly endorses what they support instead. And it’s neither of them. It’s just sort of trying to find something that pleases everyone and, as a result, not necessarily changing that much.
Rovner: Politics as usual. Well, meanwhile, Bloomberg has a really provocative story this week about the limbo that many Planned Parenthood clinics find themselves in. You may or may not remember that as part of the Republicans’ big budget bill that passed earlier this year, the organization lost all of its federal Medicaid funding for a year. But because of the shutdown, HHS has not yet issued guidance on which Planned Parenthoods — many of which have stopped providing abortions or never provided abortions in the first place — are covered by this funding cutoff. Making everybody uncertain and unable to plan appears to be the overall strategy for this HHS, doesn’t it?
Ollstein: Well, and on top of that, Planned Parenthood affiliates that were getting Title X family planning money had that withheld, had that frozen, and they’re still waiting to learn the fate of that portion of money. And so it’s just uncertainty piled on top of uncertainty.
Rovner: Yeah. This I imagine is not going to impact what sort of the big abortion fight is going forward, which is going to be about abortion pills sent through the mail. But one would assume that it is going to impact people who are looking for services that don’t have anything to do with abortion, that have to do with cancer screenings and STD [sexually transmitted disease] screenings and just regular, routine gynecologic care. I mean, that’s what these Planned Parenthoods are providing using Medicaid funds and using the Title X funds, neither of which can be used for abortion.
Ollstein: Right, and a lot of the clinics that have shut down in recent months — I’m thinking of the ones in Louisiana and Texas and Iowa — abortion is banned in those places. Those clinics were not providing abortions. So I’ve been seeing a lot of folks on the right celebrating those clinic closures. But again, those clinic closures don’t mean less abortion. Those clinic closures mean less access to these other services.
Rovner: All right, well, that is this week’s news, or at least as much as we have time for. Now we will play my “Bill of the Month” interview with Katheryn Houghton, and then we will come back and do our extra credits.
I am pleased to welcome back to the podcast KFF Health News’ Katheryn Houghton, who reported and wrote the latest KFF Health News “Bill of the Month.” Katheryn, welcome back.
Katheryn Houghton: Thank you so much.
Rovner: So, this month’s patient had insurance but ended up dropping it because she could no longer afford the premiums, an all too common story, and then two months later slipped and fell and broke her elbow. Tell us who she is, what kind of care she got, and how much she was told it was going to cost.
Houghton: Sure. So her name is Deborah Buttgereit. She had fractured her left arm near the joint. So this was a humerus break, and it shattered a bit. So she needed surgery to kind of piece the bones back together, and that’s pretty key to, say, be able to move her arm. So she was told it was going to cost $50,000 or just a little bit more than that, and all of that would be out of pocket because, like you said, she didn’t have health insurance.
Rovner: Yikes. So, she had the surgery. Presumably her arm is better. And then the bill came. How much did it end up being?
Houghton: A lot more than $50,000. It was more than $97,000. Though it is important to say the hospital applied a self-pay discount, which left her with a $78,000 bill.
Rovner: So what was the explanation about why it was so much more expensive than the original estimate?
Houghton: The original estimate is just that, and the way that hospitals put it is: It is our best guess of what you are going to have to pay. If there’s some sort of complication, it could cost more, and there is a small fine print in any good-faith estimate that says that. So for Deborah’s case, the hospital said there were surprise complications, which means surprise costs. Her doctor said they encountered complications kind of mid-procedure, so her bones shattered into more pieces than they expected. That meant more time in surgery, that meant more skill to fix the break, and that also meant more tools to fix the break. And all of that comes with more costs.
Rovner: Yes. So Ms. Buttgereit decided that she did not wish to pay, even though, what, $78,000 that they were hoping that she would, and found that eventually she could appeal the bill under a provision that I didn’t know was included in the federal No Surprises Act, which I thought only applied to people with health insurance. Tell us about this little not well-known piece of the No Surprises Act.
Houghton: Yeah, exactly. I mean, fair thought on it being surprising, because a lot of people don’t know this exists. Some of the policy experts I talked to were like, Oh, this exists. A little-known fact about this is the No Surprises Act also created a formal dispute process for uninsured patients or those paying completely out-of-pocket for a planned procedure, so even outside of that emergency care situation. And this process, you’re eligible for it if you’re paying out-of-pocket and your final tab is $400 or more than the initial estimate.
Rovner: Which this clearly was.
Houghton: By quite a bit.
Rovner: So in the end, she decided not to use this appeal process. Why?
Houghton: So the appeal process, the floor of a process starts at the good-faith estimate, and Deborah had said, more time to think pain-free, she started to question that $50,000 bill and started using online price comparison tools and saying: You know what? This all seems overpriced. I don’t want that to be the floor. So she’s been going back and forth and doing negotiations with the hospital. But honestly what I’m hearing from the policy experts that I spoke with for this story was there’s just not a good process or system for patients paying out-of-pocket to fight a big bill. And this dispute process is one of the only options that they see out there.
Rovner: And I take it this fight about what she’s eventually going to be required to pay is still ongoing.
Houghton: Last I heard it was still ongoing. She was still going back and forth with the hospital, which was standing by their price tag, and she was working on setting up a payment plan no matter what the final tally came to. But if it stays at that final $78,000 range, a payment plan means she would face payments for 60-plus years.
Rovner: And she’s already in her 60s, right?
Houghton: Yes. Yeah. She would be paying off this for the rest of her life.
Rovner: So it’s probably in the hospital’s interest to find a better solution. What’s the takeaway here for other patients who end up with an accident and a big bill and no health insurance?
Houghton: The takeaway is if you’re going to push back on a price, starting at the good-faith estimate is key. So once you’ve already gone through the procedure, that’s almost like acceptance of what that floor price would be. And so if you’re going to fight back, fight at the very beginning. That’s hard when you’re going through a, say, painful break and you don’t have a lot of the energy to deal with anything other than trying to be OK with yourself and take care of yourself. The other thing to know is just if you are uninsured, if you are paying out-of-pocket, there is this dispute process if you get to that point.
Rovner: Great. Katheryn Houghton, thank you so much.
Houghton: Thanks so much.
Rovner: OK, we’re back. It’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Shefali, you have a story that’s related to reproductive health and IVF and all of those other good things. Tell us about it.
Luthra: Sure. So this was written by Shalini Kathuria Narang, written for Rewire News Group, co-published with the 19thnews.org. The headline is, “More People Are Freezing Their Eggs — But Most Will Never Use Them.” And I thought this was so interesting. It delves into a study that showed that 6% of people who froze their eggs between 2014 and 2021 had actually come back and used them within seven years.
There’s a Q&A with the author. But what’s so striking to me about this is, I mean, I definitely felt in the 2010s there was this huge conversation around egg freezing among especially young women who were working, this idea that this is a benefit that is being made available to you, this could actually make it much easier for you to ultimately have children if it’s something you want to do later in life when it gets harder.
And I just think this is so fascinating that this was a benefit that was really promoted, an alternative that a lot of people turned to, and that it seems that a lot of people aren’t necessarily using it. I really wonder why. I’m curious how much money has been spent on this and what this means and sort of how it helps us understand people’s reproductive choices moving forward. I just am so excited to see where this research takes us and how we better understand people’s reproductive choices.
Rovner: Yeah, it was interesting. I mean, one of the things that I found really interesting about this story was that it’s actually too soon to really know how many of them get used, because we did see this increase in young women having their eggs retrieved and frozen, and those young women, many of them are still young and not yet ready to use them. I mean, they still could, in other words.
Luthra: And many of them who froze them may not have to use them, because they froze them thinking, Oh, this is for much later, and then it turns out they actually can get pregnant without using them to begin with.
Rovner: Yeah, it’s a really provocative story. Alice.
Ollstein: Yes. So I chose this new study from Brown University. It’s titled “AI Chatbots Systematically Violate Mental Health Ethics Standards.” So the number of people who turn to ChatGPT and these other AI tools for therapy, either just chatting with it or specifically prompting it to provide therapy — that’s an increasingly common practice.
But if you read this study, you might not want to do that. This says that exhibited 15 ethical risks, including failing to refer users to appropriate resources or responding indifferently to crisis situations, including suicidal ideation. The chatbots exhibited gender, cultural, or religious bias. They used what they called deceptive empathy. They created a false bond between the bot and the user. They reinforced negative thoughts and beliefs. So this is yet more evidence that therapy is best provided by a human being who was trained and not a language predictor tool.
Rovner: Maybe it’s just that I’m old, but I don’t think I want to take personal advice from anything that learned everything it knows from the internet. That’s just me. Rachel.
Roubein: My extra credit this week is a story by my colleagues Dan Diamond and Akilah Johnson at The Washington Post. The headline is “Errors in New Medicare Plan Portal Mislead Seniors on Coverage.” So Medicare open enrollment began Oct. 15, and ahead of that, the Trump administration created this directory that was aimed at helping millions of seniors try and look up what doctors and medical providers accept which insurance.
But the portal, when it first opened, it was focused just on Medicare Advantage plans, and what my colleagues found is it frequently produced erroneous and conflicting information, and that led to a scramble inside the federal government to try and fix it. Dan and Akilah wrote about the backstory, too, which is that the Trump administration announced these plans for a national directory, but then in August they said it would be a temporary directory limited to just Medicare Advantage or private plans. After Dan and Akilah raised the problems that they were writing about to the Centers for Medicare & Medicaid Services last week, officials said that they were working to address the errors and seek potential solutions.
Rovner: People in other countries that have national health insurance must laugh at us about the fact that we can’t even have accurate directories of which providers take which insurance. But this has been a long-standing problem dating back as many years as we’ve had networks of doctors. Someday someone will solve it. I don’t know, maybe AI can do it.
My extra credit this week is from ProPublica. It’s called “The Shadow President,” by Andy Kroll. It’s about the rise of Russell Vought, whose name most people don’t know unless you listen to podcasts like ours, but who is the head of the White House Office of Management and Budget, the man behind lots of Project 2025, and the person calling most of the shots for the domestic policies of Trump 2.0. Trump actually proudly introduced him this week at a lunch for Republican senators as his personal Darth Vader.
What I really like about this story, though, is not just the detail of how Vought came to his beliefs, which is interesting enough, but how OMB is so intricately in charge of just about everything an administration does, which I think most people do not appreciate. This story is part of a year-long investigation with The New Yorker, and it is well worth your time, even though it’s pretty long.
All right, that is this week’s show. Thanks this week 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 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 still on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Shefali?
Luthra: I’m on Bluesky, @shefali.
Rovner: Alice.
Ollstein: Mainly on Bluesky, @alicemiranda.
Rovner: Rachel.
Roubein: I’m on X, @rachel_roubein. Bluesky, @rachelroubein. LinkedIn, etc., Signal.
Rovner: You can find us wherever you look. We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Democrats Make This Shutdown About the ACA
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
As long predicted, much of the federal government shut down on Oct. 1, after Congress failed to agree on spending bills that keep most programs running. Republicans need at least a handful of Democratic votes to pass spending bills in the Senate. In exchange, Democrats demanded Republicans renew expanded premium subsidies for Affordable Care Act marketplace plans, which were passed during the pandemic — effectively forcing their own shutdown over ACA policies, as Republicans did in 2013. Republicans so far have refused to continue the subsidies or even discuss them — but now say they won’t negotiate unless Democrats agree to reopen the government.
Meanwhile, President Donald Trump announced a deal with the drugmaker Pfizer to lower some drug prices in the U.S., but it’s unclear how much of a difference it will make for consumers.
This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Shefali Luthra of The 19th, and Lauren Weber of The Washington Post.
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Rachel Cohrs Zhang
Bloomberg News
Shefali Luthra
The 19th
Lauren Weber
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Among the takeaways from this week’s episode:
- Democrats seized an opportunity to highlight how Republican policies are reshaping the health care system, as health care tends to be a winning campaign issue for Democrats. But as they push to extend enhanced federal subsidies and reverse Medicaid cuts, a big question arises: Will Americans notice?
- Meanwhile, some Republicans suggest they are open to renewing enhanced ACA plan subsidies with certain changes — but do not want to address the issue now, even as open enrollment approaches. And in response to Democrats’ calls to undo Medicaid cuts, the GOP is repeating a misleading talking point about benefits for people living in the U.S. without legal status — when, in fact, the policy change would largely help hospitals.
- And vaccine uncertainty continues, with new recommendations from the remade Advisory Committee on Immunization Practices awaiting sign-off — and holding up some vaccine shipments, particularly for uninsured and underinsured kids. Plus, the Trump administration has struck a deal with Pfizer. Other drug companies are likely to follow with their own deals to spare themselves tariffs. What’s less clear is how patients would benefit from these savings.
Also this week, Rovner interviews KFF Health News’ Cara Anthony, who wrote a recent “Bill of the Month” feature about an out-of-network eye surgery that left one kindergartner’s family with a big bill. If you have an outrageous or inexplicable medical bill you’d like to share with us, you can do that here.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Big Loopholes in Hospital Charity Care Programs Mean Patients Still Get Stuck With the Tab,” by Michelle Andrews.
Shefali Luthra: The Washington Post’s “Trump’s USAID Pause Stranded Lifesaving Drugs. Children Died Waiting,” by Meg Kelly, Joyce Sohyun Lee, Rael Ombuor, Sarah Blaskey, Andrew Ba Tran, Artur Galocha, Eric Lau, and Katharine Houreld.
Lauren Weber: Time Magazine’s “Trump Is Breaking Americans’ Trust in Doctors,” by Dr. Craig Spencer.
Rachel Cohrs Zhang: ProPublica’s “Georgia’s Medicaid Work Requirement Program Spent Twice as Much on Administrative Costs as on Health Care, GAO Says,” by Margaret Coker, The Current.
Also mentioned in this week’s podcast:
- KFF’s “ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire,” by Justin Lo, Larry Levitt, Jared Ortaliza, and Cynthia Cox.
- KFF Health News’ “How Federal Shutdown Hits Health Agencies, Explained to Aspen the Corgi,” by Julie Rovner.
- The Washington Post’s “White House Considers Funding Advantage for Colleges That Align With Trump Policies,” by Laura Meckler and Susan Svrluga.
- Politico’s “Top US Researchers Rush To Relocate to Europe,” by Pieter Haeck.
- Bloomberg News’ “RFK Jr. Mulls Adding Autism Symptoms to Vaccine Injury Program,” by Rachel Cohrs Zhang, Madison Muller, and Gerry Smith.
- MSNBC’s “He Helped Build the Anti-Vaccine Movement. RFK Jr. Just Hired Him,” by Brandy Zadrozny.
Click to open the transcript
Transcript: Democrats Make This Shutdown About the ACA
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 2, 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 Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: And Rachel Cohrs Zhang of Bloomberg News.
Rachel Cohrs Zhang: Hi, everyone.
Rovner: Later in this episode we’ll play my interview with my colleague Cara Anthony, who reported and wrote the latest KFF Health News “Bill of the Month,” about an out-of-network surgery that looked like it had prior approval from the insurer — but maybe not. But first, this week’s news.
So today is Oct. 2, and to the surprise of just about nobody who’s been paying attention, much of the government is in a shutdown, thanks to Congress’ failure to pass a spending bill or even a temporary patch for the fiscal year that started Wednesday. And just like in 2013, this shutdown is about the Affordable Care Act. Except in 2013 the Republicans shut down the government because they wanted to delay the start of the ACA. This time Democrats are shutting down the government to try to force Republicans to reup the additional ACA subsidies that Democrats passed during the pandemic but which expire at the end of December. That’s just the beginning of the confusion.
I’m not even going to ask when or how this ends, because truly nobody knows. But there are lots of things that are very different about this shutdown from previous ones, aside from the fact that Democrats, who are usually the ones fighting to keep the government up and running, are the ones who are forcing the shutdown this time. What has changed the most since March, when Democrats went along with a temporary spending measure that they could have blocked at the time?
Cohrs Zhang: I think obviously we saw a lot of blowback from the Democratic base in response to [Senate Minority Leader] Chuck Schumer’s decision to go along and just continue funding the government. I think the argument has been that it’s not business as usual and that Democratic leaders shouldn’t be treating it that way. And this is one of the few leverage points Democrats have in Washington right now, just because Republicans control the White House and the House and the Senate. So we have seen much more aggressive actions by the White House to exercise control over government spending and testing the waters as to how far they can go to overrule Congress’ directions for how money’s supposed to be spent in the government, which obviously plays into the government spending fight.
And we’ve also seen the passage of Republicans’ reconciliation bill in the summer, which always poisons the well a little bit when it comes to bipartisan negotiations. Democrats see an opportunity to highlight Republicans’ spending reductions in Medicaid and all these new policies that they’re passing there. And I think Democrats have always viewed health care as a winning issue for them. I think that’s a lesson that they’ve learned over and over again in midterms and elections, that this is just an issue that generally voters think Democrats do a better job on. So I think they’re seeing this as an opportunity to highlight a potential pocketbook issue for health care and setting up for the midterm elections next year.
Rovner: It’s interesting that back in March, one of the things that Chuck Schumer said is that he didn’t want to close down the government and give [President Donald] Trump basically that much more power. Well, this time they’re giving Trump that much more power and he seems to be running with it. The head of the OMB [Office of Management and Budget], Russ Vought, has already announced on social media that he’s cutting off funding for Democratic priorities, including a tunnel that’s being built between New York and New Jersey and a lot of the green energy projects that were in the Biden administration infrastructure bill, all of which have had money appropriated for them that the administration is supposed to spend. And now just this morning before we started taping, the president himself said he’s going to meet with Russ Vought to see what else they can do to basically throw sand in the gears of Democratic priorities that are supposed to be carried out. I guess this maybe is where Schumer gets to say, See, I told you so back in March.
Luthra: Potentially. I think it’s worth noting — right? — that a lot of things, which we’ll talk about later, of course, were cut off, in terms of spending that was already allocated, even without the excuse of a shutdown. So it’s not very productive to engage in counterfactuals and hypotheticals, but it’s totally plausible that even without a shutdown a lot of this funding would’ve been cut off anyway. Which — I don’t know. It’s just we are not living under really normal politics anymore, and we can’t really pretend we can know what would’ve happened.
Rovner: Yes, “unprecedented” is a word I’ve been using a lot lately. Well, we should review what happens to health programs during a shutdown, and I will post a link to the video that I did with my corgi Aspen to help explain it. What’s running and what’s not in terms of health care when the government is, quote-unquote, “shut down”? Because not everything is shut down?
Cohrs Zhang: I mean, we do have a lot of the core functions continuing in terms of emergency response at the CDC [Centers for Disease Control and Prevention]. They are cutting back on public communications of public health data that are usually pretty routine. The FDA [Food and Drug Administration] has said they’re no longer accepting new drug applications, but obviously the review of applications that they’ve already received will continue because there are a lot of positions at the FDA specifically, but across the government, that are funded through other streams from fees from industry that don’t necessarily go through the routine process. But we certainly will see less information coming out of agencies. Just the general function of them, policy announcements, policy of movement, everything slows down as things that are in motion kind of grind to a halt as everywhere is kind of strained for resources.
So I think we’ll see. I know at NIH [the National Instituted of Health] they said that they’re not taking in new patients for clinical trials and the grant reviews may be slowed down. So there’s just a lot of things that will slow down. But I think the core functions — of, like, Is this patient care? Is this emergency response? — for the large part are continuing at this time.
Rovner: And of course mandatory programs, Medicare and Medicaid, continue because they’re not affected by a shutdown, because the shutdown is only for discretionary programs. Lauren, you were going to add something.
Weber: I was just going to say I was sitting on an unrelated focus group for five hours on Tuesday night, and like 99% of the people when asked Oh, is anything happening in D.C.? had no idea about the shutdown. Like, none. I mean, just absolutely zero idea. So while all of these points are very important to talk through, I also question whether any of the messaging from both sides is getting through to the average person and whether or not the complexities of this are quite clear.
Rovner: Well, one of the things that the Democrats are shutting the government down over is the failure of Republicans to renew the expanded subsidies for the Affordable Care Act that were passed in 2021 originally and then extended through the end of this year. People are going to find out about those because there’s 24 million people who are getting ACA coverage, and 90% of them are getting subsidies, and they’re all going to find out in the next couple of weeks how much their premiums are going to go up because of the failure to renew these subsidies. How big is this shock going to be?
Cohrs Zhang: Depends on who it is, right? So, it’s like some people, especially people who are kind of in the higher income range, around 400% of the federal poverty level, if these tax credits expire, they don’t get any subsidies at all anymore. So we could see hundreds of dollars a month for beneficiaries who fall into this category. But for some beneficiaries there’s a smaller dollars-and-cents change that they’re going to see, because they’ll still get some subsidies but not as many. And I think it’s actually unclear who exactly is going to find out about these rate increases. CMS [the Centers for Medicare & Medicaid Services] has given states some flexibility as to whether they put the actual premium increase in these letters that people are going to be getting over the next month. So I think it’s going to be interesting to see how states strategize in terms of communicating with people about the potential for these increases but not scaring them away from the exchange entirely if Washington does manage to figure this out in the next couple weeks.
Rovner: Yeah, the Republicans keep saying, Oh, this is a December problem. It’s like, no, this is not a December problem. Open enrollment starts Nov. 1, and if people show up and sign up, or if they’re in a plan that suddenly they can’t afford and they might want to move to a cheaper plan if they can find a cheaper plan to move to, I mean, this is definitely not a December problem.
Luthra: And going back to your question, Julie, I mean, KFF did a very helpful analysis just looking at how much premiums could go up if the tax credits expire. And the last I checked it was they will more than double, which I noticed when my electricity bill went up this year. I think that’s pretty hard for people to not see when suddenly they’re spending potentially twice as much on their health care.
Rovner: And I will post a link to that analysis which just came out. It’s an updated analysis with new data that shows that premiums are likely to spike even more. Well, one of the big arguments that Republicans are making about this shutdown, because Democrats not only want a renewal of these subsidies, they also want a reversal of a lot of the Medicaid cuts that were in the big budget bill that passed over the summer, and Republicans say Democrats are asking for federal health funding for illegal immigrants, which is not really true. What is it that Democrats are asking for?
All right. I’m going to have to answer. I will answer this question myself because I went down the rabbit hole on emergency Medicaid. What the bill this summer did is it basically lowered the reimbursement that hospitals get when they provide emergency coverage to people who are not here with documentation. That is a long-standing program. It dates back to 1986, where hospitals can get reimbursed for treating people in medical emergencies who would be eligible for Medicaid other than the fact that they are not documented, meaning undocumented people are not eligible for Medicaid or for Medicare. Shefali, you were saying there’s a lot of this that is used for labor and delivery, right?
Luthra: Exactly. And I mean if we even think about who benefits from emergency Medicaid, it’s not really undocumented people. It is hospitals, who are required to provide emergency care. But the example where I hear about this a lot is if you are pregnant and you don’t have documentation, you will go to the hospital because you need to give birth, you need to deliver. And emergency Medicaid is what covers the cost of that, which I just found that to be a really interesting point of tension with Republicans given in particular the vice president’s frequent remarks about how much he cares about healthy births and healthy babies.
Rovner: And there’s a whole brand-new federal program aimed at improving birth outcomes. At the same time, they’re chastising the Democrats for saying, We would like to pay hospitals for delivering healthy babies — who are going to be American citizens, by the way, even if they’re mothers don’t have documentation, unless the Supreme Court changes that.
Well as if there wasn’t enough to make your head swim here, I think one of the biggest ironies is that if the Democrats get what they want in terms of getting the Republicans to either roll back some of these Medicaid cuts or extend the additional subsidies, isn’t that going to accrue to the benefit of the Republicans? Because if these cuts happen, it’s presumably the Republicans who are going to get blamed come the midterms next year.
Weber: That’s the irony of all of it, Julie. I mean, that’s the irony of the shutdown. That’s the irony of the messaging. That’s the irony of the whole thing, is that Republicans polls have shown that if these subsidies do increase, if they do double, I mean to Shefali’s point, I think we all notice when — if something costs you a thousand more dollars a year, I think people are going to sit up and pay attention to that. That will cause an issue. So yes, I mean it is somewhat surprising, but at the same day this is a lot of brinksmanship. And again, I question whether the messaging on either side is really cracking through to the American public about why both sides are arguing about the shutdown.
Rovner: Yeah, they’re not on social media and cable TV in general watching people trade these fact checks back and forth.
Weber: Yeah.
Rovner: Well, meanwhile, back at the now partially shut down Department of Health and Human Services, there is still lots of news. We will start with vaccines. Remember that Advisory Committee on Immunization Practices vote a couple of weeks ago that changed recommendations for a whole bunch of vaccines? Well, the committee’s recommendations are not the end of the process. The committee’s work needs to be officially approved by the head of the CDC or the HHS secretary, neither of which has happened yet. Without that approval, shipping can’t begin, for example, for covid vaccines for the federal Vaccines for Children Program, which provides vaccines to about half of all the children in the U.S., by the way. One thing [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has apparently done, according to reporting from MSNBC, is hire as a senior adviser to CDC Mark Blaxill, a high-profile anti-vaccine activist who is neither a physician nor a scientist. Is Kennedy just thumbing his nose now at anyone who believes in vaccines, particularly at Republican senator and doctor Bill Cassidy, without whose vote Kennedy would not now have his job?
Weber: I think Kennedy has been pretty emboldened by the president even going out further than he has publicly on vaccine issues. And I think we’re seeing his continuing leaning into the vaccine point of it all. Which I mean, this is a man who has been an anti-vaccine activist for many, many years. So it’s not completely surprising that he would hire people in that orbit or institute policies that follow what he’s advocated for for many years.
Rovner: But I mean, just, I say this every week, he promised at his confirmation hearings that he would not go after the vaccine schedule, and he has definitely not kept that promise.
Weber: Would you say that most politicians promise things that they do or do not keep, Julia, in your many years of coverage?
Rovner: I don’t consider Cabinet secretaries who promise things to members of Congress who oversee them to be sort of typical politicians. It’s one thing to run for office and then do something else. It’s quite another thing to say in your confirmation hearing for a job that you won’t do something and then just weeks or months later do it. Shefali wanted to add something.
Luthra: Oh, I was going to say to that point, Julie, when all of us watched those confirmation hearings, it was really striking to see that what RFK promised was also different from his long record of advocacy. And one watching those could come away deciding to believe what he said in the hearings or decide to believe what he said leading up to those hearings. And if you picked one, you’d be more right than if you picked the other. And I think there’s a real question now, I mean, given the point that you raised, Sen. Cassidy’s role in helping him get confirmed, his public remarks about how much he supports vaccines. There is a role Congress can play here to try and change things. And I don’t think we’ve seen that that will actually happen.
Weber: So, I’m sorry. I just wanted to throw it back to the confirmation hearing itself. Cassidy asked this question directly. He said something, I’m not quoting it directly, but some version of, You’re a 70-something-year-old man. Does a tiger really change his stripes? — and then voted to confirm him. So as Shefali pointed out, I mean he chose to listen to what he said. But I mean I would say his track record in office has certainly not followed suit on those promises.
Rovner: Well, while we’re on the subject of vaccines, Rachel, you have a story out this week about Kennedy’s plan to add autism to the list of complications eligible for compensation under the federal Vaccine Injury Compensation Program. What would that mean?
Cohrs Zhang: We’re unclear exactly what they’re planning to do, but they’re planning to change the list of conditions or symptoms that people can claim are related to vaccines in this kind of arbitration process that the federal government has set up to compensate people who do suffer side effects from vaccines. It does happen, and I think there’s bipartisan agreement that the current system for compensating people, it isn’t really working very well. It’s really backed up, and there’s arguments that it doesn’t pay enough for people who experience these things. However, I think Secretary Kennedy has made clear to his advisers that he wants parents who believe their children have autism because of vaccines to be compensated through this program, which doesn’t currently happen.
Rovner: No. And would probably bankrupt the program, right?
Cohrs Zhang: It could. It could. Depending on, there’s just so many children these days that do kind of fall under the definition of autism. They’ve talked about maybe changing a definition of some just general neurological symptoms to maybe allow people with autism to qualify. But I think there’s a clear concern from experts as to how this program works, that it’s already backed up and if it’s flooded with these new claims. There’s actually a statutory limit on how many special masters there are to oversee this process.
And unless Congress acts, then they can’t increase that number. So there’s a point at which, A, if these claims are getting granted that they just run out of money. They’re funded by a fixed tax on vaccine doses. So, again, unless Congress acts, they have a limited amount of money. And then you’re thinking about just the fixed capacity that they have to process these claims in the first place. And I think there is genuine concern here that without some support from Congress, this could completely overwhelm the program and just kind of be a roundabout way to validate the idea that vaccines cause autism.
So I think there’s much to watch in terms of what the details are coming out. We’ve just had some high-level comments from an adviser, but stay tuned on that and I think it’ll definitely be something to watch.
Rovner: Oh, absolutely. In other administration news directly affecting HHS and how it provides research funding to universities, The Washington Post is reporting that the White House is working on a plan that would reward institutions that pledge to, quote, “adhere to the values and policies of the Trump administration.” While others are reporting that Trump is about to close a deal with Harvard that involves the U.S.’ most prestigious university paying $500 million to the federal government and, so we hear, opening up and operating trade schools. And in a related piece of news, Politico EU reports that a program run by the EU’s top research council, essentially the EU’s NIH, has seen a fivefold increase in applications from U.S.-based scientists interested in moving across the pond. I’m not even sure what to make of any of this or what it could mean for the future of biomedical research, but it sounds like potentially big, big changes in how the research operation works here in the U.S.?
Luthra: It does seem like something that could ripple for years if not generations to come. I mean, research is something that happens in years-long installments. Careers are built over very long periods of time. And, I mean, when I’ve spoken to a lot of young academics, whether that is for work or even in a personal capacity, a lot of them are really navigating so much instability that is just not what they anticipated when they began their years-long Ph.D. programs. And so it’s not at all surprising that we are seeing the EU’s efforts to recruit American scientists really bear fruit. But to your point, it absolutely raises the specter that a lot of cutting-edge research, a lot of really great future biomedical work simply won’t happen here and we won’t reap the immediate benefits in a way that we have historically. I mean, our higher education and research sector has been a real crown jewel, and it’s hard to see if that stays the case.
Rovner: And it’s been a really important contributor to the economy. I mean, it’s not just the benefits of the research itself. It’s the biomedical research establishment has been something that’s been really important to the United States for a couple of generations now.
Luthra: When you go to a university town, the university is almost always the largest employer and it plays a really big role in keeping up local economies and state economies. And we don’t have a clear answer for what fills in the gap if the institutions that provide those resources disappear or significantly downsize.
Rovner: So sort of kind of related to what’s going on in the university community, President Trump is also demanding that U.S. drugmakers lower their prices and move manufacturing back to the USA — which he also demanded in his first term, though he was mostly blocked by the courts in the ways he tried to make that happen. Well, now he’s employing the same strategy that he’s using with other countries with tariffs and with universities, by negotiating individually. He’s now negotiating individually with drug companies and threatening bad things if they don’t do what he wants. And lo and behold, this week he announced a deal with Pfizer. Rachel, what has Pfizer promised to do? And what does it mean for what had been a unified wall of resistance by drug companies to Trump’s demands that they lower prices?
Cohrs Zhang: Yeah, I agree with your take there that this is a symbolic change for the industry that had warned for so long that if you take, like, put even a toe over the line of imported — tying what Americans pay for medicines to what countries abroad pay, that it was going to be a slippery slope and it was a terrifying concept. So that is a big moment.
We know at a high level what Pfizer’s committed to, but we don’t have a lot of details yet. There’s little in writing, and the press releases were pretty vague. But at a high level, I think Pfizer has agreed to reduce the prices that they offer state Medicaid programs and make those more in line with what prices abroad are. Again, Medicaid already gets really low prices for drugs, so it really is going to be a drug-by-drug, I think, question of: Is this price even lower? I think in some cases, the experts I’ve spoken with think that it’s possible that Medicaid could save money on some of these drugs, but some of them the price could be higher. And I think there’s a question of exactly what those mean. And drug pricing’s really hard, and they aren’t necessarily public, what each payer is paying for these things. So that’s one big element of this that’s important.
They’re also agreeing to sell some of their medicines online, straight to consumers, on a website branded TrumpRx. And I think it’s just kind of like a platform, like a shopping platform is how they’ve described it. You can type in the drug name and then the website would direct you to the marketplaces that the drug companies run themselves.
Rovner: And that just cuts out the middlemen, right? That doesn’t itself save money — I mean, save money for consumers.
Cohrs Zhang: Right. The price may be discounted, but most people aren’t paying the net price of what their insurer pays for a lot of medicines. They’re paying a copay or a percentage. So again, for some medicines, if you’re uninsured, yeah, it’s a lot better to pay a discounted price. But if you have insurance, it’s unclear how, whether you would save any money by going through this process. And you have to have a prescription anyway for a lot of these medicines. So I think there’s just a lot of unanswered questions about exactly how that would interplay for patients with insurance. And then you also have assurances that Pfizer will launch medicine prices that are kind of aligned with what they charge other countries. Generally companies launch in the U.S. first. So does this create a new floor and leverage for Pfizer? I think that’s going to be a really interesting question.
And then I think the last commitment that they made was if they raise prices in other countries for medicines that some of this increased revenue that they get from those drug sales abroad would go back to the federal government potentially through the Medicare program. But we don’t have a lot of details.
Rovner: I saw a story just before we started taping that not only has Pfizer stock gone up since this announcement, but other drug companies’ stocks have gone up since this announcement. Obviously in exchange for this deal, Pfizer has been sort of absolved from having to pay the tariffs that Trump has threatened for three years. And the idea is that other drug companies are likely to make these same deals, which certainly the stock market thinks is not going to cause them to lose money, which suggests that it’s not going to cause big savings for consumers, right?
Cohrs Zhang: Yes. I think that’s a good question, and it is important that analyst notes have expressed that Pfizer’s U.S. revenue, only like 5% of it is for Medicaid. So it’s a very small amount of what they make on drugs. But I think there is this looming regulatory option where Trump could kind of force drugmakers to comply with price reductions in other programs if they don’t make deals. So I don’t think this story is over. And they’ve foreshadowed that more deals are coming, and they may not have exactly the same terms as Pfizer. So I think we’re very much staying tuned here.
Rovner: Well, we will cover them as they happen. OK, that is this week’s news. Now we’ll play my “Bill of the Month” interview with Cara Anthony, and then we’ll come back and do our extra credits.
I am pleased to welcome back to the podcast KFF Health News’ Cara Anthony, who reported and wrote the latest KFF Health News “Bill of the Month.” Cara, welcome back.
Cara Anthony: Hey, thanks for having me.
Rovner: So this month’s patient — or her family, more accurately — did everything right before an elective surgery. At least they thought they did. Tell us who the patient was and what kind of care she needed.
Anthony: Yeah, this month we introduced our readers to a little girl named Chloë Jones. She was in kindergarten at the time. She needed an elective surgery. She had a condition known as ptosis. In layman’s terms, that just means that she had a droopy eyelid. Her parents didn’t want this to interfere with her vision in the future, and so they elected to have this surgery.
