What the Health? From KFF Health News: Trump Almost Unveils a Health Plan
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.
Republicans remain divided over how to address the impending expiration of more generous Affordable Care Act plan tax credits, which will send premiums spiraling for millions of Americans starting in January if no further action is taken. The Trump administration floated a proposal over the weekend that included a two-year extension of the credits as well as some restrictions pushed by Republicans, but the plan was met with strong pushback on Capitol Hill and its unveiling was delayed.
Meanwhile, the Department of Education has declared that a long list of health careers are not “professions,” meaning that students pursuing those tracks — including as nurses, physical therapists, and physician assistants — will no longer be eligible for federal student loans large enough to cover their tuition.
This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.
Panelists
Sarah Karlin-Smith
Pink Sheet
@sarahkarlin-smith.bsky.social
Alice Miranda Ollstein
Politico
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- The news of Trump’s health care plan landed as Sen. Bill Cassidy of Louisiana was working on a separate GOP proposal to direct money into health savings accounts. Congressional Republicans suggested they were left out of Trump’s planning and, among other things, opposed his proposed extension of limited ACA premium tax credits.
- Health and Human Services Secretary Robert F. Kennedy Jr. has confirmed that he ordered the change to the Centers for Disease Control and Prevention website to assert the false claim that vaccines may cause autism. That development puts Republicans in a tough spot — particularly Cassidy, a physician who voted for Kennedy’s confirmation after saying he’d secured an agreement that Kennedy would not make changes to the CDC’s vaccine policy.
- Three states have revived the lawsuit challenging the approval of mifepristone, adding to the case the FDA’s recent approval of another generic version. The Supreme Court threw out the first case, ruling then that the plaintiffs — who were doctors — lacked standing to prove harm. Yet the revived case may very well end up at the Supreme Court again.
Also this week, Rovner interviews Joanne Kenen and Joshua Sharfstein of the Johns Hopkins Bloomberg School of Public Health about their new book, Information Sick: How Journalism’s Decline and Misinformation’s Rise Are Harming Our Health — And What We Can Do About It.
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 Yorker’s “A Battle With My Blood,” by Tatiana Schlossberg.
Alice Miranda Ollstein: CNBC’s “Meta Halted Research Suggesting Social Media Harm, Court Filing Alleges,” by Jonathan Vanian.
Sarah Karlin-Smith: The Guardian’s “Influencers Made Millions Pushing ‘Wild’ Births — Now the Free Birth Society Is Linked To Baby Deaths Around the World,” by Sirin Kale and Lucy Osborne.
Sandhya Raman: KFF Health News’ “Kids and Teens Go Full Throttle for E-Bikes as Federal Oversight Stalls,” by Kate Ruder.
Also mentioned in this week’s podcast:
- The Center for Law and Social Policy’s “Tracking the Harm of DOGE Cuts.”
- The New York Times’ “Kennedy Says He Told C.D.C. To Change Website’s Language on Autism and Vaccines,” by Sheryl Gay Stolberg.
- The Atlantic’s “RFK Jr.’s Miasma Theory of Health Is Spreading,” by Katherine J. Wu.
- NPR’s “‘Nobody Wants To Come’: What If the U.S. Can No Longer Attract Immigrant Physicians,” by Yuki Noguchi.
- Campaign for Accountability’s “AI Chatbots Point Women to Unproven and Unethical ‘Abortion Pill Reversal,’ Report Shows.”
click to open the transcript
Transcript: Trump Almost Unveils a Health Plan
[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 from KFF Health News and WAMU Public Radio in Washington, D.C., and welcome 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 early this Thanksgiving week on Tuesday, Nov. 25, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go.
Today we are joined via video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning.
Rovner: And Sarah Karlin-Smith, the Pink Sheet.
Karlin-Smith: Hi, everybody.
Rovner: Later in this episode, we’ll have my interview with What the Health? panelist Joanne Kenen and Dr. Joshua Sharfstein, both of the Johns Hopkins Bloomberg School of Public Health, about their new book called Information Sick: How Journalism’s Decline and Misinformation’s Rise Are Harming Our Health and What We Can Do About It.
But first, this week’ news. So, for about 24 hours there, it looked like we might have an actual health care plan from President Donald Trump, but, alas, it was not to be. What we all heard about on Sunday felt like a plan with a lot of pieces that could actually be palatable to a lot of Democrats. A two-year extension of the covid-era enhanced tax credits with an income cap higher than the 400% that subsidies are about to revert to, and minimum premiums for those paying zero now. And, not surprisingly, or maybe surprisingly, Republicans on Capitol Hill, particularly those in the House who had been adamant about no extension of the premium subsidies, freaked out, to use a technical term. And now the announcement of the Trump plan has been “delayed.” But there is a deadline this time, Jan. 1, when the enhanced tax credits expire — and, before that, the second week of December, when the Senate is supposed to vote on a subsidy extension. That was the deal that got the government reopened. So where are the Republicans at this point?
Ollstein: It’s a total mess. Very few people have confidence that this will get done at all or in time to make a difference for the cost of people’s health care that has already gone up. So, House Republicans were, one, upset just process-wise. They didn’t like finding out that Trump was going to release a plan from news reports and social media. They felt left out of the loop.
Rovner: On a Sunday?
Ollstein: Congress has been left out of the loop on a lot of things in this administration, and this is yet another one. But they were also opposed to the substance of what was leaked. The few details they have, we still haven’t seen what this actual plan is, but they didn’t like that it was a two-year extension, even with these limitations that conservatives had wanted in terms of cutting off people of higher incomes from getting subsidies and requiring everyone to pay a minimum premium, which research shows will lead to a lot of people losing their insurance. And so even with those limitations, there were a lot of people upset. Meanwhile, on the Democratic side, yes, you had some people being cautiously optimistic about this plan, but then you had other Democratic ranking members in the House on the relevant health committees put out a statement saying, Anything short of a clean extension, without these conservative limitations, anything short of that was unacceptable. And so you really have both sides digging in, and I don’t really see how this gets solved.
Rovner [laughing]: Sandhya, what are you hearing?
Raman: I was going to say that in addition to the House being blindsided, I think it puts the Senate in an awkward position. Senate Republicans, they have been gearing up on an HSA [health savings account] proposal as kind of their alternative to extending the premium subsidies. And Sen. Bill Cassidy [R-La.] has said that he wants to do a hearing the week they come back from Thanksgiving to follow up on the [Senate] Finance [Committee] hearing, and this kind of pushes them in a totally different direction after just a few days ago, Trump himself had said, We don’t want to pay the insurance companies, we want the money to go to the consumers directly, kind of in line with one of the HSA proposals going around. So it caused a lot of confusion, and I think it just really further underscores … I don’t think a lot of people are confident this comes together.
Dec. 15 is when open enrollment ends, and I think that even if you look at some of the bipartisan stuff that has been floated before — even last week we had another one come out that was a little similar to the stuff being floated on Sunday that would extend open enrollment more to give them a little bit more time. But one thing that we kept hearing yesterday was just even the changes that were being floated yesterday, why they weren’t being supported by people that do want an extension is there’s such a short time crunch to implement these changes in basically a month.
Rovner: And now Republicans are talking about doing a whole new health bill, maybe using budget reconciliation so they won’t need Democratic votes. And I guess I’m the one that’s going to have to remind them that the ACA [Affordable Care Act] didn’t pass under reconciliation because there were a whole lot of things in it that they couldn’t put in a budget reconciliation bill. They used budget reconciliation to basically cut a deal between the House and the Senate after the Senate lost its 60th vote. But the original ACA passed with 60 votes. So if the Republicans think they’re going to do something really big next year with just Republican votes, they’re going to find out fairly quickly that a lot of that is not going to be allowed.
Ollstein: Just in time, as our Twitter friend says.
Rovner: Somebody pointed out that it’s been 10 years since Trump said he would have a health plan sometime in the next two weeks. Although as I say, this time two weeks is really going to be important. I feel like poor Sen. Cassidy, who we will talk about later with RFK [Robert F. Kennedy Jr.], also kind of got cut off at the knees by the president because he was all over the Sunday shows talking about his plan to give the money to consumers, which is what President Trump had been endorsing until he wasn’t. So we have no idea where the administration is at this point, right?
Ollstein: And I will say, something that in part led to the postponement and backlash and chaos this week is that folks on Capitol Hill, Republicans and Democrats, have no idea what the White House is going to do about this abortion issue that has been roiling — this whole debate where conservatives are saying that it’s a red line, they have to basically ban all plans on the individual market from covering abortion. Right now, it’s up to states: Half ban them, half don’t. Some require them, some allow them but don’t require them. And conservatives are demanding that there be sort of a blanket ban on that coverage, that any federal funding going to these plans, even if they pay for abortion with other money, they consider that a subsidization. And this has been a real sticking point. Democrats say they won’t accept any expansion of abortion restrictions in Obamacare; Republicans say they won’t accept anything without the additional restrictions, and we still don’t know where the White House is going to come down on this.
Rovner: Because, as I like to say every week, health care is really hard. All right. In big news that’s kind of lost already, Reuters is reporting that the White House has terminated DOGE, the Department of Government Efficiency, eight months early. In practice, DOGE has been dormant for many months, even before the departure of Elon Musk back to his day jobs at Tesla and SpaceX. But DOGE has left behind a lot of cuts. The nonprofit Center for Law and Social Policy has a tracker of all the funding and personnel changes made by the administration down to the program level, including at HHS [the Department of Health and Human Services]. I will post a link to it in the show notes.
But if you want a more personal look, you should go read my extra credit this week, which we can all talk about now. It’s an achingly beautiful New Yorker piece by Tatiana Schlossberg, daughter of Caroline Kennedy and granddaughter of JFK [President John F. Kennedy]. Tatiana, an environmental journalist and mother of two young children, is dying of a rare and difficult-to-treat form of leukemia. Among other things, she was undergoing rounds of ultimately unsuccessful treatment while watching huge cuts to health care research being made at the direction of her cousin RFK Jr., all the while realizing how those cuts will likely threaten the survival of patients like her. I heard a lot about this story over the weekend, and I wonder if it might have some impact reaching the public about what the HHS cuts are likely to mean going forward in a way that just the numbers being repeated haven’t.
Karlin-Smith: I think, I mean, it’s such a human connection story, and when she talks about not probably being able to live to see her kids grow up and the kind of research NIH [the National Institutes of Health] was funding that maybe would’ve given her a little bit of hope with a clinical trial that was working. One thing I thought about a lot reading this is she talks about how she’s, I guess, 34 or 35, she felt like she was young and healthy, she was very active, ate right. And one of RFK’s way of thinking, I guess, in the way of orchestrating his health goals is this idea that if you eat right and you exercise and you take certain personal responsibilities, you can avoid illness. And there are lots of kinds of illnesses that, unfortunately, you can do the best you possibly can on an individual personal level and you are not unfortunately exempt from getting, and cancers are one of them. And it’s not to say that there cannot be any role for those other things that can maybe help keep you healthy and prevent certain diseases, but it’s interesting to think about her realization around what can happen to you even if you’re trying your best to live a healthy lifestyle, and the juxtaposition of an administration that is, and their policies also, forgetting that this is not just based on what you eat and how often you exercise and so forth.
Rovner: To quote President Trump, who was talking about something else entirely, “Things happen.” It goes back to the ACA discussion. People who are young and healthy and think they don’t need health insurance because nothing bad is going to happen to them, and a certain number of people … bad things are going to happen no matter how exemplary healthily they live their lives. That’s why we have health insurance. Well, meanwhile, over at HHS, Secretary Kennedy over the weekend confirmed to The New York Times that he was personally responsible for the website changes at the Centers for Disease Control and Prevention that now say scientists “have not ruled out the possibility that infant vaccines cause autism.” Just a reminder, this was a change that Kennedy had promised HELP [Health, Education, Labor & Pensions] Committee chair and gastroenterologist Bill Cassidy he would not make in exchange for Cassidy’s vote to confirm him in the Senate. Yet Cassidy still demurred when asked on the Sunday shows if he regrets being the deciding vote to make Kennedy the secretary. I’m wondering if Cassidy is the new Susan Collins, the main moderate, who continually said during Trump’s first term that she was very, very concerned about many of the president’s policies, but still declined to vote against most of them. Has Cassidy kind of replaced her in that role?
Ollstein: I think Cassidy is really in a situation of his own. I don’t think he’s the new anything. I think he’s the first Cassidy, and maybe in the future we’ll be referring to other Cassidys. But I think given his medical background, and not just any medical background, like given his background specializing in hepatitis, which is one of the vaccines that people are most anxious will become unavailable or restricted in the future, and given his direct role in extracting promises in order to confirm RFK and now having those promises pretty blatantly stepped on and there not really being much repercussions. Also, him being up for reelection next year. I think it’s quite unique, all of those dynamics, as much as we see parallels with some other members.
Rovner: Yeah, it’s true. I’ll say Collins is a moderate because she comes from a moderate state. Cassidy’s from Louisiana, which is not a moderate state, it’s a very red state. So he does find himself in these extremely uncomfortable positions. Well, it’s not just vaccines and not just the CDC that’s turning against settled science. Over at the National Institutes of Health, reports Katherine [J.] Wu at The Atlantic, leaders have a new pandemic preparedness plan that suggests that rather than study pathogens and develop and stockpile vaccines, the country would be better off eating better and exercising. This kind of goes back to what you were just saying, Sarah. I’m not sure to where to start with this, other than I guess it’s better to be healthy than not. But as we’ve pointed out, even healthy people are susceptible to germs.
Karlin-Smith: Right. And so one thing her piece raises is that Kennedy, in particular, has sort of dismissed germ theory, which does not quite believe in the way that most scientists and people do of these roles, of these infectious organisms in disease. And while Katherine’s piece, I think very nicely, talks about there is some element of somebody who is not able to feed themselves enough of the right quantities of food may do worse with an infectious disease, but at the end of the day it’s about your immune system being exposed to these viruses and having some knowledge of how to fight them off. And so younger people, like in the 1918 flu, actually, in some cases would say we’re dying at higher rates even than older people. Obviously again, the pre-vaccine era, this is why so many children under the age of 5 died young. It wasn’t that these were all children born with particularly unhealthy lifestyles or something about them that made them more likely, it was just that their body needed to somehow learn to experience this antigen.
Rovner: We call them childhood diseases for a reason, right?
Karlin-Smith: Right. And I think Katherine Wu does a really good job of talking about the multifold strategies you need to be able to be prepared to fight a pandemic. And being so close to covid still, knowing that bird flu and different strains of bird flu are circulating, it does seem a bit concerning that people may be changing the forms of preparation that we’re preparing for rather than building up.
Rovner: Well, meanwhile over at the FDA, the sharp knives remain out among the top deputies to Commissioner Marty Makary. The latest missive comes from newly appointed drug regulator Richard Pazdur, who unlike many of his fellow center directors is actually a veteran of the agency. But Pazdur has reportedly warned that some of the new FDA efforts to speed the approval of drugs, including deals that trade faster reviews for lowered prices, could be illegal and dangerous to the public health. Sarah, what is going on over there?
Karlin-Smith: Yeah, so it’s been an untraditional year at FDA in terms of how this commissioner operates, but Makary’s what’s called this Commissioner National Priority Voucher program has rolled out in more detail over the past couple weeks. It’s designed to give companies a two-month review, which most FDA reviews tend to be in the six-[month] to one-year time frame. So two months is superfast. And the criteria for qualifying to try and get that is really vague, and it essentially at the end of the day results to the commissioner in their close circle kind of picking who they want. That’s raised a lot of questions because it’s just not clear. They have sort of a fair and established process. Makary has also suggested that if you give commitments to keep the price of the product low, or deal with Trump on his most-favored-nation pricing deal, we’ll give you this.
And FDA does not deal with drug pricing. It has no levers or authority to, if a company says, “Of course Marty, we’ll price this product at a fair price if you give us a two-month review.” They have no levers to enforce that, to determine what a fair price is, and it also raises ethical questions of Should FDA? And potentially again, legal questions, Does FDA have the authority to prioritize an application because a company makes these commitments over another application where a company doesn’t? And is that fair? Particularly, you have to think about normally FDA is prioritizing things based on how devastating the disease is or how quickly it kills things or are there other treatments? And so some of the criteria Makary is using, I think, is striking people as a bit more political in that sense.
Rovner: Yeah. Well, moving on to a segment called “Honey I Shrunk the Health Care Workforce,” you might’ve heard that the Trump administration is busy dissolving the Department of Education and transferring its responsibilities to other agencies. On its way out of existence, however, the department has determined that a long list of health care careers don’t qualify as professions, including nursing, social work, physical therapy, public health, and physician assistants. This is not just semantic, it means that people studying for these graduate degrees won’t be able to get federal student loans for anywhere near what tuition costs. And this comes at a time when the U.S. badly needs more, not fewer, of these health professionals for an aging and increasingly less healthy population. In fact, this feels like a way to make health care more, not less, expensive, since many of these professionals can do work otherwise done by higher-paid medical doctors. Am I missing something here?
Raman: I think you’re exactly right, especially as over the last few years we’ve seen in Congress them really ramping up, looking at ways to expand the pipeline of workers. You can’t create a health worker overnight. The more advanced the degree, the longer it’s going to take. And I mean, I think it’ll take a little while to see some of the effects of this if it stays in effect, because there’s going to be people that maybe won’t even consider some of these fields rather than if they’re midway through or about to enter one, if they know that it’s not going to be something that their family or themselves can afford. At the same time, as we’re going to have the population aging and we’re going to need more and more of these folks, so I think it’s a two-pronged thing that we’ll see over time.
Rovner: Yeah. And I know in my workforce studies, I’ve seen a lot of people who wanted to be doctors who ended up going to nursing school or physician assistant school because it was so much cheaper and it took less time, so it was sort of an easier career path. But this is throwing up another roadblock. It just seems like, why are they doing this? I guess nobody has yet said … I have to tell you, I’ve gotten dozens of emails from organizations representing a lot of these career professionals saying, “What are they doing here?” It seems puzzling.
Karlin-Smith: Some of these professions, like public health workers, don’t end up making the most money once you come out. So people talk about how well doctors, med school, is really expensive and they don’t make enough … but eventually you recover from that process. And in some of these professions, like public health, it really might not just make it totally unviable for people to go into the field because they don’t have that guarantee they’re going to be able to get a salary that will ensure they can repay their loans afterwards.
Rovner: Yes. Well and speaking of doctors, Yuki Noguchi over at NPR has a smart story about how the administration’s crackdown on immigration is giving international medical school graduates pause about wanting to come practice in the U.S. This is also a big deal because immigrant physicians are not only a big part of the physician workforce in general in the U.S., but in areas with the biggest doctor shortage they often make up as much as half of the doctors in practice. Since this administration is all about affordability, the combination of these two policies seems likely to create a giant shortage, yes?
Ollstein: Yeah. We’re cutting off our domestic pipeline and we’re cutting off our international pipeline, and this is coming … there are already shortages. There was so much burnout and people retiring early and people quitting during and after the pandemic, and this couldn’t come at a worse time, really. And there’s more punches than the one-two punch. People are also concerned about the high-skilled worker visa fees going up and that making it harder to bring in international medical workers for hospitals that are already struggling to pay an extra fee of tens of thousands of dollars is not really viable right now. So yeah, there’s a lot of concern.
Rovner: And it’s certainly not going to bring down medical prices, which I guess is maybe what I mean. I know that in the case of the cap on medical school tuition, the hope is to bring down tuition, is to force tuition down by not making the loans big enough. But it’s one thing to say that having unlimited loans is inflationary and allows tuition to go up; it’s another thing to say that cutting off the loans is going to make tuition go down.
Raman: Yeah, I mean it’s a complicated process when you also have, I mean, for a variety of degrees, the international students are often paying full price, and that subsidizes the cost of some other folks going. So there are many pieces of this puzzle, so it’ll be interesting to see what happens next.
Rovner: We will continue to watch this space. OK, we’re going to take a quick break. We will be right back.
So turning to the “everything that is old is new again,” now we have the return of the public charge rule, which Trump tried to rewrite during his first term to make it harder for immigrants to qualify for permanent residency, only to have it reversed by the Biden administration. Alice, remind us what this is and what Trump 2.0 is trying to do that’s different from what Trump 1.0 did.
Ollstein: Right. So this has gone back and forth, and it’s not a straight, clear-cut revival of the policy under the first Trump administration. I think in part that’s because that one was struck down in court, and so this trends of the new. So, basically, after the comment period and when things get finalized, this is giving, instead of directing all immigration officers to deny permanent residency applications to people who have used Medicaid and have used these social safety-net programs, it’s basically just leaving it up to the individual officer. And there’s language about considering the totality of circumstances, and so there’s a lot of concern in the immigration advocacy community that this will lead to discrimination and decisions made based on basically vibes of if someone seems like they might become a burden on society later, and so I expect there will be lawsuits for sure.
There is already a lot of concern, even though this hasn’t gone into effect yet, about having a chilling effect on immigrants who are perfectly eligible and can legally qualify for these programs not using them, avoiding health care, avoiding preventive care, avoiding testing and treatment for infectious diseases. And there were several studies about the impact of this policy in the first Trump administration that showed that it really took a toll on public health. And we live in a society if you pass a policy that impacts one part of the population, it’s going to impact other parts of the population. And so this is predicted to make things harder for citizens as well, both the cost of care and the spread of infectious diseases.
Rovner: All right. Well, finally this week, moving on to reproductive health. Remember that lawsuit in Texas that was filed by a group of anti-abortion doctors that wanted to reverse the FDA’s approval of the abortion pill mifepristone? Well, the doctors are no longer part of the lawsuit because the Supreme Court said they didn’t have standing to sue, and the case is no longer in Texas, but it is still around. And now the three states that are pursuing it, Missouri, Kansas, and Idaho, are adding to their suit the FDA’s recent approval of a second generic of the original abortion pill. Alice, how is this case still going? And now what happened?
Ollstein: It’s very much still going. It’s just been bouncing around, and now it’s being considered by a whole different court in a whole different state and they’re going to start the process all over again. And I wouldn’t be surprised if it made it all the way back to the Supreme Court, even though it’s already been there with different plaintiffs. So there was a lot of outrage in the anti-abortion community about the recent approval of another generic of mifepristone, even though the way that works is if it’s chemically identical to the versions that have been already approved, it kind of automatically goes through and it doesn’t really have anything to do with the other things they’re challenging. It’s just something else that they’re upset about.
Rovner: So they’re adding it to it. Well, we will watch that lawsuit too. And last, we don’t talk enough about AI [artificial intelligence] in health care, but a study caught my eye this week from the nonprofit Campaign for Accountability that found a number of chatbots, when asked about medication abortion, gave instructions to call a hotline that urged those with unplanned pregnancies to try “abortion pill reversal,” which is not a thing, although it is pushed by many anti-abortion activists. This appears to be a case where the flood of misinformation so outnumbers the real information that the chatbot thinks that the misinformation is the right answer. Quantity over quality, if you will. This feels like kind of a major flaw in using AI, not just for abortion questions, but for health information in general, given how much health misinformation is out there.
Raman: I think we’ve seen this in other types of health care, where they’ve tried to roll out some of these chatbots to help with different things, especially like mental health, and it’s backfired for different reasons because of it might promote something that it shouldn’t for that group. I think there was one at one point where it was offering dieting tips to someone with an eating disorder, just things that maybe might be applicable to someone else but not to that specific group. So there are definitely things that need to be hammered out in this.
Rovner: Yeah, I feel like we’re having sort of a real-time clinical trial of how AI works with the general public in health care, and I don’t know who is really keeping track of what it is doing.
OK. That is this week’s news. Now we will play my interview with Joanne Kenen and Joshua Sharfstein about their new book, and then we’ll come back and do our extra credits.
I am pleased to welcome to the podcast Joanne Kenen and Dr. Joshua Sharfstein, two of the three authors of the new book Information Sick: How Journalism’s Decline and Misinformation’s Rise are Harming Our Health — And What We Can Do About It. Our regular listeners all know Joanne, she’s the former health editor at Politico who now teaches at the Johns Hopkins Bloomberg School of Public Health and writes for Politico Magazine. Joshua Sharfstein, who I’ve known almost as long as I’ve known Joanne, is distinguished professor of the practice at Johns Hopkins Bloomberg School of Public Health. He’s a physician who’s worked on Capitol Hill and at the Food and Drug Administration, and also served as the city of Baltimore’s public health commissioner and the State of Maryland’s secretary of health and mental hygiene. Joanne and Josh, thank you so much for joining us.
Joanne Kenen: Thanks for having us.
Joshua Sharfstein: Great to be here.
Rovner: So first, explain the title. What does “information sick” mean?
Sharfstein: Well, “information sick” is a diagnosis. It’s a diagnosis both of individuals who are confused by information about health that they’re getting, and as a result can’t make good decisions for themselves and their families. And it’s also a diagnosis for our society, that there’s so much bad information on health out there, there’s so little good information that as a country, we’re at risk of making some bad decisions on health policy.
Rovner: So I have kind of a mea culpa. We have spent a lot of hours on this podcast talking about how public health officials should be doing a better job communicating to the public, combating mis- and disinformation, but without really addressing the other side, the decline of journalism. Joanne, how much of the problem is how information is communicated to the public by health officials, and how much is the changing ways that people are actually communicating with each other?
Kenen: That’s what our book, where they explore it, is this nexus. There’s been lots written about the decline of journalism, there’s been lots written about failures of public health communication, some of which may be overstated actually, and some of it’s clearly mistakes have been made. But the connection is something that we really explored starting in the class we taught a couple of years ago, and then putting together the book. People do not get information in the ways that we grew up getting information. Local news has really been eviscerated in large parts of the country. There’s county after county that does not have any local news, or that has something very meager. And that was trusted, it’s still trusted where it exists, that was a way people got health information. National news is polarized, with some outstanding exceptions. There’s just not a lot of policy news that people get. And people instead, particularly younger people, are getting … instead of their doctor, they’ve got their TikTok. And there’s a lot of wrong stuff. And it’s not only vaccines, it’s pretty much everything.
Rovner: So how much of the problem within the information ecosystem is information that’s just wrong because it’s being distributed by non-experts, and how much is from actual bad actors, those with either a potential monetary gain from spreading bad information or those purposely trying to sow discord?
Sharfstein: Well, one of the challenges is that there isn’t really good information because social media companies, in particular, have not been very forthcoming about what is on their site. It’s very clear that there are bad actors, as you say, including nations that are deliberately putting out information to confuse Americans, and including people who are really trying to make a quick dollar selling things that really shouldn’t be on the market. But there’s also a big gray area because sometimes information gets seeded, but people are passing it on, believing it to be true. And so it’s not all one or all the other, but the quantity of information that’s out there that is not reliable is staggering — so much so that this idea of a public health communication is, to some experts in the field, almost laughable because it will get washed away by the tidal wave of misleading information and make it very hard for people to know what to believe.
Kenen: There’s a communication media element in this, too. Because if you’re a reporter working for a little tiny newspaper that used to have maybe five or six reporters, and someone could have developed some expertise in health, you know, when you can, if you’re on a national beat doing it full-time, but you can develop some confidence in knowing what you’re talking about. If you’re now one of two reporters and you’re covering eight beats and health is one of them, and you don’t have an editor who can mentor you on health either, there’s a lot of bad reporting. And it’s what we call false equivalence a lot. If you don’t know if this source is an expert, and that source is a charlatan, or vice versa, you tend to put them both as equals. So they’re in the newspaper story or on the local news where you have somebody saying, “Vaccines are safe,” and somebody else saying, “They’re toxic, damaging, barbaric things that are going to kill us all.” So you’re getting something from a news outlet that you should be able to trust, but because of the shrinkage and lack of resources and lack of money and lack of expertise, you end up inadvertently feeding the misinformation monster.
Rovner: So yeah, some of it is deliberate, and some of it is kind of accidental because of the decline of journalism. So, luckily, your book doesn’t just lay out the problem, you also offer up some potential solutions. Joanne, can you summarize how journalism can do a better job of curing information sickness? And then, Josh, can you talk about how the health community can do its part?
Kenen: Well, I think that in journalism, if you’re a young reporter starting out and you don’t have the resources to do your job, there are some tools and resources. There’s more and more training opportunities in health, medicine, climate, other areas. So you can get some free training online, and I would urge anyone who’s starting out on this beat … and not just on the beat. I mean if you’re a business reporter or a politics reporter or a general assignment reporter, you’re a health reporter, you’re going to end up doing this. So there are a number of programs through philanthropies and universities, as well as journalism organizations, to bolster local news and bolster health reporting. So anyone who falls into that category who is listening, do it. You won’t come out with an MPH [master’s of public health], but you’ll come out with knowledge and confidence and competence.
Congress had been talking for, I don’t know, 15 years or so about tax breaks and other things to prop up journalism. It’s not going to pass now if it hasn’t passed in the last 15 years, I don’t see that happening in the current environment. The consolidation that we’re seeing in the media and TV stations is probably going to make it worse, not better. So if we tell our students, “There is a lot of free stuff out there. You can be informed without spending three hours and hundreds a day trying to read everything.” Our podcast is free, KFF is free, KFF Health News is free. There are things you can do to get quality information and quality journalists.
Rovner: And Josh, what’s the role of the public health community in this changing information environment?
Sharfstein: There’s a big role. And I would first echo Joanne’s point that there are new and emerging sources of journalism that are really important. The nonprofit sector is growing, and there are some large organizations, like KFF, there are some specific ones, like The Trace that covers gun violence. There are new outlets for specific communities that are really doing high-quality work, and we should all be supporting them. And in a sense, I’ll start there, because I think journalism and health and public health are facing a similar kind of challenge, and we should be supporting each other in addressing it.
Within the health sector, the first thing is getting the diagnosis right. That’s the right thing to do for a patient; it’s the right thing to do here. Information is not just something that is provided by a public health official or communicated by a health care official. It’s actually a determinant of health. How people get information, what that information says, is incredibly important for their health. And we have to realize that that fundamental determinant is in jeopardy right now. And then I would say that there are several things that are really important. The first is to engage, to not just say, “Well, that’s just not my job. I’m not going to learn the whole new TikTok thing.”| People have to realize where this information is coming from and do their best themselves and through partnerships to get better information out on these channels, and engage with the channels to try to find ways for the algorithms not to take people down a conspiratorial rabbit hole at every opportunity. The second thing, particularly for health care organizations, is to train clinicians so that they’re not just stunned and defenseless when people come in and say, “I’m not going to do chemotherapy. I’m instead going to do some unproven nutritional treatment instead.” And help their clinicians leverage the great relationships that they have with patients to be able to talk people down from the most severe manifestations of being information sick.
And the third element that I would highlight is that health care and public health have an opportunity, and really a responsibility, to win the battle in real life. Like, the online world is a mess. And a lot of the different techniques that we looked at, like fact-checking and debunking and pre-bunking and all these different ideas, have promise, but really have not won the situation. It’s a mess online. But in the real world, it’s possible to have networks of clinicians and faith leaders and business leaders and political leaders who are standing arm in arm and saying, “This vaccine really does matter and will keep people in our community safe.” And for health departments, this is a real opportunity to reconnect with some of those community roots and do great work literally in each other’s presence. In Baltimore here, there was a network of community health workers that played a really important role in bolstering vaccine confidence during the pandemic. It’s one of the reasons that Baltimore did quite well in terms of covid mortality. So I think that there’s a big agenda here, and of course it’s an agenda at a very difficult time for both health care and public health in 2025.
Kenen: I think that one thing that we learned about a lot as we researched this, it makes sense when we say it to people, they all nod, but understanding why information has power. There’s a lot that people researching it don’t understand yet, like why once people buy into a myth it’s so hard to get it out of their brain. But what does it do? It appeals to our fears, it appeals to our anxieties, it appeals to our resentments. Social media does not make you feel calm and serene and confident, it makes people agitated and angry. And it’s not a coincidence that there was disinformation before the pandemic and there’s disinformation after the pandemic, but the flowering and the sort of exacerbation during the pandemic, it’s partly because we were so vulnerable to it. We were feeling fear and resentment and anxiety, both about health and about the economic dislocation during the pandemic, particularly that first year. So we were really vulnerable, and people who were spreading it, the ones intentionally, in particular, really were able to sort of exploit that vulnerability that we had. There’s a lot of research. The role of AI is going to change things for good and bad. I mean, anything you write about this about disinformation is somewhat out of date tomorrow. But I think it’s useful for people to understand that what they’re being opposed to that’s so catchy and grabs them is often really bad for them.
Rovner: Yeah, well, bigger societal problem. But thank you for writing this book. Joanne Kenen and Joshua Sharfstein, thanks for joining us.
Sharfstein: Thanks so much.
Kenen: Thanks, Julie.
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. I have already done my extra credit this week. Sarah, how about you go next?
Karlin-Smith: I took a look at a piece in The Guardian called “Influencers Made Millions Pushing ‘Wild’ Births — Now the Free Birth Society Is Linked To Baby Deaths Around the World,” and it chronicles a movement started by two women using podcasts and Instagram and social media. And it’s not just a movement, I would say it was a business for them. I think The Guardian piece says they made about $13 million basically convincing people to give birth at home with no medical support at all. No midwife, nothing of the sort. And they oftentimes even seem to discourage people when they are in medical distress, or their baby is in medical distress, while birthing from going to the hospital. It has led to babies being born with various birth defects or disabilities that they would not otherwise have been born with. It has led to deaths of babies and, possibly, women.
And I think one thing that stood out to me is a lot of women the story talks about seem drawn to this movement for a couple of reasons. One is how high cost the U.S. health system is in terms of to get good midwifery care, go to a hospital, see an OB-GYN. So some people were drawn to it just because they felt like they couldn’t afford it, and this seemed like a good option. And other people were drawn to it because they had some kind of bad or traumatic experience giving birth the first time in the traditional medical system and were sort of ripe to be really taken advantage of and exploited.
Rovner: Yeah, it was quite a story. Sandhya, why don’t you go next?
Raman: So I picked “Kids and Teens Go Full Throttle for E-Bikes as Federal Oversight Stalls,” and that’s from Kate Ruder for KFF Health News. And this story looks to see are these bikes safe for kids? And that it’s a difficult thing to kind of spell out. There’s not a ton of federal regulations on e-bikes, and it’s a patchwork on the state and county level. And I learned a lot, I think, just because I didn’t realize that there’s no age for operating an e-bike at the federal level, but it’s kind of piecemeal at the state level for other types of motorized vehicles. So it looks at some of that and just kind of what the gaps are and some of the regulations that have been pulled back in recent months.
Rovner: As somebody who almost got taken out by, like, an 8-year-old on a motorized vehicle a couple of weeks ago, I very much felt this story. Alice?
Ollstein: So speaking of things that are bad for young people, this story is from CNBC reporter Jonathan Vanian. It is about through a lawsuit … so parents, school districts and state attorneys general have been suing social media companies, primarily Meta, which owns Facebook and Instagram, for negative mental health, emotional health impacts on young people. And through the discovery process in these lawsuits, they uncovered that Meta did research back in 2019 and found that people who stopped using these apps, even for just a week, experienced less depression, anxiety, loneliness, and social comparison. And they buried that finding and did not disclose it. And so this is coming out in the lawsuit. And they uncovered a quote from a Meta employee who said, “If they didn’t release the research, they risked looking like tobacco companies,” who found through their own research about the addictive and damaging properties and did not disclose them, and how that was a bad look later. So this is important to keep in mind as we all marinate our brains in it.
Rovner: That’s right. And another lawsuit that we will keep an eye on.
OK. That is this week’s show. Thanks, as always, to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts. As well as, of course, kffhealthnews.org. 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 folks hanging these days? Sandhya?
Raman: @SandhyaWrites on X and on Bluesky.
Rovner: Alice?
Ollstein: @alicemiranda on Bluesky, and @AliceOllstein on X.
Rovner: Sarah?
Karlin-Smith: @SarahKarlin or @sarahkarlin-smith, on X and Bluesky.
Rovner: We’ll be back in your feed next week. Until then, have a great holiday and be healthy.
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What the Health? From KFF Health News: The GOP Circles the Wagons on 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.
Millions of people in Republican-dominated states are among those seeing their Affordable Care Act plan premiums spike for 2026 as enhanced, pandemic-era subsidies expire. Yet Republicans in the White House and on Capitol Hill are firming up their opposition to extending those additional payments — at least for now.
Meanwhile, Democrats may not have achieved their shutdown goal of renewing the subsidies, but they have returned health care — one of their top issues with voters — to the national agenda.
This week’s panelists are Julie Rovner of KFF Health News, Paige Winfield Cunningham of The Washington Post, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.
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Paige Winfield Cunningham
The Washington Post
Joanne Kenen
Johns Hopkins University and Politico
Shefali Luthra
The 19th
Among the takeaways from this week’s episode:
- Democrats’ focus on insurance costs has pushed health care back into the national spotlight. But far from a bipartisan compromise, lawmakers remain split over how to address the issue, with the enhanced premium ACA subsidies still set to expire and top Republicans musing about instead putting that money into health savings accounts.
- A new change to the Centers for Disease Control and Prevention website suggests a link between vaccines and autism, amplifying the unsubstantiated claim championed by Health and Human Services Secretary Robert F. Kennedy Jr. Meanwhile, the Trump administration is facing blowback over a major report on transgender health that was written by critics of such care — and without peer review.
- And some Republicans are seeking to tie ACA subsidies to abortion restrictions, providing only the latest example of how the issue regularly becomes tangled in government spending battles. Democrats are unlikely to agree to such changes, especially if Republicans push to direct subsidies into health savings accounts — meaning, theoretically, that any abortion limitations there would be targeting citizens’ private funds.
Also this week, Rovner interviews Avik Roy, a GOP health policy adviser and co-founder and chair of the Foundation for Research on Equal Opportunity.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: CNBC’s “Cheaper Medicines, Free Beach Trips: U.S. Health Plans Tap Prescriptions That Feds Say Are Illegal,” by Scott Zamost, Paige Tortorelli, and Melissa Lee.
Paige Winfield Cunningham: The Wall Street Journal’s “Medicaid Insurers Promise Lots of Doctors. Good Luck Seeing One,” by Christopher Weaver, Anna Wilde Mathews, and Tom McGinty.
Joanne Kenen: ProPublica’s “What the U.S. Government Is Dismissing That Could Seed a Bird Flu Pandemic,” by Nat Lash.
Shefali Luthra: ProPublica’s “‘Ticking Time Bomb’: A Pregnant Mother Kept Getting Sicker. She Died After She Couldn’t Get an Abortion in Texas,” by Kavitha Surana and Lizzie Presser.
Also mentioned in this week’s podcast:
- The Washington Post’s “Fight Over Abortion Could Doom Congress’s Health Care Plans,” by Riley Beggin and Theodoric Meyer.
- The Wall Street Journal’s “RFK Jr. Discussed Curbing FDA Head’s Role After Complaints About Management Style,” by Liz Essley Whyte.
Click to open the transcript
Transcript: The GOP Circles the Wagons on 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 from KFF Health News and WAMU Public Radio in Washington, D.C., and welcome 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, Nov. 20, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go.
Today, we are joined via video conference by Paige Winfield Cunningham of The Washington Post.
Paige Winfield Cunningham: Hi, Julie.
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: Later in this episode, we’ll have my interview with Avik Roy, longtime Republican health care adviser and chair of the Foundation for Research on Equal Opportunity. But first, this week’s news.
So, Democrats may not have “won the shutdown,” but they definitely got health reform back on the national agenda. The last time we had such a full-scale health debate was in 2017, which didn’t end particularly well for Republicans. For a while, it looked like there might be enough Republicans who were worried about — oh, I don’t know — their voters seeing their ACA [Affordable Care Act] insurance made effectively unaffordable that there might be a compromise in the offing. But now it seems that ship has sailed, and the two sides have retreated to their respective corners. That certainly seemed to be the case at the Senate Finance Committee hearing on Wednesday, where Republicans and Democrats basically talked past each other for three hours. Am I missing something? Is there some glimmer of hope here that I’m not seeing that when they have this vote in a couple of weeks, the Republicans are all going to say, Yeah, let’s extend those subsidies?
Winfield Cunningham: It’s funny, Julie, I was thinking, was it last weekend, I think, that Trump tweeted about we need to bypass the insurers and send the money directly to consumers? And for a couple of days, there was all this buzz around Is this going to be yet another chance for Republicans to do something big on health care? And the whole time I was thinking: Was anybody around in 2017? This isn’t going to go anywhere. And especially, you could sort of predict this just because calls to redirect the subsidies — which are a core part of the ACA — away from the marketplaces, also a core part of the ACA — directly into tax-free savings accounts obviously [were] always going to be a no-go with Democrats. So the idea that this was kind of what Republicans were talking about, this isn’t even in the realm of possibilities that could be a bipartisan agreement on health care.
There seems for a little while to be a semi-earnest effort in the Senate to come up with some kind of bipartisan plan. I know I spoke with folks for Sen. [Jeanne] Shaheen [D-N.H.] earlier this week who say they’ve been talking to 10 to 12 Republican offices who say they’re interested in some kind of deal and extending the subsidies. But honestly, when you start stacking up all of the barriers that would be in the way of getting a deal, one of them is abortion funding. I mean, this seems —
Rovner: We’ll get to that later. Don’t jump the gun on that.
Winfield Cunningham: But that’s a huge one. And then also, just the inability, and just how far apart the parties are on talking about health care affordability and how you manage to bring down costs for people. It’s just really hard to see this going anywhere. So, my prediction is that we see Republicans kind of coalesce around their own thing. Democrats coalesce around their own thing. And ultimately, we don’t see an extension of the subsidies.
Rovner: What happens in January, though, when people actually start coming to town hall meetings and saying: Hey, we had to give up our health insurance because it was going up $4,000 a month? Might this build when these cuts actually occur in January?
Kenen: The Republicans have floated health savings accounts for actually a couple of decades now.
Rovner: Since the 1990s.
Kenen: Right, that’s decades.
Rovner: The first pilot project was in HIPAA [Health Insurance Portability and Accountability Act] in 1996.
Kenen: And it is not what people want. I mean, it is what some people want in conjunction with an HSA alone. There are plans that are a combination of — in the exchange it would be a “bronze” — but this is not what the American people have. … They have not been saying: Please, take away my health care, and give me a couple of thousand bucks instead. That’s not what we’re hearing, or my health insurance, I should say, and take away.
Rovner: That’s the point. Also, I’m seeing all these Republicans now saying we should not be giving money to the big, rich, bloated insurance companies, who we do know are unpopular instead —
Kenen: Except for Medicare Advantage.
Rovner: Thank you for finishing my sentence. So, finish my sentence for me, Joanne.
Kenen: Medicare Advantage, which has bipartisan support now — not without some qualifications and criticism — Medicare Advantage is here. Many Democrats use it, and many Democratic lawmakers support it. But Medicare Advantage is private insurers who are being paid more than government-traditional Medicare to pay for people’s health care. So it is not a coherent, well-thought-out ideologically, or technically, or politically savvy plan that is going to solve the Republicans’ problems on Jan. 1, Jan. 2, Jan. 3, and you name the date after that. People who got subsidies for health care insurance are going to lose them, and many of them are [President Donald] Trump voters. And that’s a reality, period.
Rovner: Paige, I know you’ve been looking into this pretty closely. Is there anything new here? I mean, it does seem that giving people money to go out and bargain on their own has been the Republican mantra, I know, since the 1990s. They’ve had all this time. Where is the plan?