Rovner: And they lived where?
Anthony: Just outside of St. Louis, pretty close to me, actually. But here’s the thing: They had a hard time finding a provider who was in network, and the story kind of goes on from there.
Rovner: Yeah. So I guess pediatric ophthalmologists are not a dime a dozen. And they did find somebody. And knowing that it was out of network, they asked their insurer for permission, right?
Anthony: Yeah. They asked for something called a gap exception and actually worked with their pediatrician, worked with Chloë’s primary care doctor, who wrote a letter on their behalf to say: Hey, she needs to have this surgery. Would you honor it as an in-network treatment? Because the closest person that could do this surgery was in Wisconsin, which wasn’t reasonable for them. This is a family with a lot of little kids. So they did. They dotted all of the i’s, crossed all the t’s — or so they thought, because they ended up with a huge bill.
Rovner: Yeah. So then she has the surgery, everything is great, and then the bill comes. How big was the bill?
Anthony: Thirteen thousand dollars, Julie, which was a huge surprise to the family. They didn’t have the means to pay that. So immediately, Chloë’s mom, Keyanna Jones, starts to ask questions, making phone calls, trying to figure out, Hey, what’s going on? They only paid just under $2,000, and there was no way they could pay a $13,000 bill.
Rovner: So they had this letter from the insurance company that said that they would cover this. What happened?
Anthony: Yeah, and this is why we had to ask ourselves in this case: What does covered actually mean? And in this case, the insurers said that they would cover it though without offering network discounts, the surgery itself. Now, some of her other exams that she needed, they did honor those as in network and that was fine. But the surgery itself was covered, but they weren’t willing to cover it as in network and offer those discounts, which would’ve made it much more reasonable, which is why we ended up with the $13,000 bill.
But the tricky part here is that they received letters that looked basically identical. So the letters that said that they would get those in-network discounts were just for the pre-surgery and some post-surgery exams. Those look the same as the letter that said that they were covered for the surgery. But in that letter, the insurer explained that, Hey, we are not going to offer you network discounts. So the family was really confused here, and they had to ask for some serious help.
Rovner: And what finally happened with the bill?
Anthony: Well, Keyanna has a brother who was a former state senator. So she got so frustrated with the situation, she reaches out to her brother, who’s former state Sen. Caleb Rowden, here in Missouri, and he says, Hey, reach out to the senator who represents you, Sen. Travis Fitzwater, and they got the ball rolling. She also reached out to the Missouri attorney general, wrote a letter. Representative Fitzwater also contacted the hospital and the insurer, and they worked it out. So it’s really important for people to know that they can contact their local lawmakers, and that’s what they do — they advocate for their constituents. And in this case, the family paid absolutely nothing.
Rovner: So eventually the bill was basically completely taken care of?
Anthony: It was taken care of completely. They didn’t even have to pay the copay. That’s how much this was kind of messed up. And UnitedHealthcare and both the hospital here in St. Louis just said: You know what? We’re done. So kind of wild.
Rovner: So what’s the takeaway here, besides that you can go for help? I mean, that’s obviously a big piece of it. But what’s the takeaway in the asking permission and getting what we think of as these prior authorizations, these preapproval letters for things like elective surgery?
Anthony: Yeah. I think the main thing is that even if the letters look the same, you have to read every line, make sure that you have clarity there. But it’s also, here’s another reflection of how complicated our health care system is. And in this case, the family had a happy ending. But I don’t know, had she not contacted her brother, who’s a state senator, and not everybody has that kind of advantage. But everyone can contact their local lawmaker for help. But in this case, I would just say read the fine print, and if you think you understand it, read it again because there might be something in there that you’ll catch, and hopefully you can avoid a huge bill. But I’m glad this family was taken care of.
Rovner: Oh, good advice. Cara Anthony, thank you so much.
Anthony: Hey, thanks for having me, Julie.
Rovner: OK, we are back. 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. Shefali, you chose first this week. Why don’t you go first?
Luthra: Sure. My story is from The Washington Post. I normally try and give every byline, but there are a lot. Many journalists really worked very hard on this piece. The headline is “Trump’s USAID Pause Stranded Lifesaving Drugs. Children Died Waiting.” And it’s a very impressive, in-depth investigation. It takes us to Congo, where we meet a young girl who has malaria, and she dies because she can’t get the medication she needs even though it is less than 10 miles away. And the medication never comes to her, because of the freeze on USAID [U.S. Agency for International Development] funding, and this is the taking of U.S. aid inside the State Department.
The story does a remarkable job following the grants and orders that were stopped in the United States when we have the USAID freeze take effect. And then it takes us to the people who suffered and whose lives were lost, including many children, because they couldn’t get medication that was actually not even that far away but simply couldn’t travel the last few miles to get there. It puts all of these against Secretary of State Marco Rubio’s promise that no one has died because of the USAID funding freeze and shows that that probably isn’t true. I mean, not probably, that isn’t true, because these people here in this story did in fact die because they couldn’t get medications that we purchased and sent there and then simply could not get the final step there. I think it’s a really great look at just how devastating this policy choice has been and will continue to be around the world.
Rovner: Yeah, it was quite an impressive project. Lauren.
Weber: I picked an op-ed in Time by Dr. Craig Spencer titled “Trump Is Breaking Americans’ Trust in Doctors.” It’s an op-ed after Trump and RFK Jr. talked about Tylenol and Trump went on to talk about vaccines and what that means for the rest of the country. And I will just say personally, I’ve been struck by how many of my friends from the Midwest, mom friends, regular friends, have reached out like: Hey, you are a reporter for The Washington Post that covers health. What is this? And I do think the Tylenol press conference really broke through in a way that a lot of other things have not.
And Craig makes a bunch of different points about how it essentially pits doctors against the president. And what does that do for decaying trust in medical authorities? What does it do for trust in authorities, period? And I think that’s a question we’re going to continue to see bear out over the next couple of years.
Rovner: Yeah, I think the byword of 2025 is “losing trust.” Rachel.
Cohrs Zhang: My extra credit this week is in ProPublica. The headline is “Georgia’s Medicaid Work Requirement Program Spent Twice as Much on Administrative Costs as on Health Care, GAO Says,” and that’s by Margaret Coker with The Current. And I just thought this story did a great job of just kind of being grounded in the local reporting of: What have we seen? I think there’s tremendous interest in how some of these Medicaid policies that Republicans have committed to will play out across the country. We know state Medicaid officials are already scrambling. Insurance companies, hospitals are trying to figure out: How are we going to implement work requirements at the beginning of 2027? And I think this is a really interesting test project of what that could mean. And I think the administrative burden should not be underestimated, and I think this is just a great way to quantify the infrastructure you need to run a program like this. And I think if you’re spending more on the infrastructure to track people than on the actual health care, then I think that just raises questions about the program as a whole and how efficiently it’s running. So.
Rovner: I would say a lot of eyes on Georgia because they’ve got the only one that’s actually up and running at the moment that people can study.
My extra credit this week is from KFF Health News by Michelle Andrews, and it’s called “Big Loopholes in Hospital Charity Care Programs Mean Patients Still Get Stuck With the Tab.” And it’s about how stupid and bifurcated our health system now is that you can go to a hospital, get approved for charity care, and then still get billed into bankruptcy by doctors who work at the hospital but not for the hospital. It’s kind of a perfect case study into just how dysfunctional things have gotten, and with the impending Medicaid cuts and the ACA premium increases, lots more people are going to become uninsured and likely fall into this same trap. It’s really good story.
All right, that is this week’s show. Thanks this week 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 a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Rachel.
Cohrs Zhang: I’m still on X, @rachelcohrs.
Rovner: Shefali?
Luthra: I’m Bluesky, @shefali.
Rovner: Lauren.
Weber: I’m on X and Bluesky, @LaurenWeberHP.
Rovner: Excellent. We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Public Health Further Politicized Under the Threat of More Firings
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
In a highly unusual White House news conference this week, President Donald Trump — without evidence — boldly blamed the painkiller Tylenol and a string of childhood vaccines for causing a recent rise in autism. That came just days after the newly reconstituted Advisory Committee on Immunization Practices, now populated with vaccine skeptics and opponents, voted to change long-standing recommendations.
Podcast host Julie Rovner interviews Demetre Daskalakis, who until last month was the head of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases, about the reaction to these unprecedented actions.
Meanwhile, as the government approaches a likely shutdown, with Congress at a standoff over funding for the new fiscal year that starts Oct. 1, the Trump administration is ordering federal agencies not to just furlough workers but to fire them if their jobs do not align with the president’s priorities.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, and Sandhya Raman of CQ Roll Call.
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Anna Edney
Bloomberg News
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- The federal Office of Management and Budget on Wednesday night sent a memo to government agencies asking for contingency plans in the event of a government shutdown starting Oct. 1. Such a memo isn’t unusual when it comes to pre-shutdown planning. This time around, it took an unprecedented turn in informing agency personnel that they should prepare for mass firings of employees whose programs lack alternative funding sources or who are working on a program whose mission doesn’t directly align with Trump’s priorities. Though federal RIFs, or reductions in force, and government shutdowns have each happened before, the combined RIF/shutdown threat is a first.
- It seems we are headed for a shutdown. Before adjourning until after the fiscal year ends Sept. 30, the House approved a stopgap funding measure. But, because House members do not plan to return to Washington until Oct. 6, that leaves the Senate in a jam. If senators change anything in the bill, it would require another House vote, which, because of the House schedule, might not happen before the month ends.
- There’s also interparty strife. Republicans say they want a clean bill to provide short-term funding, while Democrats have other ideas. Their prevailing attitude is that they went along with this approach in March and got burned. This week, Trump also canceled a meeting with Democratic leaders. The bottom line is that both sides are jockeying for a position that would allow them to cast shutdown blame across the aisle. Some call it a game of three-dimensional chess, while others call it a game of chicken. Either way, there will be consequences.
- Confusion and chaos have emerged as buzzwords to describe two recent events: last week’s meeting of the CDC’s Advisory Committee on Immunization Practices and this week’s White House press conference about autism. Both were marked by mixed messages. At the White House event, for instance, Trump warned pregnant women not to take Tylenol. But the FDA information that shortly followed downplayed the Tylenol risk.
- The Trump administration’s new $100,000 fee for H-1B visas could have an impact on health care. Such visas are often used by graduating medical students and other health professionals who come to the U.S. for training, then stay to practice. That $100,000 fee is steep and generated an almost immediate backlash from hospitals and health systems, especially those in rural areas — a reaction that caught administration officials off guard. Administration officials have suggested that health professionals would qualify for an exemption from this fee. What is not yet clear is what hoops the sponsoring hospitals would have to jump through to qualify for it.
- Trump has given 17 drug companies a Sept. 29 deadline by which they will have to commit to adopting his “most favored nation” pricing policy. It’s intended to increase the cost drugmakers charge in other countries while lowering prices in the U.S. Talks between the administration and the drugmakers are ongoing. So far, indications are that Trump might end up with half a loaf. Some large drugmakers have announced they will raise the prices of specific medications in other countries but have not agreed to reduce prices in the U.S.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: NBC News’ “RFK Jr. Has the Federal Vaccine Court in His Sights. Attacking It Could Threaten Vaccine Production in the U.S.,” by Liz Szabo.
Anna Edney: The Washington Post’s “Do State Abortion Laws Affect Women’s Recruiting? That’s Up to Athletes,” by Kevin B. Blackistone.
Sandhya Raman: ProPublica’s “Psychiatric Hospitals Turn Away Patients Who Need Urgent Care. The Facilities Face Few Consequences,” by Eli Cahan.
Also mentioned in this week’s podcast:
- Axios’ “Drugmakers Meet Trump Only Halfway on Pricing Plan,” by Peter Sullivan.
- Bloomberg Law’s “White House Says Doctors May Win Reprieve From H-1B Visa Fee,” by Rachel Cohrs Zhang, John Tozzi, and Jessica Nix.
Click to open the transcript
Transcript: Public Health Further Politicized Under the Threat of More Firings
[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, Sept. 25, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this, so here we go.
Today, we are joined via videoconference by Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning.
Rovner: And Anna Edney of Bloomberg News.
Anna Edney: Hey, everybody.
Rovner: So we’re going to do something a little different today. I got a chance to speak on Wednesday with Dr. Demetre Daskalakis, the former head of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases. I asked him to respond to the White House announcement on autism and last week’s rather muddled meeting of the Advisory Committee on Immunization Practices. So we’ll play that interview first, and then we’ll come back for our panel discussion. Here’s the interview.
I am so pleased to welcome Dr. Demetre Daskalakis to the podcast. Until last month, Dr. Daskalakis was the head of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases in Atlanta. He quit, along with three other senior career CDC officials, after Health and Human Services Secretary Robert F. Kennedy Jr. fired their boss, Susan Monarez, for refusing to approve in advance changes to the childhood vaccine schedule. Dr. Daskalakis, thank you so much for joining us.
Demetre Daskalakis: Thank you so much for having me.
Rovner: So, for those who haven’t been plugged into the public health doings over the past month, remind us what exactly your job was at CDC and why you felt you needed to resign following the dismissal of Dr. Monarez.
Daskalakis: So CDC is made up of centers, and so I ran one of the centers, called the National Center for Immunization and Respiratory Diseases. CDC’s not known for its pithy titles. So what that is is the center that is responsible for a lot of what you think about when you think about vaccines and vaccine-preventable diseases. That includes the resources that go out to local jurisdictions.
Rovner: And when Dr. Monarez was fired, what did that signal to you?
Daskalakis: Yeah. I think the last eight months had been hard. I think that we had other things that happened before Dr. Monarez’s resignation. I think we saw the Advisory Committee on Immunization Practices be zombified into something that was not science, we saw recommendations around covid vaccine come out on Twitter rather than through any scientific process. So those were the things that were on the way. But as ACIP was made zombified — and what I mean by that was CDC has nothing to do with it, these folks who have been installed, who are frankly anti-vaxxers for the most part, they’re the ones that are driving the agenda, the membership, all of it — so it wasn’t really doing anything of scientific consequence anymore.
But when Dr. Monarez was there, we had a scientific leader whose job it was to really be a diplomat to Secretary Kennedy and Health and Human Services, but also to really make sure that the science is what leads the policy. And so, when I saw that organization, the Advisory Committee on Immunization Practices, become some strange ideology machine, and then also saw that I wouldn’t have a scientific leader at CDC who would be able to defend the science, the game was over for me, because I couldn’t see any way that we would be leading with science. Instead, I could only see ideology. I read RFK’s books, and I know what’s coming, which is the dismantling of vaccines for the United States.
Rovner: So can you talk a little bit about how the career scientists and doctors at the CDC normally interact with the political appointees at the agency and the political folks at the top of HHS, and how that was so different in this administration?
Daskalakis: Yeah. I worked with — now that would be — four CDC directors and two secretaries of health. And so, the way that we normally interacted as career scientists was that we would produce materials; if there were questions, we would create memos and other materials to be able to present to our politicals around those issues. We would be responsive to any issues that they wanted to talk about. So for instance, if somebody said, “I want to talk about the birth dose of hepatitis B vaccine,” we would create briefing materials and opportunities for the politicals, both at HHS and CDC, to be able to have time with career scientists to really learn about the story. And that’s not what’s happened in this newest regime.
Now, let me be clear, Dr. Monarez did ask for briefings, and she did get them, so that is not the person I’m talking about. Above that, the secretary had never been briefed by anyone from the National Center of Immunization and Respiratory Diseases while I was there, so he never heard about measles, never heard about bird flu, didn’t hear about covid, though he made decisions about covid, didn’t hear about any of the things that we normally brief about. Didn’t hear anything about seasonal flu, RSV, and covid. We had been briefing folks on a monthly basis, because this was the epidemic that we have every year. So to say that there’s a glitch in the matrix is an understatement. This is an extremely atypical environment, where the head of people’s health for America doesn’t talk to people who know the science.
Rovner: So I want to ask you about the ACIP meeting, but since then, we’ve had the White House announcement on the causes of autism and a potential new treatment for it. Can you give us your take on that entire event, both the press conference announcing it and the documentation, such as it was, that was provided afterwards? I have to say, I watched all of the covid press conferences with President [Donald] Trump in 2020, and this made even my eyes cross a little bit.
Daskalakis: So let’s rehash what happened with the acetaminophen and autism issue. So they took one study and elevated that study and did this Orwellian doublespeak around it, where they said that it showed that there was a link, quote, “link,” between acetaminophen and autism. The study didn’t show that; the study showed that there was an association, and so an association does not mean cause. And so, my example that I use is when you are meeting people who have lung cancer and you ask them if they have matches in their pocket, they very often do. It’s not the matches that cause the lung cancer, it’s the tobacco; it’s the smoking.
So very similarly, there’s an association with acetaminophen, that’s the matchbook. Autism is a spectrum and it’s not a disorder or a disability for some people, it’s just part of their normal neurocognitive story, but it’s like the equivalent in my analogy of lung cancer. And so, there’s something in between there that we don’t really see, and that could be genetics and other environmental exposures. So they put all of their eggs in one basket that should make nobody feel comfortable that they have the answer for autism because they found an association that people kind of already knew about and made an announcement, mainly because the secretary promised a September announcement. And so, science can’t be rushed, this was a rush job, and I don’t like my policy fast and loose, and that’s what you’re seeing, fast-and-loose policy.
They also talked about leucovorin, which is a drug that I think many people use or know about, usually used in cancer chemotherapies that involve some kind of antifolate, so it is a rescue. So if people are getting a medicine that makes their folate low, the folinic acid is kind of like super folate that really replaces the deficiency. And so, they made big statements about this being a potential treatment for autism, but then subsequently in the writing that they put out, they were very focused on a very specific circumstance of people who have some sort of cerebral folate deficiency.
So that’s the big picture. They announced a bunch of stuff, and it didn’t go through any process, we don’t know the quality of the data, the entirety of the data was not reviewed in any systematic way, and then announcements were made without any process of actually demonstrating what work was done to get there. We’ve all been in math class — the answer to an equation isn’t just 25, you have to show the work to get there, and so it’s like they just said, “The answer is 25.”
Rovner: And in this case, this could cause all kinds of actual consequences for people, particularly for pregnant women who have pain or fever.
Daskalakis: Which is associated with poor outcome for the pregnant woman, as well as for the fetus or the child after they’re born. So there’s that reality, that it’s not inconsequential, and then you have someone saying, “Avoid it, don’t do it, at all costs, don’t do it,” and then what the FDA puts out that says, “Should use judiciously.”
So I’m going to answer the second part of your question, what did I think of the press conference? I’m going to be honest, I don’t blame the president for anything that he said. I blame RFK Jr. and the other people on that stage. Their job is to make sure that their principal knows what they’re talking about, and so they have failed their job because what happened was we had a principal who was talking about things that were, I think, beyond his scope. And then also, we thought we were just talking acetaminophen, and then all of a sudden, in a non sequitur, we heard about the vaccine schedule for kids with some very strange places that we visited, including the notion that hepatitis B is a sexually transmitted infection, and rather than the birth dose that prevents vertical transmission, mother to child, as well as household transmission, we should wait until age 12, which will manifest itself as liver cancer, liver transplant, and cirrhosis for a lot of children, especially those who maybe are at higher risk because of their social circumstance.
So that’s what I thought. I was, like, poor guy, he’s being briefed by people who don’t know anything, and so maybe they should take care of him.
Rovner: All right. Well, I want to also ask you about your reaction to the Advisory Committee on Immunization Practices’ meeting last week, where the committee voted to change recommendations for both the measles-mumps-rubella and chickenpox vaccines and the covid vaccine. At the end, it felt like everyone was confused, including the members of the committee. What stood out to you about that meeting?
Daskalakis: I felt like an oracle, because in my resignation letter, I told you this was going to happen, and it’s exactly what I thought. And so, what happened was they did no process and just did stuff. And so, let me just give you what normal is, because that’s really important, and then I’ll walk you through each one and tell you why they were abnormal.
So generally speaking, something happens, and there’s a question related to vaccine policy, there’s a new vaccine, there’s new data around safety, something happens. And that’s elevated either by ACIP members, CDC, or the working groups that live within the ACIP that do all the work on the side before the meeting. So that question comes to the work group, and the CDC folks work really hard and poll all the data in the world about the question. They in effect work to do what is, for lack of a better word, a meta-analysis, a study of studies, and they go through a process called GRADE, where they look at all the data and say, “This is good data, this is OK data, there’s bias,” really to contextualize all of the data. They then put that onto a clear table that tells you what’s happening. Now, they did that for a couple of things.
The next thing is that there are long discussions. They’re long because they’re complicated, and they go through something that’s called an Evidence to Recommendations Framework. Now, that’s jargony, but what it means is that there’s this process where they ask, “Is this an important public health question? What are the implications for equity? Do the risks and the benefits … what is the equation there? Is there more harm or more good? Is this something that is going to improve the health of people? And is this cost-effective?” There’s a lot of domains, but they go through it really methodically because they want to get all of the domains that are needed for decisions. Once they do that, they produce a recommendation. That is taken to ACIP and it’s discussed. And then they vote.
So what happened was that they didn’t do it, because RFK Jr., I know this from the inside, said, “I want on the agenda hepatitis B birth dose and MMRV.” What you saw there was politicization of the committee, ideology dominating, conspiracy theories being elevated to the level of data, and then decisions being made based on that. So if the data’s no good, if the foundation of the house is rotten, that house shouldn’t be standing, so that’s what we saw.
And I want to go back to that hepatitis B thing. So they may go and do something that’s more process. But one of the reasons that I left was that CDC is not allowed to dictate who is on the work group anymore. So if they stack the work group with people that are anti-vax people, who are naysayers, who are not basing conversations on data, but on the anecdote or unvetted studies, it won’t matter, because that process will also be rotten if there’s not a diversity of opinion and scientific expertise on the work group. So that’s what happened at ACIP.
Rovner: So following some pretty unusual public health actions just in the week since you’ve resigned, what’s your biggest concern about public health going forward?
Daskalakis: So I think that there’s a couple of things that happened that I didn’t talk about yet that are very concerning. I’ll tell you that the book that I picked up to start reading when I finished my time at CDC was [George] Orwell’s “1984,” and the reason that I picked it up was because really soon after I left, I have nothing to do with stopping it or starting it, but just saying temporally speaking, CDC changed their webpage, that was the “About CDC” webpage, into, in effect, what is a manifesto as opposed to a description of an agency that is supposed to be balanced and scientific. So it really, in effect, speaks about compliance to ideology as the principal motivator for what CDC is and will do. There were other things wrong with that document, but we don’t have the time to go into that one.
And so, I feel like — first chapter of “1984” that talks about ministries that are using doublespeak to be able to say what they do, I think we are now living it. And so that’s my fear, that everything that’s going to be coming out of CDC is going to be colored by ideology, or that data is going to be released from CDC without scientists able to explain it so that it can be used for other means or that will allow folks who are more ideologically motivated to be able to make conclusions based on inadequate analyses. So that’s what I’m worried about.
Rovner: So how do we proceed from here, both public health professionals and Americans who are just looking for health guidance?
Daskalakis: Yeah. I think we’re at a dark time, but I also think that there’s going to be light in the darkness, it just may not be today. So the first thing is trauma-informed care, your feelings are valid: This is not normal, something not good is going on, and it’s hard to figure out who to trust. And so, my recommendation to people is, and I know that this is a hard one because not everybody has access to care, is if you do have access to care, you really need to lean into your doctors — doctors, nurses, nurse practitioners, physician assistants, pharmacists — taken widely and broadly, health care professionals. So even if you don’t have a primary care doctor, you have a pharmacist, and so go to that pharmacist and talk to them. It’s not as good as having one word for the land, as had been standard for CDC, but in this environment, I think you need to go with people that you trust.
I’ll also say one of the things that should be a red flag for everybody out there is — I’m a doctor, I take care of patients — and I do actually believe that the relationship between a clinician, a health care provider, whoever they are, and their patient is very sacred. And so, whenever you hear anyone in the world trying to destabilize that relationship, saying that, “Doctors don’t know what they’re talking about, don’t listen to the pediatricians,” that is not someone you should be taking medical advice from, because they’re actually at their core trying to get you to not listen to the people who are your best allies and advocates in the health space.
Rovner: Dr. Demetre Daskalakis, thank you so much for joining us.
Daskalakis: My pleasure.
Rovner: OK. We are back with our panel, and I want to ask both of you about your reactions to the ACIP meeting and the autism announcement. But let’s turn first to the breaking news about the potential government shutdown that’s less than a week away. Last night, the Office of Management and Budget, which traditionally sets the rules for who stays on the job in a shutdown and who doesn’t, issued a memo of the sort I’ve never seen before. Rather than directing agencies to prioritize which activities are needed to preserve, quote, “life and property,” and thus who’s required to work without pay for the duration and who gets furloughed until funding is restored, this memo basically says if the activity doesn’t have another source of funding and it’s not within the administration’s priorities, agencies should prepare to fire not furlough workers. This is obviously a big ramping up of this shutdown. I know this just happened, but what kind of reaction are you guys seeing?
Raman: This to me just seems very, very highly unprecedented. We’ve had shutdowns, we’ve had near shutdowns, many of them in the past, and it has not escalated to this at any time that I’ve seen.
Rovner: Forty years, I’ve been doing this 40 years, I have never seen anything quite like this. We’ve had rifts and we have shutdowns, but we’ve never had them combined.
Raman: Yeah. And so, I think it’ll be really interesting how the next few days play out. The Senate is in for a couple of days before we would hit the shutdown, if there’s anything they can come together on. It is really difficult when you escalate to this level when they’ve been trying to negotiate so far. It’s hard. The House isn’t supposed to come back until Oct. 6.
Rovner: Oops.
Raman: So if the Senate changes anything or wants to change anything compared to what the House had passed, they’re stuck. Either the House has to come back in or they shut down until they come to a compromise on something. So I think from everyone that I’ve been talking with over the past few weeks, it seems like we’re really headed to a shutdown. It’s possible they get a few Democrats to fold and go with what’s there, but I think this last move, and then also President Trump saying that he was going to meet with Democrats earlier this week, and then saying, “No, I don’t want to,” they’ve been saying there’s not good-faith efforts to negotiate, so they’re in a pickle at this point.
Rovner: Let’s get real: This is about not whether we’re going to have a shutdown, but who gets blamed for the shutdown. Traditionally, it’s been the Democrats, and the Republicans keep saying this, who say, “Look, we’re just having a clean extension of funding, we’re just going to basically roll out the clock, kick the can down the road, so we can continue to negotiate over funding for next year. Why won’t Democrats go along with that?” And Democrats are responding, “Well, we went along with it in March, and look at what’s happened in the interim, and our base didn’t like that, so we think we should fight this time.” And then, you had the president agreeing to meet with Democratic leaders, but then the Republican leaders in Congress telling the president, “No, don’t meet with them.” It’s all strategy at this point. You’re nodding, Anna.
Edney: Yeah, yeah. I was just thinking, I think a lot of times, talking about this administration, people are saying, “There’s no plan.” But I do see the 3D game of chess at this point, and that letter very clearly mentioned if the Democrats shut down the government, that was lobbying that into the court of the Democrats saying, “This is your fault if it happens.” And I do think that the Democrats were burned last time in the sense that it seemed like they might allow a shutdown and then backtracked pretty quickly and the base just didn’t like it, and I think we’re seeing a lot from the, I don’t know what exactly to call them, thought leaders on the more liberal side saying, “Just do it, let it rip.” If it shuts down, they’re going to try to find a way to blame it on the Republicans.
So I think it’s a game of chicken at this point, but there are real consequences. These are people’s jobs who aren’t necessarily going to all want to come back to the government if things suddenly, it works out. These are activities that we rely on for everyday life that will be hurt.
Rovner: Yeah. We’ve already seen the administration trying to hire back some of the people that they laid off earlier this year because it turns out they were needed to do important jobs. I saw House Democratic Whip Katherine Clark this morning on CNN describing this letter as, “The beatings will continue until morale improves.” This really is playing with the lives of government workers who basically have come to these jobs because either they believe in them or because they usually have been stable jobs. They might, may be able to make more in the private sector, but government jobs tended to be secure, and boy, that’s not what’s happening right now. They don’t seem to be guilty parties in all of this, and yet they’re the ones who are being used as pawns.
Raman: I think one thing that I have been thinking about in reading that OMB memo is that it says that the rifts are going to affect people that aren’t also really aligned with carrying out President Trump’s priorities and mission. What does that entail? Within HHS, what falls in that bucket? We have some ideas based on previous executive orders and things that he’s made some remarks on, but there’s plenty that we don’t know.
Rovner: They could theoretically shut down the entire NIH [National Institutes of Health] or the entire CDC, which I think Secretary Kennedy might not mind.
Raman: How that would go about, I don’t know. I think that we’ll all be really looking to see what kind of contingency documents they put out. They usually put those out before, when we’re in this waiting period about a shutdown, and it would definitely be very different than the ones that we’ve had in the past for a department down or agencies. What that’ll say, I just don’t know.
Rovner: Yeah, that’s right. To be clear, the OMB memo is to the agencies saying, “Send us your contingency plans.” Normally, that would’ve happened by now, it usually comes out a couple of weeks ahead of a potential shutdown and everything. We’re playing brinksmanship here. Anna, you wanted to say something before we move on?
Edney: Oh, I don’t remember what that was. But just on the last point, I think the agencies, they usually have that contingency plan at the ready, but they can’t — I don’t think that this would’ve been the one that they had drawn up. I think they have to tear that up and start over again. And like you mentioned, the CDC, the NIH, you can, through this mandate, possibly see how you could just wipe out an entire agency.
I think on the FDA side, I just wanted to add, there are some user fees on that side that may keep the drug review side afloat, anything where they’re looking at approvals and things like that is funded, at least for a while. If this devolves for months and months, that’s not the case. But there are a lot of other parts where they’re doing inspections and keeping the drug supply and the food supply safe that could be impacted.
Rovner: Yeah. And we should point out that this does not affect things that have mandatory funding, like Medicare and Medicaid and Social Security, and, as you say, user fee funding, like the review activities at FDA.
Well, while we’re on the subject of things that are unprecedented, let’s turn back to that ACIP meeting and the White House autism announcement. One of the things that ties them together is the fact that both leave the public with more confusion than clarity over what to do about vaccines and Tylenol and, once again, leaves Americans wondering who or what they can trust. What’s the biggest takeaway from each of you? Anna, why don’t you go first, about both the autism announcement and the ACIP meeting?
Edney: Yeah, I think there just is a ton of confusion. I can’t count how many times people are like, “Remind me again, who can get a covid shot and who can’t? And what are we doing with RSV now?” There was a lot of talk before the ACIP meeting about hepatitis B and that even the ACIP members were confused.
So I think that one thing that I think this makes crystal clear is that when I know that this administration and many of the people at the top in health care don’t appreciate the medical establishment and they don’t feel that it is operated in a way that is open to modernization. But you can’t just break it all and then start over, these are guidelines and things that people rely on, and it has to be, I think, a much more thoughtful process than what we’re seeing right now. You have a lot of people who are pregnant or have young children who are freaking out, because they’re like, well, I took Tylenol for three days because I had a fever, and I think that it creates more fear-mongering, because the guidance really isn’t that different, what the FDA actually said isn’t that different from what was already out there, you’re just really scaring people now.
Raman: So I think I would say something along similar lines, the mixed messaging and the confusion of that both events is pretty stark. So I think the thing that struck me with ACIP is just the second day, we have a re-vote on something that you voted on the first day, and if you watch just one, you would assume that what happened there is done, and then going back, it’s just very unusual and makes it even more confusing.
And I think the second thing that struck me was that we had this whole shake-up of ACIP in general to be like, we don’t want conflicts of interest, we want people that are able to vote on everything. And then, here, when we have the votes, we have someone on ACIP not be able to vote on something because they’re disclosing a conflict of interest. So it struck me that we went through this whole process that was to eliminate that, and then here we are back to that, which people have been saying for a long time, it’s difficult to find anyone in this space that doesn’t have other things that are connected to vaccines.
For the autism announcement, the thing that was really interesting to me was that this was done on the White House level rather than just HHS is having an event, it’s with some agency folks there, and then them putting out information, whatever they’re talking about. This was predominantly Trump speaking in a much more aggressive, this is what is what tone, compared to the agency folks who mostly were downplaying a little bit of what he’s saying. He repeatedly said, over and over again, “Don’t take Tylenol, don’t take Tylenol, no Tylenol for pregnant women.” And then, even when you look at the FDA release that came out a little bit after really downplayed it, it said that there was an association, but there wasn’t a causal relationship that they had found between acetaminophen and autism in children. It goes back to that mixed messaging, where even if the majority of scientific professionals are saying that this goes against what a lot of the research that they’ve been doing, you’re going to be confused.
Rovner: Yes. Another thing that seems to tie together both the ACIP meeting and the autism announcement is to basically put all medical responsibility on individuals, which many consider to be blaming the victim and increasing stigma by basically saying, “Whatever you decide, whatever happens is your fault.” I feel like we’ve careened from maybe too much reliance on experts to too little. That was certainly the president’s message at that press conference, it’s like, “Well, this is just common sense.” It’s like, I thought we were supposed to be relying on gold-standard science.
Edney: That was a very stark point, where it was like, what do you mean you feel this? It’s like, I think you’re supposed to know that through research and scientific data.
But I wanted to go back, you mentioned blaming the patient, I think specifically on the autism side, this is something we see with expecting mothers a lot, because I interviewed professor Emily Oster about the autism announcement, and she dives very deep into data on a lot of things parents are concerned about, and she was telling me about “refrigerator moms” in the 1950s, and I didn’t realize this, but apparently women were blamed for different mental illnesses if they were too cold, not freezing-cold, but emotionally not available for their children enough, and so they must be causing their schizophrenia and there was a big link to that. And that continues, they’re telling the women, “If you have a fever or enough pain that you would consider popping a Tylenol, then that’s on you, just either deal with it or be responsible for the fate of your child.”
I think that’s what the medical establishment has been trying to avoid, is giving women options, and there are a lot of reasons you need to take care of that fever or you need to take care of that pain, and some of them have to do with the health of the child, the baby that they’re carrying, so …
Rovner: Right, fever is also a potential cause of problems.
Edney: Exactly.
Rovner: All right. Well, in a health-related story that doesn’t seem like a health-related story, the Trump administration late last week announced a new $100,000 application fee for H-1B visas. Now, those are usually associated with tech workers, but it turns out that an awful lot of medical professionals, particularly doctors from other countries, use them to come here to fill residency positions that American medical school graduates don’t fill — often low-paying primary care slots in rural areas. And, according to reporting from your colleagues at Bloomberg, it seems that medical personnel might be exempt from this new fee, but it’s not clear how many hoops hospitals might have to jump through to get those exemptions. At best, it doesn’t feel like this was very thoroughly thought through, particularly for an administration that says that rural health is a priority.