Winfield Cunningham: Let’s just think about the numbers here on HSA. So, I think the average subsidy [that] the average marketplace consumer gets is around $6,500. OK, that’s fine — great — if you’re healthy. If you’re sick — if you have diabetes, or you have cancer — say you have $6,500 in your account, [and] you don’t have health insurance, that’s not going to come anywhere close to the cost that you need to cover your cost of care. So this whole conversation isn’t about the healthy people, right? The conversation is about the sick people who bring up the costs, who need the insurance, who can’t afford the care. And HSAs and FSAs [flexible spending accounts] — especially HSAs, though — I think are largely used by wealthier people, healthier people, and it is a way to maybe put a couple extra hundred bucks in your pocket to pay for health care. It is not a sweeping long-term solution to making sure that people can afford the cost of care.
Rovner: Right. It’s a great way to pay for your eyeglasses and your dental care, maybe, if you don’t need a lot of dental care.
Kenen: It’s not just sick people. It’s also pregnancy. It’s also people who are healthy until they get sick. You can —
Rovner: I keep saying this: I fell and broke my wrist, and it cost $30,000. $6,500 would not have begun to put a dent in it. Sorry, Shefali. You wanted to say something?
Luthra: No, I was just going to say to Joanne’s point about pregnancy and your point about breaking bones: Some of the people who are most vulnerable in this kind of situation [are] families. Maybe you give birth, something the administration really talks about supporting. Maybe, I don’t know, you use fertility treatment. Maybe you have two kids. One gets the flu; one breaks a bone. These are not expenses you anticipated. And the very core of this pronatalist, conservative ideology of supporting families, helping it become easier to raise children, becomes a lot harder when you don’t have affordable health insurance.
Kenen: I mean, there are some. [Louisiana Republican Sen. Bill] Cassidy’s plan is a little different. Democrats are still not going to love it. It is money in your pocket of a health savings account or a flexible spending account — I keep reading different details of what it is — combined with some kind of health insurance so that the exposure is not infinite, but it’s also not nothing. It’s not the same as Trump’s plan. There’s more protection for people in his version. But we haven’t really seen what his version looks like in detail. I keep reading about all these proposals, and I can’t figure out exactly what they look like because I don’t think they know yet.
Rovner: Right, I don’t think they’ve been put on paper yet.
Winfield Cunningham: Well, yeah, I asked Cassidy’s office for details earlier this week, and they didn’t respond. I don’t know if they’re waiting to see what polls well among colleagues. But I was going to say: On the politics, I’m never great on political analysis because I feel like I’m always wrong. But I would say [the] last time Republicans tried to go after ACA in 2017, Democrats really successfully leveraged that in the following year. They talked about trying to go after protections for preexisting conditions. And you’ve already seen, I think, [that] the DCCC [Democratic Congressional Campaign Committee] already put out some ads on the subsidies. So, this is going to be a huge, huge point for Democrats. They’re going to be talking about this nonstop next year. So, I imagine it would hurt Republicans.
I’d also add, I think that Democrats sometimes have more to lose on health care than Republicans only because health care is not a top issue for Republican voters in the way that it is for Democratic voters. So, sometimes, Republicans can make missteps, and then their voters are more forgiving of it than maybe they would be of Democrats.
Rovner: Although we’ll see, because as we keep saying, there’s a lot of Republicans in a lot of these states that have been using these extra subsidies. When they go away, they’re going to be really ticked off.
Kenen: Could I just say one last thing? And we’ve said this again, we’ve said this repeatedly, but it is worth bearing, repeating is: Congress usually gives people benefits. Taking away benefits is not really a politically savvy approach. And then, yes, Medicaid isn’t until after the election, after the 2026 elections. But there’s going to be repercussions from the Medicaid law that [are] also going to be felt in the near term in terms of how are hospitals preparing, and responding, and cutting back, and what’s available in communities, and debates in their state legislatures about how they fill budget holes, and what services will be cut. This is turning into a health care year on both the ACA health costs and affordability and the impact of Medicaid that usually helps Democrats. But we are living in a time of intense short attention spans. We’re not living in … the parallels don’t always apply to the current situation, but it’s a Democratic issue.
Rovner: Yeah. Well, continuing on my theme of maybe Democrats didn’t really lose the shutdown despite what many of them said, I’m kind of surprised at all the things that did get into the continuing resolution that passed last week and reopened the government. Democrats got all the federal workers back pay, which, despite being the law, was not a given. They got the federal worker firings during the shutdown reversed with a promise of no more RIFs [reductions in force] until at least the end of the next CR at the end of January. Because the CR also included full-year funding for the Department of Agriculture, they also got SNAP [Supplemental Nutrition Assistance Program] fully funded through next September.
But two other really nerdy things were tucked into the bill that could turn into a big deal. One is the explicit rejection of a proposal to cut in half the budget of the Government Accountability Office, GAO, and preserving the right of the GAO’s head, the comptroller general, to sue the administration for violating the Impoundment Act, which is what protects Congress’ power of the purse. This is really the fight over the funding bills, right? We’ve got the Trump administration saying, Congress, we don’t actually care what you do in these spending bills. We’re going to decide how to spend this money. — which is not what the Constitution says.
Kenen: But the Congress has its objective. I mean as the administration —
Rovner: The GAO has, and they’re suing.
Kenen: Right. But at the end of the day, what’s happening in the courts is not really changing behavior all that much, so it’s still —
Rovner: Because it hasn’t all been resolved yet.
Kenen: It’s a TBD [to be determined]. I think we’ll know more after the tariffs ruling. But when they do suffer a defeat in court, they just sort of find another way around. Even if they do something, the court says they just find another way of doing what they wanted to accomplish.
Rovner: Yes, which we have seen. And apparently they did. I saw a story this week that they were trying to put in a provision that would stop what we call the pocket rescissions. Right now, the administration can say, We don’t want to spend this money, and then Congress votes on whether or not to agree with the administration. But if they do it at the end of the fiscal year, it’s too late. And that’s called a pocket rescission. There was some language to stop that, which also appears on its face to be illegal. And apparently Russell Vought of OMB [Office of Management and Budget] complained, and it was taken out of the bill before it was passed. So that fight [is] going to still continue.
Well, there’s another even more nerdy provision that resets something called the PAYGO [pay-as-you-go] scorecard to zero. Among other things, this cancels the required cuts to Medicare that would’ve been the result of the Republicans failing to offset the cost of the tax cuts in last summer’s big budget bill. You may have heard Democrats referring to these cuts and thought they meant Medicaid, thought they were misspeaking. They were not. There actually was a half-a-billion-dollar cut to Medicare that was in the offing. But canceling this kind of cuts both ways because it takes away a talking point for Democrats, right?
Kenen: Yes, but I don’t know that that one’s going to matter so much in six, 10, 12 months. Because also, we’re used to them not doing the cuts to Medicare that they’ve said. I mean, they walk to the very edge of the plank and jump back into the boat over and over again since 2012 at least, probably before that. So I don’t know that that has the staying power. It’s hard. Like the word sequester, unfortunately we understand it, but a lot of people think it’s a jury. I mean cuts that didn’t happen —
Rovner: Right, and cuts that are not going to happen. We’ll see how long it takes the Democrats to wipe the Medicare cuts out of their talking points, which they now have to do because that was in the bill. Well, meanwhile, even with the government back open, the chaos continues at Robert F. Kennedy Jr.’s Department of Health and Human Services, where just this morning we’ve seen a change to the CDC [Centers for Disease Control and Prevention] website suggesting that vaccines might cause autism. They do not. And a new large-scale study showing that fluoride in typical doses doesn’t lower kids’ IQs, which is the exact opposite of what RFK Jr. has been saying. Paige and Shefali, you’re following this report on transgender care, which is another sort of big controversial issue over at HHS.
Winfield Cunningham: Yeah. So what we saw yesterday was basically the final release of this report, which was ordered up by Trump via executive order earlier this year. And they had released an initial draft last spring, but at that time, they didn’t release the names of the authors on the report, nor did it have any peer reviewers. And that was the focus of a lot of the criticism of the report — that there wasn’t transparency there to see who was actually reviewing all of this evidence around gender-transition care for kids. So, we saw the names of the nine authors were released yesterday, as well as about eight peer reviewers. This also, not shockingly, did not engender a lot of wide confidence in the medical community about this report. And the authors of the report all have prior histories of criticizing how gender-transition care is delivered in the U.S. And critics have pointed to that saying: Well, the report’s not legitimate because basically the people were handpicked by the administration to deliver a particular conclusion.
And so I’ve been talking to some of the authors. They are of course defensive. They say, Look at the research. Look at the report. The report does skew very critical of transition care and recommends counseling first, which is something that some of the leading medical organizations are pushing back against. So, I don’t know where all this is going to go. I think the debate [is] going to continue, but certainly we’re going to see the administration use this report to try to undergird its arguments for a dramatic crackdown on transition care. They’re actually working on two rules at CMS [Centers for Medicare & Medicaid Services] right now which would penalize hospitals for providing transition care for kids. Those rules are being reviewed I think by the White House right now, but we’re probably going to see those finalized sometime next year.
Luthra: I think some really important context for us to consider here — in this conversation as well as what the actual reality of health care looks like for trans youth — and in particular, the thing that really stands out to me as we look at this report and look at these criticisms that these authors are levying, is that already, for young people who are getting gender-affirming care, it’s a very involved process. There aren’t a lot of providers who offer this to begin with. There is a lot of counseling. The idea that young people are getting these gender-affirming surgeries at a young age without any sort of long-thought, long conversation just isn’t really borne out by evidence. There is a lot of conversation, a lot of counseling. A lot of youth start with things that are reversible. You start with maybe something that doesn’t have that same level of permanence before ensuring that this is something that people truly do want. And I think that’s really important.
The other thing that really sits with me in this conversation — which I think this is a conversation that has been really built up by a lot of social conservatives who are looking for a new target after they sort of lost the war on gay marriage — is that young people are sort of a starting point. And we’ve already seen a lot of efforts in some states to expand restrictions on gender-affirming care — not only for young people, but for people of all ages who are trans. It reminds me a lot, actually, of the conversation around abortion, where you began with restrictions for young people as a pathway to restricting it writ large. And I think we have to be really aware of that context when we look at how this political and policy fight unfolds.
Rovner: Yeah, there’s also a lot less of this care you’re saying. It is hard to get. There’s less available than there was at the start of the year. We’ve seen so many of these universities and hospitals knuckle under and say, We just don’t want to be part of this because they’re threatening to take away all of our funding. There’s a new study in JAMA Internal Medicine this week that found that HHS cuts from earlier this year disrupted more than 400 clinical trials, and treatment for more than 74,000 patients who were participating in those trials. Most impacted, according to the report, were trials on infectious diseases and prevention. But a second study chronicled the deep cuts to gender-affirming care. So, it’s not even how it’s being delivered, it’s if it’s being delivered at this point, right?
Luthra: The people who are getting this health care have gone through a lot of hoops to get this care already. They have shown a real … desire is the wrong word. They have worked very, very hard to get here in a way that you don’t do if this isn’t something you have thought about a lot.
Rovner: It’s not like quitting smoking.
Winfield Cunningham: But I also add, this isn’t a conversation that’s only happening in the U.S. This is happening around the world. You have seen a huge surge of young people seeking this care. So it’s kind of a relatively new thing. And in a way, just in terms of the number of people, and you’ve seen. … I think New Zealand actually this week announced that they’re putting new restrictions on puberty blockers for young people. You’ve also seen similar things in the U.K. [United Kingdom] and the Netherlands. And they’ve also conducted reviews, just raising questions around how much evidence we have around the long-term benefits or harms of giving these treatments to kids. So I think it’s an important conversation for researchers to be having. And I think it’s unfortunate it’s gotten so politicized, because this is, to Shefali’s point, really important for a lot of children in the U.S. and around the world. And yeah, it’s really important for researchers to have a really clear picture of the best way to help them.
Rovner: Yeah, I was going to say this is one of those things that’s both a culture war issue, and a legitimate medical scientific issue that we’re looking at.
Well, meanwhile, it’s not just policy that’s a little chaotic at HHS. According to The Wall Street Journal, the secretary reportedly considered sidelining FDA [Food and Drug Administration] Commissioner Marty Makary because of his inability to control infighting between some of his division directors. Yet it feels like FDA is kind of the least of Kennedy’s worries right now. Also ongoing are fights between supporters of MAGA, the Make America Great Again movement, and MAHA, the Make America Healthy Again movement, over who should be in charge of health policy. Is this just usual infighting, or is this sort of new and different and [at] a more significant level than we often see?
Kenen: I’m not sure we know yet, because some of this stuff is boiling up pretty quickly. But we’re seeing all sorts of splits and fractures on the Republican side that we have not been accustomed to seeing. Trump is very good at unifying his party, and papering over things, and changing the subject. He’s a very, very gifted controller of narrative. And the fact that we’re seeing policy splits as well as the [Jeffrey] Epstein scandal, and all sorts of other things, it’s not one crack. There’s a bunch. And crack might be too strong a word — we don’t know yet — but we’re seeing more dissent, and more disagreement bubbling over in public than we had before.
Rovner: Yes, and that’s what’s so unusual to me. Have these people had long knives out for each other? Absolutely. Have we seen big front-page stories about it? Not so much.
Kenen: And it’s heightened since the New Jersey and Virginia races. It’s more blame-gaming going around. So I think we’re seeing a slightly different internal landscape among Republicans, as we just said, it’s apparent how much these health care versus public health versus vaccine versus MAHA versus MAGA, these … how much they splinter and stay splintered. It’s interesting to watch right now. I mean, Kennedy hasn’t been that engaged on the health policy side, the insurance fight, the HSAs, FSAs, subsidies. That’s not where his public energy is.
Rovner: He’s left that to Dr. [Mehmet] Oz mostly.
Kenen: Right. And we know what’s important to him. There’s a long list of changes he wants to make on that side. So, I think it’s interesting. I think it’s significant. I don’t know what it’s going to look like in a month.
Rovner: OK. We’re going to take a quick break, and we will be right back.
OK. We’re back. Well, there is also news, finally, this week on the reproductive health front, as you tried to jump the gun, Paige. Circling back for a minute to the impending vote on extending the enhanced ACA subsidies, abortion turns out to be a big obstacle to any potential compromise, even if there was one to be had. This shouldn’t really be surprising. Abortion very nearly scuttled the passage of the ACA itself in 2010 —
Luthra: At the very last minute.
Rovner: At the very last minute. And anti-abortion forces still think the law is too lenient, even though it’s a lot more restrictive than abortion-rights backers had wanted and fought for. Shefali, are Republicans really going to refuse to stop premium increases for voters just to please the anti-abortion movement?
Luthra: I don’t see why not. It seems like this is … I mean, really, though, the anti-abortion movement in some ways took a pretty big loss getting Trump as the Republican president. This is someone who does not really want to capitalize on the post-ops momentum with a national ban. And so they’re looking where they can to try and restrict abortion through other means — whether that meant the Planned Parenthood defunding, whether that means trying to get this mifepristone reviewed, or if it means trying to enact more restrictions through ACA subsidies. It really seems like kind of a no-brainer. If you can’t get this win for a very important constituency from the president, you do what you can everywhere else to try and get it, or get at least what you can.
Rovner: OK. Paige, now you get to say what you wanted to say before.
Winfield Cunningham: Well, no, I guess I was just going to say again, I’ve just been thinking a lot about 2017 and how health reform never seems to go forward. But yeah, this is a perennial issue. It’s all about the Hyde [Amendment] language and anti-abortion folks, and Republicans have always been very resentful of how the debate about the ACA went about. And they are upset because they think these plans are that taxpayer dollars are still going to abortions, et cetera, et cetera. And actually, I was thinking with this HSA idea of rerouting the subsidies to the HSAs, the problem would actually be even more pronounced, because they’re going to demand that you attach then abortion restrictions to money that people have in their own accounts that they’re supposed to be using for health care. And that just seems like even more of a no-go with Democrats. I think all of us knew this was a big obstacle, but it takes a little bit of time for people on [Capitol] Hill to figure this out, but I think it’s becoming more and more clear that this is just a really massive barrier.
Rovner: Yeah, it is. All right, well the abortion fight also continues in the states. South Carolina lawmakers this week held a hearing on what would’ve been the strictest abortion ban in the country, allowing judges to send women who have abortions to prison, and potentially restricting IVF [in vitro fertilization] and some forms of birth control. Apparently, that bill went a little too far, even for some Republicans on the subcommittee. The bill failed to advance, at least for now. Are we likely to see more laws like this, though, as states try to top one another in pleasing what the anti-abortion forces want?
Luthra: I think we will. This is a really long-standing and deep debate in the state-based anti-abortion movement, and in particular the debates over contraception, the debates over IVF, and especially around whether you send someone who gets an abortion to prison, whether they’re held criminally liable. And there is a very extreme movement; they call themselves abortion abolitionists. They are introducing bills and growing numbers every year, trying to build up support. Even some of the pretty conservative abortion opponents say, Oh, those people are too extreme for me. But they’re gaining influence. And I see this as a conversation and a debate that the anti-abortion movement only continues to have, especially as this is something that progresses on the state level and not necessarily the federal one.
Winfield Cunningham: I do wonder, though, how much more room there is for state bans, because you saw this huge surge in red states placing bans after Dobbs [Dobbs v. Jackson Women’s Health Organization]. At this point, I think around 17 or so states have almost-complete bans on abortion. So in a way, I think there’s been a lot of work done there. And I think the opportunity that the anti-abortion folks see is at the federal level, but of course they’re running into top appointees — Kennedy, some of the others at HHS, who, for them, this is really not a priority — and it doesn’t sound like anti-abortion folks would love to see them roll back access to mifepristone, for example. I’m not convinced that’s going to happen anytime soon because the folks pulling the levers there aren’t necessarily in the camp.
Rovner: Yeah, apparently one of the reasons that people aren’t angry with Marty Makary at FDA is because he appears to be slow-walking this mifepristone study, and he approved, even though he had to, another generic of the medication. So, I know that that’s also part of this.
Luthra: If I can add one more thing, Julie?
Rovner: Yes, please.
Luthra: Frankly, a really good litmus test for where states are heading is coming in only a few weeks when Texas’ new abortion law takes effect. And this is one of the most ambitious efforts to stop telehealth and shield law provision of abortion. And this is an area where state-based abortion opponents are very frustrated, because they see it as breaking or fundamentally incapacitating their abortion bans when people can still get medication through the mail from doctors who have not been successfully prosecuted for doing so. And so, when this law takes effect, it enables civil lawsuits against people who make medication abortion available in Texas. I think we will see: Are there civil suits filed by abortion opponents, for instance. Is there any really concerted effort to use this new tool to stop telehealth? And if so, does that spread to other states? Especially since Texas has for so long been a real pioneer in abortion restrictions and making it even harder to get.
Rovner: Yeah, where Texas goes, so go the rest of the red states.
All right, that is all the time we have for the news this week. Now we will play my interview with Republican health expert Avik Roy, and then we will come back and do our extra credits.
I am so pleased to welcome to the podcast Avik Roy here in person in our studio at KFF. Avik is co-founder and chairman of the Foundation for Research on Equal Opportunity, which studies and recommends social policies for the half of the population that earns less than the U.S. median. But he’s also a longtime health policy wonk and health adviser to Republicans, including several Republican presidential candidates over the years. And full disclosure, he is, like me, a fellow Michigan Wolverines fan.
Avik Roy: Go, Blue.
Rovner: Avik, welcome to “What the Health?”
Roy: Great to see you, Julie.
Rovner: So, how did you come to health policy? It was a bit of a winding road, wasn’t it?
Roy: Yeah, I kind of fell into it. I was working as a health care investor, actually, at Bain Capital and a couple of other places like that, as a health care investor. In 2008, [Barack] Obama gets elected and starts to talk about what we now call the Affordable Care Act, or Obamacare. And I wasn’t reading anything I agreed with. At that time, you had Ezra Klein, then at The Washington Post, and you had Jonathan Cohn at The New Republic. You had that group of young bloggers who are writing, Hey, there’s this brilliant MIT economist named Jonathan Gruber, and he’s got it all figured out, and everything’s going to work great, and premiums are going to go down. And Obama himself promised that premiums for the average family of four would decline by $2,500 per year. That’s what he campaigned on in 2008. Then on the conservative side, you had a lot of people writing things like, It’s big government. It’s unconstitutional. It’s welfare.
And I found these arguments kind of like empty calories, because for the average American who’s struggling to afford health insurance and health care, I just don’t see how that person is going to respond to that kind of argument. They’re going to be like, Look, if one side is telling me they’re going to reduce my premiums by $2,500 per family per year, and the other side is just saying, ignore this all because it’s big government, which side is the average person going to choose? They’re going to choose a side that’s going to try to reduce their health care bills. And my point of view was not aligned with either of those positions. My point of view was actually: Health care bills are going to continue to increase, and the design of the ACA has a number of flaws that are not being called out because the conservative critics just weren’t digging into the technical design — the architecture of the bill. And even though I’m not as eminent as Jonathan Gruber, I did go to MIT. And so I maybe felt a little more willing to engage in that debate.
Rovner: And you’re a doctor.
Roy: Well, I went to med school. I never practiced, don’t have a license.
Rovner: But you have, at least, the medical education. So you have a good bit of background in this. I want to think broadly. Every other developed country has some sort of national health insurance scheme. Most of them are hybrids of public and private. Some of them more public; some of them more private. Why hasn’t the U.S. been able to solve this problem that every other developed country has?
Roy: We actually do a lot of work on this at the Foundation for Research on Equal Opportunity. We have a whole annual research product we put out called the World Index of Healthcare Innovation, where we compare 32 countries around the world with the highest GDP [gross domestic product] per capita that have a population over 5 million on quality, choice, science and technology, and fiscal sustainability. So, a number of other people do these kinds of comparisons, but our study is different for two reasons. One, we don’t just look at OECD [Organization for Economic Co-operation and Development] countries, which is typically where most academics get their data. We look at countries that are outside the OECD, particularly in Asia. And we also again score countries not merely on health outcomes and equity-type measures, but we also look at things like fiscal sustainability, which we think matters for long-term equity, and science and technology. One of the defenses of the American system that you always hear is, Well, yes, our system is so expensive, but we’re also the innovation center of the world, and you can’t have one without the other.
So, one thing that we wanted to study was: Is that really true? Can you have innovation at a U.S.-like level but with a universal system that covers everybody and has good quality? And the system that has ranked No. 1 in our study every year is Switzerland. The reason that’s really interesting is because there’s a misconception, both on the left and the right, that to achieve universal health insurance you have to have a single-payer system. And that’s not actually true. There are plenty of countries — they are a minority of the industrialized countries, but it’s a robust and significant minority — that have achieved universal coverage using private insurance, not necessarily a single-payer, government-run insurer. And Switzerland is, in our view, the best example of that because Switzerland is a place where there’s an innovative pharmaceutical and biotech, and med devices ecosystem. They have universal coverage. It’s basically like Medicare Advantage for all, or Obamacare for all. It’s a universal individual market where the market is regulated and subsidized, but it works.
Rovner: I would say big subsidies. I’ve been to Switzerland. I’ve studied the Swiss health care system.
Roy: Big subsidies. It depends on your vantage point. Relative to the American system, the subsidies are actually quite low. So what Switzerland spends subsidizing health care is about 45% of what the U.S. spends per capita subsidizing health care. We actually subsidize health care per capita more than any other country in the world, because the cost of health care is so high in America that the cost of subsidizing health care is so high.
Rovner: Which was going to be my second point about Switzerland is that it’s way more regulated than a lot of Republicans think.
Roy: Well, it’s about as regulated as Medicare Advantage, or the ACA plans in terms of the insurance plan to sign. There are other things — and we don’t have to spend all of our time on Switzerland here — but you ask the question, it’s like, Why can’t we do this in America? That was your original question, and there’s a number of reasons for that. One is path dependence. With any health care system, once you’ve established it, it’s hard to change. The one thing I’ll say that we did in the mid-20th century that really put us on this path was when we excluded from taxation employer-sponsored insurance, because in World War II there were wage and price controls. Employers figured out how to get around that by offering employer-sponsored insurance that wasn’t regulated by wage and price controls. And then after the war, [Dwight D.] Eisenhower said, Yeah, let’s not tax those insurance policies because they seem to be important for people.
And it was kind of an offhanded decision. No one really knew that that was going to be this big thing. But sure enough — 80 years later, or 70 years later — here we are. And I would argue that’s the biggest driver of health care inflation, because we don’t merely have third-party payment for health care. Every country has third-party payment for health care. But we have third-party payment of third-party payment of health care. We have ninth-party payment of health care basically. And no wonder that no one has any sense of why everything is so expensive. But that’s the core driver. And unfortunately, Medicare, in particular, built on that system. When the Medicare law was passed in 1965, a key element of Medicare was to build upon and drive the benefits based on the traditional Blue Cross employer-based plan, which had by that point already ballooned into something resembling what we have now.
Rovner: So why has health care been such a low priority for Republicans? I always hear, Well, Republicans don’t really work on this because it’s not important to their voters. That can’t possibly be true anymore.
Roy: I think everything you said is just right. I think that historically, Republicans didn’t feel that it was relevant to their voters. And their voters weren’t really pushing for it because their voters were — relative to the median constituent — perhaps more likely to be employed, or more likely to be on Medicare — and therefore didn’t feel like they had to worry about affordability. But affordability, as everybody at KFF knows, and the audience that listens to your program knows, affordability is a big deal for everyone. Premiums in the employer-sponsored market have gone up, and people don’t necessarily notice that. But they notice that their paychecks have been flat. They notice their deductibles going up, and their copays going up, and that’s been a big problem both in the ACA markets, and the employer market.
But affordability is a big deal. And now that the Trump GOP has become more of a working man and woman’s party — and you see it in all the exit polls that if you actually look at who’s voting for Democrats and who’s voting for Republicans in presidential election years — the Republican electorate is now a bit more lower-income than the Democratic constituency, which has a lot more of those college grads, and grad school grads. I think you’re starting to see more of that populist concern about the affordability of health care, but there’s still an enormous amount of intellectual catch-up to get there. And I think because of this experience of studying the international health care world, I’ve been much more optimistic about the ability to achieve universal coverage in a way that’s friendly to free marketeers, people who believe in private-sector competition.
Whereas I think the traditional Republican view, which you kind of alluded to earlier — and I ran into this a lot in the 2017 repeal-and-replace debate — was it’s not the federal government’s job to ensure that everybody has affordable health insurance. That’s what I heard from a lot of the kind of old-line Republicans and Republican staffers in the 2010s. It’s not the federal government’s job to guarantee affordable health insurance for people. That should be up to ordinary people to make enough money to afford health insurance. And I disagree with that very strongly. And the reason I disagree with that very strongly is because it was the federal government that screwed it up in the first place. It was the tax exclusion for employer-sponsored insurance, and then some of the things around the design of Medicare that drive all the health care inflation that we’ve seen over the last 80 years.
So the federal government created the mess, and it is the federal government’s job to clean up the mess. And I guess you could say a big purpose of my work is to try to convince more Republicans to agree with me on that.
Rovner: So why has it been so hard for Republicans to come together on anything? The Democrats have big divisions, too, on health care. They have a big chunk of Democrats who would like “Medicare for All,” and another chunk of Democrats who would like to build on the existing system. Republicans presumably have the same kinds of divisions, just in the other direction, and yet we almost never see Republican proposals, and we do see Democratic proposals.
Roy: Well, I will quibble with you a little bit, Julie, in that there are Republican proposals. They don’t always get the same amount of media coverage that the Democratic proposals get. There is a bill that’s been introduced in both the House and the Senate, based on our work at FREOPP, called the Fair Care Act, which would achieve voluntary universal coverage. It wouldn’t force anyone to buy coverage, but everyone who wants to buy health insurance would be guaranteed to have an affordable option. It would reduce the deficit, increase coverage by about 9 to 10 million, and also reduce federal spending. It would reduce taxes, and reduce federal spending, because it would reduce the underlying cost of health care.
Rovner: How?
Roy: By, in particular, tackling the power of hospital monopolies, and being more aggressive about high drug prices. And it would also means-test the subsidies. And by means-testing, I don’t just mean means-testing Medicare, which is often what people talk about, but also means-testing the employer tax break for health insurance, for example, and really having —
Rovner: So more like Switzerland.
Roy: Exactly. So all these random digressions that I’ve been coming … there is actually a coherent idea here that I’m trying to get to, and I thank you for reminding me on that.
Rovner: Well, we’re back in the thick of it. Avik Roy, hope we can have you back again.
Roy: Thanks, Julie. I’d love it.
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. Paige, why don’t you go first this week?
Winfield Cunningham: Sure. Yeah. Well, I was really struck by this story in The Wall Street Journal called “Medicaid Insurers Promise Lots of Doctors. Good Luck Seeing One.” And this was just a really, really intensive look at some of the struggles faced by Medicaid patients when they go to their plan, they look up doctors, they try to get appointments, but it turns out that a lot of the doctors listed in the directories for these Medicaid plans don’t see patients anymore, or they’re far away. And there’s a real mismatch here between the providers’ insurer networks’ claim to offer and what is actually available to people. And of course, a lot of Medicaid patients live in medically underserved areas. So I just thought this article, they had actually looked at some patients that live near St. Louis, my hometown, and how difficult it was for them to find a timely appointment with a specialist. I just thought it was a really good, intensive look at some of the real challenges here in the Medicaid program.
Rovner: Yeah, provider directories are sort of an underappreciated huge problem in the entire health care system. Joanne?
Kenen: This is a piece from ProPublica, “What the US Government Is Dismissing That Could Seed a Bird Flu Pandemic,” by Nat Lash, with pretty cool graphics by Chris Alcantara. And basically, they’re arguing that the USDA [United States Department of Agriculture] for three and others prior to Trump — it’s not just a Trump administration policy — has been emphasizing sanitation, and what they call biosecurity practices to stop bird flu entering. They blame it on sort of bad control, like the farms let bad stuff in. And in fact, there’s increasing evidence — and ProPublica worked with researchers and experts on climate and wind patterns and everything — that it’s airborne. That it’s coming in on wind and dust. That it’s not just what’s tracked on the floor. It’s on the feathers. And that the whole approach is therefore inadequate. And also the USDA has refused to do vaccination, which many European countries are doing. So the combination of underemphasizing the role of wind and air current, and the reluctance has to do with import policies and the economy of poultry and eggs, is really putting us at greater risk.
Rovner: Yeah, very scary story. Shefali?
Luthra: My piece is from ProPublica. It is by Kavitha Surana and Lizzie Presser. It is called “Ticking Time Bomb: A Pregnant Mother Kept Getting Sicker. She Died After She Couldn’t Get an Abortion in Texas.” The story really wrecked me. It’s really important journalism. It is a story about one woman, in particular, but then gets into the fact that there are many cases like this of people who are pregnant, have medical conditions that make their pregnancy very high risk. So their health is threatened but not their lives. And as such, they don’t qualify for an exception under an abortion ban like Texas’. And the woman in this story, Tierra Walker, died. She already had a kid who now does not have his mom because she couldn’t get an abortion.
And I think what this story really gets at is a few important things. One is that the exceptions that states have passed don’t account for the fact that pregnancy can make your health really at risk, even if there’s not something really dramatic like sepsis. It is just simply all the other things that make you at greater risk of dying. The other thing that’s really important is that all these doctors who treated her never suggested an abortion. That’s important because it underscores that years later, there is still a lot of fear for health care providers operating in these states that is very obvious that being pregnant was a risk for this patient. And there was a conversation that she could have had with her medical provider, a choice that she and her family could have made about her circumstances and what was best for her. Doctors didn’t feel safe having that conversation because of state laws. And now she’s dead.
Rovner: And yeah, this is a continuation of a ProPublica series that won a Pulitzer this year. So they’ve been tracking this through several states and lots of patients, unfortunately.
All right, my extra credit this week is from CNBC. It’s by Scott Zamost, Paige Tortorelli, and Melissa Lee. It’s called “Cheaper Medicines, Free Beach Trips: U.S. Health Plans Tap Prescriptions That Feds Say Are Illegal,” and it’s a lovely take on how the U.S. health system has become such a mess that employers can now hire third-party companies who pay for patients to take all-expense paid trips to the Bahamas or the Cayman Islands to buy expensive prescription drugs at a price that still saves enough money from what’s charged in the U.S. to pay for the trip. There’s just one catch, though. While it’s not illegal to go to another country to get your own medication, some of these third parties also import drugs themselves, and that is illegal. For the umpteenth time, if the U.S regulated drug prices the way all these other countries do, drugs here would be a lot less expensive. Although I will say, I have been to both the Bahamas and to the Caymans, and they are both lovely.
OK, that is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Health?” is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X @jrovner, or on Bluesky @julierovner. Where are you guys hanging around these days? Shefali?
Luthra: I’m on Bluesky @Shefali.
Rovner: Paige?
Winfield Cunningham: I am on X @PW_Cunningham.
Rovner: Joanne?
Kenen: I’m either at LinkedIn or Bluesky @JoanneKenen.
Rovner: We’ll be back in your feed early next week for the Thanksgiving holiday. Until then, be healthy.
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What the Health? From KFF Health News: The Government Is Open
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 “What the Health? From KFF Health News.” 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.
The longest federal government shutdown in history is over, after a handful of House and Senate Democrats joined most Republicans in approving legislation that funds the government through January. Despite Democrats’ demands, the package did not include an extension of the expanded tax credits that help most Affordable Care Act enrollees afford their plans — meaning most people with ACA plans are slated to pay much more toward their premiums next year.
Also, new details are emerging about the Trump administration’s efforts to use the Medicaid program — for low-income and disabled people — to advance its immigration and trans health policy goals. And President Donald Trump has unveiled deals with two major pharmaceutical companies designed to increase access to weight loss drugs for some Americans.
This week’s panelists are Emmarie Huetteman of KFF Health News, Anna Edney of Bloomberg News, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.
Panelists
Anna Edney
Bloomberg News
Shefali Luthra
The 19th
Sandhya Raman
CQ Roll Call
Among the takeaways from this week’s episode:
- Though the shutdown deal did not include an extension of the enhanced ACA subsidies, it came with a plan for a Senate vote by next month — on what exactly, it is unclear. Senate Republicans appear to be coalescing around providing money via health savings accounts rather than through the subsidies, while House Republicans seem more fragmented. The clock is ticking; the existing credits expire on Jan. 1, and open enrollment has begun.
- Even as the Trump administration is likely to be tied up in court over its efforts to use Medicaid to crack down on health care for immigrants and trans people, they’ve had a real chilling effect. Immigrants, for instance, are skipping medical care, and hospitals are cutting back on offering gender-affirming care for trans people for fear of losing federal funding.
- Trump’s newly announced GLP-1 price deals could help Medicare enrollees afford the weight loss drugs, potentially opening up access to a new population of patients — and customers. And a steady stream of policy reversals, unexplained dismissals, and negative news coverage is leading to worries that the FDA’s credibility is being undermined by internal drama. Also in question is whether it’s interfering with the agency’s work. Drug companies would likely say yes, and some within the FDA are trying to combat these concerns.
- A major anti-abortion group is leaning into the current electoral moment, targeting key states and preparing for sizable political contributions ahead of next year’s midterm elections. Abortion opponents see an opportunity to capitalize on voters’ changing motivations and reposition themselves to fit into the post-Trump Republican Party.
Also this week, KFF Health News’ Julie Rovner interviews KFF Health News’ Julie Appleby, who wrote the latest “Bill of the Month” feature, about a doctor who became the patient after a car accident sent her to the hospital — and $64,000 into debt. Do you have an outrageous medical bill? Tell us about it!
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Emmarie Huetteman: KFF Health News’ “Immigrants With Health Conditions May Be Denied Visas Under New Trump Administration Guidance,” by Amanda Seitz.
Anna Edney: Bloomberg News’ “Bayer Weighs Roundup Exit as Cancer Legal Bill Nears $18 Billion,” by Tim Loh, Hayley Warren, and Julia Janicki.
Shefali Luthra: The 19th’s “Detransition Is Rare, but It’s Driving Anti-Trans Policy Anyway,” by Orion Rummler.
Sandhya Raman: BBC’s “Canada Loses Its Measles-Free Status, With US on Track To Follow,” by Nadine Yousif.
Also mentioned in this week’s episode:
- KFF’s “KFF Health Tracking Poll: Public Weighs in on Health Care Debate and Government Shutdown,” by Audrey Kearney, Alex Montero, Mardet Mulugeta, Ashley Kirzinger, and Liz Hamel.
- KFF Health News’ “Trump’s HHS Orders State Medicaid Programs To Help Find Undocumented Immigrants,” by Phil Galewitz.
- NPR’s “Trump Pushes an End to Medical Care for Transgender Youth Nationally,” by Selena Simmons-Duffin.
- Stat’s “FDA’s Top Drug Regulator Resigns Amid Investigation,” by Lizzy Lawrence and Adam Feuerstein.
- Stat’s “Under Vinay Prasad, Employees at a Key FDA Center Fear Speaking Out, Look for the Exits,” by Lizzy Lawrence.
Click to open the transcript
Transcript: The Government Is Open
[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 to “What the Health?” from KFF Health News and WAMU. I’m Emmarie Huetteman, a senior editor for KFF Health News, filling in for host Julie Rovner this week. I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 13, 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’re joined via video conference by Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning.
Huetteman: Anna Edney of Bloomberg News.
Anna Edney: Hi, everyone.
Huetteman: And Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Huetteman: Later in this episode, we’ll have Julie’s interview with KFF Health News’ Julie Appleby, who wrote our latest “Bill of the Month” story about a doctor who became the patient after a car accident sent her to the hospital and $64,000 into debt. But first, this week’s news.
The longest federal government shutdown in history is over. Late Wednesday, six House Democrats joined most Republicans in approving legislation that funds the government through January. That vote came after a handful of Senate Democrats broke ranks with their party last weekend and brokered a deal to end the shutdown. Although the Trump administration was still fighting earlier this week not to fully fund food stamps, the White House has said those benefits would be fully restored within hours of the shutdown’s end. That said, food banks and other safety-net programs have warned the shutdown’s consequences could linger, especially for those who were forced to redirect rent money, dip into savings, and make other sacrifices to feed their families. Notably, despite Democrats’ demands, the deal does not include an extension of the expanded tax credits that help people afford Affordable Care Act plans. That means those enhanced subsidies are still slated to expire at the end of the year. Sandhya, you were on Capitol Hill last night. What was included in the deal? And now that the shutdown’s over, can we expect a vote on extending the tax credits?
Raman: So part of that deal was that sometime in the middle of next month, the Senate is going to be able to vote on a health bill of Democrats’ choosing to extend the Affordable Care Act enhanced subsidies that are set to expire at the end of the year. There’s been a decent amount of talk already in both chambers about what a health care bill could look like, because it would need to be bipartisan to pass. There’s some multiple camps right now.
I think in the Senate, Republicans are coalescing around putting money into flexible savings accounts instead of doing an extension of the credits as something that they would want to do instead. There are other Republicans that are still open to extending the credits with some reforms attached. The House, we figured out last night, was a little bit more fragmented. They’re less united in the way the House is around doing something with the flexible spending accounts. So a lot of them are still anti-extending the credits at all. They are working on a health package, but it remains to be seen what they want to do with that, given the short amount of time they have. But I think a lot of them are also looking for the same reforms that the Senate is on the Republican side, if they do sign on to extend them.
Huetteman: Yeah, short is right. We’re already looking at that Dec. 31 deadline to extend the existing credits. And of course, we’re already in the open enrollment period at this point. People are already getting their plans for next year. Polls show that most Americans blamed Republicans for the shutdown. A tracking poll from my KFF colleagues out last week showed most Americans want Congress to extend the tax credits. Republicans are aware of this heading into the midterms next year, no?
Raman: I think that’s definitely been a big factor when talking to folks, especially ones that I think have been more interested in extending the credits are set up for our competitive races next year. There has been talk at different times of doing a one-year extension. But that puts us pretty close to the midterms, which might not be in everyone’s best interest depending on how things shake out. So, I think it’s definitely in a lot of folks’ minds, just because it is a lot more popular than it has been in previous years. But there are a lot of the more conservative folks that just have been anti-ACA for so long, that they don’t want to extend something that was … The enhanced subsidies were started by Democrats during covid. They think it’s a covid-era thing that needs to be phased out.
Huetteman: Yeah, and also notably, you might’ve noticed I said that they only funded the government through January. Does that mean we’re getting ready to do this again in a couple of months?
Raman: There’s a chance. So part of the deal got done this week is that they did three of the 12 spending bills that they do every year to fund the government. But they usually do them in order of which ones are easiest to get done. So we still have to come to agreements on some of the bigger ones, including Labor, HHS [Health and Human Services]. Education is what funds most of the health activities, and that’s usually a tougher one. So, I think it depends on a few things. Are folks sticking to their word? Do they get that health care vote that they were promised? Do other things shake out that make people at odds with each other over the next bit? But we could possibly be in the same situation if we don’t make inroads on funding the government for a yearlong situation before then.
Huetteman: Oh goodness. Well, it sounds like we’ll be back again having this conversation soon. Meanwhile, months after the president [Donald Trump] signed into law the One Big Beautiful Bill with big changes to Medicaid, new details are emerging about how the Trump administration is using the Medicaid program to promote its policy goals. My KFF Health News colleague Phil Galewitz recently reported on how the Trump administration has ordered state Medicaid agencies to investigate the immigration status of certain enrollees — providing states with lists of names to re-verify — and effectively roping the health program into the president’s immigration crackdown.
Also, NPR reports the Trump administration plans to dramatically restrict access to medical care for transgender youth. New proposals that could be released as soon as this month would block federal money from being spent on trans care. Policy experts say that would make it difficult, if not impossible, to access that care, in large part because government funding is a huge source of revenue, and losing it could force hospitals to end the programs entirely. Both of these programs are pretty striking: enlisting Medicaid to perform spot checks of immigration status, and also potentially blocking funding for trans care. Have we seen other presidential administrations use Medicaid like this? And since we’re talking about funding, is there a role for Congress here?
Luthra: My understanding is that this approach, specifically with gender-affirming care and with immigration, doesn’t really have a precedent. And what I think is really important about these is these are decisions that will be litigated, challenged, argued in court. But, even if and as that happens, there’s a real chilling effect that I think is really important. Already, we know that a lot of immigrants are very afraid to sign up even for benefits they are entitled to, because they’re worried it could count against them. We already know that a lot of immigrants with health needs are skipping their health care because they are so worried about what happens if ICE [Immigration and Customs Enforcement] shows up at a hospital. This only threatens to add to that. On the vantage of gender-affirming care, already we have seen some major hospitals and health providers drop the offering, even in anticipation of this policy coming into effect. So I think what’s really important is to understand that no matter what happens, already, people’s health is really being affected, and people are suffering as a result.
Raman: I think we’ve seen little sprinkles of some of these things that have happened in the past, but this is elevated at such a level that it’s different. Even in the first Trump administration, there were some things put in place with the public charge to crack down on what benefits immigrants could be entitled to. But I think, as with a lot of the things that we’re seeing, it’s really been amped up. I think one thing that Shefali was saying that made me think of was, we’ve already seen a lot of this chilling effect with a lot of things in abortion and reproductive care, where even if laws or regulations don’t go into effect, they’re being talked about or litigated. It already has that effect of people not wanting to show up or not knowing what’s available to them. So we have a little bit of that to look at as well.
Huetteman: Yeah, absolutely. All right, well, we’re going to take a quick break. We’ll be right back with more health news.