Edney: Right, yes. I think they may have been a little surprised by the amount of pushback from the hospital and doctor associations, saying, “We really rely on these to get doctors to rural areas.” And they almost immediately tried to massage that and say, “Oh, well, they could be included in exemptions.” But that’s all we know, “can be included” is not extremely reassuring. It’s not saying, “We’re giving you a blanket waiver for doctors,” or anything like that, and nobody knows, like you said, the hoops they might have to jump through. I would say it’s a start, and maybe they’re thinking about it, more aware of it, at this point.
Rovner: Sandhya, is there any pushback from Congress? Can the president even do this?
Raman: I think the pushback I’ve seen has been broader, not just on how this is going to affect hospitals that clearly cannot afford this in the same way that maybe some of the Big Tech companies may be able to. But I will be really interested when they come back just how lawmakers might look at this, because hospitals are the biggest employer in so many congressional districts, that if they’re pushing back, I could see people that normally don’t push back on this kind of thing saying, “If the biggest employer in my district is going to tank because of this,” it rises up as an issue for them.
Rovner: On the other hand, we haven’t seen a lot of pushback from Congress for things that we expected to see pushback on, so I guess we’ll have to watch that space.
Raman: Yeah.
Rovner: Well, finally this week, there’s good news and bad news on drug prices, which President Trump has vowed to reduce by, and I looked this up to get the quote correct, 1,400% to 1,500%. He said it many other ways, by the way. The idea of his, quote, “most-favored-nation” executive order that he issued last spring is to get drugmakers to lower U.S. prices to those charged in other countries that have price controls that we don’t have. Well, Trump is getting half of what he wanted, according to Axios. Several large drugmakers say they’re going to equalize what they charge here and overseas, but not by lowering prices for Americans, rather by raising them for Europeans and others. On the other hand, there’s still a few more days until the Sept. 29 deadline for them to do this. Anna, are you hearing anything new on this?
Edney: I haven’t heard anything new. I think we just saw, like you mentioned, what Bristol Myers Squibb did, which was a newer schizophrenia drug they raised, they said they were going to introduce that in the U.K. [United Kingdom] at the same price in the U.S., extremely convenient for the pharmaceutical companies to be able to have this reason to raise prices elsewhere. But then, of course, they can find reasons not to bring them down so far in the U.S., and we’ve seen — the only other company I can think of was Eli Lilly did this earlier this summer, saying they would do the same for their drug Mounjaro, and there was maybe some hoarding that started because people in Europe don’t want to pay the higher price.
Rovner: Mounjaro being a diabetes drug that is also the weight loss drug.
Edney: Right, right, yeah, so the weight loss drugs have seen a lot of ups and downs. But you’re right, there’s only a few days left, and it’s interesting that it hasn’t leaked … any kind of plan that the pharmaceutical companies are talking about or anything like that. Sometimes, I feel like because this administration is operating more by telling people through letters and demanding it at the podium rather than doing actual regulations — remember, the most-favored-nation policy did not work out well after challenged in court the first administration. So I think they’re often happy to get half of what they asked for in a way. But this could be tough, because it lets Trump say, “We’re no longer carrying all the water,” but it doesn’t let him say, “We decreased prices for the American people.” So we’ll have to see …
Rovner: By 1,400% to 1,500%.
Edney: Right, right, get those economists to figure that out. But we’ll just have to see what’s going on even … so much. The shutdown may take all his fire.
Rovner: Yeah. This is one of those issues that is bipartisan, that it is popular on Capitol Hill, and that lawmakers keep saying they’re going to do something about, but so far, we’re not seeing it, are we?
Raman: I think that there’s so much that they have on their plate right now and just so much that they have been at odds with each other right now, it’s something that would’ve gotten more attention in normal times, has just gotten really delayed at this point.
Rovner: These are definitely not normal times.
Raman: Yep.
Rovner: All right. Well, that is the news for 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 will put the links in our show notes on your phone or other mobile device. Anna, why don’t you go first this week?
Edney: Sure. So mine is in The Washington Post, and it’s: “Do State Abortion Laws Affect Women’s Recruiting? That’s Up to Athletes.” It was a really interesting look at basically how women athletes, specifically in basketball, and they discuss others lower down, are choosing college based on abortion laws — the states where they have less restrictive abortion laws, or more abortion rights, I guess I should say — then they’re tending to go there. And then, you have the schools more in the South, where they’re more restrictive, where they’re choosing not to go there for the four years of their college life. And it was something that I think was just a really interesting look at a topic that has been on everyone’s mind, but with so much going on, not exactly focusing on it. And it talks about other trends in college admissions and things too. So something to think about.
Rovner: Yeah. I know we’ve talked a lot about health workers avoiding states with abortion restrictions. This is the first time I’ve seen this link to younger women and sports and college, and we’ll see whether some of the states react to that. Sandhya?
Raman: My extra credit is called “Psychiatric Hospitals [Turn Away Patients Who Need Urgent Care. The Facilities Face Few Consequences],” and it’s in ProPublica by Eli Cahan. And I think what drew me to this is EMTALA [the Emergency Medical Treatment and Labor Act] has been one of those things where we have been thinking about it a lot in terms of abortion, when we’ve seen it in the news in the last few years, it’s been very abortion-focused. But this story looks at a psychiatric hospital in Colorado that got taken to task for not providing stabilizing care to patients at risk for suicide, and CMS [the Centers for Medicare & Medicaid Services] didn’t penalize them in reducing funding or imposing any penalties. It’s part of a broader thing, where over 90 psychiatric hospitals have violated EMTALA in the past 15 years. I don’t want to give away the whole thing of the story, but it goes more into this.
Rovner: Yeah, it’s a really good story. All right. My extra credit this week is from NBC News by my friend and former colleague Liz Szabo, and it’s called “RFK Jr. Has the Federal Vaccine Court in His Sights. Attacking It Could Threaten Vaccine Production in the U.S.” It’s a really good roundup about what’s likely to be the HHS secretary’s next target: the program that compensates the very small number of Americans who are injured or killed by vaccine side effects. There are risks to all vaccines, although they are very much outweighed by the benefits, and this program was created by Congress during the Reagan administration to compensate those who have suffered from those rare adverse reactions.
The program was created to keep vaccine manufacturing alive in the United States because product liability suits were threatening to shut it down entirely, while the program also makes it easier for those who are injured to receive compensation. The program is far from perfect and it could use some revisions, which Congress has tried and failed to do over the last couple of decades. But it seems clear that that’s not what Secretary Kennedy has in mind. It’s a great preview of what the next likely battle is going to be in the vaccine wars.
OK, that is this week’s show. Thanks this week to our editor, Stephanie Stapleton, 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 a review; that helps other people find us too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks these days? Sandhya?
Raman: At X and on Bluesky: @SandhyaWrites.
Rovner: Anna?
Edney: Same places, @annaedney or @annaedney.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Countdown to Government Shutdown
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Oct. 1 is the start of the next fiscal year, and unless Congress reaches agreement on continued spending, big parts of the government could shut down that day. Democrats, whose votes will be needed in the Senate, would like Republicans to extend the Biden-era extra tax credits for Affordable Care Act insurance plans as part of a compromise, but so far Republicans don’t seem willing.
Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. released his much-anticipated “Make America Healthy Again” blueprint to improve children’s health, but the report contained few specifics on how his goals would be reached.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.
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Anna Edney
Bloomberg News
Sandhya Raman
CQ Roll Call
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- Congress has less than three weeks to approve federal government spending for the new fiscal year and avert a shutdown. Democrats are pushing for the legislation to include an extension of enhanced subsidies for those covered by ACA plans, which otherwise will expire at the end of the year and contribute to an increase in premium costs. But that proposal is already getting bogged down in longtime fights over abortion funding.
- The Department of Health and Human Services is expected to cite the use of Tylenol during pregnancy in a pending report on the causes of autism — despite a lack of definitive scientific evidence. And the remade Advisory Committee on Immunization Practices is scheduled to meet next week, while some Americans are struggling to access the covid vaccine.
- The lack of teeth in the MAHA report — along with the White House’s lengthy review before publication — suggests industry officials helped shape the final product. Plus, its calls for things like healthier meals in schools and hospitals amid federal funding cuts raise an important question: Who will pay for these policy changes?
- And the Trump administration is seeking changes to federal regulations on pharmaceutical advertising that could effectively kill drug ads on television, though free-speech rights could complicate that effort.
Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:
Julie Rovner: NPR’s “What Kind of Dairy Does a Body Good? Science Is Updating the Answer,” by Will Stone.
Anna Edney: Bloomberg News’ “The Implants Were Supposed to Dissolve. They Didn’t,” by Anna Edney and Tanaz Meghjani.
Sandhya Raman: The Texas Tribune’s “Texas’ New Parental Consent Law Leaves School Nurses Confused About Which Services They Can Provide to Students,” by Jaden Edison.
Lauren Weber: ProPublica’s “‘Just Let Me Die,’” by Duaa Eldeib.
Also mentioned in this week’s podcast:
- The New York Times’ “As Trump Weighs I.V.F., Republicans Back New ‘Natural’ Approach to Infertility,” by Caroline Kitchener.
click to open the transcript
Transcript: Countdown to Government Shutdown
[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, Sept. 11, 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: Hey, everybody.
Rovner: Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: And Sandhya Raman of CQ Roll Call.
Sandhya Raman: Hello, everyone.
Rovner: No interview this week, but plenty of news. So let us dive right in. As of today, we are less than three weeks away from a government shutdown if Congress can’t pass all 12 spending bills — spoiler, that is not going to happen — or pass some sort of continuing resolution to keep the government funded while lawmakers continue working on the spending bills. Now, even though Republicans control the House, Senate, and the White House, it will take Democratic votes, at least in the Senate, to make any of this happen, because appropriations bills, unlike that budget reconciliation bill that passed earlier this summer, require 60 votes to pass rather than just 51. So how’s it all going, appropriations watchers? Sandhya, you’re there on the Hill.
Raman: It’s a work in progress. You know, I think there are a lot of different options kind of being floated around right now to try to avoid a government shutdown. So something our budget reporters reported yesterday is that House Republican leaders are trying to bring a clean CR to the floor next week, so the same spending levels that we have now through late November, early December. But that would include the ACA [Affordable Care Act] subsidy extension that the Democrats want.
There’s also, in the works right now, they’re voting as we speak, kind of, in the House on advancing three of the spending bills, but not HHS [the Department of Health and Human Services] and maybe attaching a clean CR for the rest to that. And whether or not that could eventually include something else that the Democrats want is unclear. Or it’s still in play where just now Democrats were speaking about how they want a very bipartisan — they won’t come to the table unless they’re getting their voice at the table. So it’s unclear if any of these three options are going to happen, just because so much is in flux right now and we’re still a couple weeks out from their deadline. And you know how Congress can be about this.
Rovner: Yes, three whole weeks — why should they do anything? Let’s talk about those ACA subsidies for a minute. We talked about them last week. Republicans are finally realizing that if they don’t extend the Biden-era tax credits that it’s going to be a lot of their voters who are going to see these sort of eye-popping premium increases. And the Democrats would like to sort of do a deal, but so far I’ve seen Republicans saying, Nope, not going to happen. At least not as part of this, keep-the-government-open continuing resolutions. That where they still are?
Raman: I think it depends on who you talk to. When you talk to some of the more hard-line Republicans, they just don’t want this continued. It’s something that you have to offset with a lot of money, and so they’re not on board at all. There are some of the more moderate Republicans in the House that have signed onto a bill last week that would extend it for a little bit, and so others have been a little bit more wishy-washy. But where they fall, I think that complicates things. We also have a new breakdown in the House right now where the Republicans only have a two-person majority, so it just makes it even more narrow for them to get something across if not everyone is aligned on this.
Rovner: And of course, because this is the Affordable Care Act we’re talking about, we’re going to have an abortion fight with this too, right?
Raman: You know I was just saying earlier that everything old is new again, that anytime that we get into this, we get into the debate of whether or not we include some sort of Hyde Amendment kind of language to say no federal funding for abortion except in rare circumstances. And so the anti-abortion groups have signed on and said, You should not support any sort of ACA subsidy extension that doesn’t have that language. Some of the Democrats have already come out saying that that’s a no-go. In the past, generally when we’ve had funding for health care, either if it’s in the approps cycle or something separate, there has been that language, so I’m not sure where that will land if they get to an extension. Just 15 minutes or so ago, House and Senate Democrats had said they really want to get to a bipartisan deal, but they didn’t kind of draw a line in the sand that if the ACA subsidies weren’t in whatever spending deal we get in the next few weeks that that would be a deal-breaker. So it’s complicated in terms of where the cards may land in the next few weeks.
Rovner: Long way to go.
Raman: Yeah.
Rovner: Well, meanwhile, the House Appropriation Committee this week approved its version of the bill that would fund the Department of Health and Human Services along with the Departments of Labor and Education. The House committee bill cuts HHS funding, but by far less than the Trump administration had asked, but still by a lot more than the more bipartisan bill approved by the Senate Appropriations Committee just before they left for the August recess. What is the outlook for HHS funding going forward?
Raman: I don’t think that we’ll see, whenever we get to some sort of deal, something super close to what we had advanced by House appropriators today, but I also don’t think that we’re going to see something identical to what the Senate did before recess. My guess would be a little bit more aligned with what the Senate did. They’re both run by Republicans, but that one did get, in the Senate, bipartisan support, and since they do need Democrats to pass it in the Senate, I could see it being a little bit more aligned there.
The Senate one had slightly higher spending and didn’t have as many of the new riders as in the House related to abortion and trans health and things like that. But we are in kind of a weird circumstance in that, earlier this year, instead of doing new funding, they renewed funding at the same level as last year for another year. So that’s also a possibility, which is not something that happens super often, in the past, and I don’t really see we’re getting a lot happening in either chamber until we get kind of a deal, just because they don’t have an agreement on any of the other funding really, either.
Rovner: One of the things that we do see particularly appropriators complaining about with, and we’ve talked about this, is this whole pocket rescission thing, the idea that they’ve appropriated this money, they’ve gotten a deal to pass this spending, Congress is supposed to be in charge of spending, and the administration isn’t spending money that’s been appropriated. Is there some possibility of putting in some kind of You must spend this money guarantee, or at least an effort to make a guarantee, in one of these bills? Or are they just sort of tiptoeing around this?
Raman: They’ve kind of tiptoed around that. I mean, they’re supposed to spend money. If they don’t, they can have the impoundment issues that they’ve had this year where they aren’t spending the money and get told that you’re violating the Impoundment Act, but that hasn’t seemed to stop some of these cases. I think there’s also a lot of things happening in this that haven’t happened before. We’ve had Russell Vought just kind of say that appropriations should be less of a bipartisan process than it has been. So I’m not sure if even adding that kind of language would necessarily mean that that wouldn’t happen or there wouldn’t be different ways around that.
Rovner: And of course, Russell Vought, the head of OMB [the Office of Management and Budget], is just itching to take this to the Supreme Court so that they can say that the Impoundment Act is illegal and that the administration can decide whether or not it wants to spend money that Congress has appropriated, which is obviously something that we will get to at some point with the Supreme Court, but I think we’re not quite there yet.
Well, moving on, the fallout continues from efforts at the Department of Health and Human Services to translate Secretary Robert F. Kennedy Jr.’s anti-vaccine views into policy. We now know that the ousted director of the Centers for Disease Control and Prevention, Susan Monarez, is scheduled to testify before the Senate HELP [Health, Education, Labor, and Pensions] Committee next week. That’s the committee chaired by Sen. Bill Cassidy, the Republican doctor who cast the deciding vote to confirm Kennedy back in the winter. The meeting of the CDC’s advisory committee on vaccines is also scheduled for next week. Do we know if that’s going to happen? I know several officials, including Cassidy, have called on it to be postponed. Anna, are you planning for it to take place?
Edney: I think, so far, planning for it to take place, but maybe not so sure what they’re going to discuss and whether the covid vaccines will be something that they’ll vote on, at least, because that’s what a lot of people are waiting on. That’s what has caused a lot of confusion is that the FDA [Food and Drug Administration] gave its limited approval to some of these, and then we haven’t heard ACIP’s [the Advisory Committee on Immunization Practices’] vote on that, or it hasn’t been held. And so insurers are finding ways not to cover those vaccines for some people, and people are confused whether they can get them. Pharmacies in some states need prescriptions to be able to give them out. So there’s just a lot of confusion around and people — the middle of September is already late, and so people were hoping, at least people who are interested and, once the confusion cleared up, were hoping that this will come up. But no indication for sure yet.
Rovner: One of Kennedy’s most stubborn pushbacks at last week’s hearing at the Senate Finance Committee was that he has not prevented people from getting the covid vaccine. Except in the ensuing days we’ve seen story after story about people who should be eligible for covid boosters but still haven’t been able to get them or, and as you said, haven’t been able to get them covered by insurance, even in some states where governors have tried to intervene to make them more available. I had a note from a friend in Oregon whose 80-plus-year-old husband couldn’t get the vaccine. I mean, obviously over 65 and couldn’t get a prescription from his doctor to get the vaccine because — and, of course, one of those states that doesn’t have MinuteClinics where you can go and get a nurse practitioner to give you the vaccine. I mean, what are you guys hearing about people’s ability to actually get this vaccine? We’ve now been sort of conditioned to: OK. it’s September. Kids are back to school. We should go and get our flu shots and our covid boosters.
Edney: Yeah, I think that Secretary Kennedy had said everyone can get it, and maybe there’s a tiny kernel of truth in there in the sense that if you knew all the work-arounds you could do it. Maybe you could find a way to get someone to put the shot in your arm. Who would pay for it, though? I mean, we’ve heard of people postponing because they’re hoping that insurance will cover it. They’d rather not pay $200. So essentially this is causing a lot of people to gamble with their health because they’re hoping in the next few weeks they don’t get covid while they’re waiting on insurance to possibly cover it and on direction.
So it’s not true that just anyone can get it if they want to, I don’t think, or those aren’t the stories that I’m reading, that I’m seeing, or even hearing. There was a colleague, actually, she had an interesting story. Her husband had, instead of signing up on the website for a pharmacy, because you have to answer the questions if you have any preexisting conditions, a lot of people don’t if they’re under 65. He just walked in and he said: Well, the pharmacist didn’t ask me anything there. They just gave it to me. So, I mean, people are finding ways, but it doesn’t mean that everyone can do it or pay for it.
Rovner: I feel like Kennedy has sort of conflated the I didn’t ban it with the Everybody can get it. Those are two very different things. Lauren, yes.
Weber: I mean, Kennedy also has previously said that the covid vaccine is the deadliest vaccine ever made and then claimed that [President Donald] Trump should get the Nobel Peace Prize for Operation Warp Speed. So there is a lot of dissonance between the secretary’s statements and sometimes with the reality.
Rovner: And I will note, actually going back to our budget discussion, that there was a bipartisan amendment at the House Appropriations Committee to restore the money for mRNA vaccine research that Kennedy cut. Who knows whether we’ll ever see that into law, but I was interested to see that Republicans joined with Democrats to sort of push back at that.
Edney: Yeah, I think mRNA has a lot of applications beyond vaccines that even hard-line anti-vaxxers could see. Is curing cancer a good idea, or treating it? I mean, it has a lot of other things that mRNA really is meant for.
Rovner: Yeah, and also the speed with which, I mean, that was what made Operation Warp Speed work was the speed with which you can actually make vaccines using the mRNA technology. Well, now, apparently, at least according to The Wall Street Journal, HHS is planning to link Tylenol taken in pregnancy to the rise of autism. Just the story appearing on the website tanked the stock of the drugmaker that makes Tylenol last week and has prompted quite the pushback from doctors and researchers as well as drugmakers. What do we know about the links between Tylenol, acetaminophen, and autism?
Edney: I think what we know is that there are mixed results in studies out there, that no one has definitively linked it. No one has definitively, either way. I think there’s sort of confusion. But the big study that they’re using out of Harvard to kind of say that Tylenol use during pregnancy causes autism, even the study’s authors say: That’s not what we were saying. We were saying that there is an association, but that doesn’t mean causation. I think that’s something we always come back to when we’re talking about studies. And in this sense, I think it’s unfortunate that the discussion is happening without more definitive answers.
Because when you’re talking about pregnancy, and if acetaminophen is the only thing a pregnant woman can take when she has a very high fever, then high fever can cause a lot of problems as well, and you’re scaring women off from, even, it can cause birth defects if the fever is high enough. The March of Dimes actually says there is concern that a high fever during pregnancy in the first trimester is linked to autism. So you just have this circle that nobody actually has any answers, and unfortunately I don’t anticipate that the autism report is going to provide them. It might provide more fear for pregnant women.
Rovner: Lauren, you want to add something
Weber: Yeah, I mean, Robert F. Kennedy Jr. has promised to have the cause of autism by September, which, many medical experts and autism researchers have cautioned, seems like that may not be a complete report, as this is something that has been examined for many years and it seems to be multifaceted. But I think it’s worth noting that in the lead-up to this report being due, we at The Washington Post, in looking at MAHA influencers, noticed that Tylenol has been 15 times more likely to be mentioned by these influencers in August as opposed to April. So there seems to be a lot of MAHA contingent around the Tylenol hypothesis that also potentially could be driving some of this, but we’ll see what happens when we see more of the report.
Rovner: So where exactly is President Trump on this whole vaccine issue? On the one hand, he’s been pro-vaccine in some of the comments that he’s made since Kennedy’s confrontational appearance last week at the Finance Committee. But he also posted on, he the president, also posted on his social media a video pushing the long-since discredited accusation that autism is linked to the vaccine preserved with thimerosal, which hasn’t even been in most childhood vaccines for the last two decades. I feel like the president’s kind of walking this fine line waiting to see which way public opinion falls.
Weber: I think that’s right, Julie. I think also we have to go back. The president has a history of making vaccine-skeptical comments. I mean, in presidential debates he’s asked questions about vaccines being too big for a horse for children. I mean, he’s said, certainly, things that are of vaccine-skeptical rhetoric. That said, I think he and others have seen polling recently that shows that vaccines are overwhelmingly popular. The vast majority of Americans do vaccinate their children, and while he is conscious that Kennedy and the MAHA movement brought him voters, I think he’s maybe being counseled by others that he could lose voters if he goes too far. So if anything, the man has a shrewd assessment of what’s going to win him political points. So it seems to me that it’s a messaging to both sides of the fence and it’s kind of a You pick the message you want to hear so you can stay in the tent kind of vibe is how I am interpreting it.
Rovner: Yeah, that’s my impression, too. And as we know, he’s very good at being on all sides of an issue until he actually has to come down one way or the other. Well, there was a lot more from the Department of Health and Human Services this week than just vaccine news. Secretary Kennedy issued the second part of his long-awaited Make America Healthy Again strategy to improve children’s health. It didn’t mention some of the biggest threats that we know about for children’s health, like gun violence, climate change, or tobacco. It did mention things Kennedy has talked about a lot, like exposure to chemicals and ultraprocessed food, but it didn’t really lay out concrete plans for how the administration plans to address those concerns. So what does this report say? And do we think it got watered down by the White House? Do we think it might’ve been stronger at some point?
Edney: I think with what I saw with the report when I read the report is sort of a list of a lot of the things that Kennedy would like to focus on that he sees as the biggest threats to children. Although it got watered down, I think, for sure throughout this process and certainly potentially as the White House held it for about a month or so from coming out. But a lot of people have made the point that Kennedy had to work with the heads of the EPA [Environmental Protection Agency] and the Agriculture Department on this, who are in many ways more aligned with the chemical companies and the big farmers than Kennedy himself might be or had wanted to be in this.
So you kind of lost any ability to maybe go after chemicals in the food supply or things like that. And so there weren’t a lot of concrete things that it would do or ways forward, which I would expect in a large administration report like this is kind of more of the next steps, not just the list of what’s going on. And I imagine we’ll talk about it, but there was one piece in that with drug ads that it kind of simultaneously came out with the report.
Rovner: Yes, we’ll get to that next.
Edney: Yeah, so I assume we’ll talk about that. So maybe they have some plans on some things that we just don’t know about yet. But I think that that has, for me, been a struggle in covering and watching this administration is there’s been a lot of talk and it’s hard to know what the rhetoric is versus what is actually being done. And I kind of see that continuing, and even with drug ads, when we talk about that and get there.
Rovner: Yeah. Lauren, you’ve obviously been following the MAHA movement pretty closely. What was your take from this report?
Weber: Well, my takeaway from this report is I was fascinated there were no footnotes, so there could be no AI conversation like the last time we talked about this on the podcast. But no, my other takeaway was, clearly, as Anna pointed out, it seems like industry influence had watered down some of the big pushes of the MAHA movement around pesticides. And I also, my biggest takeaway is: Who’s paying for all of this? I mean, they promised healthy, nutritious foods in schools, VAs [Department of Veterans Affairs facilities], hospitals. These are things that nutritionists have wanted for a very long time. There was talk of MAHA boxes. Where’s the funding? I mean, as far as I understand, all the funding’s getting cut everywhere I turn around. So I’m curious where the funding for this transformation of America’s health care is coming from. And I also think it’s worth noting that in there there was a conversation around some pet projects among folks that are involved in the Trump administration. I’m very curious. Right now it was basically a bullet points with no action plan. So as Anna smartly pointed out: When will the rhetoric become reality? We shall see.
Raman: I was just going to agree with Lauren. That was kind of exactly my takeaway is that if you’re calling for more research and this and this and then the White House at the same time, when they put out their budget proposal, they called for a 40% decrease in NIH [National Institutes of Health] funding. It just seems counterintuitive. And even thus far in the appropriations process, the Senate didn’t even have money for MAHA in theirs. The House did. But we don’t know if that happens. And so I am very curious how they would get to do some of these things that they’re exploring, because it really did seem more like an executive order in the formatting, is like: This is early on. Explore this issue. Rather than Here are concrete things we need you to do.
Rovner: And I would just, to underscore something that Lauren said, a lot of talk about how to improve nutrition for kids and things about the SNAP [Supplemental Nutrition Assistance Program] food stamp program, then at the same time that the “Big Beautiful Bill” cut food stamps. So there is sort of right hand not recognizing what the left hand is doing. Well, Anna, as you mentioned, on the same day, the administration issued its not-so-earth-shaking MAHA report, the president signed an order that could end those annoying direct-to-consumer TV ads for pharmaceuticals, at least as we know them.
This is the moment where I get to repeat the fact that the U.S. and New Zealand are the only developed countries that allow drugmakers to advertise their products on TV. The executive order purports to return to the status quo before 1997, when drug companies basically couldn’t advertise on TV, because they were required to talk at so much length about possible side effects and contraindications. Now, I think both Republicans and Democrats in the past 28 years would’ve loved to have taken this same action. Drug ads aren’t exactly popular with the public. But there’s a First Amendment issue here, right? Something about commercial speech?
Edney: Yes. Yeah, certainly. It seems like long ago the train left the station on banning these pharmaceutical ads completely, because the free-speech protection seems to have encompassed this and it feels like no getting rid of them. There’s been no successful effort. So what the Trump administration has said that they’re going to do is change that regulation that allowed them, the drugmakers, to water down their statement in those ads on all of the awful side effects that can happen to you by taking drugs. And so right now in a drug ad, they can just say, Talk to your doctor and visit this website to see what the side effects are.
And so they want to roll that back and so be able to take it back to having to list all of them, which if you’ve looked at a drug pamphlet, a prescription drug pamphlet, I mean, that could take several minutes to get through, and so effectively possibly killing a lot of these advertisements. I think this is still a situation that where the devil’s in the details. We haven’t seen the regulation. And I feel like this happens pretty often where they say they’re going to roll back a huge thing and then it becomes a little bit different than that when the actual regulation is out. But you never know. I mean, I would love — I’m not a fan of drug ads, either, so it’s not like I need to listen to them on the—
Rovner: Yeah, could they at least get rid of the jingles?
Edney: Right. So you don’t say them all day in your head.
Rovner: Yes.
Edney: But yeah. And then they said that, the FDA commissioner said, they were going to be sending out warning letters to potentially thousands of companies, and Just to let you know, we’re going to be cracking down on this, because that’s not something the FDA has done a lot in recent years, making sure that they’re complying with regulations in their advertisements. But they made it into more of a — a warning letter’s a very strong thing that the FDA can do. What this is is more of a form letter saying, Just to let you know we’re going to, not that you specifically violated it, but we’re going to start cracking down on this. So I’ll be curious to see where this lands. They also want to go after more of the social media influencers because they don’t fall under these regulations, so bring them more in line with the idea that they need to talk about the side effects and not just how much weight they quickly lost or something along those lines.
Rovner: But certainly we would expect the drug companies, if not TV networks, to sue to protect the right to run these ads, in cases of the networks to get paid to run these ads.
Edney: Definitely. I think that there’ll be some litigation over this, and that first requires the regulation to be made, and so that also takes some time. So this could be a kind of a long haul.
Rovner: Yeah, it was actual big news. Well, last week we caught up with some but not all of the reproductive health news that happened over our break. One thing I didn’t want to leave out is that lawsuit that the Supreme Court threw out earlier this summer, challenging the FDA’s approval 25 years ago of the abortion pill, mifepristone. It is not dead yet. While the justices said the anti-abortion doctor group that sued originally did not have standing to sue, since then three states — Missouri, Kansas, and Idaho — have replaced the group as plaintiffs, and now Texas and Florida are asking to join the suit as well. Sandhya, the original suit sought to wipe away the FDA’s original approval. That’s now off the table. But the states do want the courts to effectively end the mailing of the pills and return to the FDA’s tighter rules that were enforced before the pandemic, right? Just that could have a major impact.
Raman: It really could, just, if you look at in the last few years, how much of it, abortion, is medication abortion, how much of that has been telehealth after covid, and if you look at what’s happening in some of the states right now. Texas has cracked down on it. But then there’s [Texas] Attorney General [Ken] Paxton last year had sued a doctor in New York for allegedly mailing medication abortion to Texas. And then just this week, the attorney general of New York, Letitia James, has intervened in that lawsuit. So it’s going to be a battle between two of probably the most front-and-center attorney generals, especially in these kinds of issues. So I think with those odds, it’s something that I would definitely watch to see does this go back to the Supreme Court at some point. Even if it’s not this case, this issue is rising up again.
Rovner: Yeah, that’s right. That’s what I was going to say. I mean, at some point the Supreme Court is going to have to adjudicate this question about these blue-state shield laws. Not only has Texas gone after this doctor in New York, Louisiana, I believe, has indicted this doctor in New York, has tried to charge her criminally, which Attorney General James in New York is also trying to prevent. So I mean, we’re going to see this come to the Supreme Court at some point, right?
Raman: I do think so. Just because of how front and center this within the whole movement has kind of become, and especially I think even if we look past, in the past few weeks, how much more mifepristone has come up is something that Republicans want HHS to look into. RFK Jr. has brought it up. There could even be changes on that level that spur a lawsuit, or I think that there’s a lot going on, and so even if it’s not this specifically, something else will nudge it that we see that elevate.
Rovner: Well, meanwhile, anti-abortion groups, or should I say anti-in-vitro-fertilization groups, are now promoting something called “restorative reproductive medicine” as an alternative to IVF. According to Caroline Kitchener writing in The New York Times, quote, “the concept addresses what proponents describe as the ‘root causes’ of infertility, while leaving I.V.F. as a last resort,” close quote. Groups that support IVF are not amused. The American Society of Reproductive Medicine, which represents doctors that treat infertility, calls “restorative reproductive medicine” and “ethical IVF,” quote, “misleading terms that threaten access.” Sandhya, is this yet another effort to ban reproductive technologies that have pretty broad political support by basically rebranding bans?
Raman: You know this one is interesting because it also, to me, has a tinge of kind of what we see in MAHA in that it’s kind of pointing to We’re doing this whole-person thing to elevate health care in the same way that they’ve said: It’s not that you’re having these issues because of something you need medicine for. It’s the food. It’s the chemicals and that kind of stuff. So I’m curious, A, if this gets kind of elevated more just because there’s similar thinking in both of those, but also just kind of how the messaging plays out. When we’ve had some of these IVF battles, we’ve had people walking kind of a fine line because maybe they’ve used it themselves or someone in their lives had but that they know that some of the people in their base do have some issues related to if all the embryos get used and things like that. So elevating this does seem like something that would be politically easier for certain people to message on, but I’m not sure.
Rovner: Lauren, you want to add something.
Weber: Yeah, I mean, I think we talked about Trump toeing a political line earlier in this podcast, and I see this as a similar version of that. I mean, this is the president who vowed to expand access to IVF, but some of his hard-right conservative base has issues with it. They see it as potentially interfering with life itself. And so I think offering up this alternative health care strategy, which, to be clear, there could be good things in there — treating women with endometriosis, investing in the root causes of infertility. There’s nothing inherently wrong with that. In fact, there’s a fair amount of lack of information where it becomes questionable and where I—
Rovner: There’s also, I said, there’s nothing inherently controversial about any of that.
Weber: No, I think there’s a lot of people that would be very excited about that. I think where it hits a line that’s confusing and that Caroline’s story kind of gets into is, is it at the expense of — that’s usually the entry point, which a lot of these health organizations have made clear. Those are all great things to do, but at some point there is potentially a need to hit the next step, and there is concern that this movement could replace the push for IVF. And so I think that tension point and how Trump and the administration is kind of toeing that line with both the MAHA group and the far right is really interesting.
Rovner: Yeah, I mean, I would add that IVF is expensive, involved, unpleasant. It’s not something that people turn to as a first choice anyway, so I was a little bit sort of taken. It’s like, yes, I would think that people with infertility do explore most of their other options first. But yes, what’s wrong with having more research to try and solve the problem before you actually have to resort to IVF? We will watch this one as well.
All right, 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. Anna, why don’t you go first? You have your story, which I’m really glad you’re doing.
Edney: Thank you. Yeah, I appreciate that. So mine was from last week: “The Implants Were Supposed to Dissolve. They didn’t.” So I did an investigation into this device called BioZorb that’s made by a company called Hologic. And they have a huge women’s health division and a breast division that — so a lot of mammogram machines that they sell and things like that. But they were selling BioZorb. It was supposed to revolutionize breast cancer treatment because, at least the idea, this isn’t what they had FDA approval for, but what it was talked about as is something that could help women when they were healing, that their breasts would grow back after a tumor was taken out. Their breasts would grow back more, heal more full-looking, not have dips and maybe other deformities that can happen with a lumpectomy. And instead, these women have experienced all kinds of awful infections, and some people actually had the device poking through their breasts because it was supposed to dissolve, but it was years where some people still had it.
A woman I talked to, it shattered inside of her. So there were 24 pieces of plastic, sharp shards in her breast that were causing immense pain. A lot of people complained about pain, but the key to this is that Hologic and a company that invented the device and sold it early on, called Focal, were hiding these complaints. They were not handing them over to the FDA as they should have, and some for as long as 10 years. So nobody knew what was going on, but women were still being implanted with the devices. I think it’s just a bigger story about oversight of devices and also how devices come to market, because this device was never studied in humans, in women, despite it being implanted inside of them. And that’s actually really typical to how devices make their way through the FDA.
Rovner: Really important investigation. Thank you. Sandhya.