We’re back. In an Oval Office announcement last week, President Trump unveiled agreements with the pharmaceutical giants Eli Lilly and Novo Nordisk to offer some Americans lower prices on their weight loss drugs. Under the deals, the Trump administration says, most eligible patients on Medicare and Medicaid, or those who use the planned TrumpRx website, would pay a few hundred dollars a month for some of the most popular GLP-1 drugs. That’s compared to current price tags, which can be $1,000 or more. Anna, these are only some of the most recent deals between the Trump administration and drugmakers. What does this mean for Americans who take these weight loss drugs, and what do the companies get in exchange?
Edney: Yeah, I think for Americans who take these or are hoping to take these, I think, is probably where it really opens up. Because … Medicare was not covering these. Now that they’ve come to the table and made a deal, it might open it up to some Medicare beneficiaries. I don’t think you’re going to see everyone on Medicare who wants it be able to get it. I think it’ll be a little stricter on what BMI [body mass index] and comorbidities and things that they need to meet, but it will open access to some Americans. Medicaid, I think, it might not be as beneficial for people’s pocketbooks because they’re already paying extremely low out-of-pocket prices, and Medicaid already negotiates very low prices. That might not be the big change that it was hyped up to be.
But on the Medicare side, certainly, the companies benefit from that, too, because that opens a new patient population to them. And through TrumpRx — that’s the other place where they made this deal for lowered prices on the GLP-1s — a lot of people have employer coverage that they might be trying to already get these drugs through, and then they’re not paying a whole lot out-of-pocket. But there are employer coverage plans that aren’t covering GLP-1s because they’re just so expensive. So it could be a place where some people might go to try to comparison shop and get their GLP-1s that they didn’t have access to before.
Huetteman: I also noticed, in looking at the Trump administration’s fact sheet on this, that they were heralding that the companies had agreed to some extra American manufacturing. Let’s say concessions. Am I correct about that? Is this connected to tariffs by any chance?
Edney: Yeah, I think that that’s been going on in conjunction with some of these deals. As you usually hear the companies say, And we’re opening a new factory in Virginia or somewhere. And certainly they’re trying to avoid the tariffs. As with a lot of these things, some of it, in some cases, they have been factories that the companies were already planning to open, and then they just pumped up for this purpose. I think for so many of this — and even for the prices, the lower prices that these companies are negotiating — we just haven’t seen the details that will matter on what the company’s got, and what the American people actually benefit from for all of this, and what these factories will mean or will be making. These are things that might not come online for several years. So you can say you’re building something, but will we see it once Trump is out of office?
Huetteman: Exactly. And a lot of the framing has been: We’re helping Americans by bringing this work back to America, so that Americans can do the work, so that Americans can benefit from the drug prices. But it seems like there’s at best a lag on that sort of benefit. Right?
Edney: Definitely. Definitely a lag on being able to bring some of that stuff online. I think with a lot of the Trump administration’s health policies — and I use that word loosely — it is that it is a lot of negotiation and handshakes. And so we don’t really know how solid those efforts will be in the years to come.
Huetteman: Well, we can definitely keep an eye on that. In other news: Drama, drama, drama at the Food and Drug Administration. With a steady stream of controversial policy reversals, unexplained dismissals, and just plain unflattering stories, concerns are growing that mismanagement at the FDA is undermining the usually cautious agency’s credibility. In some of the latest developments, Stat reported the FDA’s top drug regulator resigned after being accused of using his position to punish a former associate. Stat also reported that dozens of scientists are considering leaving the already diminished FDA office that regulates vaccines, biologics, and the blood supply to get away from a toxic work environment. What are the ramifications of problems at the FDA? Is the internal drama interfering with business there?
Edney: I think the pharmaceutical industry would say yes, definitely. They’re feeling like their applications for new drugs aren’t getting reviewed in time. They’re worried that they’re not going to be reviewed in time. And this starts with the administration letting go hundreds of workers in those offices, but also, is now … There’s just been such chaos at the top. You had Vinay Prasad, who is the head of vaccines and biologic drugs there, who has been let go and then brought back. And then now we have the head of the drug center, George Tidmarsh, who resigned under investigation for basically using his position to fulfill a vendetta against an old colleague who pushed him out of some companies. And so I think, certainly, there’s a lot of potential for disruption, as people are trying to avoid retaliation, avoid getting in the crosshairs of all of this.
And recently, the FDA has now put Rick Pazdur, who was the head of their cancer center, in charge of the drug center to try to show some stability to encourage the pharmaceutical industry. Because he is someone who’s really pushed for innovation, pushed for trying to get drugs to the market faster. And he’s been at the FDA for, I think, 26 years. So, they’re trying to show some stability with that. But we’ll have to see how that goes because he’s also been highly criticized in the past by Prasad, and they’ll be working closely together at the head of those two centers.
Huetteman: Well, finally, in reproductive health news, a federal judge ruled late last month that the FDA violated federal law by restricting access to mifepristone. While the government’s restrictions remain in place for the politically controversial medication, which is used to manage miscarriages as well as abortions, the judge did order the FDA to consider the relevant evidence in order to “provide a reasoned explanation for its restrictions.” And a major anti-abortion group, Susan B. Anthony Pro-Life America, announced plans for it and its super PAC [political action committee] to spend about $80 million in at least four states to support anti-abortion candidates in the midterm elections next year. Shefali, what does this say about how abortion opponents see this moment? What are they looking to gain in the midterms and beyond?
Luthra: It’s so interesting to me to see how much anti-abortion groups are really — and, in particular, SBA — leaning into this moment. And they really see this as a reversal of last year’s election, where Trump certainly won. But we do know from polling that voters largely opposed abortion restrictions, supported abortion rights. I think some really useful context is to consider that the president, despite being backed by abortion opponents, has not really been the champion many of them would’ve hoped for. He hasn’t actually done very much on abortion, has not taken the very meaningful steps that you might’ve expected in a post-Dobbs landscape [Dobbs v. Jackson Women’s Health Organization] to remarkably restrict it, beyond the normal things any Republican president does. And so I think what we’re seeing here is an effort to reposition the anti-abortion movement beyond this presidential administration. Thinking ahead to what does it look like if there is a post-Trump GOP?
How do you build out a movement that is a more staunch ally to the anti-abortion movement going forward? One other thing that I think is really noteworthy is: A lot of abortion opponents are looking at polling that says that voters who support abortion rights aren’t prioritizing it in the same way they might have a year ago. And they’re really hoping that things can revert to how they used to be. Or the voters who were these single-issue abortion voters were on their side, were supportive of restrictions, and then might be mobilized by these kinds of really seismic investments in elections.
Huetteman: Yeah, absolutely. I’m thinking about now how there was such a reaction about a month ago — check me on the timing — when a generic version of the abortion pill was put out. What was the reaction like then, and what does that say about how they feel the Trump administration is reacting to their needs?
Luthra: A lot of abortion opponents were really livid about this, and approving this generic was pretty standard. It was not that complicated of a process. This drug has been available for so long in other forms. But it underscored that a lot of people who oppose abortion feel like they’re really just waiting. The HHS and the FDA have promised this review of mifepristone that they say could ultimately lead to restrictions. But all it has really been has been a promise this review is ongoing, is coming. There will eventually be results, but there haven’t been any. So to be waiting for some kind of policy that people keep telling you is coming, and then at the same time, to see actually the FDA moving to make abortion medication more available — not less — is really frustrating for a lot of people who hope that this administration would be an ally to them.
Huetteman: Absolutely. OK. That’s it for this week’s news. Now, we’ll have Julie’s interview with KFF Health News’ Julie Appleby. And then we’ll do our extra credits.
Julie Rovner: I am pleased to welcome back to the podcast, KFF Health News’ other Julie, Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month.” Julie, welcome back.
Julie Appleby: Thanks for having me.
Rovner: So this month’s patient is actually a doctor, so she knows how the system works. But, as so often happens, she was in a car accident and ended up in an out-of-network hospital. Tell us who she is and what kind of care she needed.
Appleby: OK. Her name is Lauren Hughes, and she was heading to see patients at a clinic about 20 miles from where she lives in Denver back in February when another driver T-boned her car, totaling it. She was taken by ambulance to the closest hospital, which turned out to be Platte Valley Hospital, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians there recommended immediate surgical repair because they wanted to wash out that wound on her knee. And also, she needed some screws in her ankle to hold it in place.
Rovner: So then after the surgery and an overnight stay, she goes home, and then the bills start to come. How much did it end up costing?
Appleby: Well, she was billed $63,976 by the hospital.
Rovner: And the insurance company denied her claim. What was their argument?
Appleby: Yeah, this is where it gets complicated, as many of these things often do. Her insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER. But it denied the surgery and the overnight stay charges from the hospital, which did happen to be out-of-network. Four days after her surgery, Anthem notified Hughes in a letter that after consulting clinical guidelines for her type of ankle repair, its reviewer determined that it wasn’t medically necessary for her to be fully admitted for an inpatient hospital stay. So, the note said that if she’d needed additional surgery or had other problems such as vomiting or fever, an inpatient stay might’ve been warranted. But they didn’t have that in this case. And generally, people don’t stay overnight in the hospital after broken ankle surgery.
Rovner: Of course, she had no car and she …
Appleby: Right? Her car was totaled. She had no way to get home. She had nobody to pick her up. And it turns out, there’s a couple more little quirks. So the surgery charges were denied because this quirk that under Anthem’s agreement with the hospital, all claims for services before and after a patient are approved or denied together. So, since the hospital stay was generally not required after the ankle surgery, the surgery charges itself were denied as well. Even though Anthem said they always felt that that was medically necessary — that she needed the ankle surgery — it all came down to this overnight hospital stay.
Rovner: So, isn’t this exactly what the federal surprise billing law was supposed to eliminate — being in an accident, getting taken to an out-of-network hospital for emergency care? How did it not apply here?
Appleby: Right. Well, that’s where it’s so interesting because initially, that’s what everybody thought: The No Surprises Act would cover it. And the No Surprises Act from 2022, it’s aimed at preventing these so-called surprise bills, which come when you go to an out-of-network hospital or provider. And in those cases, it limits your financial liability for emergency care to the exact same cost sharing as if you had been in an in-network hospital.
So in this case, it applies to emergency care, and we saw that it did actually cover some of her emergency room charges, and that kind of thing. But generally though, emergency care is defined as treatment needed to stabilize a patient. So once she was stabilized before the surgery, she enters this post-stabilization situation. And if your provider determines that you can travel using nonmedical transport to an in-network facility, you might lose those No Surprises Act protections. Generally, you’re asked to sign some paperwork saying you want to stay at the out-of-network facility, and you want to continue treatment, and you waive your rights in that case. Hughes does not remember getting anything like that. And this case didn’t come down to the No Surprises Act. It was a question of medical necessity. Your insurer has broad power to determine medical necessity. And if they review a situation and determine that it’s not medically necessary, and you’re post-stabilization, that trumps any No Surprises Act protections.
Rovner: So what eventually happened with this bill?
Appleby: So what eventually happened was that the hospital resubmitted the charges as outpatient services. And that seemed to be the crux of the matter here. It was that inpatient overnight hospital stay. If she was kept [on] an observation status — which is a lower level of care, hospitals get paid a little bit less — that would’ve seemed to solve the problem. And that’s what happened here. Platte Valley resubmitted the bill, and her insurer paid about $21,000 of that bill. There was another $40,000 that was knocked off by an Anthem discount. And in the end, Hughes only owed a $250 copayment.
Rovner: Wow.
Appleby: Yeah.
Rovner: Of course, you left out the part where we actually called and made it …
Appleby: Well, there was that, too. And she was very savvy, as you mentioned. She also got her HR department at her employer involved. She wrote letters. She was not going to give up on this. That’s one of the advice that she gave is not to wait — not to delay too long if you get a notice of not medical necessity — but to quickly and aggressively question insurance denials once they’re received. Make sure you understand what’s going on. Try to get it escalated to the insurers and the hospital’s leadership. All of those things. And I think another takeaway for folks is — and this is harder because, look, you’re in the emergency room, you don’t know what’s going on — but it might be worth asking, Hey, am I post-stabilization? Am I being admitted as an inpatient? Am I being held for an observation stay? Is there some kind of difference with that in terms of my insurance coverage? And you could perhaps try to put this to the hospital billing department. But it’s even better if there’s a way you can call your insurer. But that’s not always realistic in these kinds of emergency situations.
Rovner: Yeah, and just out of curiosity, if somebody totals my car and I end up [in] an ambulance needing surgery, I’m going to assume that the other driver’s insurance is going to pay my medical bills. Why didn’t that happen?
Appleby: Well, in this case, the way it was explained to me is the other driver had the minimum coverage needed in the state of Colorado. And so it did pay nearly $5,000 toward some of these charges. But that’s about all it paid.
Rovner: Wow. Well, now, obviously, as you said, Lauren Hughes is a doctor. Savvy about the way the system works, or doesn’t in this case. Even then, it took her months and called us to work this all out. How should somebody with less expertise handle a situation like this? Is there somebody they can turn to help, assuming that they’re not cognizant enough to start asking questions about their admission status while they’re still in the emergency room waiting for surgery?
Appleby: Right. Again, that is so complicated. If you can, call your insurer and see what they have to say. And again, it may be after hours. It may be not possible. Perhaps see if you can chat with the hospital billing department. But again, some of this is going to be after the fact. And remember, the billing in this situation came down to how the hospital coded the billing. They coded it as an inpatient hospital stay, and that’s after the fact. And there’s not a lot you can do about it. But in the end, it was resubmitted as an outpatient service, and that made all the difference in this case.
Rovner: Wow. Another complicated one. Or I guess you can just write to us. Julie Appleby, thank you very much.
Appleby: Thanks for having me.
Huetteman: All right, now it’s time for our extra-credit 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. Anna, how about you go first this week?
Edney: Sure. This story is from a few of my colleagues at Bloomberg. “Bayer Weighs Roundup Exit as Cancer Legal Bill Nears $18 Billion.” And I thought this was an interesting story, not just because there is the possibility that the world’s most-used weed killer could be going away because it’s just folding under so many legal challenges related to cancer. But it’s also just a deep dive to look at this herbicide that has affected all of our lives and how it came to be, what’s going on with it now, why it’s not working. And also at this company, Bayer, that in the middle of these legal challenges, bought the company that owned Roundup. So I just think it’s an interesting look at the whole situation and something that we’ve probably all consumed before in certain ways, through just fruits and vegetables and different seeds and things.
Huetteman: Definitely. Shefali, how about your story?
Luthra: Sure. So I picked a four-part series by my colleague at The 19th, Orion Rummler. The headline for the piece I picked is “Detransition Is Key to Politicians’ Anti-Trans Agenda. But What Is It Really Like?” I think this is a really smart package of stories because, as Orion notes, people who have “detransitioned” — transitioned and then transitioned back — are a really central part of the modern conservative movement’s efforts to target trans health and, in particular, trans health for young people. Saying, look at these people who transitioned and then came back and regretted it. But there hasn’t been a lot of journalism actually looking at people who navigate this experience beyond those who are these political tokens. So Orion does exactly that. He talked to people who have had the experience of transitioning and then detransitioning in some way.
He notes that this is a pretty rare experience to have this journey with one’s gender, but that the people he interviewed, he profiled, said that they felt really frustrated with how the conversation has unfolded. In fact, their transitioning was an important part of their journey to discover their gender, and that they are deeply concerned that restrictions on trans health could be harmful to them and their loved ones as well. I think this is really valuable journalism, and I’m so excited that Orion did it, and I hope everyone reads it.
Huetteman: That’s really interesting. Thank you for sharing that one. Sandhya, what do you have this week?
Raman: So I pick, “Canada Loses Its Measles-Free Status, With US on Track To Follow,” and it’s by Nadine Yousif for the BBC. So this week, the Pan-American Health Organization, Canada is no longer measles-free. And so that means that the Americas region as a whole has lost its elimination status. I thought this was important because in the U.S., we’re at a 33-year high with measles. And Mexico has also seen a surge in cases. And just an interesting way to look at what’s happening a little broader than just the U.S. lens, as all these places are seeing fewer people vaccinated against measles.
Huetteman: Thanks for sharing that story, Sandhya. My extra credit this week is a great scoop from my KFF Health News colleague Amanda Seitz. The headline is, “Immigrants With Health Conditions May Be Denied Visas Under New Trump Administration Guidance.” Amanda got her hands on a State Department cable that expands the list of reasons that would make visa applicants ineligible to enter the country, including now age or the likelihood they might rely on government benefits. And it gives visa officers quite a bit of power to make those calls.
Now immigrants, they’re already screened for communicable diseases and mental health problems. But the new guidance goes further and emphasizes that chronic diseases should be considered. And it calls on those visa officers to assess whether applicants can pay for their own medical care, noting that certain medical conditions can “require hundreds of thousands of dollars’ worth of care.”
All right, that’s this week’s show. Thanks this week to our editor, Stephanie Stapleton, and our producer-engineers, Taylor Cook and Francis Ying. “What the Health?” is available on WAMU platforms, the NPR app, and wherever you get your podcasts. And, as always, on kffhealthnews.org. 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 folks these days? Sandhya?
Raman: I’m on X and on Bluesky @SandhyaWrites.
Huetteman: Shefali?
Luthra: I’m on Bluesky @Shefali.
Huetteman: And Anna?
Edney: X or Bluesky @AnnaEdney.
Huetteman: We’ll be back in your feed next week. Until then, be healthy.
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What the Health? From KFF Health News: The State of the Affordable Care Act
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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.
Open enrollment for health plans under the Affordable Care Act began Nov. 1, yet it remains unclear how much the estimated 24 million Americans who purchase from the ACA marketplaces will be expected to pay in premiums starting in January. Unless Congress acts to extend tax credits added to the program in 2021, most consumers will be expected to contribute much more out-of-pocket; in some cases, double or triple what they are paying in 2025.
The politics of this year’s ACA fight are also complicated. Democrats are using the only leverage they have — a government shutdown — to try to force Republicans to negotiate over the expiring ACA tax credits. Yet many, if not most, of the people who will face much higher premiums in 2026 are from GOP-dominated states such as Texas and Florida, and belong to professions that tend to be more Republican than Democratic, such as farmers and ranchers, or small-business owners.
In this special episode of “What the Health?” from KFF Health News and WAMU, host Julie Rovner talks to Cynthia Cox, a vice president at KFF and the director of its Program on the ACA. Cox explains what the nation’s health system looked like before the passage of the health law, how it has contributed to lower health spending and better insurance coverage, and the peculiar politics of the current fight.
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Cynthia Cox
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Transcript: The State of the Affordable Care Act
[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 from KFF Health News and WAMU Public Radio in Washington, D.C. Welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News.
Usually, I’m joined by some of the best and smartest health reporters in Washington, but today we have a special episode. We’re taping this week on Monday, Nov. 3, at 10 a.m. As always, and especially this week, news happens fast, and things might’ve changed by the time you hear this. So here we go.
Today, we’re going to explore the state of the Affordable Care Act with one of my favorite experts, KFF’s Cynthia Cox, who’s a vice president and director of the program on the ACA. Open enrollment for 2026 health plans began on Saturday, Nov. 1, and there is so much confusion. I thought it would be helpful to see where we’ve been and, possibly, where we’re going.
Cynthia, thank you so much for joining us.
Cynthia Cox: Yeah, thanks for having me, Julie.
Rovner: I want to start by reminding everyone how the Affordable Care Act changed the health care system, what problems the law tried to solve, what problems were left for another day. I feel like people have either forgotten or never knew what things were like pre-the ACA.
Cox: It has been quite awhile, so let’s, I guess, rewind 15 years or so.
There were a couple of big problems that the ACA was trying to address in the U.S. health care system. One was that there were a lot of people who were uninsured. And that was partly because of cost reasons and partly because of the second big problem that the ACA was trying to solve, which was that people who have preexisting conditions were often denied access to health insurance.
And to explain that a bit more, what that looked like, was if you had a serious illness like cancer or diabetes or some other illness that might require expensive treatments, and if you had any gap in your coverage — say, you left your job and then needed to find some other health insurance after a period of time — then the insurer would often just deny your application and say they wouldn’t insure you. And if you had a less severe condition, maybe even something like acne where you needed Accutane treatment or something, then they would still give you insurance, but they could charge you more. They would charge a surcharge for covering that preexisting condition.
And then still another issue with preexisting conditions was that insurers didn’t have to cover your treatment for a condition, too. So, you might get a health insurance coverage for certain treatments but, say, it might exclude mental health treatment or even pregnancy care or prescription drugs or other things that didn’t need to … There was no minimum standard for what needed to be included in these health insurance plans that were sold to individuals.
Usually, insurance that was sold to larger businesses or that larger companies offered was pretty comprehensive. The ACA did make some changes to those plans, too, like setting out-of-pocket limits and prohibiting lifetime caps. But most of the changes were in what was called the individual market, where people would buy their own health insurance on their own, usually when they were between jobs, or between school, or maybe a stay-at-home parent, or that sort of thing.
Rovner: Or even a self-employed individual, which was …
Cox: Yes. Exactly.
Rovner: … growing in the early parts of this century.
Cox: Yeah.
Rovner: I think people don’t remember how much of a wild West the individual market really was at that point. The Congress had regulated the employer market in 1996 with HIPAA [Health Insurance Portability and Accountability Act], which was about a lot more than confidentiality. But that’s for another day. But the individual market was so crazy that you could get insurance — it wasn’t really insurance — or you could get charged more just for being a woman, right?
Cox: Exactly. You could even be charged based on what your job was. People who had risky professions might’ve been excluded from health insurance, too. There were very few rules or standards in this market, it was …
One insurer might have insured you, and another insurer wouldn’t have. And there was no way to really know what was going to be available to you without having to maybe apply to multiple companies and go through a lengthy underwriting process, too.
Rovner: How did the ACA change that?