Raman: So my extra credit is called “Texas’ New Parental Consent Law Leaves School Nurses Confused About Which Services They Can Provide to Students,” and it’s at The Texas Tribune, by Jaden Edison. And I picked this because I thought it was something really interesting that I’d never really thought about before, but there’s a new law in Texas that you have to get parental consent before the nurse or whoever at the school can do health services for students. And they’re getting more confused about if they would also be penalized for handing out Band-Aids or ice packs or just first aid. And school districts are required by the law to discipline violations of the law, but how it’s kind of being done across the state is a little varied, and some places have been saying they’ll only even intervene if it’s life-threatening. So I think it’s interesting as part of the parental consent movement of when is this something that is debilitating and if someone doesn’t have a form signed, how that’s going to affect kids at school.
Rovner: Yeah, a lot of good discussion about thinking things all the way through. Lauren.
Weber: Mine is titled “‘Just Let Me Die,’” by ProPublica, written by Duaa Eldeib. And it is just a heartbreaking tale, one that ProPublica has been doing really well, where they examine the fact of prior authorization and what it means for patients. And it’s about a gentleman who was trying to get approved for mental health stays after several suicide attempts. It’s a gutting story. And the reviewer at the end of the appeal process, he was so appalled by what had happened that he called the wife of the man who had been trying to get these appeals. And it’s an important read, especially as Congress is weighing things on prior authorization and as [Centers for Medicare & Medicaid Services Administrator Mehmet] Oz has vowed to expand prior authorization for some things. So a lot here to be unpacked. And ProPublica, again, big props for how they’ve covered the prior auth issue in the last couple of years.
Rovner: Yeah, it’s been fodder for a lot of — really a lot of — good stories. All right. My extra credit this week is from NPR by Will Stone. It’s called “What Kind of Dairy Does a Body Good? Science Is Updating the Answer,” and it’s a really clear story about how it turns out that full-fat dairy, at least in some cases, isn’t nearly as bad for you as other high-fat animal products appear to be. It looks at this one case where science is working as it’s supposed to, with researchers continually updating and refining what they know and recommend. Bottom line seems to be that full-fat cheese and yogurt — probably not bad for you, maybe even good for you. But butter? Still not great. It’s too bad for me. I like butter. Also, what matters is what else is in your dairy products. It’s one of those really well-done pieces that it’s like: OK, this is what we know. This is what we’re trying to find out. This is what’s new. This is the kind of consumer-helpful information we should have more of.
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 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 still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Sandhya.
Raman: On X and on Bluesky, @SandhyaWrites.
Rovner: Anna.
Edney: Same places, @annaedney.
Rovner: Lauren.
Weber: Same spots, @LaurenWeberHP. The HP is for “health policy.”
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Happy 60th, Medicare and Medicaid!
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
On July 30, 1965, President Lyndon B. Johnson signed landmark legislation creating Medicare and Medicaid. Sixty years later, the programs represent a fifth of the federal budget and provide coverage to nearly 1 in 4 Americans. In addition, the way Medicare and Medicaid structure and pay for medical care has set the standard for the private sector as well.
On this week’s special episode of KFF Health News’ “What the Health?” podcast, host Julie Rovner interviews two experts on the history, development, impact, and future of Medicare and Medicaid.
First, Rovner talks with Medicare historian and University of North Carolina health policy professor Jonathan Oberlander. Oberlander is the author of the book “The Political Life of Medicare” and a former editor of the Journal of Health Care Policy, Politics and Law.
Then, Rovner chats with Sara Rosenbaum, professor emerita at George Washington University. Rosenbaum has spent nearly her entire career working on Medicaid policy and has helped shape key priorities at the federal and state levels.
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Transcript: Happy 60th, Medicare and Medicaid!
[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 this special episode of “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m usually joined by some of the best and smartest health reporters in Washington. But this week we’ve got something special for you. It’s an episode marking the 60th anniversary this summer of Medicare and Medicaid, the twin government health programs that have largely shaped the way the U.S. pays for and delivers health care for the past half-century. To bring us the story, I sat down with two of my favorite experts on the subject, University of North Carolina professor Jonathan Oberlander and George Washington University’s Sara Rosenbaum. Here are my chats, starting with Jonathan Oberlander on Medicare.
I am so pleased to welcome Jonathan Oberlander to the podcast. He’s a professor of social medicine, professor of health policy and management, and adjunct professor of political science at the University of North Carolina School of Medicine in Chapel Hill and one of the nation’s leading experts on Medicare. John, welcome to “What the Health?”
Jonathan Oberlander: Great to see you, Julie.
Rovner: So Medicare, to me at least, remains the greatest paradox in the paradox that is the U.S. health care system. It is at once both so popular and so untouchable that it’s considered the third rail of politics, yet at its core, it’s a painfully out-of-date and meager benefit that nevertheless threatens to go bankrupt on a regular basis. How did we get here?
Oberlander: Wow. Let’s talk about the benefits for a minute. And I think one of the things we can say about Medicare in 2025 as we mark this 60th anniversary is it still bears the imprint of Medicare in 1965. And when Medicare was designed as a program — and the idea really dates back to the early 1950s — it was not seen as a comprehensive benefit. It was intended to pay for the most consequential costs of medical care, for acute care costs. And so when it was enacted in 1965, the benefits were incomplete.
And the problem is, as you know very well, they haven’t been added to all that much. And here we have, all of us know, as we get older, we generally don’t get healthier. I wish it was true, but it’s not. And older persons deal with all kinds of complex medical issues and have a lot of medical needs, and yet Medicare’s benefits are very limited, so limited that actually a very small percentage of Medicare beneficiaries have only Medicare. Most Medicare beneficiaries have Medicare plus something else, and that may be an individual private plan that they purchase, called a Medigap plan, or maybe a declining number of people have retiree health insurance that supplements Medicare. Some low-income Medicare beneficiaries have Medicaid as well as Medicare, and they’re dual-eligibles. And some Medicare beneficiaries have extra benefits through the Medicare Advantage program, which I’m sure we will have a lot to say. So the bottom line, though, is Medicare has grown. What, about 70 million Americans rely on Medicare. But the benefit package — with some intermittent exceptions that are significant, such as the addition of outpatient prescription drugs in 2006 — really has not kept pace.
Rovner: So let’s go back to the beginning. What was the problem that Medicare set out to solve?
Oberlander: Well, it was both a substantive problem and a political problem. The origins of Medicare are in the ashes, the failure, of the Truman administration proposals for national health insurance during the mid- and late 1940s. And after they had lost repeatedly, health reformers decided they needed a new strategy. So instead of national health insurance, what today we would call single-payer, a federal-government-run program for everybody, they trimmed their ambitions down to initially just hospital insurance, 60 days of hospital insurance for elderly Social Security beneficiaries. And that was it. And they thought if they just focused on older Americans, maybe they would tamp down the controversy and the opposition of the American Medical Association and charges of socialized medicine, all things that had really thrown a wrench into plans for national health insurance.
It didn’t quite work out as they thought. It took about 14 years from the time Medicare was proposed to enacted, and there was a big, divisive, controversial debate about Medicare’s enactment. But it was fundamentally a solution to that political problem of: How do you enact government health insurance in the United States? You pick a more sympathetic population. Now, there was a substantive problem, which was in the 1940s and especially 1950s, private health insurance was growing in the United States for Americans who are working-age. And that growth of employer-sponsored health insurance really left out retirees. They were expensive. Commercial insurers didn’t want to cover them. And the uninsured rate, if you can believe it, for people over age 65 before Medicare was around 50% — not 15% but five-zero, 50%. And so here you had a population that had more medical needs, was more expensive, and they had less access to health insurance than younger people. And Medicare was created in part to end that disparity and give them access to reliable coverage.
Rovner: So as you mentioned, Medicare was initially just aimed at elderly Social Security recipients. What were some of the biggest benefit and population changes as the years went by?
Oberlander: So in terms of populations, in 1972, Medicare added coverage for persons who have end-stage renal disease. So people who need dialysis, no matter what the age — it’s a lifesaving technology — they can qualify for Medicare. It didn’t really make sense to add it to Medicare. It’s just it was there. So they added it to Medicare. And also a population we don’t talk nearly enough about, younger Americans with permanent disabilities who are recipients of Social Security Disability Insurance for a couple of years. They qualify for Medicare as well and are a very important part of the Medicare population. Beyond that, Medicare’s covered population has not really changed all that much since the beginning, which actually would be a great disappointment to the architects of Medicare, who thought the program would expand to eventually cover everybody.
In terms of benefits, the benefit package has been remarkably stable for better and actually probably for worse, with the exception of, for example, the addition of outpatient prescription drug coverage, which came online in 2006, the addition of coverage for various preventive services such as mammography and cancer screenings. But Medicare still does not cover long-term stays in nursing homes. Many Americans think it does. They will be disappointed to find out it does not. Medicare does not cover, generally, hearing or vision or dental services. Traditional Medicare run by the government does not have a cap on the amount of money that beneficiaries can spend in a year on deductibles and copayments and so forth. So really its benefits remain quite limited.
Rovner: Even to this day we keep hearing about “Medicare for All,” “Medicare for All,” “Medicare for All.” Why has this never happened? And might it?
Oberlander: Medicare was never intended just to be for older persons. The original vision was enact federal health insurance for the elderly, demonstrate that it works, then expand it to children next. And that way you have people towards the end of life and at the beginning of life covered. And after you do that, carry out essentially a pincer movement and cover the rest, the middle ages, and bring them into Medicare until it’s Medicare for all.
And so that was their aspiration, and it did not happen that way. Some of it has to do with the costs of Medicare and the unexpectedly high cost at the beginning of the Medicare program. And when Medicare was seen as a fiscal problem, there wasn’t a lot of political space to expand it. Some of that has to do with just history. If you look at the late 1960s when the Johnson administration was considering expanding Medicare to children, which might’ve changed the trajectory of Medicaid and actually of all of U.S. health care policy, the Vietnam War was raging and the costs were really high and they didn’t want to add the expense of that, so they chose not to do it.
Part of it has to do with a shift in the political winds. And Medicare was enacted at a very liberal time in American political history. And in the 1970s, American politics shifted to the right, so that arguably Jimmy Carter, a Democrat who became president in 1976, he was arguably more conservative on a health policy than Republican Richard Nixon was, the president that preceded him. So as American politics shifted to the right, the idea of Medicare for all through this incremental strategy sort of vanished. And in fact, Democrats largely abandoned that, and they went in a different direction, which eventually culminates in the Affordable Care Act. They went to building on Medicaid and building on private insurance.
What’s interesting is you have seen in the last decade this resurgence of “Medicare for All,” and of course pushed most famously by Bernie Sanders in the Senate and through his presidential campaigns. And it has a lot of appeal. You look at the public opinion polls, it actually polls pretty well. I think a lot of that is really an indictment of U.S. health care and dissatisfaction with all kinds of things about American health insurance. But it faces so many obstacles. If it was easy to do, it would’ve been done already. And interest group opposition, having to raise taxes, which is not easy in the United States, allegations of socialized medicine in a country that has a strong libertarian focus, dislodging around 160 million people with private insurance and putting them into Medicare — there are just enormous obstacles to Medicare for All. So I suspect it’s going to continue to be part of the debate, but we are a long way from it.
Rovner: Medicare is also the biggest single payer in the nation’s health care system and for decades has set the standard for how private insurance covers and pays for health care. Is that still the case?
Oberlander: It is in many ways. Medicare, at the beginning, had very permissive payment policies. It was essentially a blank check to the health care industry, to physicians and hospitals. And not surprisingly, as a result, Medicare’s cost ran up really high in its first decade. When you get into the 1980s, Medicare becomes an innovator in payment reform in the United States. And in the early 1980s, it starts with hospitals and adopts what we call prospective payment for hospitals in the early 1980s, and then a fee schedule for physicians later on at the end of the decade in the 1980s. And Medicare has continued to be an important innovator. It is the home today for experiments in accountable care organizations and other innovations that we would term value-based purchasing.
And really, if you look at, for example, how many commercial insurers pay, they use Medicare’s physician fee schedule. Now they don’t pay the same amount, because they’re not as big as Medicare. They don’t have the same leverage. And in fact, hospitals on average are paid about twice as much by commercial insurers than Medicare and physicians about 20% to 30%. Commercial insurers use the fee schedule that Medicare has, and then they adjust the dollar amount because they simply don’t have the same kind of influence that Medicare does.
Rovner: I was going to say we hear a lot about administrative costs for health insurance. Medicare actually has among the lowest administrative costs, right?
Oberlander: Yeah, Medicare is fairly low in administrative costs. And of course administrative costs are one of the reasons American health care is so much more expensive than other countries. And if you think about it, once you enroll in Medicare, you’re generally enrolled for the rest of your life. And that contrasts with private insurance. It also contrasts with Medicaid, where people turn on and off and it creates all kinds of instability. Medicare is a program that is federally administered, although of course a large share of the program is now delegated out to private insurers, and that is changing the complexity of administrative arrangements in Medicare, among other things.
Rovner: We should probably go back and talk about how Medicare has so many pieces, A and B and C and D. How did that happen? I mean, I like to say it was not made confusing on purpose, but it was definitely made confusing.
Oberlander: Yeah. So at the beginning, Medicare was created with Part A and Part B. Part A really was insurance for inpatient services and hospitals, Part B for outpatient and physician services. And there were two reasons for that. One is they were marrying the standard and a lot of private insurance at the time. So we had Blue Cross for hospitals and Blue Shield for physicians, and that was just like Medicare Part A and Part B. The other reason is the original Medicare proposal was really just Part A, as we mentioned before, just for hospital insurance, funded by payroll taxes through the Social Security system.
Part B, the idea that you would have this insurance that beneficiaries could obtain for physician services that was going to be funded by paying premiums and general revenues, that was added very, very late in the Medicare debate. And so it came at a different time. So it got it added on as Part B. And then eventually we added Part C, which are private plans that beneficiaries can choose now, called Medicare Advantage, HMOs [health maintenance organizations] and PPOs [preferred provider organizations], and the whole alphabet soup, as an alternative to traditional Medicare. And then Part D, and Part D is prescription drug coverage. So I think we may be running out of the letters. We certainly have enough to confuse everybody.
Rovner: We certainly do. So we keep hearing about how Medicare is going broke. Is that true? And can it be fixed? And how hard would it be?
Oberlander: People have been worried about Medicare going broke since about 1970. And my philosophy on this is if you’ve been worrying about something being unsustainable for a half a century and it’s still here, you’re probably worrying about the wrong thing. So the chances of Medicare literally ever going broke and going away are, if not zero, as close to zero as you can get. What this has to do with is the way that Medicare is funded. And so Medicare Part A, hospital insurance, is funded almost entirely by what we call an earmarked payroll tax, the payroll tax that workers and their employers pay just for that.
Rovner: And it’s part of the Social Security tax, right?
Oberlander: And it’s part of the Social Security tax that people pay. And each year, the actuaries from Medicare project: How much money are we taking in? How much do we have in balances for Part A? And what do the expenditures look like? And so when you hear people say the Medicare trust fund is going to go, quote, “bankrupt” in now it’s about a decade, I think, projected from now, what they really mean to say is: OK, when we get to 2036, Medicare right now is not projected to have 100% of the funds it needs to pay for Part A services. We’ve had multiple periods during Medicare’s political history when we’ve gotten down to seven years, five years, four years. And Congress has never let that trust fund go insolvent. Politically, think about it. If there’s one thing we know about members of Congress, they want to be reelected. There are 70 million people in Medicare. I’m pretty sure a good way not to get reelected would be to get to say, I don’t know, October in 2036 right before the 2036 midterm elections, and say: We’re sorry. Medicare is just going to stop paying.
So the good news is things can change. Congress can adopt policies, which they have in the past, that extend Medicare’s finances and strengthen its finances. So I think there is good reason to be concerned about how do we stabilize Medicare financing. But in terms of what keeps me up at night, Medicare going bankrupt, I wouldn’t let that bother me, and I wouldn’t let it bother you.
Rovner: So how have the politics of Medicare changed over the years? I mean, at the beginning it was very— it was supported by Democrats and opposed by Republicans, and now it’s President [Donald] Trump who says, Thou shalt not touch Medicare.
Oberlander: There’ve been some twists and turns. If you look at the vote on Medicare enactment in 1965, it was not the vote on Obamacare in 2010. There were some Northern Republicans, moderate liberal Republicans, who voted for it, and conservative Democrats who voted against it. So it was mainly a partisan debate but not exclusively a partisan debate. And I would say in between 1965 and it passed in 1995, the politics of Medicare were consensual. There was a lot of bipartisanship. If you think about the payment reforms in Medicare that we have today and that shape Medicare today, the prospective payment system, the Medicare fee schedule, those were sponsored by Republican presidents and supported by bipartisan majorities in Congress.
And as you will vividly remember, because I know that you covered this, the biggest benefit —attempted benefit — expansion in Medicare’s history at the time in 1988 was sponsored by [President] Ronald Reagan, a conservative Republican. In 2003, the expansion of prescription drug coverage was under a Republican president, George W. Bush. So the partisan tides have not flowed in predictable ways, but I do think it’s fair to say, since 1995, there has been an erosion of bipartisanship in Medicare and a real breakdown. And the reason I choose that year as a demarcation point is for the first three decades of Medicare’s life, it never lived under a Republican-majority Congress. And in 1995, after Republicans swept the ’94 elections that brought [Rep.] Newt Gingrich to the speakership in the House and a Republican majority in the Senate, was the first time you had Republicans in Congress as a majority governing Medicare, and they pursued ambitious Medicare reform plans. And in the decades since then, Democrats and Republicans have disagreed very sharply over Medicare and over the future of Medicare.
Now, Donald Trump has thrown a wrench in the politics in Medicare, as he has in many things, because he is not a traditional Republican in many senses, including on Medicare. And he said explicitly when he ran for president the first time that the effort by [Rep.] Paul Ryan, who was chair of the Budget Committee, also speaker of the House, to really reform Medicare and accelerate privatization and make large cuts in Medicare, he said it was politically stupid. Why would Republicans want to do that? And so he has moved the Republican Party to a different place in Medicare, and you can see it in this budget bill that just passed that did all kinds of things to Medicaid and very little to Medicare. I think the question is whether that Trump effect is going to endure past Trump. And so when we get out to, oh, I don’t know, 2029, 2030, what is the Republican consensus in Congress going to be? Have they actually moved in that direction? Or, particularly with the soaring budget deficits, is it going to go back to really a debate between Democrats and Republicans about the future of Medicare?
Rovner: So let’s talk about privatization. Medicare Advantage, the private health plan alternative to traditional Medicare, is now more than half the program, both in terms of people and in terms of budget. Is this the future of Medicare? Or will we look back in many years and see it as kind of a temporary diversion?
Oberlander: I think it’s the present and probably the future. The future is always so hard to predict, Julie, because it’s unwritten. But, I mean, this is really a shocking outcome historically, because what Medicare’s architects expected was that the program was going to expand government health insurance to all Americans, first with the older population, then adding children, then adding everybody. Did not turn out that way. The original aspiration was Medicare for all through any incremental means. Instead, 60 years later, we don’t have Medicare for all, but Medicare is mostly privatized. It’s a hybrid program with a public and private component that increasingly is dominated by private insurance. And the fact that over half of Medicare beneficiaries are enrolled in these private plans is a stunning development historically, by the way with lots of implications politically, because that’s an important new political force in Medicare that you have these large private plans, and it’s changed Medicare politics.
I don’t think Medicare Advantage is going anywhere. I think the question is: How big is it going to get? And I’m not sure any of us know. It’s been on a growth trajectory for a long time. And the question is: Given that all the studies show that Medicare Advantage plans are overpaid, and overpaid by a lot, by the federal government and it’s losing a lot of money on Medicare Advantage and it’s never saved money, is there going to come a point where they actually clamp down? There have been some incremental efforts to try and restrain payments. Really haven’t had much effect. Are we actually going to get to a place where the federal government says: We need savings, yeah. This 22% extra that you’re getting, no, we can’t do that anymore?
So I think it’s an open question about: How big is it going to get? Is it going to be two-thirds of the Medicare program, three-quarters of the Medicare program? And if so, then what is the future, turning the question on its head, of traditional Medicare if it’s that small? And that’s one of the great questions about Medicare in the next decade or two.
Rovner: So for all the needs that Medicare does pay for, one huge hole that remains is its lack of coverage for long-term care, which I think you mentioned at the outset. I wrote my first story on Medicare’s lack of a long-term care benefit in 1986 when I was in my 20s. Now I am in my 60s, and we still haven’t solved the long-term care dilemma. Why has this one thing been so very difficult to address?
Oberlander: It is the issue that will not speak its name. It’s such a huge problem, and we don’t talk about it. And the way we organize and pay for long-term care in the United States is really terrible. The costs of long-term care in nursing homes has skyrocketed. It’s, as anybody who knows who’s had a family member deal with this, it is absolutely a staggering cost to pay for somebody to stay in a nursing home. And I think, paradoxically, one of the reasons we don’t talk about it is actually because of that cost, because the budgetary implications of this are so high that members of Congress and presidential administrations just don’t go there. And what we’ve done instead is we’ve created a kind of de facto nonsystem where people spend down, often in not very ideal ways, to qualify for Medicaid. So we’ve got Medicaid as a major payer for institutional long-term care.
We have expanded home health, long-term care, both in Medicare and Medicaid, and that’s a growing part of the system. Private insurance has never really developed. It’s not very stable. The insurance is expensive and hard for people to afford and often not very good. And I think as the baby boomers age, of course the need for long-term care just keeps growing and growing, and yet we paid more attention to it when you were in your 20s. Not to date you, but you did it first. I mean, we paid much more attention, I think you would agree, to this issue on the national stage back when [Sen.] Claude Pepper was in Congress, what, 40 years ago, and it is not really talked about anymore. We’ve kind of swept it up under the rug. And the result of that is a lot of Americans are left with terrible situations when somebody needs a long-term care stay.
Rovner: And 40 years later, people still don’t know that Medicare doesn’t cover most long-term care.
Oberlander: And yes, people still don’t know. And yeah, they assume that: Medicare, of course, it’s a program for older persons. Of course it must cover long-term care. And unfortunately it does not.
Rovner: So one other thing that Medicare does do that most people don’t realize is educate most of the health care workforce, certainly doctors. People don’t realize the way that Medicare subsidizes the training of doctors. Is that something that we’re going to have to look at going forward?
Oberlander: Medicare does play a huge role in subsidizing medical education, and I think — you ask: Is it something we have to look at? It’s something that of course provides a lot of social value. I think that the issue for Medicare, and not just for graduate medical education but for all of Medicare, is this: We have a federal budget deficit that was already enormous. We just added to it and added to it a lot in the so-called One Big Beautiful Bill. So we have red ink as far as the eye can see. And my prediction, which I don’t think takes a lot of courage, is that sooner or later, probably sooner, members of Congress are going to look up and see: Wait a minute. We have this gargantuan deficit. And they’re going to say — it’s a deficit that is going to have exploded because of the tax cuts — but they’re going to say: Oh, look at this deficit. We’ve got to tame government spending.
Well, OK. Where does the government spend money? And of course, why did Willie Sutton rob banks? That’s where the money was. That’s what he famously quipped. Well, where does Congress go for budgetary savings? And this has been true for 40 years now. They go to Medicare. So I think there is a reckoning coming where Congress will look for major savings in Medicare as a result of the broader fiscal picture in the United States, and that is going to have implications for all parts of Medicare.
Rovner: So last question. I know you don’t want to predict the future. Is Medicare going to be around in another 60 years when you’re ready for it?
Oberlander: I’m going to be ready for Medicare closer to six years than 60 years. I won’t be around in 60 years. Yes, yes. The most important thing to say about Medicare is that retirement in the United States today is unimaginable without Medicare. Medicare is a cornerstone of health security, of retirement security, in the United States. It is absolutely unthinkable that we wouldn’t have the Medicare program. And for all the problems and challenges that it has, it’s also important at the end of the day to remember the successes it’s had and the vital access to medical care that it’s provided. And to think about what the world would look like for older Americans and persons who have permanent disabilities who did not have Medicare, what would happen if Medicare was not there? So I think there’s no question that Medicare is going to be here in 60 years. The question is: What form is Medicare going to take?
Rovner: Excellent. Jonathan Oberlander, thank you so much.
Oberlander: It was great to be with you, Julie.
Rovner: I am so pleased to welcome Sara Rosenbaum to the podcast. Sara is professor emerita of health, law, and policy at George Washington University, one of the, if not the, leading experts on Medicaid. She’s also the person who has taught me at least 80% of what I know about the program. So I am extra thrilled that she’s agreed to come be our guide. Sara, welcome.
Sara Rosenbaum: Thank you for having me. It’s such a pleasure to be on the show.
Rovner: Let’s start at the beginning. Medicaid was kind of an afterthought to Medicare when they were both created 60 years ago. How did Medicaid come to be?
Rosenbaum: Yeah, it’s a really interesting question. This is, of course, the lore, that Medicaid was an afterthought. If you look at the original act — which of course was an outgrowth of an earlier law, the Kerr-Mills Act, which had been enacted about five years before — and you read the original statutory language, which we lawyers revel in doing, you are amazed. This was not such a big afterthought. I would say that Wilbur Cohen and Wilbur Mills and Lyndon Johnson and everybody else had a good idea of what they were doing. They knew that they were planting the seeds for a program that ultimately would come to be the foundation of health insurance for low-income people across the United States, as well as, of course, specific categories such as people with very severe disabilities.
Rovner: Why don’t you remind us what Kerr-Mills was?
Rosenbaum: Yeah. So Kerr-Mills was an earlier, a limited, federal grant program, very much structured the way Medicaid is structured today, open-ended grants, but it really focused on the elderly. And of course it predated Medicare. And Kerr-Mills kind of helped make the case for Medicare, because it was obvious that it was such a limited program in its reach. It could not do what a universal insurance program for people who had attained a certain age, and ultimately also who become disabled, would do.
Rovner: So what was the difference between Medicare and Medicaid supposed to be when they were signed into law 60 years ago?
Rosenbaum: Yeah. So Medicaid was very much structured in the classic style of a state grants program. It has come, of course, to be so much more than that. But it was a grant to states, and states would set up state plans. This is all language that has become very familiar to us. And they would provide medical assistance, as it was called, to certain categories of poor people. And the theory was that the program would start with these people, but tucked into the — the categories were cash welfare recipients — but tucked in there were a group of people known as the medically needy, in the early days.
And the medically needy, I always felt, was sort of the first seeds of something much bigger, because the point was that it was a program for people who were low-income, who couldn’t afford their medical care, but didn’t get cash welfare. So the theory was exactly the theory that has carried the program for 60 years now. And originally the thought was that it would really — and of course this has turned out to be the case — that that would enable people who had very serious health care costs for things that Medicare did not cover — nursing home care, home health benefits ultimately, those kinds of really big-ticket long-term care items outside of Medicare, because Medicare was really sort of like Blue Cross Blue Shield for old people like me.
Rovner: You weren’t old at the time, though.
Rosenbaum: I was not. I was just a kid. But the program was meant to replicate what folks had had through, during their working years. And so it was very important and very profound, but limited.
Rovner: So Medicare’s long been the more politically popular of the two programs—
Rosenbaum: Yes.
Rovner: —primarily because of the political clout of older voters, which is how it was created. How was it that Medicaid became the program that grew so much?
Rosenbaum: Well, I believe that Medicaid, and this is I think what Wilbur Cohen understood—
Rovner: And you might remind us who Wilbur Cohen was.
Rosenbaum: Wilbur Cohen was the genius behind so much of the early social welfare thinking who sort of was a bridge between the academic thinking about assistance, the legal thinking about assistance. By then, by the time Wilbur Cohen was working his magic in the Johnson administration, maybe the single most important article on social welfare policy ever written had been written by Charles Reich, “The New Property.” That sort of spelled out how Americans had come to expect help from the government as a right. So he was the brain trust, the one-man band behind thinking through, with members of Congress, what Medicare and Medicaid would look like. He was really the architect.
Rovner: He was the secretary of health, education, and welfare at that point, right?
Rosenbaum: Yeah. Well, I think he was actually the deputy, but you could be correct. I don’t remember whether he ever assumed the top position or whether he in fact was second in command. It’s worth checking. But he was the guy. He knew that what would propel Medicaid forward is that, unlike Medicare, which is tied to a premium structure, Medicare is funded through premium payments, which is great, but premium payments are quite unique because they are actuarially based. They are sort of a very tightly controlled form of financing, because you’re asking — whether it’s the government or now, of course, private insurers that contract with the government — you’re asking them to take on a lot of financial risk. And so everybody wanted the — like it was really going to work that way — wanted the assurance of premium structure.
Well, Medicaid was not. Medicaid is a classic public health statute. It’s general revenue. And so every time something happened that required an intervention by the federal government where health care was concerned, you could just add a few pages to the Medicaid statute and end up with, voilà, a fix. So I was very privileged. I began my career in the first decade of Medicaid’s existence, shortly after the first great leap had happened when we created, in 1972, the Supplemental Security Income program, for people with profound disabilities or the elderly who were very, very poor. And that, of course, was accompanied pretty much by Medicaid. People were entitled to Medicaid.
And by the time I came along, everybody was looking at another great leap. And that great leap, under the Carter administration, because of a lot of people’s work along the way, was children. Interestingly, the original statute — and this is what I mean when I say, “You go through the statute” — there’s all kinds of stuff that tells you where everybody knew this thing was going. There was the used-to-be-famous Ribicoff Amendment. Sen. [Abraham] Ribicoff of Connecticut offered an amendment to give states the flexibility to cover low-income children without regard to whether they lived in families that received cash welfare. And not too many years later, along comes the Department of Health and Human Services, based at HEW, that says, You know what? And of course this is way before the reproductive health politics of today. Somebody said, You know, if we added an unborn component to the Ribicoff child option, then you could cover poor pregnant women.
And the original Ribicoff child program, therefore, including its the-unborn component, which was regulatory, were incredibly important. But they were tied to cash welfare assistance, and of course cash welfare assistance began to sink and sink and sink and sink. And by the mid-’70s, people said, Well, what if we decoupled this category from cash welfare funding levels and just let poor children have Medicaid? And there then ensued essentially a decade-long effort to add poor children and pregnant women as groups in their own right to the Medicaid program. And—
Rovner: That was when I started covering it.
Rosenbaum: Yes.
Rovner: I was going to say it was almost sort of a stealth expansion, because it happened bit by bit by bit. But that was the strategy.
Rosenbaum: That was the strategy. And of course the architect of that strategy — there were many, many parents of that strategy — but the true hero of that strategy was Congressman Henry Waxman and his extraordinary staff, who were so brilliant, not only in thinking through what they would be able to get done in the House — he was of course a chair of the [Energy and Commerce] health subcommittee at that point in the House — but also what those of us working outside of government would have to do by way of delivering support in the Senate. And so every year became sort of, at the beginning of the year, a strategy session with the singular Karen Nelson, who was the staff director for the health subcommittee. And we would all sit and say: OK, this year we’re going to do X. And so we’ve got to round up — this is what you could move in the House, and this is what we have to go round up in the Senate, and these are the outside groups.
It was, they were amazing that way — I mean, political athletes. And their political athleticism was used to achieve this extraordinary breakthrough, not just for children but later on for long-term services and supports for the elderly, for people with disabilities. We all have that kind of amazing legislative prowess to thank, and they sent the program on its way. So by the turn of the 21st century, we had a Medicaid program in which it was a given that low-income children and pregnant women would have coverage. It was a given that the program was propelled — of course, there were many other things along the way — but would be a much more robust responder to long-term care needs, and to adults, to working-age adults, because we recognized parents as a group of people who could be helped.
So all these seeds were here. And Medicaid had done amazing other work in the early 21st century, like enabling a response to the catastrophe of New Orleans, because it’s a general revenue program, or the World Trade Center attacks, where suddenly thousands of people needed health insurance. And so Medicaid was constantly the first responder, whether it was a structural first responder like coverage for poor people or whether it was a first responder to naturally occurring or man-made disasters. And that was the brilliance of the early years.
Rovner: I was going to say also, Medicaid was used, I know in the last 30 or so years, to basically give states more money during economic downturns.
Rosenbaum: Absolutely. This is one of the things that everybody was so sensitive to, that as the program was building, building, building, what the federal government could — now see, just how much debt the federal government can manage to work under — what the federal government could absorb in the way of spending in order to advance social welfare policy. States, because their economies are very differently structured, as are their political and legal systems, could not. And so, many times — many times — preferred financing has been used to make it possible for states to do all kinds of things. And look, we could go back to Sen. Russell Long, not exactly a civil rights icon, who was the father of Medicaid’s extraordinary family planning benefit, who made sure, along with Sen. [Herman] Talmadge, who similarly was not exactly a civil rights pioneer—
Rovner: Couple of Southerners.
Rosenbaum: Yes. That the family planning benefit not only would be expansive but would be paid to the states at 90% federal financing. So this idea goes all the way back to the early years, and you’re absolutely right that the financing has been used to make it possible for states to do things, to make it possible for states to maintain their programs during downturns, right up through the covid pandemic, of course. And that’s been a tremendously important part of the story, just like Medicaid has been used to support the health care safety net, both hospitals through its disproportionate-share hospital payment program, its other elements that give states the ability to fund their public health systems, county-operated public health systems, through Medicaid, and of course one of the most interesting stories of all, which is the extent to which Medicaid literally took a few dozen experimental clinics from the Great Society years that were struggling to survive — there were a few hundred by the time it happened — and created the financing system that today has created community health centers which serve 32 million people. So, I mean, Medicaid is the powerhouse. It is the powerhouse.
Rovner: Today we think of Medicaid, as you were saying, in terms of this major population — seniors in nursing homes, low-income moms and kids, people with disabilities. But Medicaid’s also become the nation’s leading provider of things like drug treatment and rehabilitation and mental health care. How much has that been overlooked in the modern Medicaid discussions?
Rosenbaum: Well, I think all of these things tend to get overlooked until they’re threatened, right? So all of a sudden, for the past six months, everybody’s had a 101 into what Medicaid does, because every few years we find we go through the same thing. This year was tougher than any we’ve faced before. But I put all of Medicaid’s contributions to mental health and addiction treatment in the category of long-term services and supports that Medicaid, because of its financing structure, has been able to essentially wrap around of a terribly deficient private insurance system and Medicare system that just do not, they’re not structured to fund these things. Somebody’s got to fund these things. And Medicaid has stepped up each time. And that’s why I think the battle over Medicaid that we have all been living through since January of this year is so profound, because the achievements of the program sort of reach into everything — chronic health, public health, insurance coverage. I always tried to explain to my students that there was no one thing that Medicaid does. You can’t just describe Medicaid as insurance. It’s way more than that. So you are absolutely right to point this out.
Rovner: I feel like in 2017 in the fight over the repeal of the Affordable Care Act, that was sort of a big change for Medicaid. I think people had finally realized that Medicaid had grown larger than Medicare, that it was not just a program for the poorest of the poor, that it did all of these other things that you’re talking about, and that really a lot of, I guess, the stigma had been taken away. And yet this Congress felt comfortable — I don’t know if I’d say “comfortable” — but a majority of them voted to make these really deep, profound changes. I mean, what is that going to mean going forward both to the health care system and to the political system?