Cox: The ACA created a lot of standards, and the way that it did that was to say: Here are the only ways that you can vary premiums. Rather than having rules about every single little thing that could have been covered, the ACA was basically like, OK, here are the only ways that insurers can change things.
The only ways that insurers can change premiums are based on how old you are, where you live, and if you smoke cigarettes or used tobacco, and then also, just how many people are signing up for the coverage. So basically, if your whole family is signing up, then obviously that’s going to be more than if just you is signing up.
And then it basically prohibits all those other things, like you can’t rescind coverage based on preexisting conditions or exclude coverage based on preexisting conditions, or … It basically is saying: If you have a preexisting health condition, that is not a reason for an insurance company to charge you more or deny you coverage or carve out certain benefits. So now the health insurance that is sold to individuals — which now we’ve started calling these the ACA marketplaces or Obamacare markets or that sort of thing — so that coverage that’s sold there looks a lot more like the coverage that had been available to people with large employer coverage before the ACA.
Basically, it was trying to bring the standards for individual insurance coverage up to what already had been the standards for employer coverage. And, in doing so, it made health insurance more expensive in the individual market because when health insurers have to pay out claims for people who are sick, then that brings up their average costs, which they have to spread out, meaning higher average premiums that they’re charging.
Those premiums today are no more expensive than the premiums that employer plans have. They cover similar benefits. It costs about the same, but when you get coverage through work, your work is paying for a large part of that premium. And when you pay your premium, it’s usually with some sort of tax benefit, too. So I think a lot of us who have employer coverage just don’t realize how expensive employer coverage is. And the ACA …
Rovner: We also don’t realize how much we’re getting subsidized by the government because that’s …
Cox: That, too. Yes.
Rovner: … one of the big fights. It’s like: Why are we giving these people subsidies? It’s like: You’re getting a subsidy, too, if you have employer coverage.
Cox: Yeah, exactly. Yeah, it’s a tax benefit.
And so basically, in the individual market or Obamacare markets, the premiums — the raw total gross, whatever word you want to say, how much the insurance company is charging — is about the same as in the employer market, and it covers about the same services. It’s very similar coverage, and that’s why it’s expensive. But that’s also why there are tax credits that are available to help individuals afford coverage. Because if you’re low-income, there’s no way you’re going to be able to afford full-price health insurance.
Rovner: And the tax credits have been a big boon to this market, right? Including …
Cox: That’s right.
Rovner: … the expanded tax credits from 2021.
Cox: Yeah. The ACA included premium tax credits to begin with. But the enhanced tax credits — which is what Congress is debating right now — those were passed in 2021, and those basically just boosted the amount of financial assistance that people were getting.
When the ACA was first passed in 2010, there was a lot of talk about, well, how do we make health insurance affordable, but also how do we define what affordable is? There was not really a standard against which to say, OK, this is what a low-income person can afford to pay. This is what a higher-income person can afford to pay.
And so there was a table basically in the law that said, at the time, that a low-income person would pay 2% of their income for a premium, and a higher-income person would get no financial help, but a middle-income person would pay 10% or so of their income. And it turned out that that definitely helped people afford coverage.
But a couple of issues that existed in the early ACA were that those higher-income or even middle-income people were priced out of health insurance if they didn’t get a tax credit. And those were often small-business owners, or entrepreneurs, or self-employed people who were a pretty vocal group about how they were being harmed by higher premiums and not getting any financial help to pay for their costs. This was a group that got a lot of media attention and was really part of why we were even talking about repealing or replacing the ACA. It was that group of people who did not get any financial help but had higher premiums that were really, arguably, harmed by the ACA, especially if they had been healthy and had been able to get insurance before the ACA. That was one issue.
And then the other issue was just that take-up was not as high as what expectations had been, and I think a lot of that was even for lower-income or people who were getting a tax credit, maybe they just weren’t getting enough financial assistance to make that coverage affordable or attractive.
Rovner: And we should talk about the mandate, because that was the big fight over the ACA … the idea was if you were going to let all these sick people into the individual market, we needed to get more healthy people into the individual market. And maybe the tax credits wouldn’t be enough, so we’re going to require people to either pay a tax penalty or buy insurance. And that was so controversial that it got repealed.
Cox: Yeah. The idea here was, well, if you’re going to allow people with preexisting health conditions to come in and buy health insurance, what’s to stop them from waiting until they get sick to get that coverage? And if they do that, then there was this word that suddenly everyone became a health economist back in 2010 and heard about adverse selection or death spirals.
And so the concern was that if you wait until you’re sick to get health insurance — if everyone waits until they’re sick to get health insurance and only sicker people are buying health insurance — then basically that makes premiums astronomically high. No insurance company is going to want to even participate in a market like that because it could lead to what’s called a death spiral — meaning the premiums just get higher and higher and higher and higher until no one can afford to purchase that coverage.
And so the individual mandate, sorry, was one way in which people were basically compelled to purchase insurance and not wait until they were sick. Basically, there were carrots and sticks in the ACA. The sticks were the individual mandate and also this short open enrollment window. So if you didn’t sign up during open enrollment and you found out you had some serious illness after open enrollment ended, you would have to wait until the next open enrollment to sign up. And then the carrot was the tax credit, basically making coverage affordable.
So when the individual mandate penalty was reduced to $0 — effectively getting rid of the individual mandate — there was a lot of concern that that was going to lead to a death spiral or adverse selection at least. It didn’t really play out that way, I think, because what really mattered was the carrots. The open enrollment window is still there as a stick, but I think people want health insurance. It just needs to be affordable enough for them to get it. And so the tax credits are really key there to making the coverage affordable and attractive for someone to buy it even if they are not sick.
Rovner: And the enhanced credit just made the carrot that much bigger, right?
Cox: Yeah. It basically supersized the carrot.
That’s when you see when these enhanced tax credits rolled out, people started buying this coverage a lot more. The markets doubled in size. It went from about 11 million people signed up to over 24 million people signed up just within a few years of these enhanced tax credits being available.
Rovner: So there were also some things in the ACA that were supposed to help dampen, if you will, the acceleration of health care spending. The consensus is those didn’t work quite as well, but they were there, right? It’s not that [the] law just ignored the cost of health care.
Cox: Yeah. The law did not ignore the cost of health care. But I will say, I think the primary emphasis was on making health insurance affordable for individuals rather than making it affordable for our society. There were some measures put in place to slow the growth of health care. And actually, another thing that President [Donald] Trump did in his first term was use authority from the ACA to implement price transparency rules for hospitals to try to get at hospital prices. And there were, of course, other efforts, too, but I would say nothing that really made a huge impact on total health care spending as a nation.
We have seen health care spending has slowed. It’s not growing as quickly as it was before the ACA in general. I don’t know if you can attribute all of that to the ACA, though, but we still are, as a nation, spending about 20% of our GDP [gross domestic product] on health care. Whereas other countries that are large and wealthy, like the United States, spend closer to 10, 11, 12% of their GDP, and that’s regardless of whether they’re a single-payer nation or not. Even countries that have multiple payers will still spend significantly less on health care than the United States does.
Rovner: But the Republican talking point that this is all, that health care spending has gotten out of control because of the ACA isn’t true.
Cox: Yeah, no. In fact, I think health care spending growth has slowed since the ACA.
When you look at the individual market, which is where so much of the emphasis has been in changing how preexisting conditions are covered and that sort of thing, yes, premiums are higher today in the individual market than they were in the pre-ACA individual market. But individual market premiums today are really similar to employer premiums today, where the ACA, really, barely touched those plans.
I think the issue is that health insurance is just really expensive in this country, and it’s really expensive because we spend a lot on … we pay high prices for doctor’s visits, hospital stays, prescription drugs. And the ACA did do some things to try to address those underlying reasons why health care is so expensive in the U.S., but it wasn’t really the main focus. I think the main focus of the ACA was to subsidize coverage and make it affordable for individuals. But that still means that it’s expensive for society.
Rovner: So who are the individuals in the ACA individual market, if you will? There’s — what? — 24 million of them?
Cox: Yeah. There’s 24 million of them, and about half of them are either small-business employees, or owners, or self-employed people, and that’s because a lot of us get coverage through work.
But we work at bigger companies where that company offers a benefit as part of your total compensation package. You get your salary, and you also get your health insurance. Smaller companies often do not offer health insurance. They’re not required to, especially very tiny companies like mom-and-pop shops or that sort of thing. Also, even people who are not affiliated with a small business are still usually working or in a working household. They might just be working part-time, or they might be a stay-at-home parent where their spouse works, and they just don’t get health insurance for themselves.
And so generally speaking — because you have to have an income of at least the poverty level to be getting a subsidy in this market — these are working individuals or working families. Also, a lot of farmers and ranchers rely on the ACA marketplace because, again, that’s a field where they don’t necessarily get health insurance through work. So that’s a big part of it.
The other thing that’s pretty common is pre-retirees or early retirees. So basically, people who are not quite old enough to be on Medicare — since you have to be 65 to get on Medicare — you see a lot of 64-year-olds buying ACA marketplace coverage.
Rovner: I think the thing that confuses most people, at least the most people that I talk to, is that we keep hearing that ACA premiums are going up an average of 17% next year, or 30%, or more than 100%. And all of those numbers are actually correct because they’re referring to different things. So what’s the difference between premiums the insurers charge and the premiums consumers have to pay?
Cox: Yeah, there are too many percentages out there for a normal person to keep track of, so I will do my best to explain it.
Basically, there’s two ways to think about premiums in the individual market. There’s how much the insurance company is charging for their premiums. That’s the revenue that the insurance company is bringing in. But a lot of that is not paid by individuals. The federal government is paying a large share of that in the form of a tax credit.
So then the other way that people think about premiums in this market is how much individuals are paying out of their own pockets for their premiums. And if you’re just a regular person shopping on healthcare.gov, that’s what you see as your premium payment is how much you have to contribute as an individual.
The amount that the insurance companies are charging, we have a couple of different numbers on that. We have what they requested to state regulators was an 18% increase on average. Four percentage points of that, they were saying, was this extra premium increase that they weren’t otherwise going to charge. But they were saying, we think that when these enhanced tax credits expire, that healthier people are going to drop their coverage, meaning we’re going to be left with a sicker group of enrollees, so we’re going to have to charge even higher premiums than we otherwise would have. Either way, even if the enhanced premium tax credits had been extended, insurers in this market still would’ve been raising premiums by double digits.
That’s the steepest increase that we’ve seen in many years in this market. But we’re also, I think, looking at double-digit premium increases for employer plans, too. It’s just an expensive year coming up. That’s how much …
And then we have newer data that just looks at silver plans. This is super wonky. But basically, a certain plan that is the benchmark against which subsidies are calculated. The insurers are actually charging 26% more on average for that plan. So I think that these requested rates might’ve understated how much insurers are actually charging. And so these are really significant premium increases. But …
Rovner: I would say a really important piece of this is that if the tax credits weren’t changing, people wouldn’t be paying these increases. Right? They would be absorbed …
Cox: Exactly.
Rovner: … by the tax credit.
Cox: Yeah. Nine out of 10 people in this market get a tax credit right now. And if the tax credits were extended, people would pay the same next year that they do this year. Their out-of-pocket premium payment would be held relatively flat. They would not be paying these increases that insurance companies are charging.
Looking into next year, there are people who will lose the tax credit altogether if the enhanced tax credits expire. These are the middle-income, small-business owners who we were talking about before. They will lose the tax credit. So they will get less financial help or no financial help, and then they will also have to pay this double-digit premium increase that insurers are charging. So that’s this double-whammy effect for that group of people.
But even the people who continue to get a tax credit, they’ll just get a smaller tax credit next year. They’re still also going to see their premium payments go up, not because of what the insurance company is charging, but because of Congress not extending the enhanced premium tax credits. So that means that they have to pay a larger share of their income. So a low-income person, instead of paying nothing each month, will have to start paying 2% to 4% of their income. A middle-income person, instead of paying maybe 6% to 8% of their income, might pay 8% to 10% of their income.
Again, for most people, this is not a function of what the insurance company is charging. It’s actually a function of what Congress sets the law to be and how much of a tax credit they get.
Rovner: If the tax credits do expire, as currently scheduled, is there any way for people to offset that increase, like buying a less generous bronze plan instead of a silver plan? And what would that mean for their out-of-pocket spending on health care? It’s a trade-off, right?
Cox: Yeah. Our analysis shows that if people stay in the same plan, they would see a premium increase of 114% on average. But for many people, it could be an option to switch to a lower level of coverage. So maybe instead of buying a silver plan, they buy a bronze plan.
But the issue there is, a lot of the people who are buying ACA marketplace coverage right now are so low-income that they’re getting really generous financial help for their deductibles, too. It’s not just their premiums. So instead of a silver premium having a deductible of a few thousand dollars for that person, their deductible might be less than a hundred dollars now. And so if they were to switch from a silver plan to a bronze plan, they might still be able to keep a zero premium payment, or near-zero premium payment, but their deductible would be $7,000 more than it is today. Either way, they’re going to see their costs go up. It’s just, do they see them go up when they go to the doctor, or have an emergency, or have a hospitalization, or fill a prescription drug? Or do they see their monthly costs go up for each month that they’re paying their premium?
If you’re young and healthy, it might make sense to take the risk and get the bronze plan. But if you’re pretty sure you’re going to use some health care next year, then it makes sense to just pay the higher premium so that you can keep that low deductible.
Rovner: Yeah. One of the main Republican talking points is all these people who have insurance but don’t file claims every year, which they say is evidence of widespread fraud. But isn’t it also possible that some of those people don’t use their insurance because they literally can’t afford these four- and five-figure deductibles?
Cox: Yeah. It’s also … There’s a lot of reasons why someone might not use their health insurance. We certainly know whether you’re getting your coverage through work or through the ACA marketplaces. If you have a high deductible, then that can be a significant cost barrier. Also, lower-income people face other non-cost-related access barriers, like getting time off of work, or just the ability to find an appointment.
But also the market has gotten younger. And with enhanced premium tax credits attracting more people to buy coverage, this was part of the whole idea was that you get younger, healthier people to sign up for coverage and not wait until they’re sick. And so that also can make it look like there’s less utilization of care. But if you’re just young and healthy, then you might not be going to the doctor either way.
And also just …
Rovner: It’s the opposite of the death spiral, right?
Cox: Right. A health spiral is what some people have called it.
But I think there’s also just some issues with the data source that was used to do that. I won’t go into all those details, but I think … there’s something there. There is fraud. There’s no question that there’s fraud in this market. And it’s being committed mostly by agents and brokers who are signing people up either without their knowledge, or switching their plan, or switching the name of the broker so they can get the commission. But I think the scale of the fraud has been exaggerated.
Rovner: Something else I think has gotten pretty lost in the fight over extending these additional tax credits is that it’s not the only change coming to the Affordable Care Act for 2026. Republicans made some major alterations to the law in their big budget bill that they passed last summer. Let’s start with the changes to how much people might have to repay if they estimate their income incorrectly. What’s that change?
Cox: I think this is probably one of the biggest changes aside from the expiration of the enhanced premium tax credit, and it hasn’t gotten a lot of attention. So I’m worried that people who are buying their own coverage might not know about this.
Congress has basically repealed any limits on how much you would have to repay when you file your taxes the following year after you enroll in ACA marketplace coverage. The idea is that when you sign up for ACA coverage, you have to project what you think your income will be by the end of the next calendar year. That can be really hard for someone who, say, gets their income from driving Uber or working shifts at a restaurant, or so on and so forth. Or even a small-business owner might have a hard time projecting exactly how much their income will be next year. And so, if you guess wrong — in other words, if you say, now I think I’m going to make $50,000 next year, but you end up making $60,000 next year — then you might have to repay a significant amount of the tax credit.
The other simultaneous thing is that with the enhanced premium tax credits going away next year — if that actually does come to be — then this subsidy cliff will come back, meaning that if you make just a dollar too much, meaning just over 400% of the poverty level, then you’ll have to repay the entire tax credit, which could be thousands, if not tens of thousands, of dollars. And so people who are right around that cutoff will need to be really careful about if they have control over their income. For some people, it might make sense to make sure that your income is below four times the poverty level. Or you can also adjust your tax credit midyear or decide to wait and get the tax credit at the time you file your taxes instead of getting it up front.
Rovner: Yeah, I think this is a big deal. And also there’s going to be less help available for people to actually sign up for coverage, even though there’s all these big changes happening.
Cox: Yeah. When the ACA was first passed, there was this idea that it was going to be like going online and booking your own hotel, or airplane, or whatever, and that’s just not how it has panned out. Most people need help signing up for health insurance. It still is a complicated process. And so they turned to agents, brokers, and what are called navigators, who are nonprofit organizations that have helped people buy insurance. But the Trump administration has cut funding for the navigator program really significantly, and so there’s going to be fewer of those folks to help.
Also, I think this is just going to be probably one of the busiest and most chaotic ACA open enrollment periods ever, probably, and so many …
Rovner: 2013 wasn’t great but …
Cox: Yeah. But there weren’t so many buying it back then.
Rovner: … where the website didn’t work.
Cox: Yeah, yeah.
I remember that well, but also, there were not that many people shopping. Now, there’s three times as many people shopping for coverage.
Rovner: True.
Cox: I don’t know if there are more agents or brokers than there were back then, but I suspect not. But there’s just going to be busy people. And so if you need to make an appointment with an agent or broker, then go ahead and do that as soon as you can.
Rovner: Yeah. This is the trade-off here. On the one hand, people want to wait and see if Congress maybe comes to some deal on these expanded subsidies. On the other hand, it’s going to be really hard to sign up at the last minute.
Cox: Yeah, yeah. So if it were me — and I obviously would feel more comfortable signing up on my own without the help of someone — but I would personally prefer to wait and see what happens. I wouldn’t wait too long, but I might wait till Thanksgiving or early December and wait to make a decision about my plan until then. But you can’t advise everyone to do that because if you need an agent or broker to help you, maybe get that appointment as soon as you can. But maybe also just keep an eye out on things and decide before Dec. 15 if you want to change your plan.
Rovner: So it’s not just the expanded tax credits. There’s also [a] new restriction on who’s eligible. There are a lot of people who are immigrants — who were here legally — who have been eligible for tax credits who no longer will be, right?
Cox: Yeah. There has been a lot of talk about undocumented immigrants getting this coverage. And just to be clear, the ACA marketplaces are not where undocumented people come to get health insurance. You can’t even buy this coverage without a subsidy if you’re undocumented.
Now, there had been an exception for DACA [Deferred Action for Childhood Arrivals] recipients. That is no longer going to be an option for folks. And then also even some folks who are here legally but just have not been in the country for long enough to qualify for Medicaid. So you have to be in the country for five years before you can qualify for Medicaid. And it had been that if you were, say, here for two years and still waiting to get Medicaid eligibility, you could get subsidized coverage on the ACA marketplace. And so some of those folks will no longer be able to this year, and then all of those folks will no longer be able to in the coming year.
Rovner: I know the Trump administration tried to make even more changes in its annual regulation governing the marketplace, although some of those have been blocked by the courts. What are some of those changes that aren’t happening this year but that people may have heard about and that may, depending on what the courts do, come into play next year?
Cox: I think one of the most important ones was this idea that they were going to change how auto re-enrollment works. So a lot of people in the ACA marketplaces get a zero premium plan. And like all other health insurances out there, whether it’s your homeowner’s insurance or your car insurance, you just get automatically re-enrolled from one year to the next. And that’s true for these ACA marketplaces, too.
So the Trump administration had a rule that said: Well, if you were going to be auto-re-enrolled into a zero-premium plan, we want to make sure that you still want that plan. Because if you’re not paying anything each month, you might be just getting automatically re-enrolled without your knowledge. And so the idea was that you would get charged $5 a month until you actively re-enroll. That was one of a few things that was …
There was a stay in a court decision basically saying: We need to hear more about this before the court could make a final decision. But long story short, that’s not going into effect this year. But there will be other changes to auto re-enrollment in the coming years, basically due to the summer reconciliation package where auto re-enrollment would effectively end. And so that’s an even bigger deal, but that’s not going into effect yet. That will be in the coming year.
Rovner: Yes. So more people will have to actually go in and do something with their policy, but there are fewer people to help them. Do I have that right?
Cox: That’s right. Yeah. So there’s going to be a lot of activity this year. This year and in coming years. Yeah.
Rovner: So what’s the bottom line here for people who now have Affordable Care Act coverage or who plan or hope to have it for next year?
Cox: I think, first of all, watch this closely and don’t make any decision about dropping your coverage or even dropping down to a lower level of coverage until probably early December is probably the right time to really make a final decision on this. You can still start making all of your plans and getting all your paperwork together and talk to an agent or broker, but just keep watching this until there’s some sort of clear resolution about what’s going to happen in Congress. Because if the enhanced premium tax credits do get extended, you’re probably better off keeping the same level of coverage that you have now. Or for newer people, they’re probably better off in a silver plan than a bronze plan in many cases. So you don’t want to make a significant change to your coverage just yet until you know what’s going to happen next year.
But it’s a difficult situation for people to be in. They have to, at a certain point, just make a judgment call. And I think that can lead to people picking a plan that’s not necessarily the best one for them, or even going without insurance because they just don’t feel like they can afford it anymore.
Rovner: This is a conundrum. It’s obviously a conundrum for the Democrats because they’re keeping the government closed — which they normally don’t want to do — demanding that these tax credits be extended. Ironically, a lot of the people who will be helped if the tax credits do get extended are Republicans in Republican states. They’re small-business people. There are people in a lot of these very red states where we saw enrollment skyrocket. Why don’t the Republicans want to do that? It’s their voters who would be helped.
Cox: Yeah. That’s right.
I think from the Republican perspective, this would be new government spending, because if Congress does nothing, these enhanced premium tax credits expire. So from the Republicans’ perspective, it would cost $35 billion a year in new government spending to extend these enhanced premium tax credits. That’s a lot of money, and that’s coming at a time when Republicans have already shown willingness earlier in the year to make significant cuts to existing health programs like Medicaid work requirements.