Rosenbaum: Well, I’ve spent a lot of time thinking in the post-enactment period about: When was the die cast? When was the die cast that set everybody spinning? And I think they, congressional leaders and the White House leadership, understood the fatal error they’d made in 2017, which was separating the tax reforms from the spending reforms, because of course we were then able to battle the spending reforms on our own turf, right? Here, because of the decision that was made back, I’m sure, almost a year ago—
Rovner: Literally the idea to do one “big, beautiful” bill.
Rosenbaum: Yes. And that meant that Medicaid, along with food stamps, or SNAP [the Supplemental Nutrition Assistance Program], along with everything else, just became pay-fors. They just became offsets. And the name of the game then became beating back every attempt to deprive Congress of pay-fors to do the thing that it really wanted to do, which was tax reform. And so we were all reduced to — “we” in the sense of people who worked on social welfare policy, including a lot of my friends who work on tax policy but as a social welfare concern — we were all reduced to bystanders in this effort to get to a trillion dollars.
Rovner: A trillion dollars in cuts.
Rosenbaum: A trillion dollars in cuts. And therefore it opened the door to extraordinary things. I mean, for example, if I could take just a second on it, on the work requirements. The experiments from Arkansas and New Hampshire and other states, that formed the basis for so much of the opposition to work requirements, were very destructive. But the way they worked was people who were on Medicaid would then have to report in if they were working, which was not good, because they couldn’t navigate the red tape and fell off. But the model that has been passed, that’s been enacted, is like dropping a hydrogen bomb, because you will no longer be able to enroll in Medicaid if you cannot navigate the red tape. And so many of us kept pointing out that this was a terrible idea in any event, but to impose this at the point of enrollment meant that you were not just simply destabilizing coverage for people who had it, you were preventing people from getting it.
And the way the statute is written, literally every person on Medicaid today who’s an affected person, the working-age adults in expansion states, is going to have to reapply for the benefits. It is huge. Huge. And because you can’t have Medicaid at the point of enrollment unless you could meet these requirements. And so I had many, many disputes along the way with people who thought it would be 3 million or 4 million or 5 million people losing their coverage. It’s potentially 20 million people, 20-plus million, the expansion population, because while there are exemptions, you’re going to have to prove an exemption. And some of the exemptions will be easier than others. But interestingly, the way Medicaid works in expansion states, people just enroll as low-income people.
So whether you’re a parent, whether you have a disability and you’re waiting for Social Security to make the determination and you’re sort of on as a poor person while that’s happening, it doesn’t show up. What shows up is you’re a low-income person. And you’re going to be confronted with having to prove your worth to get health care. And when we tried to confront this, we were told quite bluntly that people were told: No, no, it’s the enrollment that’s going to remove everybody. That’s where the savings come from. And so it lost all of its humanity, and I think it drove home to me the point that this was all about the money and that’s why they were able to succeed.
Rovner: So obviously, I mean, I know a big source of enrollment for Medicaid is health care providers themselves. People show up, they’re uninsured, and there’s somebody smart there who says, Hey, you’re eligible for Medicaid, so we can get paid. This is going to have a huge impact on the provider community, isn’t it?”
Rosenbaum: Yes. And those providers that have, say, experience in trying to help their patients enroll in or keep their coverage will struggle mightily, because they’re losing huge amounts of revenue. We did a couple of quick analyses of just how much money, for example, community health centers stood to lose, and it’s over a five-to-seven-year period. It’s in the tens of billions of dollars. A friend of mine in Georgia told me that they’re about to lay off their entire — this is, We’re not affecting children, we were told. They’re about to lay off their entire child outreach staff, who help families with children all over Georgia enroll in and keep their coverage — for the children. And so they can’t afford them anymore.
Rovner: So what happens next? Does this happen? And if it happens, does it take out the underpinnings of the entire health care system? Or does Congress eventually realize what it’s done and change its mind?
Rosenbaum: Well, yeah, I mean, I think people are saying, Well, the two-year runway. It’s like two years until it becomes effective. The two-year runway is going to sort of make people forget about this, and then, boom, it’ll be upon us. I don’t think so. I think the two-year runway will end up shining a huge light on the fact that states cannot implement the whole system. I mean, while we are very focused on the number of people who will lose their coverage, the states are confronting an insurmountable problem here. They’ve never had to link Medicaid to work records. And Congress did everything it could to make matters so much worse. For example, they could have just said that: We’re going to import the same requirements that apply to SNAP to Medicaid. And so if you’re getting SNAP in your working age, then you automatically enroll in Medicaid. They didn’t do that. They didn’t do that. It’s a different-enough set of eligibility criteria and exemption categories. For example, SNAP ends, I think, at about 60, and the Medicaid work requirements go all the way to 65.
Rovner: Age 60 and 65. Yeah.
Rosenbaum: Yes, exactly. But I mean, the exemptions are different. The requirements are different. And so people are talking about, Oh, we’ll just align reporting systems. No, no, no, no. You are liable for all kinds of error rate penalties. If you just rely on SNAP, you can’t. So states have no way to deal with this, health care providers that will be called upon to literally provide the documentation. My guess is that Russell Vought, the head of OMB [the Office of Management and Budget], who is really the person in charge of implementing all of this, is not going to take attestations as evidence. They’re going to require documentary evidence and files about health exemptions and continuing health exemptions. This is all just to get some health care. It’s not like you can eat with your Medicaid card or pay your rent with your Medicaid card.
So the astonishingness, I don’t think that’s a word, but the astonishingness of this all, I think, is only going to build and build. And of course so much attention was paid to rural hospitals, and so they tucked in this little teeny-tiny rural hospital program. And quite frankly — I just did a post with my colleague Anne Reid about this at HealthAffairs — if you read the fine print — and Carole Johnson has an excellent one — if you read the fine print — we’re not so fine print — if you read the print of the statute, we noted that offsetting lost revenue is only one of 15 different activities. In fact, you can’t just go to the government and say, you can’t go to Russell Vought and say, Please give us our allotment so that we can offset, the way the fund worked back during covid. You have to spend your money. My favorite is that you have to spend your money on things like consultants to help you design payment reform strategies, payment reform strategies for people who are no longer injured. So there’s no mitigation strategy for this, and I think the hope is that Congress will call it back
Rovner: If it doesn’t, is this, I mean, the one sort of silver lining that I’d been sort of thinking about is, well, maybe if we tear down the health care system we’ll have to start again and build a better one. Is it possible that we could get there? Or are we just going to limp along?
Rosenbaum: I have those thoughts often, and then I stop and think, well, those of us with health insurance could sit there and say, Yeah, maybe we just tear down the health system to start again. Meanwhile, of course, we will have millions of people without health care. So interestingly, the Affordable Care Act, of course, was designed not to tear down the health care system but to strengthen the health care system. But it was the brilliance of the Affordable Care Act was that it saw the holes and it sort of tried to fix them. And if we’d left it alone, with everybody in this, what I consider to be, sort of an intermediate arrangement, we could have done exactly what you are talking about, with just about everybody in the United States covered. We could have begun to really do the serious work of moving to something more unified, better, and of course cheaper and more efficient. That’s right — far easier to use. But we have decided instead to tear the Affordable Care Act apart, both the access to the marketplace by rolling back the assistance and of course the Medicaid reforms.
Rovner: Well, happy birthday, Medicaid.
Rosenbaum: Happy birthday, Medicaid. Today’s the day.
Rovner: I know.
Rosenbaum: Yeah.
Rovner: Thank you so much, Sara Rosenbaum.
Rosenbaum: Thank you for having me. It was a — it was both uplifting and sad.
Rovner: OK. That’s this week’s show. I hope you enjoyed it. 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 a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. We’re going to take a short break to let our hardworking staff have some rest. We’ll be back in your feed the Thursday after Labor Day. Until then, be healthy.
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KFF Health News' 'What the Health?': Trump Further Politicizes Science
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
A new executive order from President Donald Trump has potentially broad implications for the future of the federal research enterprise by transferring direct funding decisions away from career professionals to political appointees.
And a gunman, reportedly disgruntled over covid vaccines, attacked the headquarters of the Centers for Disease Control and Prevention in Atlanta, highlighting how increasingly inflammatory rhetoric from health critics endangers the public health workforce.
This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.
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Alice Miranda Ollstein
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Among the takeaways from this week’s episode:
- Trump’s executive order highlights the tension between how Congress has directed federal science funding and what the administration can do to alter that course. Congress has traditionally set the parameters and experts have made the judgments for moving forward. The National Institutes of Health, considered an American crown jewel, specifically has remained apolitical. But this step opens the door to concerns about grant cancellation and adds to growing uncertainty in scientific research. Even investors are starting to hold back. The ripple effects could be much bigger than the Trump administration anticipates.
- Many CDC staffers blame Health and Human Services Secretary Robert F. Kennedy Jr. and other agency leaders for stoking the negative climate that led to last week’s attack. Kennedy appears to have doubled down on his language, however, announcing decisions and policies that continue to fuel vaccine opposition and hesitation.
- This week, Kennedy also made the unprecedented move of calling on the Annals of Internal Medicine, a medical journal, to retract a study that found that the aluminum adjuvant in many childhood vaccines did not cause harm. The journal refused to retract the study based on Kennedy’s scientifically unsubstantiated claims that the additive was damaging.
- More fallout is emerging about the GOP-backed sweeping budget law enacted this summer. Republicans have argued that its cuts to Medicaid — most of which will not kick in until after the midterm elections — would touch only waste, fraud, abuse, and people who weren’t entitled to the coverage. In reality, the sprawling nature of Medicaid is already becoming clear as institutions — ranging from hospitals to community health centers — prepare for cuts that could limit their ability to provide services.
- The CDC reported this week that Americans are eating less ultra-processed food but that it is still a big part of the American diet. The Trump administration has talked a big game about addressing this public health issue yet has seemed loath to require the food industry to do anything. Much of the administration’s efforts have focused on “voluntary” changes. Former FDA chief David Kessler this week highlighted a regulatory, legal way the administration could compel more action.
Also this week, Rovner interviews Aaron Carroll, president and CEO of the health services research group AcademyHealth, about how to restore the public’s trust in public health.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: ProPublica’s “Veterans’ Care at Risk Under Trump as Hundreds of Doctors and Nurses Reject Working at VA Hospitals,” by David Armstrong, Eric Umansky, and Vernal Coleman.
Alice Miranda Ollstein: The New York Times-KFF Health News’ “Why Young Americans Dread Turning 26: Health Insurance Chaos,” by Elisabeth Rosenthal and Hannah Norman.
Sarah Karlin-Smith: The New York Times’ “This Ohio Farm Community Is a Mecca for the ‘MAHA Mom,’” by Caroline Kitchener.
Shefali Luthra: Stat’s “Inside the American Medical Association’s Sudden Strategy Shift in Washington,” by Theresa Gaffney.
Also mentioned in this week’s podcast:
- The Washington Post’s “This Phrase Was Meant To Increase Trust in Science. It Backfired,” by Aaron E. Carroll.
- Stat’s “Former Surgeon General: The CDC Shooting Must Be a Wakeup Call,” by Jerome Adams.
- PBS NewsHour’s “Federal mRNA Funding Cut Is ‘Most Dangerous Public Health Decision’ Ever, Expert Says,” by Geoff Bennett and Karina Cuevas.
- The Washington Post’s “How Schools Could Be Hit by Medicaid Cuts,” by Terell Wright.
Click to open the transcript
Transcript: Trump Further Politicizes Science
[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, Aug. 14, 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 Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Good morning, everybody.
Rovner: Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: And Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hi.
Rovner: Later in this episode we’ll have my interview with Aaron Carroll, president and CEO of AcademyHealth. He’ll talk about how the public has lost trust in public health and how public health might win it back again. But first, this week’s news.
I want to start this week with a story that maybe hasn’t gotten as much attention as I think it should. Last week, President [Donald] Trump issued yet another executive order, this one called “Improving Oversight of Federal Grantmaking.” It really should be called “Implementing Political Oversight of Federal Grantmaking” because that’s what it does. Sarah, before we get into this, explain how federal science grants work now and the role of political appointees vis-à-vis career and outside experts.
Karlin-Smith: I guess I would say right now there’s very little political oversight. You have various scientific committees and federal experts that make the decision of how to reward the money, and it’s going to be very broken down by people’s areas of scientific specialty. So, and this order is really trying to put it more in the hands of political people that have a lot less scientific knowledge.
Rovner: That’s a polite way to put it.
Karlin-Smith: I think the reason why maybe it hasn’t gotten attention is this is sort of an extension of a lot of stuff they have tried to do throughout the administration, but they’ve either gotten pushback from universities or other parties or through the courts. And part of what seems to be going on here is they maybe have learned some lessons about their legal failures and they are trying to see if they can kind of adjust their strategy to maybe make it more foolproof. But there’s a lot of tension between how Congress has directed this federal funding to be spent and what the administration can really do to change the process around it.
Rovner: Yeah, I mean, I feel like until now this has been very much Congress setting the parameters and career people and outside experts making the judgments about what kind of science should be funded, right? Am I missing something here?
Karlin-Smith: I don’t think you are. I guess one thing that strikes me about this is I think that the U.S. scientific infrastructure and NIH [the National Institutes of Health] in general has not been political in the way I think other parts of our health system, our public health system in particular, have been over the years. Like, NIH, it’s gone through some periods maybe in the past decade or so where the funding wasn’t quite where people want it. But in general it’s been a pretty bipartisan priority. People do not want to mess with this system. It’s kind of a crown jewel of the U.S. that has helped spur both our universities and private industry and technology. So I think this is just a bit of a very different kind of strategy and approach from the Trump administration than we’ve seen from other administrations in terms of even trying to do this.
Rovner: It has been political in the sense of Disease Group A goes to members on Capitol Hill and say, Please fund our disease, and then they’ll put a line in the Appropriations Committee report to Please fund this disease. But when it comes to how, what specifically the kinds of research for that disease gets funded, that’s been left up to experts. So, under this order, not only will political appointees be in charge of potential funding announcement as well as grant approvals, but it also orders creation of a system to cancel ongoing grants for, quote, “convenience,” meaning apparently any reason that the administration might want to invoke. That’s something, as Sarah points out, that this administration has been doing since January, although various courts have pointed out kind of repeatedly that that’s not legal. But this could create so much uncertainty in scientific research so as to just basically bring things to a screeching halt. I see you nodding, Alice.
Ollstein: Yeah, I think that this is going to deter a lot of researchers from even embarking on the process, because why would you pour years of effort into writing these grants, recruiting subjects, setting up these labs when you know that the funding could be yanked at any time? That kind of uncertainty doesn’t comport with the years-long stability required to really get somewhere with this kind of research. And it’s no wonder that other countries right now are aggressively recruiting American scientists and American scientists are saying, Yeah, I would rather go abroad and have more stability, more of a guarantee that my research won’t be messed with and won’t be suddenly defunded, rather than stay here. And that’s going to be an enormous loss of knowledge here and an enormous loss of economic power over time.
Karlin-Smith: The other thing about, in talking to some of the groups that advocate for the universities here, that they were saying even prior to this order, with some of the earlier actions, what they were hearing, what was happening is is that other countries are actually recruiting scientists to work for them or fund them, but letting them stay in the U.S. And here so they’ve even come up with ways to even make it pretty easy for people to switch. But then the catch is probably that that research or IP [intellectual property] and so forth will actually belong to other countries, particularly China is one that is interested in that, in the many ways an adversary of the U.S.
Rovner: So, yeah, because I was going to say, one of the headlines I saw this morning was of investors who were starting to hold back because of all the uncertainty about the U.S. research establishment. I mean, this is a big chunk of the economy. I mean, it feels like the Trump administration trying to punish Harvard and Columbia and other universities, but I feel like the ripple effects of this could be much bigger than even they anticipate.
Ollstein: Well, absolutely, and I know we’re going to talk a lot about trust in health science and where that’s going, but I think there are two sides to people’s fears about this right now. One, that good, gold-standard, important research won’t get funded but also that shoddy or biased research will get funded. If you politicize that, you have both risks.
Rovner: Yeah, that’s true. Well, to segue, meanwhile, as if federal health officials aren’t uncertain enough right now, a gunman shot up the headquarters of the Centers for Disease Control and Prevention in Atlanta last week, killing a law enforcement official. Reports differ, but there’s evidence that the gunman, who apparently shot himself, blamed his covid vaccine for his mental health woes and wished to get back at the public health agency. To quote Jerome Adams, surgeon general in Trump’s first administration, in a Stat op-ed published over the weekend, quote: “One thing is clear: This tragedy is not an isolated event. It is a dire reflection of ever escalating threats public health workers face in a climate increasingly shaped by misinformation, politicization, and inflammatory rhetoric,” close quote. And it’s not just the shooting itself. Apparently the way higher HHS [Department of Health and Human Services] officials have tried to calm the nerves of CDC staff hasn’t really worked very well, from what we’re hearing.
Karlin-Smith: I mean, I think there’s a lot of CDC staff, and people in the public health space, blame the leadership of this current HHS for stoking these fears, and the rhetoric that they were using for a number of years prior to coming into office, for kind of creating a situation where this happened. And not only have they not really wanted to take that on head-on and talk about it or take any responsibility for it, they’ve sort of fueled the flames with comments HHS Secretary Robert F. Kennedy has made since the incident on news outlets, continuing to kind of double down on the language that suggested. And of course in the past few weeks they’ve made other decisions that have, I think, to people who have questioned vaccines and some of the technology that this person might’ve been upset about, sort of seem to back up their concerns, unfortunately, unscientifically, like pulling back on mRNA vaccine research funding.
Luthra: I was going to say, I think there’s another point that you made, Julie, that’s really important, which is looking at this in the broader context even of the past five years. And we’ve seen this real escalation of threats against public health workers across the country, and that really took off in a different way with the right-stoked skepticism around the covid vaccine, which we’ll talk about in a moment. But that’s had consequences already, whether that is people not wanting to enter public health, people leaving the profession, and it’s affecting our ability to monitor diseases, to do public health prevention, to do all those kinds of things that are becoming even more important and even more difficult as other parts of the health care safety net are being constrained.
Rovner: Yeah. And the mantra that we keep repeating is that public health, when it works, is invisible. Well, if it’s not there and it doesn’t work, it’s not going to be invisible anymore.
Ollstein: Well, and also this is coming at a time when a lot of people, if they’re not being straight-up laid off from these agencies, are feeling driven out in other ways by the uncertainty, by My department was cut, and then it was restored because of a lawsuit, and then it was cut again, and thinking, Why should I put up with this, the way the administration has disparaged bureaucrats, basically? But also these nonpartisan scientists who work for the government. And so this is coming on top of all of that. And so if someone was on the fence about, Should I stay and keep working for CDC or not? — this certainly isn’t going to convince them to stay, both the fear as well as the agency’s response to the incident.
Rovner: So HHS Secretary Kennedy was not very quick to respond to the CDC shootings, but he has been busy with other things this past week. One was an unsuccessful effort to get a prominent medical journal, the Annals of Internal Medicine, to retract a large vaccine study out of Denmark — and by “large” I mean 1.2 million children — that found that cumulative aluminum exposure to children via vaccines is not a safety risk. I honestly can’t remember an HHS secretary ever demanding a study be retracted because they disagreed with its finding. How unusual is this?
Karlin-Smith: Very unusual. I mean, I think the scientific basis for what he’s saying and pushing for. And the journal has already said, No, we are not retracting this, pretty bluntly. And this adjuvant has been something people have been worried about Kennedy going after. It came up a little bit the last CDC advisory committee on vaccines.
Rovner: Yeah, explain what aluminum adjuvant is.
Karlin-Smith: And it’s basically something they’ve been putting in vaccines since I think the 1930s. And it helps basically boost your body’s response to it. So it makes the vaccines better. And the last CDC advisory committee on vaccines, after Kennedy sort of overhauled the panel and put a lot of his people on there who don’t really trust vaccines very much, they removed thimerosal as an adjuvant for a flu vaccine, which I think was seen as problematic but won’t have huge, huge consequences, especially for the U.S. But they did—
Rovner: Because it had already been removed from most vaccines.
Karlin-Smith: Right. But they did also sort of tease that they were going to look at this adjuvant. And when I talked to people about that, they were much more concerned about it, because it’s in many more products and they don’t believe there’s really good alternatives for it. And it could basically be a move to push companies out of this space of making a lot of vaccines that children really need and benefit from.
Rovner: Or make vaccines less effective.
Karlin-Smith: Right. So they just don’t have good alternatives. So, yeah, it’s one thing people have been watching, is kind of the next step of where they go in vaccine politics here.
Rovner: What they’re going to go after. Well, meanwhile, the fallout continues over Kennedy’s cancellation of half a billion dollars in research on mRNA vaccines, which somebody mentioned earlier. This week, an international virologist group representing more than 80 labs reaffirmed their support for the technology. Michael Osterholm, one of the nation’s very top epidemiologists, said on the “PBS News Hour” that this was, quote, “unequivocally … the most dangerous public health decision I have ever seen made by a government body.” Why are scientists reacting so strongly to this particular policy change?
Karlin-Smith: One of the big reasons is because of how fast this technology can be used to develop vaccines and the ability for it to be helpful in a pandemic. So while we have other, older vaccine technologies, this one is really much faster in being able to update vaccines and make new vaccines. So that’s a crucial public health benefit to it, and that, I think, really scares people.
Rovner: Yeah, I know that the flu vaccine is still made using chicken eggs, right?
Karlin-Smith: Right. It’s grown in an egg. So, right, if you think about potential of flu pandemics, bird flu comes up. That’s one place where having the new mRNA technology would be really valuable. It’s also being studied for all different types of diseases outside of it, the infectious disease space, and cancer. And people are really excited about that, too. At this point, it doesn’t seem like the administration is as interested in cutting off that sort of funding.
Rovner: Yeah, well, we will have to see. Well, meanwhile, over at the FDA [Food and Drug Administration], we note the return of Vinay Prasad as head of the Center for Biologics. Sarah, didn’t he quit just, like, two weeks ago? What is going on over there?
Karlin-Smith: Strange times. Yeah, I think he was gone for maybe it might’ve been about 10 days. I don’t even think it was two weeks. He was kind of forced out. He drew attention from some right-wing allies of Trump, particularly Laura Loomer, after he halted the shipping of a gene therapy product after some safety events, some deaths. And that caused a lot of right-wing people that hadn’t really maybe paid much attention to the FDA or Prasad to look into his history. They pulled up some of his past, which was, he was probably, he was fairly Democratic and aligned with more of the left wing prior to maybe the covid pandemic. He had really strongly criticized Trump and made pretty, I mean, he’s quite a character in his colorful statements. So he had talked about having a voodoo doll of Trump, and I think if you know Trump, that’s not the kind of thing he’s probably going to personally stand for.
So it seems as if the White House pushed him out. But Martin Makary, the head of the FDA, and even HHS Secretary Kennedy seemed to eventually sort of convince the White House to let him back. And here he is. The question, I think, in a lot of people’s minds is does he have to sort of modify his decision-making or regulatory philosophy now that he’s brought back, whether it’s to sort of appeal to these right-wingers who basically have heralded Trump as this sort of head of a right-to-try movement, and this idea that there should be a more libertarian attitude toward regulation of medicine and people should basically have more options to try things.
Rovner: Yeah. It goes back to sort of the whole right-to-try thing and this drug for muscular dystrophy, right? Isn’t that sort of what prompted the big kerfuffle?
Karlin-Smith: Right. Right. So this Duchenne muscular dystrophy treatment has a really sort of long, complicated, controversial track record because Peter Marks, who used to have Vinay Prasad’s job before him, actually overruled a lot of his scientific reviewers in approving the product. And Prasad had a long history of criticizing Marks for doing that. And then right over the past few months it came out there had been some deaths in the space, mostly in non-ambulatory people. So this is a very devastating muscle-wasting disease, and eventually most people end up wheelchair-bound. And what ended up happening right before Prasad left is they agreed to let the drug back on the market for people that are still ambulatory, where they think the safety risk is less. And it’s still right now off the market for those.
But yeah, it’s sort of ironic because Prasad, while he’s sort of repeated a lot of the anti-vaccine rhetoric of Kennedy and Makary, particularly when it comes to covid vaccines, his philosophy, and what he was known for prior to coming to the FDA, was actually having kind of stricter standards for approval than many at FDA maybe had, or he would argue. And that doesn’t really align with the Trump philosophy or this libertarian, right-wing philosophy around this idea of right to try and people should have access to things if they’re willing to take the risks. So that’s where I think we’re watching moving forward, because actually outside of the covid vaccine space where he was sort of heavy-handed, he also made a number of decisions around gene therapies besides this one in his first, short stent at the FDA that did seem, again, a little bit more anti that right-to-try philosophy.
Rovner: Yeah. Well, we will definitely be watching that one closely. All right, moving on. We are seeing still more fallout of the big budget bill that passed earlier this summer. In rural New Hampshire, a community health center is closing at the end of October, citing Medicaid cuts, among other things. The Washington Post has a story this week about how the Medicaid reductions could lead to a decrease in services and an increase in wait times for things like counseling and speech therapy provided at schools for children with disabilities. I know Republicans were counting on these cuts not really having much of an impact prior to next year’s midterms. And they keep swearing that services won’t be cut except for people who are undocumented or who refuse to work. But that’s not how this is all playing out, right?
Luthra: There’s just no way that is how it can play out. And I think what we’re seeing in real time is how sprawling Medicaid is. It touches so many corners of so many people’s lives. There’s a reason it became this really sacred-cow component of things you can and can’t touch. And I think one thing that will be really interesting is, just again, as we think about something like community health centers, which Republicans also often tout as this really great model. We talk about that for family planning, especially. Oh, you can go there — you don’t need your Planned Parenthood, for instance. And what does happen when all of these places that so many people rely on are gone?
And I think one thing that you pointed out, Julie, that’s also so important is that many cuts may not be taking effect right away, but institutions have to make plans now. They are anticipating that that money isn’t coming back. And even if we don’t see some of the formal cuts having their start date until later on, it’s just not possible, I think, to imagine that we won’t see institutions have to adapt and scale back and see people navigate what that means.
Rovner: Yeah. If there are 10 million more people mostly without Medicaid, all of these places like community health centers who get a lot of their funding from Medicaid are going to lose a lot of their funding. I think this just didn’t carry through. I mean, we heard a lot from the hospitals, but it didn’t carry through to the other providers whose livelihoods basically depend on their patients having some form of insurance. And usually that’s Medicaid.
Ollstein: Right, and even with the hospitals, Congress was pressured into creating this kind of rural hospital slush fund to prop up the places that might be most impacted by this. But if all of the people who will be going to those hospitals lose their coverage, that might not be enough to make up for the loss, not to mention all of the hospitals that aren’t eligible for that money. And so I think Shefali’s absolutely right. The lesson in 2017 that Medicaid is not just the poor-people program was not learned. It didn’t stick. And now you’re seeing people relearning that, Oh, this impacts seniors in nursing homes. Oh, this impacts kids getting special services in schools. Oh, this impacts all of these groups that aren’t the working poor.
Rovner: Yeah, I think we’re going to continue to see this sort of spool out as we go. Well, finally this week, a priority for the Trump administration that’s shared by most of the public — cutting down on so-called ultraprocessed food. The CDC reported last week that Americans are eating fewer of their calories via ultraprocessed food, but it is still more than half of the calories consumed. And pushing for at least a partial solution is not the current FDA commissioner but a former one, David Kessler, who served under Presidents George H.W. Bush and [Bill] Clinton and has campaigned against processed food for pretty much as long as I can remember. While Trump administration officials have been urging food companies to do things voluntarily, Kessler this week filed a petition arguing that the FDA has the authority to declare certain ingredients used in ultraprocessed food as not, quote, “generally recognized as safe.” Making food companies prove these processed ingredients actually are safe could be a real tool in the fight against these foods, right? I mean, Sarah, this whole “generally recognized as safe” has been one of the big FDA loopholes over the years.
Karlin-Smith: Right. So, basically since the 1990s, due in some degree to probably staffing shortages and so forth, FDA has kind of allowed companies to self-certify that a lot of these ingredients are considered “generally recognized as safe.” And I think now there’s sort of some sense that maybe that wasn’t scientifically, and health, the best idea. So, Kessler’s basically saying you should give companies some cushion, maybe like 12 months or so, and say, Look, you either need to pull these ingredients out of your food or really, truly prove to us with the science that these are safe. Then he’s kind of calling Kennedy’s bluff a little bit and basically being like: Look, you keep talking about this. You’re really furious about the ultraprocessed food. Look, I found your regulatory hook, your legal way to do it. Now go do it.
And I think the food industry, like many other big industries in the U.S., are pretty powerful, as you said. Given the amount of food we consume with these ingredients, it’s a huge — it would be probably quite difficult to make these changes in a year or so forth. But Kessler’s pretty smart. He was the person that really led the regulation of tobacco at FDA. And so I think he’s basically trying to say, Look, here’s a strategy — now go do it, and see if they’ll really follow through on anything.
Rovner: Yeah, I was absolutely fascinated by this in terms of sort of calling the bluff, because that’s what you were saying. On the one hand, they’ve talked a big game on something that, unlike the Medicaid cuts, is popular with the public. On the other hand, they seem very loath to require the food industry to do anything.
Karlin-Smith: Right. I mean, their main food achievement so far is getting commitments on certain food dyes, which for the most part actually aren’t that used anymore. And I think even the safety concern around them is generally seen as pretty low. Now they’re not really adding anything to your food other than color. So there’s an argument that even if there’s just even some slight hypothesis that there’s the danger, you should get them out. But the theme, and we talked a lot about this a little bit last week in the podcast, is they’re talking a lot more than they’re actually making achievements so far in the public health space.
Rovner: I guess you can sum this up in: It’s less What color are your Froot Loops? than Should you be eating Froot Loops at all? Or, Should you be feeding them to your children?
Karlin-Smith: That’s perfect.
Rovner: Yeah. All right. Well, I’ll be fascinated to see if they actually follow up on this. All right, that is this week’s news. Now we’ll play my interview with AcademyHealth president and CEO Aaron Carroll, and then we’ll come back and do our extra credits.
I am so pleased to welcome Aaron Carroll to the podcast. Aaron is president and CEO of AcademyHealth, the leading national organization for health system researchers, in addition to being a top-notch health policy expert himself. Aaron is also a pediatrician and formerly a pediatrics professor and associate dean at the Indiana University School of Medicine. Aaron Carroll, thanks so much for joining us.
Aaron Carroll: Thanks for having me.
Rovner: So, I wanted to talk to you mostly about your op-ed published in The Washington Post last week. We will link to it in our show notes. It’s called: “This Phrase Was Meant To Increase Trust in Science. It backfired.” The phrase in question is “Follow the science.” Tell us why you think it backfired.
Carroll: Well, for a couple of reasons. The biggest is that I think it to some extent conflates science and policy, and it makes it sound like that once we have science that policy naturally follows from it and that anyone who is rational will know the right answer. The problem with that is that science is sort of a set of facts, or an explanation of the world as we best understand it, but policy should take good science, and then it has to incorporate societal values, people’s preferences, what I would call utility values almost, and all the trade-offs that come with policy. And so good science should inform policy, but good science is not the same as policy.
I provide a number of examples. One would be like, look, we have great science that shows vaccines are unsurpassed to preventing infectious disease. We also have science that shows that eating raw or undercooked eggs can cause salmonella. The first might justify vaccine mandates in schools. The second certainly doesn’t mandate banning sunny-side eggs. Just because something is true, you have to think about their differences when you come into policy. And too often we use that phrase almost as a cudgel to say: We have science, therefore this is the only policy that makes sense. And if you disagree, then you’re not following science. That’s just not the case.
Rovner: And that’s pretty much what happened during the pandemic, wasn’t it?
Carroll: Yeah. I mean there were so many times where we were making the best guess, because you have science, but the science isn’t terribly great and it’s not really up to date. So you have to make policy decisions from that. But different people are going to make different policies, and different groups, depending upon where they’re focusing, might make different policies. And that is OK. But we sort of fell into a trap where there could only be one voice, one truth. It really brooked no dissent, and it had to be sort of put out nationwide. And when there was pushback that the policy decisions didn’t necessarily follow from the science, everyone didn’t always react to that as well as they should have.
Rovner: And now it’s being hung around people’s necks, whichever side they were on.
Carroll: Yeah.
Rovner: Even if the science has changed since then.
Carroll: Yeah. I mean, I helped to run Indiana University’s pandemic response, and we used to do at least a weekly webinar where we would answer questions, and all the time I would say things like: This is the best answer we have right now. That’s why we’re going with this. And let me explain to you why. And these are the trade-offs. We’re trying to do the best by everyone. These are the pros. These are the cons. Let’s talk it out. And if the data change in the future, we’ll change the policy. We’re doing the best we can. But that kind of nuance, that kind of long-form answer, was too often not acceptable or not possible during the pandemic, because we wanted things to be reduced to sound bites. We wanted things reduced to easy algorithms. We wanted everyone to sort of do whatever our chosen sort of arbiter of truth said. And if people disagreed, we really accused them of disagreeing with science. And there’s a real difference between science and policy.
Rovner: So, how do we start to win back that trust?
Carroll: I think a couple of ways. One is, I think, we have to start listening as well as we do speaking. I think too few of us actually are willing to spend time talking with people who truly disagree with us, and that’s going to limit our ability to enact good policy. I like to point to the fact that there are change management experts who will argue that there are three reasons people resist change. They don’t understand it, they don’t like it, or they don’t like you, which is really about trust. But we treat too many things as if they only fall into that first bucket. It’s a knowledge dissemination problem. And if we just speak out facts louder and louder and more stridently, then everyone will come and listen to us. So if we just keep broadcasting facts over social media, then everyone’s going to agree with us.
It completely ignores that there’s a section of people who are completely rational but don’t like the change, because of trade-offs. I hated wearing a mask. It fogged up my glasses completely. I would do it, but I hated it. And every time someone lectured me on how easy it was and I should just get over it, I got angry. We’ve got to be better about understanding there are trade-offs in policy, and we have to address those trade-offs. And of course there’s that huge third bucket of people that don’t trust us. That’s only going to come from slow, honest conversation with people who disagree with us. And we don’t want to do that, either. We want to shout at people over social media. We want to push people away who don’t agree with us. We want to belittle them.
That’s a problem. In the op-ed, I talked about that, as a pediatrician, I’ve been dealing with parents that don’t want to do what I tell them is best for decades. I don’t slap ’em. You have to build trust. You have to listen to them empathetically. You have to discuss the reasons why you might want to do something or not do something. And you have to build those kinds of relationships over time. It’s slow. It can be tedious. But that’s how you get people to change their mind, not by just shouting or belittling them. And we do that too often.
Rovner: One thing I’ve noticed over almost 40 years of doing this is that some of the best explainers of policy have been pediatricians — C. Everett Koop, David Kessler, Bill Roper, all pediatricians of one sort or another. What is it that they teach you that lets you communicate so well?
Carroll: I trained in Seattle. People were refusing vaccines back in the ’90s, and they weren’t the same people who are refusing vaccines today. You had to learn to deal with that. I would make recommendations about how to sleep, how to eat, how to control tantrums, how to do behavior change, how to parent. And I’m competing with Grandma, and I’m competing with other relatives who have very wildly different opinions about how things should be done. And you have to learn how to deal with that, with people who just don’t agree with you right away and who aren’t swayed by data and evidence but by trust. And people get more riled up about when they’re pregnant and, I think, when they have small children, than almost any other time in their lives, about they can’t make a mistake, they’ve got to do the right thing, and they’ve got to balance competing voices who are telling them very different information. Maybe we’re just better used to it or trained to it, but a lot of this stuff that we’re arguing about now, a lot of pediatricians have been dealing with for a long time.
Rovner: So, this administration, obviously, for anybody who’s listened to the podcast for more than five minutes knows, is not really helping matters right now, are they?
Carroll: I mean, we’re not doing a lot of really good communication and a lot of really good listening. I think we’re seeing a lot of top-down decisions that are not perhaps based on the best data and evidence, are not as justified as well as you might want to expect, and who are dismantling or removing many of the tools that we use to produce the data and evidence that can produce sound policy. No one would argue, I think, that the NIH couldn’t have reform. No one could argue that the USPSTF [U.S. Preventive Services Task Force] is perfect and never needs to be touched. ACIP [The Advisory Committee on Immunization Practices] could be refined. I think there were decisions made about covid vaccines and boosters that produced hearty debate years ago, and lots of decisions on ways that some of these organizations work could be refined. But we don’t want to throw out the baby with the bathwater. A lot of the infrastructure that we have in place is to make sure that things are nonpartisan, that we’re relying on the best evidence, that we’re doing the best job that we can to make sure that these things are not biased or partisan in any way.
And a lot of the steps, I think, that are being taken to wipe away a lot of this infrastructure are not going to reinforce trust. The answer isn’t to shut down discussion, which is happening too often around the country. It’s to move and lean into open dialogue. We have a meeting coming up in the next few months, Health Datapalooza, which really brings together lots of people from the current administration who should be there, plus lots of people from industry, plus researchers, plus health systems, and those who provide the care, coming together and having an open dialogue, open discussion, learning to listen to each other, and learning to realize we’re all really human beings and we need to be able to learn. Both ways is how we move forward. And unfortunately, we’re moving in a direction that tries to shut down that kind of debate and just shouting that the other side is wrong.
Rovner: I know AcademyHealth has been pretty outspoken about the disappearing databases at HHS in particular. I mean, what could that mean for public health? And, I mean, now it’s not just databases that are being taken down but there’s a concern about data being put up that’s not necessarily trustworthy.
Carroll: I mean, again, we can’t improve what we can’t measure, and we can’t make change if we don’t know where we’re starting from or where we need to go. And you can make an argument, I suppose, that a lot of these data would still be available without the federal government collecting it, but no one is as good or thorough or has the mandate of law to pull a lot of these data sources together in ways that people can use. And these aren’t just, like, esoteric research things. Some of these are, like, how public health officials monitor the health of their citizens. Some of these are about what clinicians might want to know to talk to their patients about what’s going on in their area, or what trends are in certain diseases, or how things work. People, clinicians, patients need these data. There are — a lot of them are mandated by law, and if we don’t have them up, people suffer.
This isn’t, again, like we’re just punishing researchers or scientists. This is punishing people, and, again, at AcademyHealth, our mission is to promote the creation and use of data and evidence to improve health and health care for all. You can’t do that without the data, and no one can do it if they don’t trust the data. So much of this, again, is about trust, which is about transparency, which should be a nonpartisan issue. We advocated for this same kind of thing under the Biden administration when they tried to restrict Medicare data and how researchers could get and use it. And we were out in front saying: That’s not OK. People need access to this data. And that the same thing is true under the Trump administration. We want more people to have more access to the best and most trustworthy data, always.
Rovner: Well, thank you for fighting the fight for good science and good policy. Aaron Carroll, thanks a lot.
Carroll: Thank you.
Rovner: OK. We’re back. And 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. Shefali, why don’t you go first this week?
Luthra: Absolutely. My story is by Theresa Gaffney from Stat News. The headline is “Inside the American Medical Association’s Sudden Strategy Shift in Washington.” I picked this because I knew Julie and I would both get a real kick. There’s just a lot of fun in following the political trajectory of the AMA, which as we know began as this more conservative political organization, has undergone this transformation in more recent years, becoming more interested in causes, sometimes aligned with more of the political left, whether that is expanding access to health care, whether that is opposing abortion restrictions, and then had really gone quiet when we saw this big attack on a lot of medical institutions from the new administration. And this story looks at how that is starting to shift and the AMA is now trying to actually act in response to all of the things that have been happening to scientists and health care providers, and where that is coming from within the medical community and what it could mean.
Rovner: It’s a really interesting story. And Shefali’s right. One of my hobbies is following the AMA’s political trajectory. Alice.
Ollstein: So I have a piece in The New York Times by some KFF stalwarts, and it’s called “Why Young Americans Dread Turning 26: Health Insurance Chaos.” So, it sets up that if Congress doesn’t renew the ACA [Affordable Care Act] subsidies that are expiring later this year, people are going to face an even worse cliff when they turn 26 and they have to start buying their own insurance. But the article talks about all of the ways that cliff is already worse now before that even happens, largely because there’s just less regulation of plans, and so people are buying crappier plans that don’t adequately cover them when they actually need them and get sick, and the process, because the navigators have been defunded, and there just isn’t a lot of outreach and promotion going on under the Trump administration.
People are very confused and overwhelmed by all of the options and are largely going without insurance. And I think what’s important from the story is you may think: Oh, this doesn’t affect me. I’m not a 26-year-old. I have my insurance. I’m fine. As we learned in the past, this impacts everybody. If young and healthy people are driven out of these markets, that impacts everybody’s costs and makes things more expensive for the rest of us. So definitely worth paying attention to.
Rovner: Yeah, it’s a really good piece. Sarah.
Karlin-Smith: I took a look at a piece in The New York Times by Carolyn Kitchener, “This Ohio Farm Community Is a Mecca for the” quote “‘MAHA Mom.’” And it’s about what is essentially sort of a — the story kind of describes it as the idea of the 1960s, 1970s, like, hippie farm commune but kind of MAHA [“Make America Healthy Again”] style, and maybe a bit more luxurious. And it’s essentially a look at how this community develops and operates and tries to live by some of the, quote-unquote, “MAHA principles” around how the foods you eat or grow. And it’s kind of a fascinating look as to what they’re trying to do and how they want to live their lives.
Rovner: Yeah, it’s the new age of the New Age. Fascinating. Well, my extra credit this week is from the “Who Could Possibly Have Seen This Coming” category. It’s from ProPublica. It’s called “Veterans’ Care at Risk Under Trump as Hundreds of Doctors and Nurses Reject Working at VA Hospitals,” by David Armstrong, Eric Umansky, and Vernal Coleman. And despite vows by Trump officials that they could cut tens of thousands of jobs at the department without harming clinical care, it turns out that the cuts are deterring clinical care workers from signing up to work at the VA [Department of Veterans Affairs] in the first place. It seems that 40% of doctors offered work at the VA in the first quarter of this year said no. That’s quadruple the rate of rejection from just the year before. And between January and June, the VA lost twice as many nurses as it hired.
While VA officials accused ProPublica of cherry-picking numbers, I will point out that separately this week, the VA’s inspector general, in its annual report, found that every one of the VHA’s [Veterans Health Administration’s] 139 medical centers reported staff shortages, with those reporting, quote, “severe shortages” for specific jobs up 50% from the year before. So, that doesn’t sound very much like cherry-picking.
OK. That is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our fill-in editor today, Stephanie Stapleton, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe where you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me still on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Shefali?
Luthra: I’m at Bluesky, @shefali.
Rovner: Alice.
Ollstein: On Bluesky, @alicemiranda, and still on X, @AliceOllstein.
Rovner: Sarah.
Karlin-Smith: Bluesky, X, LinkedIn — @SarahKarlin or @sarahkarlin-smith.
Rovner: We’re going to take a little bit of a summer break for the rest of the month. Next week we’ll have a special episode on the 60th anniversary of Medicare and Medicaid, and the week after we’ll be dark so our hardworking staff can have some time off. We’ll be back in your feed with all the news on the Thursday after Labor Day. Until then, be healthy.
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2 months 1 week ago
Medicaid, Multimedia, Public Health, CDC, Children's Health, FDA, HHS, KFF Health News' 'What The Health?', NIH, Podcasts, Trump Administration, U.S. Congress, vaccines
KFF Health News' 'What the Health?': Kennedy Cancels Vaccine Funding
The Host
Emmarie Huetteman
KFF Health News
The Host
Emmarie Huetteman
KFF Health News
Emmarie Huetteman, senior editor, oversees a team of Washington reporters, as well as “Bill of the Month” and KFF Health News’ “What the Health?” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.
Health and Human Services Secretary Robert F. Kennedy Jr.’s announcement that the federal government will cancel nearly $500 million in mRNA research funding is unnerving not only for those who develop vaccines, but also for public health experts who see the technology behind the first covid-19 shots as the nation’s best hope to combat a future pandemic.
And President Donald Trump is demanding that major pharmaceutical companies offer many American patients the same prices available to patients overseas. It isn’t the first time he’s made such threats, and drugmakers — who scored a couple of wins against Medicare negotiations in the president’s tax and spending law — are unlikely to volunteer to drop their prices.
This week’s panelists are Emmarie Huetteman of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.
Panelists
Sarah Karlin-Smith
Pink Sheet
@sarahkarlin-smith.bsky.social
Sandhya Raman
CQ Roll Call
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- Explaining the decision to cancel some mRNA vaccine funding, a priority for vaccine critics, Kennedy falsely claimed that the technology is ineffective against respiratory illnesses. Researchers have been making headway into mRNA vaccines for maladies such as bird flu and even cancer, and the Trump administration’s opposition to backing vaccine development weakens the prospects for future breakthroughs.
- Trump’s insistence that big-name drugmakers voluntarily lower their prices underscores how few tools the presidency has to deliver results on this important pocketbook issue for many Americans. Medicare’s ability to negotiate drug prices took a hit under Trump’s big tax-and-spending law, which included two provisions advocated by the pharmaceutical industry that would delay or exclude some expensive drugs from the dealmaking process.
- A year after Trump promised on the campaign trail to secure coverage of in vitro fertilization, the White House reportedly is not planning to compel insurers to pay for those pricey reproductive services — a change that would require an act of Congress and could raise costs overall.
- And with Congress back home for its August recess and a late September deadline looming, the annual government funding process is in progress — but unlikely to resolve quickly or cleanly. Senate appropriators are further along in their work than usual, but the House of Representatives has yet to release its version, which is expected to cut deeper and hit social issues like abortion harder.
Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:
Emmarie Huetteman: KFF Health News’ “New Medicaid Federal Work Requirements Mean Less Leeway for States,” by Katheryn Houghton and Bram Sable-Smith.
Sarah Karlin-Smith: Slate’s “Confessions of a Welfare Queen,” by Maria Kefalas.
Sandhya Raman: CQ Roll Call’s “Sweden’s Push for Smokeless Products Leads Some To Wonder About Risks,” by Sandhya Raman.
Lauren Weber: The New York Times’ “‘Hot Wasps’ Found at Nuclear Facility in South Carolina,” by Emily Anthes.
Also mentioned in this week’s podcast:
- The Washington Post’s “How RFK Jr.’s mRNA Crackdown Affects Vaccinemaking and Future Pandemics,” by Carolyn Y. Johnson and Lauren Weber.
- The AP’s “Fact Focus: Trump Says He’s Cut Drug Prices By Up to 1,500%. That’s Not Possible,” by Melissa Goldin.
- The Washington Post’s “Medicare, Medicaid Plan To Experiment with Covering Weight Loss Drugs,” by Paige Winfield Cunningham.
- The Washington Post’s “White House Has No Plan To Mandate IVF Care, Despite Campaign Pledge,” by Riley Beggin and Jeff Stein.
click to open the transcript
Transcript: Kennedy Cancels Vaccine Funding
[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.]
Emmarie Huetteman: Hello, and welcome back to “What the Health?” I’m Emmarie Huetteman, a senior editor 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, Aug. 7, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. Here we go.
Today, we’re joined via video conference by Lauren Weber of The Washington Post.
Lauren Weber: Hey, everybody.
Huetteman: Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning.
Huetteman: And Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Huetteman: It’s August, and here in the nation’s capital that means Congress has flown the coop, and a lot of the federal city has gone with them. No interview this week. And you may be wondering why you’re hearing my voice instead of the incomparable Julie Rovner. Julie’s out this week having surgery to repair her broken wrist. Good news: She’s on the mend and she’ll be back in your podcast feed very soon. Get well soon, Julie. Let’s get to the news.
On Tuesday, the Trump administration announced that the secretary of Health and Human Services, Robert F. Kennedy Jr., has canceled almost $500 million in federal grants and contracts to develop mRNA vaccines. That technology, of course, was responsible for the first covid vaccines, and researchers have been working on new ways to use mRNA, including against bird flu and even cancer. But in explaining his decision, Kennedy made false claims about mRNA vaccines, including that they do not protect against respiratory illnesses. Kennedy’s opposition to the covid vaccine, in particular, is well-documented. But before becoming health secretary, he advocated for federal officials to revoke approval for mRNA-based covid shots.
Sarah, you’re our pharmaceutical industry expert. What will this mean for vaccine development? Without this government funding, can that research continue?
Karlin-Smith: I think people are really concerned, particularly about the speed of vaccine development for pandemic situations. That’s a classic market failure in that companies aren’t that incentivized to work on developing products for hypothetical situations that may never come to pass, but we obviously want to be prepared for strains of the flu that can be particularly harmful and stuff. So I think that’s where people are really concerned.
I think, in general, this is just another mark in some of the vaccine actions that have taken place since this administration took over that makes people a little more nervous about just investing in the vaccine field, whether it’s mRNA or vaccines in general. FDA has made some unusual decisions around the indications for covid vaccines moving forward. The [Centers for Disease Control and Prevention’s] whole [Advisory Committee on Immunization Practices] has changed. So I do think there’s broader concern beyond the mRNA vaccines and our need to have this technology to really prepare for a pandemic about how confident industry will be in the places they normally would invest money on their own.
Huetteman: Lauren, you had a story yesterday about how Kennedy’s decision is intensifying concerns about our ability to fight future pandemics. Can you tell us what you’re hearing from public health experts?
Weber: Yeah. We spoke to a number of public health experts and vaccine experts, mRNA experts, who said, Look, this is the technology that you want to be spry, to be able to alter something, to fight potentially a bird flu. It’s also used in revolutionary ways to fight maybe even cancer here in the future. There’s a lot of fear about how this could have a chilling effect, as Sarah was pointing out, on the development pipeline and what that means in a pandemic situation.
I do think it’s important to note that just this morning, Trump was asked about this and said he was going to have a meeting on it at noon. Not sure exactly what that means, but potentially that could be something. Robert Malone, who’s an ACIP member, sent out an email trying to rally MAHA [“Make America Healthy Again”] supporters to make sure that they backed up Kennedy’s decision.
I think it’s also important to take a step back and look at Kennedy’s past remarks on mRNA, as you alluded to. This is a man who falsely called the covid vaccine “the deadliest ever made.” He’s described it as a poison in the past. Some anti-vaccine factions of MAHA have really been pushing to try and limit access to mRNA technology. You’ve seen this also in some Republican and far-right states, that are more right. You’ve seen some legislation suggested to remove access to mRNA technology. There’s a big question among some of the folks we talked to on if this is a bit of a signal to the base.
Karlin-Smith: I was going to say, ironically, the mRNA vaccines was probably the biggest success of the Trump administration’s first term in office. He was instrumental in spearheading the fast development of the vaccines for covid.
Huetteman: Right, Operation Warp Speed. Interesting how far we’ve come. To be clear, this isn’t all of the government’s mRNA contracts, right? This is just a piece of the research funding?
Karlin-Smith: This is a piece of it coming through BARDA [the Biomedical Advanced Research and Development Authority], which is particularly designed to help fill those market gaps in pandemic preparedness, but they’ve also cut other mRNA vaccine contracts previously in this administration, including a big one around bird flu, which people are concerned about right now. I’ve even seen some media reports where people, researchers in the cancer but mRNA space, were concerned about grants just being flagged just because they had the terminology. It’s not everything, but I think there’s certainly fears that this is just a step in a bigger process that is problematic.
Huetteman: Absolutely. We’ll be keeping an eye on that. And vaccine contracts aren’t the only thing that President Trump’s team is undoing this week. Under a new federal rule, VA hospitals would no longer be able to perform abortions in cases of rape, incest, or health endangerment. You may remember that the Biden administration introduced that policy at the Department of Veterans Affairs in 2022, after the Supreme Court ended the constitutional right to an abortion. The policy has allowed veterans and their relatives to obtain abortion services even while they are stationed in states with restrictions.
Meanwhile, lots of news to get to this week. In prescription drug news, late last week, President Donald Trump sent letters to more than a dozen drugmakers insisting that they drop their prices within 60 days. Specifically, the president demanded that pharmaceutical companies offer many American patients the same prices that drugmakers charge abroad. Over the weekend, Trump told reporters that his administration is dramatically lowering drug prices, “up to 1,500%,” he said — which, well, I think that technically means the drugmaker would pay you.
Anyway, Trump told drugmakers that if they don’t lower drug prices, “We will deploy every tool in our arsenal.” What can the president do to force drugmakers to comply?
Karlin-Smith: I think, in some ways, he doesn’t have as many tools in the toolbox as he probably would like to think. At least, not ones that are making the industry particularly fearful right now. He doesn’t have the power to just issue a regulation saying, “The Medicare-Medicaid reimbursement rates are tied to the rates countries are paying abroad.” That would have to be through legislation. And I think there are reasons that both Republicans and Democrats don’t really like this most-favored-nation approach to drug pricing. There is some sort of limited authority for them to do a demonstration project through CMS’ [Centers for Medicare & Medicaid Services’] Medicare-Medicaid Innovation Center. They could come up with a test of this in some kind of limited area. They tried to start implementing that [in] his last term and they got scuttled by lawsuits, so we’ll see if they have a way to avoid that problem this time.
But the ironic thing is that when the administration issued this executive order in May calling for this most-favored-nation pricing, he set this 30-day-ish deadline of saying, OK, we’ll tell you what prices we want, you guys lower them. If not, we’re going to do rulemaking. One thing that came up when he issued this letter, these letters on Friday, giving industry another 60 days is, Well, why are they not just going through with some kind of rulemaking or next steps? It almost seemed to some people like almost a more muted threat because they haven’t done the follow-through yet or come up with what the follow-through is here.
Huetteman: Now, where is the Medicare’s drug negotiation ability in this equation? Why isn’t the president doing more to leverage Medicare’s power to negotiate at this point?
Weber: Well, that’s really interesting because in the “Big, Beautiful Bill,” there were two provisions that a lot of people missed that limited the ability to negotiate on some key drugs, which has been estimated to likely cost the American taxpayer and the government billions of dollars over the next couple years.
Huetteman: Yeah, the CBO says that those changes will cost Medicare at least $5 billion in missed savings over 10 years.
Weber: Yes, that’s what’s called effective lobbying. Essentially, what happened is some pharma companies were able to tuck in provisions that key drugs, I think it was Keytruda, I’m not sure if I’m pronouncing that right, or Keytruda, which is used to treat cancer, it’s a drug by Merck. It had $17.9 billion in U.S. sales in 2024. That’s the kind of drug that they won’t be able to negotiate prices on for a bit.
Huetteman: Yeah, that’s right. Of course, that also means that Medicare patients will be subject to paying their percentage of those higher prices as well. On top of talking about this CBO score there, we’re talking about drug prices that real people are paying for their expensive cancer drugs right now. I guess I’m curious why Trump isn’t using the negotiation process in order to lower those drug prices?
Raman: I would add that something that makes this more difficult is that Trump has been very back-and-forth about a lot of his opinions on different things that he’s going to do throughout the last several months in this process. Even if you look at something like how we would deal with tariffs on the pharmaceutical industry, we’ve been a little bit all over the place. I think even if he’s not demonstrating the clear idea of which way he’d want to go, it makes it a little bit harder for the regulators, whether it would be in Congress or through the FDA, to do anything, given that he’s been changing a lot what he’s hinting at wanting to do.
Huetteman: Yeah, that’s right. Actually, Sarah, you brought up the CMS innovation option. There’s a story out about this this week. The Washington Post reports that the Trump administration is considering using that center to do a pilot project to expand access to GLP-1 drugs for weight loss purposes by allowing state Medicaid and Medicare Part D plans to cover them.
Now, insurance premiums are slated to go way up next year. If I’m not mistaken, the cost of covering GLP-1 drugs is one reason that insurers have cited for those premium hikes. If this happens, can we expect that the cost of those drugs would strain state and federal budgets?
Karlin-Smith: Actually, one I guess positive thing is that some GLP-1 drugs are slated to be subject to negotiation through the IRA [Inflation Reduction Act] program next year, so that there’s maybe positive news around the prices of those going down. Again, that’s obviously only for Medicare. But the problem on the back end is that, based on law, Medicare is not allowed in Part D to cover drugs for weight loss.
The Biden administration had tried through rulemaking to make an argument that weight loss drugs and drugs that treat obesity are two different things, hearkening back to — when that law was written we really didn’t understand obesity as a disease process and all the health problems it has on your body. We thought of weight loss as more of a cosmetic thing. The Trump administration actually pulled that rule, so this would be a much more small step in the direction of trying to get coverage. The report says it would be a “voluntary demo.”
The biggest question in my mind, which is again, knowing that these drugs, even with cheaper prices, would likely raise costs, is what is the incentive for health plans to voluntarily want to participate in this? What would the government have to do to incentivize this? Without some sort of push there for states and for Medicare Part D plans, I’m not sure the private plans are just going to pick up these products given the amount of people that would qualify for them. I think we need a lot more details from the Trump administration to know if they can actually make this feasible.
Weber: I just find this to be such a fascinating move considering [CMS Administrator Mehmet] Oz and Kennedy have such different opinions about weight loss drugs, as does MAHA as a whole. We at The Washington Post had reported previously that Oz does have financial ties to Ozempic through his show — they had to run a sponsored ad to some extent — and also through other means. It’s fascinating to see that clearly this is going forward, despite Kennedy having said repeatedly, often, constantly that he does not want to pay for these drugs, that he thinks other interventions, healthy diet and lifestyle, should be implemented. Which Oz has also really promoted as well. So fascinating to see how this experiment plays out. I agree with Sarah; I’m not sure where the incentives are, considering the cost that this will be to see it play out.
Huetteman: And one year after Trump promised coverage for in vitro fertilization services on the campaign trail, The Washington Post reports that the White House does not plan to require health insurers to cover IVF. The president had said that “if he were elected, the government would either pay for IVF services itself or require insurance companies to do it.”
What’s standing in the way here? What’s involved in making something an essential health benefit?
Raman: I think this whole process has been interesting. In February, Trump had put out an executive order directing his administration to come up ways to reduce the out-of-pocket costs for IVF. At the time, it’s pretty vague in terms of what that would entail. After the deadline passed, in part, I think a lot of people weren’t surprised because a) IVF is very expensive. And b) I think there are a lot of complicated nuances to some of his base and whether or not they fully support IVF. We had a lot of this last year, with people saying that they support it, but then also some of the folks that are more pro-life have some stipulations about not wanting embryos destroyed. It just complicated that some of the people that were talking to him about some of the other abortion-related issues were not on board with all of the IVF things. I think that has played definitely a factor in what they’re going to do with this.
But it’s also a hard thing to do, to just make this something that — even with prescription drugs, reducing the costs of those is not simple. In order for them to make it an essential health benefit, I think, is also more complicated given the issues that we’ve been having with preventative care, and just the concerns about the [U.S. Preventive Services Task Force] getting removed and what that’ll do to different things that are covered. It’s complicated and I wouldn’t really see this changing on IVF in the near future, at least from the executive level.
Karlin-Smith: It needs to go through Congress to be an essential health benefit. I think there’s a theme in some of the topics we’re coming up to today where Trump is clearly coming up to the limits of his bully power and his threats of negotiation. I think Martin Makary, the head of the FDA, said, “You get more bees with honey.” Well, unfortunately, sometimes it’s just not enough to attract these industries to make major changes.
Yes, they’ve gotten some sort of minor concessions, I think. I know they would like to think they’re transformative, but I think a lot of what they’ve gotten voluntarily is pretty minor, in terms of both health impact, and also how much it harms industry in terms of, like, food dyes. Or even the insurance companies saying, Oh, sure, we’ll do better on not going crazy on prior authorization.
I think Trump now has to actually double-down and work with policymakers on rule writing, or work with Congress. It’s more complicated, especially again, as Sandhya said, IVF is something that’s complicated for his base to support.
Huetteman: That’s right. This all came out of the blowback about how far towards banning abortion the country was going to go under Trump. This was a way to say, We’re preserving some parts of the reproductive health that are really important to people in our base, right?
Raman: Yet even when Congress has tried to look at any of the IVF legislation in the past, it’s fallen on party lines. There have been ones that have been more messaging on either side. I think the closest we’ve gotten is that, on the defense side, trying to consider measures there for folks with Tricare, but it’s difficult to get folks on board with things like this through Congress.
Huetteman: Well, speaking of Congress, Congress has left the building. August recess has begun and lawmakers are back home. Say, how is that government funding coming along. Sandhya?
Raman: I think we’re in a similar place to many years in that it’s August, they’re out. We need government funding by the end of September, and we’re nowhere close to getting that. I would say on the plus side, the Senate is further along than they usually are. Before they left, they did mark up the Labor, HHS, Education funding bill, and that was overwhelmingly bipartisan. It included some money that would be a boost for NIH [the National Institutes of Health], which I know was a big concern for a lot of folks given what was in the White House proposal. It maintains funding for some of the programs that would be cut under the White House, things like Title X, Ryan White HIV. It also has a little bit of a pushback on making sure that the agencies continue the staffing to keep up some of their statutory duties.
But again, it’s just the Senate. The House has not put out their bill. I would expect theirs to be a bit more conservative, given that the head of the Appropriations Committee in the Senate is Susan Collins, who’s been a little bit more moderate. The House is expected to release theirs and mark up theirs right after they get back. They meant to do it before recess but got pushed back because of reconciliation and that changing their schedule.
It depends what they say in theirs and how much difference there is. I would expect there to be a lot of differences. It seems like we’re headed toward the usual of at least some sort of temporary spending to kick it down the line. Whether or not that ends up being a year again, like we did this year, or a short-term thing, we’re not sure yet. It depends on where we are in September.
Huetteman: Right. And possibly preceded by a lot of fighting over social issues that get thrown into the health bill, and fights over the actual funding levels, if I had to guess, based on how House lawmakers have been talking about it so far.
Raman: Oh, no. I think just the fact that we had such a big rescissions debate this year and the fact that we might do that again, it has definitely left a sour taste for a lot of Democrats who are worried that if whatever they vote for here might just get clawed back later on down the line. That’ll be another thorn in it.
Huetteman: Awesome. Well, thanks for that take. That’s this week’s news. Now it’s time for our extra-credits segment. That’s where we each recognize a story we read this week that 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.
Lauren, why don’t you go first this week?
Weber: I have a doozy of a story from The New York Times titled “‘Hot Wasps’ Found at Nuclear Facility in South Carolina,” by Emily Anthes. Yeah, it’s the stuff of nightmares. It’s all about how wasps became radioactive — four wasps’ nests near a South Carolina nuclear facility.
Huetteman: Yikes.
Weber: If this gave you bad dreams, it definitely did for me. Essentially, what some of the researchers have posited is that wasps could have burrowed in some sort of bad wood or wood that was contaminated or other parts of the area that are contaminated. But this idea that it sounds like something out of Chernobyl, or something like that. But this idea that in the U.S., you could have a nuclear facility that is potentially transforming some of the near-wildlife is concerning in terms of cleanup efforts, and also concerning in terms of contamination control. Clearly, there’s more that needs to be dug into there. Hopefully everyone sleeps after hearing about this.
Huetteman: Woof, yeah. I might need to take an Ambien tonight. Sandhya, how about you go next?
Raman: My extra credit is from me in Roll Call. It’s my last dispatch from my reporting trip in Sweden earlier this year. And it’s called “Sweden’s Push for Smokeless Products Leads Some To Wonder About Risks.” It looks a little bit at some of the public health impacts as Sweden has really tried to reduce their smoking rate to become smoke-free. The U.S. is also at a low from smoking. Some of the things that public health experts are thinking about as people shift to other products and how they’re able to message to the remaining smokers that are not willing to give that up still.
Huetteman: Awesome. Thanks for telling us about your work there. And Sarah?
Karlin-Smith: I looked at a story from Slate, “Confessions of a Welfare Queen: I Study Poverty for a Living, and I Never Thought I’d Need Medicaid. Then My Child Was Diagnosed With a Terminal Illness,” by Maria Kefalas. It’s a personal story from a mother whose family needed Medicaid when their young child was diagnosed with an illness that was going to severely require intense medical care and limit her lifespan. They were able to take advantage of what are known as “Katie Beckett waivers” that were instituted by Ronald Reagan to allow states to voluntarily allow higher income requirements so that people could get Medicaid and care for their children at home. The original girl it was named for was otherwise basically going to be stuck living her life, and she lived until 34, in a hospital.
The purpose of the story is really to point out that now that the “Big, Beautiful Bill” has passed and there are $1 trillion in spending cuts to Medicaid, that these are some of the sorts of people and programs, because it is not a mandatory program, that may unfortunately be on the first for the chopping block. I think the piece does a good job of pointing out, while there’s been a lot of rhetoric around the people who are going to get hurt by this are people that are not working or somehow abusing the system, and the mother does a pretty good job of talking about how both she and her husband continue to work. Most of the families that need this program, to the extent they can, want to keep working. You just get a really human picture of the type of people that are at risk of losing services.
Huetteman: Yeah, for sure. It’s a really illuminating story. Thanks for talking about it. My extra credit this week is from my colleagues here at KFF Health News. The headline is “New Medicaid Federal Work Requirements Mean Less Leeway for States.” It’s by Katheryn Houghton and Bram Sable-Smith.
They report that at least 14 states are in progress designing their own work requirement programs. But now, with the passage of Trump’s law last month, which institutes federal work requirements, those states must make sure that their programs meet federal standards. In some cases, the states are actually going even further than federal requirements, my colleagues report. For instance, Arizona state law would institute a five-year lifetime limit on Medicaid coverage for “able-bodied adults.”
OK, that’s this week’s show. Thanks as always to our producer-engineer, Francis Ying, and to Stephanie Stapleton, our editor this week. If you enjoyed 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 LinkedIn. Where are you guys these days? Sandhya?
Raman: I’m on X and Bluesky @SandhyaWrites.
Huetteman: Sarah?
Karlin-Smith: A little bit of everywhere, but X, Bluesky, LinkedIn @SarahKarlin or @sarahkarlin-smith.
Huetteman: And Lauren?
Weber: I’m at X and Bluesky @laurenweberhp. Yes, the HP is for “health policy.”
Huetteman: We’ll be back in your feed next week. Until then, be healthy.
Credits
Francis Ying
Audio producer
Stephanie Stapleton
Editor
To hear all our podcasts, click here.
And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.
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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This story can be republished for free (details).
2 months 2 weeks ago
Health Care Costs, Health Industry, Medicaid, Medicare, Multimedia, Pharmaceuticals, Public Health, Abortion, Cancer, CMS, Drug Costs, FDA, HHS, KFF Health News' 'What The Health?', Podcasts, Prescription Drugs, reproductive health, Trump Administration, U.S. Congress, vaccines, Veterans' Health, Women's Health
KFF Health News' 'What the Health?': Next on Kennedy’s List? Preventive Care and Vaccine Harm
The Host
Julie Rovner
KFF Health News
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.
In his ongoing effort to reshape health policy, Secretary of Health and Human Services Robert F. Kennedy Jr. reportedly plans to overhaul two more government entities: the U.S. Preventive Services Task Force and the National Vaccine Injury Compensation Program. Ousting the existing members of the task force would give Kennedy a measure of control in determining the kinds of preventive care that are covered at no cost to patients in the United States. And while it’s unclear what the secretary would do to the vaccine injury program, Kennedy has made no secret of his belief that vaccines can do more harm than good.
Meanwhile, last week marked the 35th anniversary of the Americans with Disabilities Act, and President Donald Trump signed an executive order that would enable local and state governments to forcibly hospitalize some people who are homeless and struggling with mental health problems.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.
Panelists
Anna Edney
Bloomberg News
Joanne Kenen
Johns Hopkins University and Politico
Shefali Luthra
The 19th
Among the takeaways from this week’s episode:
- Less than two months after Kennedy removed all members of the Advisory Committee on Immunization Practices, he is reportedly considering a similar purge of members of the task force that recommends the preventive services insurers must cover — a list whose services, some of them controversial among Trump officials, include drugs that prevent HIV and certain cancer screenings. He is also considering changes to the federal program that compensates people who experience adverse effects from immunizations.
- This week Vinay Prasad, the Food and Drug Administration’s top vaccine official, resigned just months into his tenure. Prasad had come under attack, notably by right-wing personality Laura Loomer, and had been blasted for some agency decisions about new drugs for rare diseases — despite his work limiting the use of covid shots.
- Trump’s newly announced trade deal with the European Union includes a 15% tariff on brand-name pharmaceuticals, which would include, for example, the diabetes drug Ozempic, often used for weight loss. But it would be difficult to lower prices on brand-name drugs through tariffs; it is unlikely that drugmakers, facing higher import costs, would relocate production to the United States.
- Also, Trump’s big tax and spending law, hastened through Congress weeks ago, renders some lawfully present immigrants ineligible for Affordable Care Act subsidies. But a new KFF Health News column points out that the change would actually raise premiums for everyone else, taking more healthy people out of the insurance pool.
Also this week, Rovner interviews George Washington University health policy professor Sara Rosenbaum, one of the nation’s leading Medicaid experts, to mark Medicaid’s 60th anniversary this week.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Cosmetic Surgeries Led to Disfiguring Injuries, Patients Allege,” by Fred Schulte.
Anna Edney: The Washington Post’s “Morton Mintz, Post Reporter With a Muckraker Spirit, Dies at 103,” by Stefanie Dazio.
Joanne Kenen: ScienceAlert’s “New Kind of Dental Floss Could Replace Vaccine Needles, Study Finds,” by David Nield.
Shefali Luthra: The New Yorker’s “Mexico’s Molar City Could Transform My Smile. Did I Want It To?” by Burkhard Bilger.
Also mentioned in this week’s podcast:
- The New York Times’ “Top F.D.A. Official Resigns Under Pressure,” by Christina Jewett.