I think it is a complicated issue for Republicans and that I think many of them would just rather these enhanced premium tax credits expire. But I think you’re seeing some Republicans, especially in parts of the country where premium increases would be very steep, or where maybe they’re in a swing district where they’re looking at this and saying, oh, actually most of the growth in the ACA marketplaces has been in Southern red states. Most of the people benefiting from these enhanced tax credits live in a state that was won by President Trump or in a congressional district that was won by a Republican. So it’s a complicated issue for Republicans.
Rovner: Well, we will keep track of what’s happening. Cynthia Cox, thank you so much.
Cox: Thank you.
Rovner: Thanks this week to our fill-in editor, Stephanie Stapleton, and our fill-in producer-engineer, Taylor Cook. A reminder: “What the Health?” is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, at kffhealthnews.org. 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. Cynthia, are you hanging on social media these days?
Cox: Yes. @cynthiaccox on both X and Bluesky.
Rovner: We will be back in your feed next week. Until then, be healthy.
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What the Health? From KFF Health News: Happy Open Enrollment Eve!
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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.
Open enrollment for 2026 Affordable Care Act insurance plans starts in most states Nov. 1, with no resolution in Congress about whether to continue more generous premium tax credits expanded under President Joe Biden or let them expire at the end of this year. It is unclear whether the backlash from millions of enrollees seeing skyrocketing premiums will move Democrats or Republicans to back away from entrenched positions that are keeping most of the federal government shut down.
Meanwhile, the Trump administration — having done away earlier this year with a Biden-era regulation that prevented medical debt from being included on consumers’ credit reports — is now telling states they cannot pass their own laws to bar the practice.
This week’s panelists are Julie Rovner of KFF Health News, Paige Winfield Cunningham of The Washington Post, Maya Goldman of Axios, and Alice Miranda Ollstein of Politico.
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Maya Goldman
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Alice Miranda Ollstein
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Among the takeaways from this week’s episode:
- Tens of millions of Americans are bracing to lose government food aid on Nov. 1, after the Trump administration opted not to continue funding the Supplemental Nutrition Assistance Program during the shutdown. President Donald Trump and senior officials have made no secret of efforts to penalize government programs they see as Democratic priorities, to exert political pressure as the stalemate continues on Capitol Hill.
- People beginning to shop for next year’s plans on the ACA marketplaces are experiencing sticker shock due to the expiration of more generous premium tax credits that were expanded during the covid pandemic. The federal government will also take a particular hit as it covers growing costs for lower-income customers who will continue to receive assistance regardless of a deal in Congress.
- In state news, after killing a Biden-era rule to block medical debt from credit reports, the Trump administration is working to prevent states from passing their own protections. In Florida, doctors who support vaccine efforts are being muffled, and the state’s surgeon general says he did not model the outcomes of ending childhood vaccination mandates before pursuing the policy — a risky proposition as public health experts caution that recent measles outbreaks are a canary in the coal mine for vaccine-preventable illnesses.
- And in Texas, the state’s attorney general, who is also running for the U.S. Senate as a Republican, is suing the maker of Tylenol, claiming the company tried to dodge liability for the medication’s unproven ties to autism. The lawsuit is the latest problem for Tylenol, with recent allegations undermining confidence in the common painkiller, the only one recommended for pregnant women to reduce potentially dangerous fevers and relieve pain.
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’ “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage,” by Bernard J. Wolfson.
Alice Miranda Ollstein: ProPublica’s “Citing Trump Order on ‘Biological Truth,’ VA Makes It Harder for Male Veterans With Breast Cancer To Get Coverage,” by Eric Umansky.
Paige Winfield Cunningham: The Washington Post’s “Study Finds mRNA Coronavirus Vaccines Prolonged Life of Cancer Patients,” by Mark Johnson.
Maya Goldman: KFF Health News’ “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown, New England Public Media.
Also mentioned in this week’s podcast:
- The Washington Post’s “Average Obamacare Premiums Are Set To Rise 30 Percent, Documents Show,” by Paige Winfield Cunningham
- KFF Health News’ “Doctors Muffled as Florida Moves To End Decades of Childhood Vaccination Mandates,” by Arthur Allen.
- CBS News’ “The Quiet Collapse of America’s Reproductive Health Safety Net,” by Céline Gounder.
Click to open the transcript
Transcript: Happy Open Enrollment Eve!
[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, from KFF Health News and, starting this week, from WAMU public radio in Washington, D.C., and welcome 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. 30, 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 video conference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Maya Goldman of Axios News.
Maya Goldman: Good to be here.
Rovner: And we welcome back to the podcast one of our original panelists, Paige Winfield Cunningham of The Washington Post. So great to see you again.
Winfield Cunningham: Hi, Julie. It’s great to be back.
Rovner: Before we dive in, we have a little of our own news to announce. Starting this week, we’re partnering with WAMU, Washington D.C.’s public radio station, to distribute the podcast. That means you can also now find us on the NPR app. And welcome to all you new listeners. OK, onto the news. We are now 30 days into the federal government shutdown, and there is still no discernible end in sight. And this Saturday is not only the start of open enrollment in most states for the Affordable Care Act health plans, which we’ll talk more about in a minute. It’s also the day an estimated 42 million Americans will lose access to food stamps after the Trump administration decided to stop funding the SNAP [Supplemental Nutrition Assistance] program. That’s something the administration did keep funding during the last Trump shutdown in 2019, and, according to budget experts, could continue to do now. So what’s behind this? As I think I pointed out last week, not such a great look to deprive people of food aid right before Thanksgiving.
Ollstein: So I think this follows the pattern we’ve seen throughout the shutdown, which is just a lot of picking and choosing of what gets funded and what doesn’t. The angle of this I’ve covered is that out of all of the uniformed forces of the government, the Trump administration dug around and found money to keep paying the armed members, but not the public health officers, who are also part of the uniformed branches of the country. And yeah, you’re seeing this in the SNAP space as well. President Trump and his officials have openly threatened to go after what they see as Democrat programs. So it’s just interesting what they consider in that category. But you’re seeing a lot of choices being made to exert maximum political pressure and force various sides of this fight to cave, but we’re not seeing that yet either.
Rovner: Yeah, they are. I mean, it seems this is also backwards because it’s usually the Republicans who are shutting down the government, the Democrats who are trying to pressure them to reopen it. And now, of course, we’re seeing the opposite because the Democrats want the Republicans to do something about the Affordable Care Act subsidies, and the Republicans are going after previously what had been kind of sacrosanct bipartisan programs like food stamps and the WIC [the Special Supplemental Nutrition Program for Women, Infants, and Children] program, for pregnant and breastfeeding moms and babies. And now, apparently, they’re going to stop funding for Head Start, the preschool program for low-income families with kids. On the one hand, you’re right, they are programs that are very cherished by Democrats, but I feel like this whole shutdown is now sort of going after the most vulnerable people in America.
Goldman: It’s also been interesting because [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has tried to use SNAP as a vehicle for his Make America Healthy Again agenda, right? Trying to get states to limit the sugary drinks that their SNAP programs offer. And he’s, like, really touted that as part of the agenda. And now there does not seem to be any interest from HHS in speaking out about that.
Rovner: Well, of course, and SNAP isn’t an HHS program.
Goldman: Exactly. Exactly.
Rovner: It’s a program in the Department of Agriculture, which is even more confusing, but you’re absolutely right. I mean, it’s odd that some of the things that he’s been pointing to are things that this administration is kind of trying to lay at the Democrats’ feet, as in, You want this program, reopen the government. So as I mentioned, Saturday is the start of Obamacare open enrollment in most of the states. And, Paige, you got a sneak peek at the premiums for plans in the 30 states that use the federal marketplace, which is now open for what we call window-shopping before open enrollment officially begins. What did you find?
Winfield Cunningham: Yeah. So I got some documents at the end of last week showing that the average premium for the second-lowest-cost silver plan — which, of course, is what, we know … that’s what the subsidies are pegged to — is going up 30%, which is the second-highest premium increase. The highest we saw was 2017 to 2018. But this is a really, really significant increase. And of course, CMS [the Centers for Medicare & Medicaid Services] didn’t include that number in the document that it finally released this week. So the documents I saw had some sort of numbers like that, which were all stripped out of the official documents. But all of this is just so interesting because I was thinking about, back to 2017-2018, and the politics of this are so flipped right now because basically it was the Democrats then who didn’t want to talk about premium increases and the Republicans who were yelling about it.
So it’s funny how that has changed. But I guess on the politics of this, it seemed for a while like Democrats were thinking maybe the Nov. 1 start of open enrollment would provide this out for them to pass the spending bill because they could say, like, OK, we tried. Now open enrollment has started, or the premiums are kind of baked, so we can’t really do anything to change it now. But I don’t think we’re going to have anything this week. It seems like both sides are pretty dug in still. I mean, I guess the other thing I would say on these costs, it’s really highlighting a weakness that we’ve known for a long time in the Affordable Care Act, which is that, like, yes, it made health insurance affordable for a lot of people, but there’s always been this smaller number of people that are above 400% federal poverty that have had no shield from insurance costs. They have the last four years, and now they’re not going to have one anymore. And it’s funny because Democrats are talking about this, but that’s sort of a problem they hadn’t wanted to acknowledge for a long time in the early years of the Affordable Care Act. And as you guys all know, there’s not going to be any political will for bipartisan work to create affordable options for these folks unless the subsidies get extended, which, of course, that doesn’t seem very likely at the moment from how things stand.
Rovner: Yeah. Going back to what the Republicans sort of announced, their talking points, is that, well, first the premium increases aren’t that big and that the expiring extra subsidies aren’t that big a piece of it, both of which are actually kind of true. But, of course, that’s not where the sticker shock is coming from. The sticker shock is coming from the expiration of those tax credits that’s going to …
So people who had been shielded from these very high premiums are no longer going to be shielded from them. And that’s why, if you look at social media, you see all these screenshots now of insurance that costs $3,000 a month for people who were paying $150 a month, which is obviously not affordable. Why is it so difficult to explain the difference? I’ve been working on different ways to explain it for the last three weeks.
Goldman: I was trying to figure this out last night, when I was writing something for my newsletter today. And I think one of the really confusing parts about this is that, like Paige said, like Paige scooped, premiums are going up a certain amount, and that’s not actually what people are seeing. That’s not what almost anyone is going to actually face. Either you’re getting that huge sticker shock because you’re losing your subsidies that you had this year or you’re continuing to have subsidies, they’re not quite the same, but you’re still not going to pay a 30% increase. And so I think that that’s really confusing for me even, and hard to explain.
Winfield Cunningham: I think one way to think about this is like the party that is going to bear the brunt of the premium costs to a large degree is the government because for people that are before 400% federal poverty, they are basically guaranteed under the Affordable Care Act that they’re not going to have to pay more for premiums over a certain percentage of their income. And so this just means, like, the subsidies are getting really expensive for the federal government, which goes back to the issue of kind of like why Democrats didn’t extend these enhanced premiums indefinitely — because it’s just expensive to do it. This is the government subsidizing private health insurance. And then it’s also significant again for those people over 400% poverty who had had a cap on what they would pay. I think it was 9.5% of their income under the enhanced … and now they have no cap.
Rovner: I think 8.5% of their income, actually, under the enhanced premiums.
Winfield Cunningham: Under the enhanced. OK.
Rovner: It’s going to go back to 10%.
Winfield Cunningham: Yeah. Yeah. But there’s no cap if you’re like over, over 400%.
Rovner: 400%.
Winfield Cunningham: Right. Yeah. Yeah.
Rovner: That’s right.
Winfield Cunningham: Yeah. But that’s why people are confused. And the other thing is, like, the administration is correct, that the vast majority of people in the marketplaces will continue to get subsidies. And we are basically going back to what the situation was before covid, but it’s that smaller number of people that are at the higher income levels. But the other thought I had was, of course, the health care industry and Democrats are talking a lot about this and spreading these huge premium increases far and wide and making sure everybody hears about them, but it’s like a relatively small number of people, if you think about it.
And I think it’s only like a couple million people in the marketplaces who are at that higher income levels. And I wonder if that factors into Republicans’ calculations here, where they’re looking at how many voters are actually seeing these massive premium increases, having to pay for all of them. And in the whole scheme of the U.S. population, it’s not like a ton of people. So I just wonder if that’s one reason they’re sort of, like, seem to be increasingly dug in on this and very reticent to extend these subsidies.
Rovner: Although I would point out that when the Affordable Care Act started, it was only a small number of people who lost their insurance, and that became a gigantic political issue.
Winfield Cunningham: This is very true.
Rovner: So it’s the people who get hurt who sometimes yell the loudest, although you’re right. I mean, at that point, the Democrats stayed the course and eventually, as Nancy Pelosi said, people came to like it. So it could work out the same way. It does help explain why everybody’s still dug in. Maya, you wanted to say something.
Goldman: I was just going to say, I think it’ll be interesting to see, if subsidies aren’t extended, how this affects premiums next year for people and for the federal government, because if a couple million people drop out of the ACA marketplace because it’s too expensive, and those people tend to be healthier, then the remaining pool of people is sicker, and then that’s the death spiral, right? So …
Rovner: Yeah. Although it is …
Goldman: Obviously, that’s a lot of what ifs, but …
Rovner: … only the death spiral that goes back to prior to covid, which — it was kind of stable at 12 million. I’m sort of amused by seeing Republicans complaining about subsidizing insurance companies. It’s like, but this was the Republicans’ idea in the first place, going back to the very origin of the ACA.
Ollstein: And we should not forget that there is a group of people who are going to be losing all of their subsidies, not just the enhanced subsidies. And that’s legal immigrants, and that’s hundreds of thousands of people. So, like Maya said, that will probably mean a lot of younger, healthier people dropping coverage altogether, which will make the remaining pool of people more expensive to insure. So these things have ripple effects, things that impact one part of the population inevitably impact other parts of the population. And again, these are legal tax-paying immigrants with papers — will be subject to the full force of the premium increases because they won’t have any subsidies.
Rovner: Yes, our health system at work. All right, we’re going to take a quick break. We will be right back with more health news.
Moving on, the federal government is technically shut down, but the Trump administration is still making policy. You might remember last summer, a federal judge blocked a Biden administration rule that prevented medical debt from appearing on people’s credit reports. The Trump administration chose not to appeal that ruling, thus killing the rule. Now the administration is going a step further — this week, putting out guidance that tries to stop states from passing their own laws to prevent medical debt from ruining people’s credit, and often their ability to rent, or buy a house, or purchase a car, or even sometimes get a job. According to the acting head of the federal Consumer Financial Protection [Bureau], Russell Vought — yes, that same Russell Vought who’s also cutting federal programs as head of the Office of Management and Budget — states don’t have the authority to restrict medical debt from appearing on credit reports, only the federal government does, which of course he has already shown he doesn’t want to do. Who does this help? I’m not sure I see what the point is of saying we’re not going to do it and states, you can’t do it either. Part of this, I know, is Russell Vought has made no secret of the fact that he would like to undo as much of the federal government as he can. In this case, is he doing the bidding of, I guess it’s the people who extend credit, who, I guess, want this information, want to know whether people have medical debt, think that that’s going to impact whether or not they can pay back their loans, or is this just Russell Vought being Russell Vought?
Goldman: I guess, in theory, maybe it goes back to the idea that if you have consequences for medical debt, then people will pay their bills, and maybe that would help the health systems in the long run. But I also think that — I don’t know what health systems have said about this particular move, to be honest — but I think there’s an interest in making medical debt less difficult for people to bear in the whole health system. So I’m not sure how popular that is.
Rovner: Yeah. Yes. Another one of those things that’s sort of like, we’re going to hurt the public to thwart the Democrats, which kind of seems to be an ongoing theme here. Well, as we tape this morning, the Senate health committee was supposed to be holding a hearing on the nomination of RFK Jr. MAHA ally Casey Means to be U.S. surgeon general. Casey Means was going to testify via video conference because she is pregnant, but, apparently, she has gone into labor, so that hearing is not happening. We will pick up on it when that gets rescheduled. Perhaps she will appear with her infant.
Back at HHS, a U.S. district judge this week indefinitely barred the Trump administration from laying off federal workers during the shutdown, but at the Centers for Disease Control and Prevention, it appears the damage is already done. The New York Times’ global health reporter, Apoorva Mandavilli, reports that the agency appears to have had its workforce reduced by a third and that the entire leadership now consists of political appointees loyal to HHS secretary Kennedy, who has not hidden his disdain for the agency and the fact that he wants to see it dissolved and its activities assigned elsewhere around the department. What would that mean in practice if there, in effect, was no more CDC?
Winfield Cunningham: Hopefully we don’t have another pandemic. There’s just a lot of stuff the CDC does. And it’s been really confusing to follow these layoffs because in this last round, I remember trying to figure out with my colleague Lena Sun how many people were sent notices and then hundreds were sort of, those were rescinded and they were brought back. But yeah, I mean, I think we’re going to see the effects of this over the next couple of years. When I’ve asked the administration broadly about the reductions to HHS, what they say is that the agency overall has grown quite a lot in its headcount through the pandemic, which is true. I think they got up to like 90,000 or so. And then, according to our best estimates, maybe they’re back around 80,000, although I’m not entirely sure if that’s accurate. Again, it’s really been hard to track this.
Rovner: Yeah. I’ve seen numbers as low as 60,000.
Winfield Cunningham: It may be lower. Yeah. Yeah. So I think actually the 80,000, that may have been the headcount before the pandemic. Anyway, all that to say, it did grow during the pandemic, and that’s kind of the argument that they’re making, is that they’re just bringing it back to pre-pandemic levels.
Rovner: But CDC, I mean, it really does look like they want to just sort of devolve everything that CDC does to the states, right? I mean, that we’re just not going to have as much of a federal public health presence as we’ve had over these past 50, 60 years.
Winfield Cunningham: For sure. They’ve definitely targeted CDC. I mean, they mostly left CMS alone and FDA because, statutorily, I think it’s easier for them to shrink CDC, but it definitely is going to have massive effects over the next couple of years, especially as we see future pandemics.
Ollstein: And the whole argument about returning to pre-covid, that doesn’t fit with what they’re actually cutting. I mean, they’re gutting offices that have been around for decades — focused on smoking, focused on maternal health, all these different things. And so this is not just rolling back increases from the past few years. This is going deeper than that.
Winfield Cunningham: Well, yeah, it’s not like they’re just cutting the roles that were added since the pandemic.
Ollstein: Exactly.
Rovner: It’s not a last-in, first-out kind of thing. Well, as I said, since it looks like public health is now mostly going to be devolved to the states, let’s check in on some state doings. In Florida, where state Surgeon General Joseph Ladapo last month announced a plan to end school vaccination mandates. My KFF Health News colleague Arthur Allen has a story about how health officials, including university professors and county health officials, who actually do believe in vaccinating children, are effectively being muzzled, told they cannot speak to reporters without the approval of their supervisors, who are likely to say no. Seeing the rising number of unvaccinated children in a state like Florida, where so many tourists come and go, raising the likelihood of spreading vaccine preventable diseases, this all seems kind of risky, yes?
Goldman: Yes. That was a fantastic article from your colleague, and there was a really illuminating line, which I think had been reported before, but a reporter asked the surgeon general if he had done any disease modeling before making the decision. And he said, Absolutely not, because this to him was a personal choice issue and not a public health issue. And I think that just goes to show that we have no idea what is going to happen as a result of this public health decision and it could have massive ripple effects.
Rovner: But what we are already seeing are the rise of vaccine-preventable diseases around the country. I mean, measles, first in Texas, now in South Carolina; whooping cough in Louisiana; I’m sure I am missing some, but we are already seeing the consequences of this dwindling herd immunity, if you will. Alice, you’re nodding your head.
Ollstein: Yeah. And I’ve heard from experts that measles is really sort of the canary in the coal mine here because it’s so infectious. It spreads so easily. You can have an infected person cough in a room and leave the room, and then a while later, someone else comes in the room and they can catch it. Not all of these vaccine-preventable illnesses are like that. So the fact that we’re seeing these measles outbreaks is an indication that other things are probably spreading as well. We’re just not seeing it yet, which is pretty scary.
Rovner: And of course, one of the things that the CDC does is collect all of that data, so we’re probably not seeing it for that reason, too. Well, meanwhile, in Texas, Attorney General and Republican Senate candidate Ken Paxton is suing the makers of Tylenol. He’s claiming that Johnson & Johnson spun off its consumer products division — that includes not just Tylenol, but also things like Band-Aids and Baby Shampoo — to shield it from liability from Tylenol’s causing of autism, something that has not been scientifically demonstrated by the way — even Secretary Kennedy admits that has not been scientifically demonstrated. My recollection, though, is that Johnson & Johnson was trying to shield itself from liability when it spun off its consumer products division, but not because of Tylenol, rather from cancer claims related to talc in its eponymous Baby Powder. So what’s Paxton trying to do here beyond demonstrate his fealty to President Trump and Robert F. Kennedy Jr.?
Ollstein: I was interested to see some GOP senators distancing themselves from the Texas lawsuit and saying like, Look, there is no proof of this connection and this harm. Let’s not go crazy. But as I’ve reported, it’s just very hard to get good information out to people because there just isn’t enough data on the safety of various drugs, because testing drugs on pregnant women was always hard and it’s gotten even harder in recent years. And so, based on the data we have, this is a correlation, not causation. But it would be easier to allay people’s fears if we had more robust and better data.
Rovner: Yeah. Does a lawsuit like this, though, sort of spread the … give credence to this idea that — I see you nodding, Maya — that there is something to be worried about using Tylenol when pregnant? Which is freaking out the medical community because Tylenol is pretty much the only drug that currently is recommended for pregnant women to deal with fever and pain.