- KFF Health News’ “Lawfully Present Immigrants Help Stabilize ACA Plans. Why Does the GOP Want Them Out?” by Bernard J. Wolfson.
- The Texas Tribune’s “Texas Man Sues California Doctor in Federal Court, Testing a New Angle to Crackdown on Abortion Pills,” by Eleanor Klibanoff.
click to open the transcript
Transcript: Next on Kennedy’s List? Preventive Care and Vaccine Harm
[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 31, 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 Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.
Joanne Kenen: Hi, everybody.
Rovner: Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: And Anna Edney of Bloomberg News.
Anna Edney: Hi.
Rovner: Later in this episode we’ll have the second of our two-part series marking the 60th anniversary of Medicare and Medicaid, which was yesterday, for those keeping track. This week, Sara Rosenbaum of George Washington University, one of the nation’s leading Medicaid experts, takes us through the history of that program and what the next 60 years could bring. And if you want to hear more from both our Medicare and Medicaid experts, we’re going to put the full-length versions of both interviews together for a special episode later in August. But first, this week’s news.
Before we start, I hope you’ll bear with me this week. I slipped and fell and broke my wrist. So my typing and some of my thinking skills are a little lacking at the moment. But on this week of the 35th anniversary of the Americans With Disabilities Act, which we will talk about in a few minutes, I am very grateful for all the various technological advances that are now available to those of us with disabilities, whether permanent or temporary, and which allowed the podcast to actually come to you this week. So, now, here we go.
It was another busy week at HHS [the Department of Health and Human Services]. Secretary Robert F. Kennedy Jr., having already fired all the members of the vaccine advisory board, is reportedly now taking aim at the U.S. preventive health services task force. Now, this was not wholly unexpected. When the Trump administration switched sides on that lawsuit over the task force brought in Texas earlier this year, we assumed that RFK Jr. wanted to do something exactly like this. Right, Shefali?
Luthra: We certainly did, because it wouldn’t have otherwise made a lot of sense to argue that they could continue to make recommendations unless, perhaps, RFK Jr. wasn’t going to listen to them. It just, once again, really bears noting that this was something many people discussed as a likely possibility, given his record, when he was nominated to be secretary. And there were some senators who suggested that perhaps he had made individual promises, commitments, to actually keep the expert panels in place. And here we are. He did not do that.
Rovner: Yeah. And we should say he has, at least as of this moment, he has not yet fired all of the members, but certainly there are indications that he’s considering it. And obviously that was what they argued to the court, was that, Hey, it’s OK for the Senate not to confirm the members of this task force, because the secretary has control over them. So here’s the secretary suggesting that he’s going to take control over them.
Edney: And now the senators show support for the task force. It’s just this circle that keeps on going where they need to try to bolster the backing, but the writing was on the wall when they voted to confirm him.
Rovner: Well, apparently the secretary isn’t finished with vaccine policy, either. He’s also taking aim at the 1980s-era Vaccine Injury Compensation Program, or VICP. That’s what provides a no-fault way for people injured by vaccine side effects to get compensation for those injuries. This program was literally created to prevent the vaccine industry from going out of business in the 1980s because it was being sued into oblivion. I know that RFK Jr. said the program is, quote, “broken” and he intends to, quote, “fix it.” But does anybody have any idea what he might be planning for it? I will remind people, like, I’m shouting into the wind, that this was an act of Congress created by Congress, reformed by Congress. I don’t know whether the secretary can just take it apart on his own.
Kenen: He can try, or leave it intact but create some kind of barriers to filing, or—
Rovner: Actually, I think he wants to make it easier for people to get compensation.
Kenen: He wants it easier to get compensation. We don’t know what it will do. But they keep finding workarounds or just ignoring things. So we can’t say we can or cannot do, because we don’t know what they’re going to do. But his whole health persona really is built on the fact that he believes that vaccines are damaging or dangerous and they kill more people than they save. And therefore, apparently all of us could just get a payout because we had a shot. But it’s not as much of a moneymaking business in general, not for a specific new shot, but vaccination is not as profitable as the public may perceive. Yes, the covid shots, there was some exceptional things about the speed and scale, etc.—
Rovner: Right. Because everybody got one at the same time.
Kenen: And they’re subsidized, etc., or some of them were. So Anna knows more about this than I do. Basically, it was designed to both protect people who were — nobody, even the strongest pro-vaccine people, nobody denies that there is such a thing as an injury. They would say it’s rare and not autism, but when it is, it is rare, but someone should get compensation and the care they need.
Rovner: And Anna, we’re really looking at the potential for some of these vaccine makers to just say, We’re going to wash our hands of making vaccines. Right?
Edney: Yeah, absolutely. The point of this program was to, like Joanne said, admit that there can be injury but to make it no-fault so that the vaccine makers could continue providing vaccines for the majority of people who respond well to them and to not be caught up in court battles for millions and billions of dollars all the time. And there may be some complaints, but it does seem that people, by and large, are able to get some compensation from this. And you mentioned covid vaccines. Those aren’t included in this program, so that may be something he is looking at, because they’re done through a different program, which is maybe some complaints about it or that it’s a little less likely to pay out or to give as much compensation. And so maybe a way of expanding it is to include the covid vaccines. But if it becomes that — Well, you can keep using this program, but we’re also going to make it easier to sue the vaccine makers — we’re going to see the companies be wary of being involved in providing vaccines at that point.
Rovner: Well, in still more vaccine-related news, the controversial head of the FDA’s [Food and Drug Administration’s] vaccine division resigned unexpectedly this week. Anna, tell us why Vinay Prasad was so controversial. And why did he leave after only three months on the job?
Edney: Yeah, this was a huge amount of drama at the FDA. So Prasad himself can be a polarizing figure. He has been at UCSF [the University of California-San Francisco] for a long time and gained prominence as someone who criticized the agency for what’s called accelerated approvals, getting certain drugs, particularly cancer drugs, quickly to patients even when they hadn’t proven necessarily that they worked. And he criticized that program. He got to the FDA. He was head of the vaccines division, which also covers biologic drugs. And under this division was a drug made by a company called Sarepta. Every one of their drugs that has come to market has had a lot of drama surrounding it because these are drugs for very, very sick, usually young boys who have Duchenne muscular dystrophy, and it’s a huge parent population that wants these drugs, even when maybe they don’t always show that they work very well.
Well, a few kids have unfortunately died while taking these drugs in recent months, and so the FDA was looking at that, and it came out that there was another death in a clinical trial of an older gentleman, and no one knew definitely if it was related to the drug. And so once that became public, it’s not like the FDA or the company came out with it, but once it became public, the FDA kind of seemed to overcorrect and try to have the drug be paused, and then maybe take it off the market. And so Vinay Prasad was at the center of this debate. Already he was disliked by some of [President Donald] Trump’s higher-up people, particularly Laura Loomer. We may have heard her name before.
Rovner: We have.
Edney: She goes after some nominees, successfully in many cases. And Rick Santorum also got involved at this point. He has a daughter with a rare disease and didn’t like the way that this rare-disease drug was being treated. So essentially Prasad, who clearly for the last several years has only wanted to be at the FDA, has left after three months, was pushed out after three months.
Rovner: Wow. It’s quite the drama. I’ll link to a story or two if you actually want to go deeper.
Kenen: But one of the criticisms that Laura Loomer had is that he used to be a Democrat.
Edney: Right.
Kenen: Well, that would also apply to RFK Jr.
Edney: Right. That’s true.
Rovner: It would. Oh, I’m sure the drama, both at FDA and at HHS writ large, is far from over. Well, speaking of turning the clock back, President Trump issued a new executive order that would end the, quote, “housing first” policy that has driven homelessness strategy since the late 1990s. I guess this is also not a surprise. Trump complained repeatedly on the campaign trail about how homeless encampments were destroying cities. We’ve had a recent Supreme Court case on this, but this new policy seeks to not just allow but encourage localities to force at least some homeless people off the streets and into residential treatment. I imagine this is going to make for another long line of lawsuits, right?
Kenen: Well, there’s housing first itself. It’s not without controversy. There’s a philosophical divide. Housing first means you house people and then you deal with their social and economic and physical and psychological and drug abuse, etc. Get a roof over their head and then you deal with everything else. Other people say, No, get them into treatment and stabilize them, and then you put them in housing, and they have to … Housing first has been the dominant philosophy in addressing homelessness in recent years. That’s a different debate. This is, like, put them in an institution against their will, which the courts have power to do in limited cases. There are times when a court can say, This individual doesn’t want to be hospitalized, but for their own safety they really need to be. But that’s one by one and not that common, and it’s limited. I believe it’s 30 days. I might be wrong about that.
But this is a whole different thing. It’s a combination of this, We’re going to force them into institutional settings for treatment, whether they want it or not, combined with the Supreme Court decision of about a year ago allowing cities and local government, not just cities but governments, to forcibly clear away, to dismantle encampments, to force people out. So you have it coming from both the administration’s policies and the court decisions. This creates a whole — and housing money is being cut. Housing assistance is being cut. So you really have this tremendous shift in how we approach homelessness at a time when homelessness is high, while homelessness has been high. And nobody’s saying that there’s not a mental health component for some, but by no means all, people who are homeless. But this is not in accord with how the health and homelessness advocacy and treatment world has been approaching it. This is a significant shift.
Rovner: And as you point out, this is a health and social service issue, too, because we are seeing money cut and money diverted that, basically this executive order will say, We’re going to give more money to localities that sort of handle this the way we want and less money to others. So I imagine this is going to have trickle-down effects for some time to come.
Kenen: Yeah. And the clearing the encampments is going on, and we should know it’s not only a conservative state. California has done it. Other states have done it. So the idea of dismantling these — we’ve all seen these encampments — that is happening in various places in the country already, and this is sort of an extra step. It’s not only do you clear them, but this would envision forcing them into treatment, often in an institutional setting.
Rovner: Well, meanwhile, as I mentioned at the top, this week marks the 35th anniversary of the Americans With Disabilities Act, which I also covered, by the way. Secretary Kennedy spoke at an event marking the occasion on Monday. But an awful lot of the disability community is up in arms about the cuts to Medicaid, which they say will roll back much of the progress the movement has made in the past three and a half decades, much of it for people getting in-home types of assistance. And yet the ADA was pushed hard and signed by a Republican administration, that of President George H.W. Bush. Is this yet another formerly Republican priority being kind of tossed out the window?
Luthra: I think to your point, a lot of things that used to be bipartisan in the health policy world are not anymore. The other example is something like Title X, and it’s just we have really seen this shift of things that used to be broadly uncontroversial, because the health implications are clear, become much more so and largely become rejected by Republicans in a way that is just really, really different from what you might’ve imagined even, I don’t know, 10, 15 years ago.
Rovner: And my favorite piece of Title X trivia: It was signed by Richard Nixon, but it was sponsored in the House by then-Rep. George H.W. Bush. So he both sponsored Title X, the Family Planning Program, and signed the ADA into law. Boy, it feels like a million years ago and not 35.
Well, moving on to health care costs. It is tariff week in Washington — again — and not surprisingly, prescription drugs are a big part of that conversation. The trade deal that President Trump announced with the EU while he was in Scotland last weekend includes a 15% tariff on brand-name prescription drugs imported from Europe. That will include things like, I don’t know, the blockbuster weight loss drug Ozempic? Anna, how does Trump think this is going to eventually lower drug prices in the U.S.? It sounds like it’s just going to raise them.
Edney: Yeah. I think most people agree with your sentiment that it’s going to raise them. I think a lot of this is focused on bringing drug-making back to the United States and trying to get companies to do more of that here. Whether you see that from brand-name companies seems like it could be really difficult. I know Botox is made in Ireland, and this is a facility where, because it’s essentially a toxin, a very deadly toxin if released—
Rovner: Yes, it’s botulism.
Edney: Right. This is a facility that is highly guarded. A colleague of mine wrote a story on it many years ago now, but you had to go underground. They’re not just moving this thing over to the United States. So I think for brand-name drugs that it’s going to be particularly difficult to lower the prices based on tariffs, or to say We’re moving production over here in any capacity. So what the thinking of how exactly this works or is beneficial will be interesting to see, because they’re also still doing — this would not apply to these — but they’re doing this national security assessment for tariffs on drugs from other places and trying to figure out if there’s a national security reason to be putting tariffs on them. For the most part, when drug quality comes into question, it’s not usually the European drugmakers that we’re concerned about.
Rovner: And we’re still waiting to hear about the generic-drug makers in India and China, right?
Edney: Yeah, exactly. We’re waiting to see what they’ll decide. They’re still doing their investigation, the administration is, to see what those tariffs might be from India or China, or any other countries that are making generic drugs.
Rovner: Another story that we will continue to watch, and glad to have Anna here to continue to help us watch that. Now, it’s time for this week in what we’re still learning about the impact of the big tax and spending bill that President Trump signed on July Fourth. This week’s installment comes from my KFF Health News colleague Bernard Wolfson, whose column points out that eliminating eligibility for Affordable Care Act subsidies for immigrants who are here legally will mostly just raise premiums for everyone else by taking more healthy people out of the insurance pool. I get the administration’s insistence on not having people who are not here legally collecting benefits. We’ve talked about emergency Medicaid, but that’s a different issue. But what’s the justification for taking coverage away for people who are here because they’re refugees or victims of abuse, or those with temporary protected status? I don’t honestly understand what the point is of this.
Kenen: There’s a stigmatization across the board as being an immigrant, right? So the administration is not embracing immigrants who are here legally. We’ve all seen reports of people who are here legally still being picked up by immigration officials. It’s very messy. Sometimes people just say, OK, we’ll save money this way, not understanding that the costs pop up someplace else in the system and it may be more expensive. So not just in terms of that individual, but if things are going untreated in communities because people aren’t seeking care, communicable diseases can also spread. So there have been attempts to blame disease outbreaks on immigration when that’s not the case.
Rovner: Going back hundreds of years.
Kenen: Right. Smallpox was brought here by immigrants, right?
Rovner: Yeah.
Kenen: Hundreds of years ago.
Rovner: By the European immigrants.
Kenen: Right. That’s what I—
Rovner: And given to the Native population.
Kenen: Right. Right. So it’s just part of an overall gestalt about immigrants and immigration, and sort of treating them as leeches, not as people who live here.
Rovner: But I feel like both — it’s funny because this connects back to the whole tariff issue. The idea that Trump has here is to make things more “America First,” have more things made in America, and obviously more people made in America, and more Americans here to be served in America. But both of these things would take a long time. I guess the idea of not allowing legal immigrants to have benefits is to discourage people from coming here legally. One can’t see any other thing that would make that logical. And the idea of the tariffs, Anna, as you said, is to have companies build more manufacturing here. Both of those things would take a lot longer than Donald Trump is likely to be president. He doesn’t usually have a long-term view of things, and yet both of these issues are long-term issues, right?
Edney: Yeah. I think at least for the tariffs and for — there’ve been these small announcements with certain companies where they’ll say, Well, because of Trump, we’re going to build a new plant in Indianapolis. And that plant sure isn’t, like, it’s five years away, but he can make these announcements. And Joanne, and you’re absolutely right that he obviously wants to degrade immigrants in any way that he can, but also Obamacare, right? That’s still a thing that they’re in certain ways willing to go after.
Rovner: Good point. It’s a twofer.
Edney: Yeah, exactly. Exactly. So if you can erode Obamacare some and have a sicker population, and people being angry that they had to pay more, but Republicans have been good at still attaching that to Democrats: Oh, Obamacare. So I don’t know, maybe that comes back around.
Rovner: Yeah. Well, question answered. OK. Turning to abortion, the on-again, off-again Planned Parenthood funding is apparently on again, at least for now. You may recall last week a judge had allowed some of the defunding included in the budget bill to begin, but now another federal judge has said, Nope, you’ve got to keep letting Planned Parenthood collect from Medicaid for non-abortion-related services. Shefali, what comes next?
Luthra: The case continues to go through the courts. We know that right now that is in a federal district court. It could eventually go to the appellate courts. It could eventually make its way to the Supreme Court, including the debate over whether this proceeding is allowed to take effect or not. In the meantime, I’ve been talking to a lot of clinics, and they are preparing for the real possibility that they lose their Medicaid funding. Some of them are not optimistic about the long-term legal viability of this injunction, and so they’re thinking: What will we do if we lose all of these Medicaid dollars? Will we be able to see patients in the volume that we do? Will we be able to get funds from the state? Some are in active conversations with state governments. Some are looking to private fundraising. Others are thinking about which clinics they would close and also how they would do that in a way that minimizes service loss to patients, while acknowledging that some ability to access care — whether that is abortion or STI [sexually transmitted infection] screening or contraception or cancer screening — will simply not be replaced.
Rovner: Yeah, and I have to say, for all the million times I have said on this podcast, an administration can’t cut off Planned Parenthood from Medicaid, because it’s written into the Medicaid law, that doesn’t mean that Congress can’t cut off Planned Parenthood, because they can change the law. So I’m also a little bit wondering what the justification for Planned Parenthood being able to argue — I know that they’re arguing that they’re going after Planned Parenthood specifically, and that that’s not allowed. But certainly Congress can change the Medicaid law if it wants to. Congress wrote the Medicaid law.
Luthra: And I think it’s worth throwing in a couple of other components as well, considering there are multiple lawsuits at play right now, not just the original from Planned Parenthood. There’s the liberal states’ attorneys general. There’s the Maine Family Planning suit, as well. But conservative states do have an avenue to block Medicaid funds going to Planned Parenthood now, if they choose. The Supreme Court gave them that opportunity in the South Carolina case earlier this year. So no matter what happens in this case, there is a very real likelihood that in many parts of the country, Planned Parenthood clinics will lose funding they are reliant on and will probably have to close many facilities.
Rovner: Yeah. And just to reiterate, this goes back to the Title X Family Planning Program that we were talking about earlier, so it all comes full circle this week. This week we also have the latest chapter in the continuing fight between states with abortion bans and those with shield laws to try to protect doctors who are sending abortion pills through the mail into those states with abortion bans. According to The Texas Tribune, a man from Galveston is suing a doctor in California for sending his girlfriend pills to end her pregnancy. The man is being represented by Jonathan Mitchell, whose name may well be familiar to you as the originator of, most now, of Texas’s various abortion bans. The suit seeks both damages for the man who’s suing and an injunction on behalf of, quote, “all current and future fathers of unborn children in the United States.” Shefali, that feels pretty broad.
Luthra: It certainly does feel very broad. When I read it, I really wondered: How do you decide who are future potential parents of unborn children? Is that—
Rovner: Fathers, fathers.
Luthra: Excuse me. Yes. Potential fathers. Even more, how — is it everyone who has sperm? I don’t know. But this is part of a really central strategy to where the anti-abortion movement is right now. They are very upset about shield law prescription and provision of abortion medication. In Texas, they are trying a bunch of things to try and block this, whether that is this particular suit, whether that is one from the attorney general that continues to move back and forth, whether that is trying to get new state laws enacted during this special session. We’ll see if that happens with all the redistricting that is going on.
Rovner: This is all about Texas, by the way.
Luthra: And Texas is a really important player. But we did just see a group of attorneys general around the country from conservative states just reach out to members of Congress this week and say, Can you pass some kind of law that will block shield law prescription? We’ve also seen a case out of Louisiana that is held up in court right now because it’s a criminal case. But this is just such an important goal for them, because the reason abortions haven’t gone down is because people can keep accessing care through the mail. And if they can stop that, it will have tremendous implications for people in states with abortion bans, but also in other parts of the country where maybe it’s just too much of a pain or too far to go to a clinic and you can have a doctor mail you that care.
Rovner: Yeah. Well, clearly the abortion fights continue. We will continue to follow them. All right, that is this week’s news. Now, we’ll play excerpts of my interview with Medicaid expert Sara Rosenbaum, and then we will come back and do our extra credits.
I am so pleased to welcome Sara Rosenbaum to the podcast. Sara is professor emerita of health law and policy at George Washington University, one of the, if not the, leading experts on Medicaid. She’s also the person who has taught me at least 80% of what I know about the program. So I am extra thrilled that she’s agreed to come be our guide. Sara, welcome.
Sara Rosenbaum: Well, and thank you for having me. It’s such a pleasure to be on the show.
Rovner: So let’s start at the beginning. Medicaid was kind of an afterthought to Medicare when they were both created 60 years ago. How did Medicaid come to be?
Rosenbaum: It’s a really interesting question. This is, of course, the lore, that Medicaid was an afterthought. If you look at the original act, which had been enacted about five years before, and you read the original statutory language — which we lawyers revel in doing — you are amazed. This was not such a big afterthought. I would say that Wilbur Cohen and Wilbur Mills and Lyndon Johnson and everybody else had a good idea of what they were doing. They knew that they were planting the seeds for a program that ultimately would come to be the foundation of health insurance for low-income people across the United States, as well as, of course, specific categories such as people with very severe disabilities.
Rovner: So what was the difference between Medicare and Medicaid supposed to be when they were signed into law 60 years ago?
Rosenbaum: Yeah. So Medicaid was very much structured in the classic style of a state grants program. It has come, of course, to be so much more than that, but it was a grant to states, and states would set up state plans. This is all language that has become very familiar to us. And they would provide medical assistance, as it was called, to certain categories of poor people. And the theory was that the program would start with these people, but tucked into — the categories were cash welfare recipients — but tucked in there were a group of people known as the medically needy, in the early days. And the medically needy, I always felt, was sort of the first seeds of something much bigger, because the point was that it was a program for people who were low-income, who couldn’t afford their medical care, but didn’t get cash welfare.
So the theory was exactly the theory that has carried the program for 60 years now. And originally the thought was that it would really — and of course, this has turned out to be the case — that that would enable people who had very serious health care costs for things that Medicare did not cover — nursing home care, home health benefits ultimately, those kinds of really big-ticket long-term care items outside of Medicare — because Medicare was really sort of like Blue Cross Blue Shield for old people like me.
Rovner: You weren’t old at the time though?
Rosenbaum: I was not. Right. I was just a kid. But the program was meant to replicate what folks had had during their working years, and so it was very important and very profound, but limited.
Rovner: So Medicare’s long been the more politically popular of the two programs.
Rosenbaum: Yes.
Rovner: Primarily because of the political clout of older voters, which is how it was created. How was it that Medicaid became the program that grew so much?
Rosenbaum: What would propel Medicaid forward is that, unlike Medicare, which is tied to a premium structure, right? Medicare is funded through premium payments, which is great, but premium payments are quite unique. Because they are actuarially based, they are a very tightly controlled form of financing, because you’re asking — whether it’s the government or, now, of course, private insurers that contracted the government — you’re asking them to take on a lot of financial risk, and so everybody wanted the assurance of premium structure. Well, Medicaid was not. Medicaid is a classic public health statute. It’s general revenue. And so every time something happened that required an intervention by the federal government where health care was concerned, you could just add a few pages to the Medicaid statute and end up with, voilà, a fix. And by the mid-’70s, people said, Well, what if we decoupled this category from cash welfare funding levels and just let poor children have Medicaid? And there then ensued, essentially, a decade-long effort to add poor children and pregnant women as groups in their own right to the Medicaid program.
Rovner: I feel like in 2017, in the fight over the repeal of the Affordable Care Act, that was sort of a big change for Medicaid. I think people had finally realized that Medicaid had grown larger than—
Rosenbaum: Yes.
Rovner: —Medicare, that it was not just a program for the poorest of the poor, that it did all of these other things that you’re talking about, and that really a lot of, I guess, the stigma had been taken away. And yet this Congress felt comfortable — I don’t know if I’d say comfortable — but a majority of them voted to make these really deep, profound changes. What is that going to mean going forward, both to the health care system and to the political system?
Rosenbaum: Well, I’ve spent a lot of time thinking in this post-enactment period about when was the die cast that’s had everybody spinning. And I think congressional leaders and the White House leadership understood the fatal error they’d made in 2017, which was separating the tax reforms from the spending reforms. Because, of course, we were then able to battle the spending reforms on our own turf, right?. Here, because of the decision that was made back, I’m sure, almost a year ago—
Rovner: Literally the idea to do one “big, beautiful” bill.
Rosenbaum: Yes. And that meant that Medicaid, along with food stamps, or SNAP [the Supplemental Nutrition Assistance Program], along with everything else, just became pay-fors. They just became offsets. And the name of the game then became beating back every attempt to deprive Congress of pay-fors to do the thing that it really wanted to do, which was tax reform. And so we were all reduced to — “we” in the sense of people who worked on social welfare policy — to bystanders in this effort to get to a trillion dollars. And therefore—
Rovner: A trillion dollars in cuts.
Rosenbaum: A trillion dollars in cuts, and therefore it opened the door to extraordinary things.
Rovner: So what happens next? Does this happen? And if it happens, does it undergird or take out the underpinnings of the entire health care system? Or does Congress eventually realize what it’s done and change its mind?
Rosenbaum: Well, I think the hope is that — some people are saying: Well, the two-year runway. It’s like two years until it becomes effective. The two-year runway is sort of going to make people forget about this, and then boom, it’ll be upon us. I don’t think so. I think the two-year runway will end up shining a huge light on the fact that states cannot implement the whole system. While we are very focused on the number of people who will lose their coverage, the states are confronting an insurmountable problem here. They’ve never had to link Medicaid to work records, and Congress did everything it could to make matters so much worse. For example, they could have just said that, We’re going to import the same requirements that apply to SNAP to Medicaid, and so if you’re getting SNAP in your working age, then you automatically enroll in Medicaid. They didn’t do that. They didn’t do that. It’s a different-enough set of eligibility criteria and exemption categories. For example, SNAP ends, I think, at about 60, and the Medicaid work requirements go all the way to 65.
Rovner: Age 60 and 65.
Rosenbaum: Yes, exactly. But the exemptions are different. The requirements are different. And so states — people are talking about, Oh, well, it’s just the line reporting systems. No, no, no, no. You are liable for all kinds of error rate penalties. If you just rely on SNAP, you can’t. So states have no way to deal with this. So there’s no mitigation strategy for this, and I think the hope is that Congress will call it back.
Rovner: If it doesn’t, is this — the one sort of silver lining that I’d been sort of thinking about is, well, maybe if we tear down the health care system, we’ll have to start again and build a better one. Is it possible that we could get there, or are we just going to limp along?
Rosenbaum: I have those thoughts often, and then I stop and think, well, those of us with health insurance could sit there and say, Yeah, maybe we just tear down the health system to start again. Meanwhile, of course, we will have millions of people without health care. So I — interestingly, the Affordable Care Act, of course, was designed not to tear down the health care system but to strengthen the health care system. But it was the brilliance of the Affordable Care Act was that it saw the holes and it sort of tried to fix them. And if we’d left it alone with everybody in this what I consider to be sort of an intermediate arrangement, we could have done exactly what you are talking about. With just about everybody in the United States covered, we could have begun to really do the serious work of moving to something more unified, better—
Rovner: Cheaper.
Rosenbaum: And of course, cheaper.
Rovner: More efficient.
Rosenbaum: More efficient. That’s right. Far easier to use. But we have decided instead to tear the Affordable Care Act apart, both the access to the marketplace by rolling back the assistance and, of course, the Medicaid reforms.
Rovner: Well, happy birthday, Medicaid.
Rosenbaum: Happy birthday, Medicaid.
Rovner: Thank you so much, Sara Rosenbaum.
Rosenbaum: Thank you for having me. It was a — it was both uplifting and sad.
Rovner: OK, we’re back. And 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. Joanne, why don’t you go first this week?
Kenen: The story I’m doing is in ScienceAlert: “New Kind of Dental Floss Could Replace Vaccine Needles, Study Finds,” by David Nield. OK, I should begin with a caveat, which is I basically don’t like it when journalists hype findings. It’s something that was only in a dozen mice or something. My exception is when something is really, really sort of just interesting to learn about. Then it’s OK to report it as long as you just sort of shout: This is only in mice! We don’t know if it’s going to work in people! But it is an interesting study.
One reason people don’t get vaccines is they’re afraid of needles. And if you could actually apply the vaccine to a dental floss pick and get it — because the line between our gums and our teeth is permeable, stuff can get in and out. That’s why we have to clean it. If you could treat a dental floss with the vaccine instead of just plain old dental floss or a needle in your arm or leg or whatever, maybe that could be a way of improving. And so these animal studies have been suggestive that this is a worthwhile course to follow. But before you go out to the drugstore with your dental floss and ask them to put the vaccine stuff on it — they’ve done it with a couple of people with dye, not with vaccine, just to sort of trace it. We are a long way away, but it was interesting enough for me to decide that we could discuss it.
Rovner: I thought it was pretty cool. Shefali?
Luthra: My piece also is dentistry adjacent, even dentistry directly relevant. It is from The New Yorker. It is by Burkhard Bilger. The headline is “Mexico’s Molar City Could Transform My Smile. Did I Want It To?” This is a really fun read. He travels to this town. Los Algodones, in Mexico, is right across the border, and it is where a lot of people go to get dental work. It is much cheaper there than getting it in America. So he goes through the history of dental work, why it has been something that people really do not enjoy, the pain associated with it, how many bad dentists are out there, also the stigma and violence against dentists. And then he talks through his own personal journey of trying to figure out: Does he need this dental work? How much would it cost to get it in this Mexican town compared to getting it in the U.S.?
He talks to a dentist there, talks to a celebrity dentist as well, and in the end decides to keep his teeth as they are, which is very beautiful to me as someone who hates going to the dentist. But it’s a really fun read to think about how expensive health care is, how often things are marketed to us that maybe we do or don’t need, and also why dentistry has really been siloed out of all other health care for basically all of our history.
Rovner: Yeah, it really has. It’s a wonderful combination of stories. Anna.
Edney: Mine is not dental-related. I apologize. But this is an obit in The Washington Post by Stefanie Dazio, “Morton Mintz, Post reporter with a muckraker spirit, dies at 103.” And I wanted to talk about him because he was the reporter responsible for bringing to light everything that was going on with thalidomide. He wrote a 1962 front-page Washington Post profile on Francis Kelsey, the FDA pharmacologist who essentially blocked thalidomide from getting to market in the U.S., and she faced a lot of pressure and a lot of name-calling and things to stand in the way. And he took on the story, and he did many amazing stories, so it’s just, it’s worth a read. He wrote a lot about the pharmaceutical industry as well, and so I think it’s just nice to remember him.
Rovner: It is. I will point out he was a fellow Michigan Daily alum, a close family friend. My mother actually worked on the Michigan Daily with his younger sister and then later worked with him at The Washington Post for years, so I can attest, not just a great reporter but a really swell guy. All right, well, my extra credit is not dental-related, either. It’s another great investigation from my KFF Health News colleague Fred Schulte. It’s called, “Cosmetic Surgeries Led to Disfiguring Injuries, Patients Allege.” And it’s mostly about a chain you’ve probably seen advertised called Sono Bello and how this private-equity-owned business and some others like it are being sued in scores of medical malpractice and negligence lawsuits, claiming under-trained medical professionals have caused disfiguring injuries and, in at least a dozen cases, wrongful deaths. The subtext of this story, of course, is that this is another one of those not quite med spa but not quite ambulatory surgery center categories that’s not very well regulated by either the FDA or most states. So it’s yet another good case of buyer beware when it comes to protecting your health.
OK. That’s this week’s show. As always, thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. Extra-special thanks this week to Taylor Cook, who’s editing our Medicare and Medicaid anniversary interviews. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Shefali.
Luthra: I am at Bluesky, @shefali.
Rovner: Joanne.
Kenen: Bluesky and LinkedIn, @joannekenen.
Rovner: Anna.
Edney: Bluesky or X, @annaedney.
Rovner: We’ll be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Here Come the ACA Premium Hikes
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Much of the hubbub in health care this year has been focused on Medicaid, which faces dramatically reduced federal funding as the result of the huge budget bill signed by President Donald Trump earlier this month. But now the attention is turning to the Affordable Care Act, which is facing some big changes that could cost many consumers their health coverage as soon as 2026.
Meanwhile, changes to immigration policy under Trump could have an outsize impact on the nation’s health care system, both by exacerbating shortages of health workers and by eliminating insurance coverage that helps keep some hospitals and clinics afloat.
This week’s panelists are Julie Rovner of KFF Health News, Julie Appleby of KFF Health News, Jessie Hellmann of CQ Roll Call, and Alice Miranda Ollstein of Politico.
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Julie Appleby
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Jessie Hellmann
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Alice Miranda Ollstein
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Among the takeaways from this week’s episode:
- Many Americans can expect their health insurance premiums to rise next year, but those rate hikes could be even bigger for the millions who rely on ACA health plans. To afford such plans, most consumers rely on enhanced federal government subsidies, which are set to expire — and GOP lawmakers seem loath to extend them, even though many of their constituents could lose their insurance as a result.
- Congress included a $50 billion fund for rural health care in Trump’s new law, aiming to cushion the blow of Medicaid cuts. But the fund is expected to fall short, especially as many people lose their health insurance and clinics, hospitals, and health systems are left to cover their bills.
- Abortion opponents continue to claim the abortion pill mifepristone is unsafe, more recently by citing a problematic analysis — and some lawmakers are using it to pressure federal officials to take another look at the drug’s approval. Meanwhile, many Planned Parenthood clinics are bracing for an end to federal funding, stripping money not only from busy clinics where abortion is legal but also from clinics that provide only contraception, testing for sexually transmitted infections, and other non-abortion care in states where the procedure is banned.
- And as more states implement laws enabling doctors to opt out of treatments that violate their morals, a pregnant woman in Tennessee says her doctor refused to provide prenatal care, because she is unmarried.
Also this week, Rovner interviews Jonathan Oberlander, a Medicare historian and University of North Carolina health policy professor, to mark Medicare’s 60th anniversary later this month.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Republicans Call Medicaid Rife with Fraudsters. This Man Sees No Choice but To Break the Rules,” by Katheryn Houghton.
Julie Appleby: NPR’s “Many Beauty Products Have Toxic Ingredients. Newly Proposed Bills Could Change That,” by Rachel Treisman.
Jessie Hellmann: Roll Call’s “Kennedy’s Mental Health Drug Skepticism Lands at FDA Panel,” by Ariel Cohen.
Alice Miranda Ollstein: The Associated Press’ “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals Are Ultraprocessed,” by Amanda Seitz and Jonel Aleccia.
Also mentioned in this week’s podcast:
- KFF Health News’ “Insurers and Customers Brace for Double Whammy to Obamacare Premiums,” by Julie Appleby.
- The Congressional Budget Office’s “Estimated Budgetary Effects of Public Law 119-21, to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14, Relative to CBO’s January 2025 Baseline.”
- The CBO’s “How Changes to Funding for the NIH and Changes in the FDA’s Review Times Would Affect the Development of New Drugs.”
- KFF’s “KFF Health Tracking Poll: Public Views on Recent Tax and Budget Legislation,” by Grace Sparks, Shannon Schumacher, Julian Montalvo III, Ashley Kirzinger, and Liz Hamel.
- The Washington Post’s “Digging Into the Math of a Study Attacking the Safety of the Abortion Pill,” by Glenn Kessler.
click to open the transcript
Transcript: Here Come the ACA Premium Hikes
[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 24, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go.
Today we are joined via videoconference by Jessie Hellmann of CQ Roll Call.
Jessie Hellmann: Hi there.
Rovner: Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: And my KFF Health News colleague Julie Appleby.
Julie Appleby: Hi.
Rovner: Later in this episode we’ll have the first of a two-part series marking the 60th anniversary of Medicare and Medicaid, which is July 30. Medicare historian and University of North Carolina professor Jonathan Oberlander takes us on a brief tour of the history of Medicare. Next week we’ll do the same with Medicaid. But first, this week’s news.
So, we have talked a lot about the changes to Medicaid as a result of the Trump tax and spending law, but there are big changes coming to the Affordable Care Act, too, which is why I have asked my colleague Julie Appleby to join us this week. Julie, what can people who buy insurance from the ACA marketplaces expect for 2026?
Appleby: Well, there’s a lot of changes. Let’s talk about premiums first, OK? So there’s a couple of things going on with premiums. It’s kind of a double whammy. So, on the one hand, insurers are asking for higher premiums next year to cover different things. So in the summer they put out their rates for the following year. So there’s been a lot of uncertainty this year, so that’s playing into it as well. But what they’re asking for is some money for rising medical and labor costs, the usual culprits, drug costs going up, that kind of thing. But they’re tacking on some extra percentages to deal with some of the policy changes advanced by the Trump administration and the Republican-controlled Congress. And one key factor is the uncertainty over whether Congress is going to extend those more generous covid-era tax subsidies. So we’re looking at premiums going up, and the ask right now, what they’re asking for, the median ask, is 15%, which is a lot higher. Last year when KFF did the same survey, it was 7%. So we’re getting premium increase requests of a fairly substantial amount. In fact, they say it’s about the highest in five years.
And then on top of that, it’s still not clear what’s going to happen with those more generous subsidies. And if the more generous subsidies go away, if Congress does not reinstate them, there’ll be costs from that, and people could be paying maybe 75% more than they’re paying this year. And we could talk some more about that. But that’s kind of the double whammy we’re looking at, rising premiums and the potential that these more generous subsidies won’t be extended by Congress.
Rovner: So there were some things that were specifically in that tax and spending bill that drive up premiums for the ACA, right? Besides not extending the additional subsidies.
Appleby: Well, that’s the biggest piece of it, but yes. They’re tacking on about 4% of that 15% medium increase is related to the uncertainty. Well, they’re assuming that the tax credits will expire. It was not in the bill. Congress could still act. They have until the end of the year. They could extend those subsidies. So that’s about 4%. But one of the things that people haven’t really been talking about are tariffs, and some of the insurers are asking for 3% because they expect drug costs to go up. So there’s those things that are going on. And then there’s just sort of the uncertainty going forward for insurers about what’s going to happen with enrollment as a result of both these premium increases, and then looking a little bit further down the line, there are some changes in the tax and spending bill and some rules that are going to substantially reduce enrollment.
So insurers are worried that the people who are going to sign up for coverage are the ones who are most motivated, and those are probably going to be the people who have some health problems. And the folks who aren’t as motivated are going to look at the prices and maybe the additional red tape and will drop out and leave them with a sicker and more expensive pool to cover. So all of that is factoring in with these premium rate increases that they’re trying to put together. Now remember, a lot of these insurers put in these premium increase requests before they knew the outcome of the tax and spending legislation. They could still modify them.
Rovner: And Jessie, as Julie said, there’s still a chance that Republicans will change their minds on the increased subsidies and tack them onto something. And there’s a big bipartisan health bill on drug prices and other expiring programs that still could get done before the end of the year? Yes?
Hellmann: There have been discussions about a bipartisan health bill, though the main author of it, Sen. Bill Cassidy, himself even seems kind of skeptical. I talked to him this week, and he’s like, It might happen, it might not. But there are a bunch of other health extenders that Congress will need to get to, like telehealth, some Medicare and Medicaid payment things. So there’s definitely something to attach it to. Republicans are not friendly to the ACA. As you mentioned, they made a bunch of changes to it in this tax and spending bill. So I think the people I talk to think it’s a long shot that they’re going to pass billions of dollars in a subsidy extension in this bill. Though there are Republicans who do care about this issue, like Sen. Lisa Murkowski of Alaska. She’s kind of been sounding the alarm on this. She thinks that Congress needs to do something to mitigate which could be very big premium increases for people. So there is some pressure there, but it doesn’t seem like the people who should be thinking about this right now have started thinking about it much yet.
Rovner: One presumes they’ll start thinking about it when they start seeing these actual premium increases. I sound like a broken record, but we keep saying, the people who these premium increases are going to hit the hardest are voters in red states.
Appleby: Last year, in 2024, 56% of ACA enrollees lived in Republican congressional districts and 76% were in states won by President [Donald] Trump. So I’ve got to think they’re thinking about it. When I did the reporting on this story, I spoke with a couple of folks, and they said that some people in Congress are looking at maybe they can mess around or maybe they can do something with the subsidies that’s not keeping them as they are but might deal with a piece of it. For example, there is something called a subsidy cliff. So if you make more than 400% of the federal poverty level, you used to not get any subsidies. That would come back if they don’t extend this. And so 400% of the federal poverty level, you make a dollar more, you don’t get a subsidy. So this year — and this year will be the numbers that next year’s rates are based on — $62,600 for one person is 400% of the federal poverty level and $84,600 for a couple. So people are going to start getting, if they don’t extend the tax credits, they’re going to start getting notification about how much they owe for premiums next year.
And this is going to be one of the first effects that people are going to see from all these changes in Washington, the tax and spending bill and the other things, when they get these premiums for January. And if they make even a dollar over that, they’re not going to get any subsidy at all. So what I’m told by some of my sources is that maybe they’re thinking about raising that cliff, maybe keeping the cliff but maybe moving it up a little bit to 500% or 600%. But it’s totally unclear. Like you all are saying, nothing may happen. We may go through Dec. 31 and nothing happens, but I’m hearing that they are maybe talking a little bit about that.
Rovner: Alice.
Ollstein: Yeah. And there’s a couple interesting dynamics that I think could influence the politics of this and what Congress feels motivated to do or not do. So, like Julie was saying, this would hit in January. And a lot of the stuff in the bill they just passed is designed to not hit until the midterms, but this would hit before the midterms. And so that’s got to be on their minds. And then, like you were saying, not only would this hit Republican voters the hardest, but a reason that’s more true today than it was the last time they took a round at the Affordable Care Act in 2017 is because all of these red states have expanded since then. You have a lot more enrollment, even in states that didn’t expand, and so, like we mentioned, are going to have a lot of Republican voters who get hit and have this sticker shock. And the party in power in Congress and the White House could be to blame.
Rovner: Yeah. One of the things in 2017, there were, what, 12 million people who were buying coverage on the marketplaces. And now there’s 24 million people who are buying coverage on the marketplaces. So it’s a lot more people, just plain, in addition to a lot more people who are likely in some of these red states. So we will follow this closely.
Meanwhile, the fallout continues as people find out more about the new tax and spending law. The Congressional Budget Office is out with its final numbers on the bill as enacted. It’s now estimating that 10 million more people will be uninsured in 2034 as a result of the new law. That’s down from the 11.8 million estimate of the original Senate bill. That’s because the parliamentarian bounced the provisions that would’ve punished states using their own money to cover undocumented people. That was not allowed to be considered under the reconciliation procedure.
We also have a brand-new poll from my colleagues here at KFF that find that more people know about the law than did before it passed, and it’s still unpopular. We’ll post a link to those numbers so you can see just how unpopular it is. As we’ve discussed, lots of Republican senators and House members expressed concern about the impact the Medicaid cuts could have on rural hospitals in particular. So much so that a $50 billion fund was eventually added to the bill to offset roughly $155 billion in rural Medicaid cuts. Even more confusing, that $50 billion is likely to be distributed before some of the cuts begin — as you were just saying, Alice — and not necessarily to just rural areas. So is this $50 billion fund really just a big lobbying bonanza?
Ollstein: Well, it’s certainly designed to function as softening the blow. But these are different things. The hospital could be propped up and stay open, but if no one has Medicaid to go there, that’s still a problem. And the money is sort of acknowledging that a bunch of people are going to lose their coverage, because it’s meant to give the hospital something to use for uncompensated care for people who have no coverage and come to the ER. But that still means that people who lost their insurance because of other provisions in the bill, they might not be going to their preventive care appointments that would avoid them having to go to the emergency room in the first place, which costs all of us more in the long run. So there’s a lot of skepticism about the efficacy of this.
Rovner: Jessie, are you seeing the lobbying already begin for who’s going to get this $50 billion?
Hellmann: Yeah, because the legislation leaves a lot of how the money will be handed out to the HHS [Department of Health and Human Services] secretary, and so that’s something that they’re going to start thinking about. It reminds me a lot of the provider relief fund that was set up during covid. And that didn’t go very well. There were lots of complaints that providers were getting the funding that didn’t need the funding, and the small safety net hospitals weren’t getting enough of the funding. So I’m wondering if they’re going to revisit how that went and try to learn any lessons from it. And then at the same time, like Alice said, this just isn’t a lot of money. It’s not going to offset some of the pain to rural providers that the bill has caused.
Rovner: Yeah. Well, another piece that we will be watching. Meanwhile, the cuts to SNAP [Supplemental Nutrition Assistance Program] food benefits conflict with another stated goal of this administration, improving health by getting people to eat healthier food. Except, as we know, healthier food is often more expensive. Other than not letting people buy soda and candy with their SNAP cards, has the administration tried to address this contradiction at all? I’m seeing a lot of blank stares. I’m assuming that the answer to that is no. We’re hearing so much about food and unhealthy food, and we’re getting rid of seed oils and we’re getting rid of dyes, but at the same time, it’s the biggest cut ever to nutrition assistance, and yet nobody’s really talking about it, right?
Appleby: Sounds like, I think, the states are really worried, obviously, because they’re going to have to make up the difference if they can. And so what other programs are they going to cut? So I’m sure they are talking with folks in Congress, but I don’t know how much leverage they’re going to have. Do you guys have any idea whether the states, is there anything else that they can do to try to get some of this funding?
Rovner: There’s no — I’ve seen no indication. As we said, there’s already some buyer’s remorse on the health side. Last week we talked about [Sen.] Josh Hawley introducing legislation to restore some of the Medicaid cuts that he just voted for, but I haven’t seen anybody talking about restoring any of these nutrition assistance cuts or any of the other cuts, right?
Appleby: Right. And from what I’ve read, the SNAP cuts won’t fully take effect until after the midterm elections. So maybe we’re just not hearing about it as much because it hasn’t really hit home yet. People are still trying to figure out: What does all this mean?
Rovner: Well, one thing that has hit home yet, I’ve wanted for a while to highlight what some of the changes to immigration policy are going to mean for health care. It’s not just ending legal status for people who came and have lived in the U.S. legally for years, or reinterpreting, again, the 1996 welfare law to declare ineligible for Medicaid and other programs many legal immigrants who are not yet permanent residents but who have been getting benefits because they had been made legally eligible for them by Congress and the president. One of the big changes to policy came to light last week when it was revealed that immigration officials are now being given access to Medicaid enrollment information, including people’s physical addresses. Why is this such a big deal? Alice, you’ve been following this whole immigration and health care issue, right?
Ollstein: Yes. Experts are warning that this is very dangerous from a public health perspective. If you deter people from physically wanting to visit a clinic or a doctor out of fear of ICE [Immigration and Customs Enforcement] enforcement there, which we’ve already seen — we’ve already seen ICE try to barge into hospitals and seize people. And so fear of that is keeping people away from their appointments. That makes it harder to manage chronic illnesses. That makes it harder to manage infectious diseases, which obviously impacts the whole community and the whole society. We all bear those costs. We live in an interconnected world. What impacts part of the population impacts the rest of the population.
And so what you mentioned about the Medicaid data, as well, deters people who are perfectly eligible, who are not undocumented, who have legal status, who are eligible for Medicaid. It deters them from enrolling, which again deters people from using that health care and keeping their conditions in check. And so there’s a lot of concern about how this could play out and how long the effect could last, because there are studies showing that policies from the first Trump administration were still deterring immigrants from enrolling even after they were lifted by the Biden administration.
Rovner: And we should point out that this whole address thing is a big issue because, as you say, there, maybe, there are a lot of families where there are people who live there who are perfectly, as you say, perfectly eligible. You’re not eligible for Medicaid if you’re not here legally. But they may live in a family, in a household with people who are not here with documentation, and they’re afraid now that if they have their addresses, that ICE is going to come knocking at their door to get, if not them, then their relatives or people who are staying with them.
Appleby: Yeah. And I think it’s also affecting employment. So nursing homes are already saying that they’re losing some people who are losing their protected status or this or that. So they’re losing employees. Some of them are reporting, from what I’ve read, that they are getting fewer applicants for jobs. This is going to make it even tougher. Many of them already have staffing issues, and the nursing home industry has said, Hey, how come we’re not getting any special consideration? Like maybe some of the farmers or other places are supposedly getting, but I don’t know if that’s actually happening. But why aren’t they being considered and why are they losing some of their workers who are here under protected status, which they’re going to lose? And some of them may also be undocumented — I don’t know. But that’s just the nursing homes. Think of all the people around the country who need help in their homes, and maybe they’re taking care of elderly parents and they hire people, and some of those people may not be documented. And that’s a vast number of folks that we’re never going to hear about, but if they start losing their caregivers as well, I think that’s going to be a big impact as we go forward.
Rovner: And it’s also skilled health workers who are here on visas who are immigrants.
Appleby: Right.
Rovner: In rural areas in particular, doctors and nurses are usually people who have been recruited from other countries because there are not enough people or not health professionals living in those rural areas. The knock-on effect of this, I think, is bigger than anybody has really sort of looked at yet.
Ollstein: Absolutely. States have even been debating and in some cases passing legislation to make it easier for foreign medical workers to come practice here, making it so that they don’t have to redo their residency if they already did their residency somewhere abroad, things like that, because there’s such shortages right now, especially in primary care and maternal care and a lot of different areas.
Rovner: Yeah. This is another area that I think we’re only just beginning to see the impact of. Well, there is also news this week in Trump administration cuts that are not from the budget bill. In a report from the Congressional Budget Office that’s separate from the latest budget reconciliation estimate, analysts said that the Trump administration’s proposed cuts to the budgets of the National Institutes of Health and the Food and Drug Administration could reduce the number of new drugs coming to market. That would not only mean fewer new treatments and cures but also a hit to the economy. And apparently it doesn’t even take into account the uncertainty that’s making many researchers consider offers to decamp to Canada or Europe or other countries. There’s a real multiplier effect here on what’s a big part of U.S. innovation.
Hellmann: I’ve been talking to people on the Hill about this who traditionally have been big supporters of the NIH and authorizing and appropriating increases for the NIH every year. And they are still kind of playing a little coy. The White House is suggesting a budget cut at the NIH of 40%, which would be massive. It’s so massive that the CBO report was like: We cannot estimate the impact of this. We’re going to estimate a smaller hypothetical. Because they just can’t.
And so I think it’ll be interesting to see how it plays out in the appropriations process. You do have senators who are more publicly concerned about it, like Sen. Susan Collins of Maine, who obviously is on the Appropriations Committee. So we might see a situation where Congress ignores the budget request. That usually happens, but these are weird times. And so I think there are questions about, even if they do, if Congress does proceed as normal and appropriate the money that they typically do for NIH, what is the administration going to do with it? They’ve already signaled that they’re fine not spending money that has been appropriated by Congress. And so I think that there’s a big question about that.
Rovner: At some point, this has to come to a head. We’ve been — as I say, I feel like a broken record on this. We talk about it a lot, that this is money that’s been appropriated by Congress and signed by the president and that we keep hearing that people, particularly at NIH, are not being allowed, for one reason or another, to send out. This is technically illegal impoundment. And at some point it comes to a head. We know that Russ Vought, the head of the Office of Management Budget, thinks that the anti-impoundment law is illegal and that he can just ignore it. And that’s a lot of what’s happening right now. I’m still surprised that it’s the end of July and Congress is going out for the August recess — and Jessie, I know you’re talking to people and they’re playing coy — that they haven’t jumped up and down yet. The NIH in particular has been such a bipartisanly supported entity. If you’ve ever been around the campus in Bethesda, all of the buildings are named after various appropriators of both parties. This is something that is really dear to Congress, and yet they are just basically sitting there holding their tongues. At some point, won’t it stop?
Hellmann: I think maybe they’re hoping to say something through whatever legislation that they come out with, whatever spending legislation. But, yeah, they’re not being very forceful about it. And I think people are obviously just very afraid of making the Trump administration angry. Lisa Murkowski of Alaska has said this, like she kind of fears the repercussions of making the president mad. And he’s on this spending-cut spree. So I definitely expected more anger, especially the bipartisan history of the NIH has lasted so long. It’s kind of a weird thing to see happen.
Rovner: Yeah. Of all the things that I didn’t expect to see happen this year, that has to be the thing that I most didn’t expect to see happen this year, which was basically an administration just stopping funding research and Congress basically sitting back and letting it happen. It is still sort of boggling to my mind. Well, we also learned this week about hospitals stopping gender-affirming care of all kinds for minors, under increasing pressure from the administration. And we’re not just talking about red states anymore. Children’s hospitals in California and here in Washington, D.C., have now announced they won’t be offering the care anymore. Wasn’t it just a few months ago when people were moving from red states to blue states to get their kids care? Now what are they going to be able to do?
Ollstein: I think a lot of what we’re seeing play out in the gender-affirming care fight, it reminds me of the abortion rights fight. There are a lot of themes about the formal health care system being very, very risk-averse. And so rather than test the limits of the law, rather than continuing to provide services while things are still pingponging back and forth in courts, which is the case, they’re saying, just out of caution, We’re just going to stop altogether. And that is cutting off a lot of families from care that they were relying on. And there’s a lot of concern about the physical and mental health impacts on — again, this is very small compared to the general population of trans kids — but it’s going to hit a lot of people. And yeah, like you said, this is happening in blue states as well. There’s sort of nowhere for them to go.
Rovner: Yeah. We’re going to see how this one also plays out. Well, turning to abortion, we talked last week about how a federal appeals court upheld a West Virginia law aimed at banning the abortion pill mifepristone. And I wondered why we weren’t hearing more from the drug industry about the dangers of state-by-state undermining of the FDA. And lo and behold, here come the drugmakers. In comments letters to the FDA, more than 50 biotech leaders and investors are urging the agency to disregard a controversial study from the anti-abortion think tank the Ethics and Public Policy Center that officials are citing as a reason to reopen consideration of the drug’s approval. Alice, remind us what this study is and why people are so upset about it.
Ollstein: So it’s not a study, first of all. Even its supporters in the anti-abortion movement admitted, in private in a Zoom meeting that I obtained access to, that it is not a study. This is an analysis that they created. They are not disclosing the dataset that it is based on. It did not go through peer review. And so they are citing their own sort of white-paper analysis put out by an explicitly anti-abortion think tank to argue that abortion pills are more dangerous than previously known or that the FDA has previously acknowledged. There’s been a lot of fact checks and debunks of some of their main points that we’ve been through on this podcast also before. The Washington Post did an in-depth fact check if people want to look that up. But suffice it to say that that has not deterred members of Congress from citing this and to pressure the FDA.
And now you have the FDA sort of promising to do a review. If you look at the exact wording of what [FDA Commissioner Marty] Makary said, I’m not sure. He said something like, Like we monitor the safety of all drugs, we’re going to blah, blah, blah. And so it’s unclear if there’s anything specific going on. But the threat that there could be, like you said, is really shaking up the drugmaking industry. And you’re hearing a lot of the same alarms that we heard from the pharmaceutical industry when this was before the Supreme Court, when they were afraid the Supreme Court would second-guess the FDA’s judgment and reimpose restrictions on mifepristone. And they’re saying, Look, if we can’t count on this being a process that just takes place based on the science and not politics and not courts coming in 25 years later and saying actually no, then why would we invest so much money in developing drugs if we can’t even count on the rules being fair and staying the same?
Rovner: Yeah. We will see how this goes. I was surprised, though. We know that that Texas case that the Supreme Court managed to not reach the point of, because the plaintiffs didn’t have standing, is still alive elsewhere. But I didn’t realize that this other case was still sort of chugging along. So we’ll see when the Supreme Court gets another bite at it. Meanwhile, the fight over funding for Planned Parenthood — whose Medicaid eligibility, at least for one year, was canceled by the new budget law — continues in court. This week a judge in Massachusetts gave the group a partial win by blocking the defunding for some smaller clinics and those that don’t perform abortions, but that ruling replaced a more blanket delay on the defunding. So many clinics are now having their funding stopped while the court fight continues. Alice, what’s the impact here of these Planned Parenthood clinics closing down? It’s not just abortion that we’re talking about. In fact, it’s not even primarily abortion that we’re talking about.
Ollstein: Absolutely. So this is one, it’s set to hit a lot of clinics in states where abortion is legal. And so these are the clinics that are serving a lot of people traveling from red states. And so there’s already an issue with wait times, and this is set to make it worse. But that’s just for abortion. Like you said, this is also set to hit a bunch of clinics in states where abortion is illegal and where these clinics are only providing other services, like birth control, like STI [sexually transmitted infection] testing. And at the same time we’re having a lot of other funding frozen, and so this could really be tough for some of these areas where there aren’t a lot of providers, and especially there are not a lot of providers who accept Medicaid.
Rovner: Meanwhile, a number of states are passing conscience laws that let health professionals opt out of things like doing abortions or providing gender-affirming care if they violate their beliefs. Well, in Tennessee now we have a story of a pregnant woman who says her doctor refused to provide her with prenatal care, because she’s not married to her partner of 15 years. She said at a congressional town hall that her doctor said her marital status violated his Christian beliefs, and he’s apparently protected by the new Tennessee state law called the Medical Ethics Defense Act. I’ve heard of doctors refusing to prescribe birth control for unmarried women, but this is a new one to me, and I’ve been doing this for a very long time. Are these just unintended consequences of these things that maybe state lawmakers didn’t think a lot about? Or are they OK with doctors saying, We’re not going to provide you with prenatal care if you’re pregnant and not married?
Ollstein: So one, as we just said, we’re in a situation where there is such a shortage of providers and such a shortage of providers who accept certain coverage that being turned away by one place, you might not be able to get an appointment somewhere else, depending where you live. And so this isn’t just an issue of, Oh, well, just don’t go to that doctor who believes that. People have very limited choices in a lot of circumstances. But I—
Rovner: Apparently this woman in Tennessee said she’s having to go to Virginia to get her prenatal care.
Ollstein: Well, exactly. Yeah. Exactly. This isn’t like people have tons of options. And also this is an example of a slippery slope, of if you allow people to be able to refuse service for this reason, for that reason, what else could happen? And some states have more legal protections for things like marital status, and some do not. And so it’s worth thinking through what could be sort of the next wave.
Rovner: Well, we’re certainly going to see what the outcome of this could be. Well, before we end our news segment this week, I want to give a shoutout to tennis legend Venus Williams, who at age 45 won a singles match at a professional tournament here in Washington this week and said in her post-match interview that she came back to playing because she needed the pro tour’s health insurance to take care of several chronic conditions that she has. So see, even rich athletes need their health insurance. All right. That is this week’s news. Now we will play my interview with Medicare historian Jonathan Oberlander, and then we will come back and do our extra credits.
I am so pleased to welcome Jonathan Oberlander to the podcast. He’s a professor of social medicine, professor of health policy and management, and adjunct professor of political science at the University of North Carolina School of Medicine in Chapel Hill and one of the nation’s leading experts on Medicare. Jon, welcome to “What the Health?”
Jonathan Oberlander: Great to see you, Julie.
Rovner: So Medicare, to me at least, remains the greatest paradox in the paradox that is the U.S. health care system. It is at once both so popular and so untouchable that it’s considered the third rail of politics, yet at its core it’s a painfully out-of-date and meager benefit that nevertheless threatens to go bankrupt on a regular basis. How did we get here?
Oberlander: Wow. So let’s talk about the benefits for a minute. And I think one of the things we can say about Medicare in 2025 as we mark this 60th anniversary is it still bears the imprint of Medicare in 1965. And when Medicare was designed as a program — and the idea really dates back to the early 1950s — it was not seen as a comprehensive benefit. It was intended to pay for the most consequential costs of medical care, for acute care costs. And so when it was enacted in 1965, the benefits were incomplete. And the problem is, as you know very well, they haven’t been added to all that much. And here we have a population, and all of us know as we get older, we generally don’t get healthier. I wish it was true, but it’s not. Older persons deal with all kinds of complex medical issues and have a lot of medical needs, and yet Medicare’s benefits are very limited, so limited that actually a very small percentage of Medicare beneficiaries have only Medicare. Most Medicare beneficiaries have Medicare plus something else. And that may be an individual private plan that they purchase called a Medigap plan, or maybe a declining number of people have retiree health insurance that supplements Medicare.
Some low-income Medicare beneficiaries have Medicaid as well as Medicare and they are dual-eligible. Some Medicare beneficiaries have extra benefits through the Medicare Advantage program, which I’m sure—
Rovner: We’ll get to.
Oberlander: —we’ll have a lot to say. So the bottom line, though, is Medicare has grown. It has, what, about 70 million Americans rely on Medicare. But the benefit package — with some intermittent exceptions that are significant, such as the addition of outpatient prescription drugs in 2006 — really has not kept pace.
Rovner: So let’s go back to the beginning. What was the problem that Medicare set out to solve?
Oberlander: Well, it was both a substantive problem and a political problem. The origins of Medicare are in the ashes, the failure, of the Truman administration proposals for national health insurance during the mid- and late 1940s. And after they had lost repeatedly, health reformers decided they needed a new strategy. So instead of national health insurance, what today we would call a single-payer, federal-government-run program for everybody, they trimmed their ambitions down to, initially, just hospital insurance, 60 days of hospital insurance for elderly Social Security beneficiaries. And that was it. And they thought if they just focused on older Americans, maybe they would tamp down the controversy and the opposition and the American Medical Association and charges of socialized medicine, all things that are really throwing a wrench into plans for national health insurance. It didn’t quite work out as they thought. It took about 14 years from the time Medicare was proposed to enact it. And there was a big, divisive, controversial debate about Medicare’s enactment. But it was fundamentally a solution to that political problem of, how do you enact government health insurance in the United States? You pick a more sympathetic population.
Now, there was a substantive problem, which was in the 1940s and especially 1950s, private health insurance was growing in the United States for Americans who are working-age, and that growth of employer-sponsored health insurance really left out retirees. They were expensive. Commercial insurers didn’t want to cover them. And the uninsured rate, if you can believe it, for people over age 65, before Medicare, was around 50%. Not 15 but five zero, 50%. And so here you had a population that had more medical needs, was more expensive, and they had less access to health insurance than younger people. And Medicare was created in part to end that disparity and give them access to reliable coverage.
Rovner: So as you mentioned, Medicare was initially just aimed at elderly Social Security recipients. What were some of the biggest benefit and population changes as the years went by?
Oberlander: So in terms of populations in 1972, Medicare added coverage for persons who have end-stage renal disease, so people who need dialysis no matter what the age. It’s a lifesaving technology. They can qualify for Medicare. It didn’t really make sense to add it to Medicare — it’s just it was there. So they added it to Medicare. And also a population we don’t talk nearly enough about, younger Americans with permanent disabilities who are recipients of Social Security Disability Insurance. For a couple of years they qualify for Medicare as well and are a very important part in the Medicare population. Beyond that, Medicare’s covered population has not really changed all that much since the beginning, which actually would be a great disappointment to the architects of Medicare, who thought the program would expand to eventually cover everybody.
In terms of benefits, the benefit package has been remarkably stable, for better and actually probably for worse, with the exception of, for example, the addition of outpatient prescription drug coverage, which came online in 2006, the addition of coverage for various preventive services such as mammography and cancer screenings. But Medicare still does not cover long-term stays in nursing homes. Many Americans think it does. They will be disappointed to find out it does not. Medicare does not cover, generally, hearing or vision or dental services. Traditional Medicare run by the government does not have a cap on the amount of money that beneficiaries can spend in a year on deductibles and copayments and so forth. So really its benefits remain quite limited.
Rovner: So Medicare is also the biggest payer in the nation’s health care system and for decades set the standard in how private insurance covered and paid for health care. So let’s talk about privatization. Medicare Advantage, the private health plan alternative to traditional Medicare, is now more than half the program, both in terms of people and in terms of budget. Is this the future of Medicare? Or will we look back in many years and see it as kind of a temporary diversion?
Oberlander: I think it’s the present and probably the future. The future is always so hard to predict, Julie, because it’s unwritten. But this is really a shocking outcome historically, because what Medicare’s architects expected was that the program was going to expand government health insurance to all Americans, first with the older population, then adding children, then adding everybody. Did not turn out that way. The original aspiration was Medicare for all, through any incremental means. Instead, 60 years later, we don’t have Medicare for all, but Medicare is mostly privatized. It’s a hybrid program with a public and private component that increasingly is dominated by private insurance. And the fact that over half of Medicare beneficiaries are enrolled in these private plans is a stunning development historically, by the way with lots of implications politically, because that’s an important new political force in Medicare that you have these large private plans and it’s changed Medicare politics.
I don’t think Medicare Advantage is going anywhere. I think the question is, how big is it going to get? And I’m not sure any of us know. It’s been on a growth trajectory for a long time. And the question is — given that all the studies show that Medicare Advantage plans are overpaid, and overpaid by a lot, by the federal government, and it’s losing a lot of money on Medicare Advantage, and it’s never saved money — is there going to come a point where they actually clamp down? There’ve been some incremental efforts to try and restrain payments. Really haven’t had much effect. Are we actually going to get to a place where the federal government says: We need savings, yeah. This 22% extra that you’re getting, no, we can’t do that anymore. So I think it’s an open question about, how big is it going to get? Is it going to be two-thirds of the Medicare program, three-quarters of the Medicare program? And if so, then what is the future, turning the question on its head, of traditional Medicare if it’s that small? And that’s one of the great questions about Medicare in the next decade or two.
Rovner: Thank you so much.
Oberlander: Oh, thanks for having me. It was great to see 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 devices. Julie, why don’t you go first this week?
Appleby: Yeah. I found this story on NPR quite interesting. It’s maybe something that a lot of us have thought about, but it just added a lot of numbers to the question of how many chemicals are in our beauty products — basically, the makeup we use, the lotions, our hairspray, the stuff that happens at the salon, that kind of thing. And it’s called “Many Beauty Products Have Toxic Ingredients. Newly Proposed Bills Could Change That.” And it was written by Rachel Treisman. Basically it says that the average American adult uses about 12 personal care products a day, resulting in exposure to about 168 chemicals, which can include things like formaldehyde, mercury, asbestos, etc., etc. OK, so that’s interesting. But it also talks about how the European Union has banned more than 2,000 chemicals, basically, but the FDA puts limits on only about a dozen.
So this has caused four Democratic lawmakers to introduce a package of legislation, actually they’re calling the Safer Beauty Bill Package, and it’s four bills. And basically one of them would ban two entire classes of chemicals, phthalates and formaldehyde-releasing chemicals. And it also calls for some other things as well, which they say hasn’t been done and needs to be looked at. So I just thought it was an interesting thing that pulled together a lot of data from various sources and talked about this package of bills and whether or not it might make a difference in terms of looking at some of these chemicals in the products we use all the time and requiring a little bit more transparency about that. It’s a step. I don’t know if it’s going to resolve everybody’s concerns about this, but I just thought it was an interesting little piece looking at that topic.
Rovner: It’s worth remembering that the FDA’s governing statute is actually called the Food, Drug, and Cosmetic Act.
Appleby: That’s right.
Rovner: The cosmetics often gets very short shrift in that whole thing. Alice, why don’t you go next?
Ollstein: Yeah. So I have a piece from The Associated Press. It’s called “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals are Ultraprocessed.” And so this really gets at something we’ve been talking about on the podcast, where the administration is really fixated on a few kind of superficial food health things like colored dyes in food and frying something in beef tallow instead of vegetable oil. But something fried in beef tallow is still unhealthy. Froot Loops without the color dye are still unhealthy. And these meals that he is promoting as a service for Medicare and Medicaid enrollees are unhealthy. So this article is about how they do have chemical additives, they are high in sodium and sugar and saturated fats, and so it’s not in sort of keeping with the overall MAHA [Make America Healthy Again] message. But in a way it kind of is.
Rovner: From the oops file. Jessie.
Hellmann: My extra credit is from my colleague Ariel Cohen at Roll Call. It’s called “Kennedy’s Mental Health Drug Skepticism Lands at FDA Panel.” She did a story about something that kind of, I think, flew under the radar this week. The Trump administration is starting to make good on its promise to look at SSRIs [selective serotonin reuptake inhibitors], and the panel was very much full of skeptics of SSRIs who sought to undermine the confidence in using them while pregnant. And Marty Makary himself, FDA commissioner, claimed it could cause birth defects and other fetal harm. That was a statement that was echoed by many of the panelists. There was only one panelist who talked about the benefits of SSRIs in pregnant people who need them, the risks of postpartum depression to both the mom and the baby. And so I think this is definitely something to keep an eye on, is it looks like they’re going to keep looking more at this and raising questions about SSRIs without having much of a nuanced conversation about it.
Rovner: Yeah. I did see something from ACOG, from the American College of Obstetricians and Gynecologists, this week pushing back very hard on the anti-SSRI-during-pregnancy push. So we’ll see how that one goes, too. My extra credit this week is from my KFF Health News colleague Katheryn Houghton, and it’s called “Republicans Call Medicaid Rife With Fraudsters. This Man Sees No Choice but To Break the Rules.” And it’s about something that didn’t really come up during the whole Medicaid debate, the fact that if Republicans really want people to go to work, well, then maybe they shouldn’t take away their health insurance if they get a small raise or a few extra hours. The subject of this story, only identified as James, technically makes about $50 a week too much to stay on Medicaid, but he otherwise can’t afford his six prescription medications and he can’t afford the care that he needs through even a subsidized Affordable Care Act plan, or his employer’s plan, either.
The point of the ACA was to make coverage seamless so that as you earn more, you can still afford coverage even if you’re not on Medicaid anymore. But obviously that isn’t happening for everyone. Quoting from the story: “‘I don’t want to be a fraud. I don’t want to die,’ James said. ‘Those shouldn’t be the only two options.’” Yet for a lot of people they are. It’s not great, and it’s not something that’s currently being addressed by policymakers.
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 a review. That helps other people find us, too. As always, 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 folks hanging on social media these days? Jessie?
Hellmann: I’m @jessiehellmann on Twitter and Bluesky.
Rovner: Alice.
Ollstein: @AliceOllstein on X and @alicemiranda on Bluesky.
Rovner: Julie.
Appleby: @julie_appleby on X.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': The Senate Saves PEPFAR Funding — For Now
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
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.
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Joanne Kenen
Johns Hopkins University and Politico
Shefali Luthra
The 19th
Sandhya Raman
CQ Roll Call
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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