Goldman: Yeah. I think some of my colleagues have reported on the concern of another death spiral here, right? Where people get concerned, perhaps without basis, of taking Tylenol or any other drugs, vaccines even, because there are lawsuits and then the makers of these drugs say it’s not worth it for us to make these anymore. And then they don’t make them. And then it’s like a bad cascade of events. And so it’s obviously too soon to see if that’s what’s happening here, but it’s certainly something to watch.
Rovner: But as we’ve pointed out earlier, not treating, particularly, fever can also cause problems. So …
Ollstein: Right. Basically all of the alternatives are more dangerous. Not taking anything to treat pain and fever in pregnancy can be dangerous and can lead to birth effects. And taking other painkillers and fever reducers are known to have dangerous side effects. Tylenol was the safest option known to science. And now that that’s being questioned in the court of public opinion, people are worried about these ramifications.
Winfield Cunningham: I think about the effect on moms who have kids with autism who are now thinking back to their pregnancies and thinking, Oh my gosh, how much Tylenol did I take? I know I took, I had pregnancies that I took plenty of Tylenol during. My nephew has autism, and I was talking to my sister about this, and she was like, “I took Tylenol.” And what they’re doing is, I guess, other reflection I have on it is, in general, there’s just less research on most things than we need. And there are some studies showing a correlation, which as we all know is not causation. And what it looks like the administration did was they took those tiny little nuggets of suggestions and have blown them up into this overly confident declaration of Tylenol and pregnancy and probably unnecessarily causing many women to blame themselves or think, Should I have done something differently during my pregnancy? when they were really just doing what their doctor recommended they do.
Ollstein: I’m surprised that we haven’t seen legal action from Tylenol yet. I imagine we might at some point, especially if there is some kind of government action around this, like a label change. I think we will see some sort of legal action from the company because this is absolutely going to impact their bottom line.
Rovner: Yeah. All right. Well, finally this week, more news on the reproductive health front. California announced it would help fund Planned Parenthood clinics so they can continue providing basic health services, as well as reproductive health services, after Congress made the organization ineligible for Medicaid funds for a year and the big budget bill passed last summer. California’s the fourth state to pitch in joining fellow blue states Washington, Colorado, and New Mexico. Meanwhile, family planning clinics in Maine are closing today due to that loss of Medicaid funding. And at the same time, the Health and Human Services Office of Population Affairs, which oversees the federal family planning program, Title X, is down apparently from a staff of 40 to 50 to a single employee, according to my colleague Céline Gounder. Is contraception going to become the next health care service that’s only available in blue states, Alice?
Ollstein: So Title X has been in conservatives’ crosshairs for a long time. There have been attempts on Capitol Hill to defund it. There have been various policies of various administrations to make lots of changes to it. Some of those changes have really limited who gets care. And so it’s been a political football for a while. Of course, Title X doesn’t just do contraception. It’s one of the major things they do, providing subsidized and sometimes even free contraception to millions of low-income people around the country. But they also provide STI testing, even some infertility counseling and other things, cancer screenings. And so this is really hitting people at the same time as the anticipated Medicaid cuts, and at the same time Planned Parenthood clinics are closing because they got defunded. And so it’s just one on top of another in the reproductive health space. Each one alone would be really impactful, but taken all together, yeah, there’s a lot of concern about people losing access to these services.
Winfield Cunningham: I think the politics of this are more interesting to me than the practical effect. I mean, under the ACA, birth control has to be covered, right? by marketplace plans. Generally speaking, if people have insurance, they do have coverage for a range of birth control. But the Title X program is interesting because it seems to like overlap between the MAHA priorities and the social conservatives. Of course, as Alice said, this has long been a target of social conservatives. I think in Project 2025 called for any Title X, I believe. And then there’s this current in the MAHA movement that’s kind of like anti-hormonal birth control and there’s also these kinds of streams of pronatalist people, of have more babies, don’t take birth control. So that’s kind of interesting to me because there’s this larger narrative I think in HHS right now of the RFK MAHA people versus the traditional conservative, anti-abortion people. So that’s just like one program where I see overlap between the two.
Rovner: One of my favorite pieces of congressional trivia is that Title X has not been reauthorized since 1984, which, by the way, is before I started covering this. But I’ve been doing this 39 years and I have never covered a successful reauthorization of the Title X program. So it’s obviously been in crosshairs for a very, very long time. Maya, did you want to add something?
Goldman: I was just going to say to Paige’s point, telling women that they can’t take any painkillers during pregnancy is not a good way to raise the birth rate.
Rovner: Yes. That’s also a fair point. Well, meanwhile, red states are trying to expand the role of crisis pregnancy centers, which provide mostly nonmedical services and try to convince those with unplanned pregnancies not to have abortions. In Wyoming, state lawmakers are pushing a bill that would prohibit the state or any of the localities from regulating those centers “based on the center’s stance against abortion.” This comes after a similar proposal became law in Montana, the efforts being pushed by the anti-abortion group Alliance Defending Freedom. Is the idea here to have crisis pregnancy centers replace these Title X clinics and Planned Parenthoods?
Ollstein: I think there are a lot of people that would like to see that, but, as you said, they do not provide the same services, so it would not be a one-to-one replacement. Already, there are way more crisis pregnancy centers around the country than there are Planned Parenthood clinics, for example, but that doesn’t mean that everyone has access to all the services they want.
Rovner: And many of these crisis pregnancy centers don’t have any medical personnel, right? I mean, some of them do, but …
Ollstein: It’s really a range. I mean, some have a medical director on staff, or maybe there’s one medical person who oversees several clinics, some do not. Some offer ultrasounds, some don’t, some just give pamphlets and diapers and donated items. It’s just really a range around the country. And states have also been grappling with how much to, on the conservative side, support and fund such centers. And on the other side, states like California have really gone to battle over regulating what they tell patients, what they’re required to tell patients, what they can’t tell patients. And that’s gotten into the courts and they’ve fought over whether that violates their speech rights. And so it’s a real ongoing fight.
Rovner: Yes, I’m sure this will continue. All right, 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’ll put the links in our show notes on your phone or other mobile device. Maya, why don’t you go first this week?
Goldman: Sure. So this story is from KFF Health News and New England Public Media. It’s called “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown. And I think this stood out to me because I was just in Vegas last week for health, but this, I think, is a really interesting issue to explore through a public health lens, the issue of sports betting and betting addiction. And there are states that are trying to do a lot of work around this and just organizations. And then of course the gaming companies themselves have their own pushback on that, and I think this story just lays it out really well and it’s an important issue that gets very overlooked.
Rovner: Yeah, it is a public health issue, an interesting one. Alice?
Ollstein: I chose a story from ProPublica by reporter, Eric Umansky, and it’s called “Citing Trump Order on ‘Biological Truth,’ VA Makes It Harder for Male Veterans With Breast Cancer To Get Coverage.” So this is one of many examples that you could give of policies intended to target transgender folks having spillover effects and impacting cisgender folks, too. In this instance, it’s now harder for male veterans to qualify to get treatment for breast cancer. Men can get breast cancer. Let’s just say that. Men can and do get breast cancer, and it can be harder to detect and very lethal, and obviously very expensive to treat if you don’t have coverage. And so this story has a lot of sad quotes from folks who are losing their coverage, especially because they likely acquired cancer by being exposed during their service to various toxic substances. And so I think, yeah.
Rovner: Yeah. A combination of a lot of different factors in that story.
Ollstein: Definitely.
Rovner: Paige?
Winfield Cunningham: Yeah. So my story is by, actually, my colleague Mark Johnson. I sit next to him at The [Washington] Post, and the headline is “Study Finds mRNA Coronavirus Vaccines Prolonged Life of Cancer Patients.” I was really struck by this story because it talks about how patients with advanced lung cancer, they were given the covid vaccines and it somehow had the effect of supercharging their immune systems. And, actually, their median survival rates went up by 17 months compared with those that weren’t given the vaccines. And, of course, this administration has really gone after the covid vaccines and the mRNA research, in particular, and canceled $500 million in funding for mRNA research. And all of the ACIP’s [Advisory Committee on Immunization Practices’] moves on vaccines have gotten so much attention. But I think the thing that also is going to be perhaps even more impactful is pulling back on this really promising research, because it has sort of become politicized because the covid vaccines have become politicized. And it seems a shame that we’re pulling back on this really promising research. So I thought that was a really interesting story by my colleague.
Rovner: Yes. Yet another theme from 2025. My extra credit this week is from my KFF Health News colleague Bernard J. Wolfson, and it’s called “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage.” And it’s a good reminder about something we did talk about earlier this year when the Republican budget bill passed. It limits federal grad school loans to $50,000 per year at a time when the median tuition for a year in medical school is more than $80,000. The idea here is to push medical schools to lower their tuition, but in the short run, it’s more likely to push lower-income students either out of medicine altogether or to require them to take out private loans with more stringent repayment terms, which could in turn push them into pursuing more lucrative medical specialties rather than the primary care slots that are already so difficult to fill. It’s yet another example of how everybody agrees on a problem: Medical education is way too expensive in this country. But nobody knows quite how to fix it.
OK. That is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Health?” is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, kffhealthnews.org. If you already follow the show, nothing will change. The podcast will show up in your feed as usual. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me at X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Maya?
Goldman: I am on X as @mayagoldman_ and I’m also on LinkedIn, just under my name.
Rovner: Alice?
Ollstein: @alicemiranda on Bluesky and @AliceOllstein on X.
Rovner: Paige?
Winfield Cunningham: I am still @pw_cunningham on X.
Rovner: Great. We will be back in your feed next week. Until then, be healthy.
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As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction
It isn’t easy to promote moderation and financial discipline from the bowels of a casino.
But that’s what Massachusetts state workers try to do every day, amid the clanging bells and flashing lights of the slot machines.
At the MGM Springfield in western Massachusetts, workers wearing green polos stand outside their small office, right off the casino floor.
It isn’t easy to promote moderation and financial discipline from the bowels of a casino.
But that’s what Massachusetts state workers try to do every day, amid the clanging bells and flashing lights of the slot machines.
At the MGM Springfield in western Massachusetts, workers wearing green polos stand outside their small office, right off the casino floor.
Above them, a sign reads “GameSense,” the state’s signature program to curb problem gambling. A mounted screen cycles through messages such as “Keep sports betting fun. Set a budget and stick to it.”
The workers hand out free luggage tags and travel-size tissues to encourage people to stop and chat. If they succeed, they give customers brochures displaying the state’s gambling helpline number and website. They can even enroll them in a program called “PlayMyWay,” which allows customers to set monthly spending limits on how much they gamble.
Outside the casinos, GameSense is marketed on social media and on sports betting apps and websites. Meanwhile, the state’s Department of Public Health puts its own moderation messages on buses and billboards.
“That’s a big movement in 12 years,” said Mark Vander Linden, who oversees the GameSense program in Massachusetts.
Massachusetts’ first casino opened in 2015, and as the gaming industry grew, the state developed what it calls a “responsible gaming” program, funded by a surtax on gambling industry profits.
At first, state regulators tried various strategies to educate customers about the addictive nature of gambling, as well as the financial risks.
“It was much more about making sure that there are brochures that are available that explained the odds of whatever game it was,” Vander Linden said.
Since then, Massachusetts has put in place additional regulations on a booming industry that now includes widespread sports betting. For example, there’s no betting on Massachusetts college teams, and no gambling by credit card. All gambling companies must allow customers to set voluntary limits and sign up for a “voluntary self-exclusion list” that bans them from casinos or sports betting over various time intervals.
A Patchwork of State Policies
Some states have set similar limits to curb problem gambling, but others have very few. In the absence of a nationwide policy, or a national gambling commission to oversee the industry, each state is on its own.
A growing number of addiction researchers and policymakers say it’s time to take bolder — and more unified — steps to combat gambling disorders. They point to the explosion of the gaming industry since 2018, when the U.S. Supreme Court opened the door for states to legalize sports betting and unleashed an aggressive industry, now legal in 39 states. (Forty-eight states have legalized at least some form of gambling, including lotteries.)
Compared with the U.S., several other countries have gone much further in regulating the gambling industry, and some experts in the U.S. are looking to them as potential models.
For example, Norway’s government has a monopoly on all slot machines so it can control the types of games offered, and every gambler in the country is limited to losing 20,000 kroner (about $2,000) a month.
In the United Kingdom, most adults are limited to betting 5 pounds (about $7) on every spin on a slot machine, and gambling companies are subject to a 1% levy that goes into a fund for treatment and prevention of gambling disorders.
Last year, a report published in the medical journal The Lancet called on international health leaders to act quickly on regulations before gambling disorders become widespread and common — and that much harder to stop.
But policy leaders point out that the U.S. has less appetite for corporate regulation than many other countries, especially under the Trump administration. At the same time, they warn that doing nothing could pose a serious public health threat, especially now that sports betting apps allow people to gamble anywhere and anytime.
Fears That More Gambling Means More Addiction
Even before the marriage of online gaming and cellphones, researchers had estimated 1% to 2% of Americans already had a gambling disorder, and an additional 8% of people were at risk of developing one.
Some U.S. politicians fear the problem will only get worse.
“The sophistication and complexity of betting has become staggering,” said Democratic U.S. Sen. Richard Blumenthal of Connecticut. “And that’s why we need protections that will enable an individual to say no.”
Blumenthal has cosponsored the SAFE Bet Act, legislation that would impose federal standards on sports betting companies.
The bill proposes a ban on gambling ads during live sporting events, mandatory “affordability checks” for high-spending customers, limits on VIP membership schemes, a ban on artificial intelligence tracking for marketing, and the creation of a national “self-exclusion” database, among other rules.
“States are unable to protect their consumers from the excessive and abusive offers, and sometimes misleading pitches,” Blumenthal said. “They simply don’t have the resources or the jurisdiction.”
The gambling industry is strongly opposed to the SAFE Bet Act. Federal standards would be a “slap in the face” to state regulators, said Joe Maloney, a spokesperson for the American Gaming Association.
“You have the potential to just dramatically, one, usurp the states’ authority and then, two, freeze the industry in place,” he said.
‘Responsible Gaming’ Versus the Public Health Approach
New regulations are also unnecessary, Maloney said. The industry acknowledges that gambling is addictive for some people, he said, which is why it developed an outreach/awareness initiative known as “responsible gaming.”
That includes messages on buses and billboards warning people to stop playing when it’s no longer fun and reminding them the odds of winning are very low.
“There’s very direct messages, such as, ‘You will lose money here,’” Maloney said.
He said his industry group does not collect data on whether such measures reduce addiction rates. But he said gambling restrictions are not the answer.
“If you suddenly start to pick and choose what can be legal or banned, you’re driving bettors out of the legal market and into the illegal market,” Maloney said.
Public health leaders argue that the industry’s “responsible gaming” model doesn’t work.
“You need regulation when the industry has shown an inability and unwillingness to police itself,” said Harry Levant, director of gambling policy for the Public Health Advocacy Institute at the Northeastern University School of Law in Boston.
One reason the industry’s approach is “ethically and scientifically flawed” is that it puts all the blame and responsibility on individuals with a gambling disorder, Levant said. “You can’t say to a person who is struggling with addiction, ‘Well, just don’t do that anymore.’”
Levant comes to the issue from personal experience. He is in recovery from a gambling addiction. A former lawyer, Levant was convicted in 2015 for stealing clients’ money to fund his betting habit. Since then, he not only has become an advocate for stronger regulations but also is a trained addiction therapist.
The American Gaming Association said it supports treatment for gambling disorders and helps pay for some referral and treatment services through state taxes. But Levant called that “the moral equivalent of Big Tobacco saying, ‘Let us do whatever we want for our cigarettes, as long as we pay for chemotherapy and hospice.’”
Instead, Levant advocates for a public health approach that would help prevent addiction from the get-go. That means putting limits on marketing and on the types, and frequency, of gambling — for everyone, not just those already in trouble.
To make his case, Levant opens his laptop and pulls up a corporate infomercial produced by Simplebet, a DraftKings subsidiary.
In the video, the company boasts about getting more people to gamble on sports through what’s called microbetting during live games. “We drive fan engagement by making every moment of every game a betting opportunity. Automatic, algorithmic, powered by machine learning and AI,” the voiceover said.
That’s the kind of constant engagement that promotes addiction, Levant said. (Contacted by KFF Health News and NPR, DraftKings declined to comment, instead sending a link to its “responsible gaming” program.)
Lawmakers Want To ‘Stop the Worst Excesses’ Before the Next Gambling Trend
Some of those gambling mechanisms would be limited by the SAFE Bet Act, which Levant and his colleagues at the Public Health Advocacy Institute helped write.
But if the legislation doesn’t get through the current regulation-averse Congress, then states need to take strong action on their own, Levant said.
The Massachusetts Legislature is currently considering the “Bettor Health Act,” which would impose additional rules on sports betting companies.
“The goal is not to stop gambling entirely,” said Massachusetts state Rep. Lindsay Sabadosa, a cosponsor of the bill. “It’s to stop the worst excesses of online sports betting.”
The Massachusetts bill includes components of the federal legislation, such as mandatory “affordability checks.” Those would cap how much money some gamblers can lose. Affordability checks are modeled on a pilot program in the United Kingdom.
“If you’re only allowed to have two drinks, we know that you’re not going to get drunk, right?” Sabadosa said. “If you’re only allowed to gamble $100 a day because that’s an affordable amount, you’re not going to go broke. You’re still going to be able to pay the rent.”
The Bettor Health Act would also ban “prop” bets, which are wagers placed during a live game, such as who makes the first shot in basketball, or who hits the first home run in baseball.
But state tax revenue from sports betting rose to $2.8 billion in 2024 — a welcome source of funding for struggling state budgets. Because of that potential boost, Levant fears that state legislatures will shy away from further regulation.
States may even be tempted by the promise of additional revenue from new types of gambling, such as “iGaming.” That refers to online versions of roulette, blackjack, and other casino-style games, playable at any hour, from the comfort of home.
IGaming is currently legal in seven states, but pending legislation in other states, including Massachusetts, could expand its markets.
“We have empathy for how hard it is for states to balance their budgets in this current political environment,” Levant said, “but states are starting to recognize that the answer to that problem is not to further push a known addictive product.”
This article is part of a partnership with NPR and New England Public Media.
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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KFF Health News' 'What the Health?': Nutrition Programs Face Their Own 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.
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.
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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?': Schrödinger’s 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.
Democrats and Republicans are both facing potential political consequences in their continuing standoff over federal government funding. Republicans are likely to face a voter backlash if they refuse to agree to Democrats’ demands that they renew additional tax credits for Affordable Care Act marketplace plans, since the majority of those facing premium hikes live in GOP-dominated states. For their part, Democrats are worried that Republicans will violate the terms of any potential spending deal.
At the same time, the Trump administration is using the shutdown to try to lay off thousands of federal workers, including those performing key public health roles at the Centers for Disease Control and Prevention.
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 Lauren Weber of The Washington Post.
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Anna Edney
Bloomberg News
Joanne Kenen
Johns Hopkins University and Politico
Lauren Weber
The Washington Post
Among the takeaways from this week’s episode:
- As the federal government shutdown drags on, there has been little progress toward a deal on government spending — or on the expiring ACA marketplace subsidies Democrats are fighting to renew. Potential subsidy compromises could, for instance, implement a minimal premium in place of $0 premiums, to reduce enrollment fraud, as Republicans want.
- A federal judge halted the Trump administration’s latest layoffs of federal workers amid questions about the layoffs’ legality. The administration in particular dealt a heavy blow this round to the CDC, an agency that has been battered by staff reductions, policy shifts, and even violence.
- New reporting shows the Trump administration explored the feasibility of tracing abortion pill residue in wastewater, following up on an anti-abortion claim that the drugs may be contaminating the water supply. Yet advocates could have an ulterior motive: developing the ability to trace use of the pill to further crack down on abortions.
- And President Donald Trump unveiled a deal with a second drugmaker, AstraZeneca, that allows the company to avoid tariffs in exchange for building a new U.S. facility. But as with the first deal, it’s unclear how much money the agreement will save patients.
Also this week, Rovner interviews health insurance analyst Louise Norris of Medicareresources.org about the Medicare open enrollment period, which began Oct. 15.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Politico’s “RFK Jr.’s Got Advice for Pregnant Women. There’s Limited Data To Support It,” by Alice Miranda Ollstein.
Anna Edney: The New York Times’ “The Drug That Took Away More Than Her Appetite,” by Maia Szalavitz.
Joanne Kenen: Mother Jones’ “From Medicine to Mysticism: The Radicalization of Florida’s Top Doc,” by Kiera Butler and Julianne McShane.
Lauren Weber: KFF Health News’ “Senators Press Deloitte, Other Contractors on Errors in Medicaid Eligibility Systems,” by Rachana Pradhan and Samantha Liss.
Also mentioned in this week’s podcast:
- The Washington Post’s “She Left the Medical Mainstream and Rose To Be RFK Jr.’s Surgeon General Pick,” by Lauren Weber and Rachel Roubein.
- The Bulwark’s “There’s Something Weirdly Familiar About This New GOP Argument,” by Jonathan Cohn.
- Politico’s “4 GOP Ideas for an Obamacare Subsidies Compromise,” by Benjamin Guggenheim.
- The New York Times’ “The E.P.A. Followed Up on an Unusual Request About Abortion Pills,” by Caroline Kitchener and Coral Davenport.
- Bloomberg News’ “WHO Warns Against Three India-Made Cough Syrups After Child Deaths,” by Satviki Sanjay.
click to open the transcript
Transcript: Schrödinger’s 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, Oct. 16, 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 Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: Anna Edney of Bloomberg News.
Anna Edney: Hi.
Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.
Joanne Kenen: Hey, everybody.
Rovner: Later in this episode we’ll play my interview with health insurance expert Louise Norris, who will explain some of the changes coming with this year’s open enrollment for Medicare, which began Wednesday. But first, this week’s news.
So, today is Day 16 of the government shutdown, and there is still no discernible end in sight. This week Republicans shifted their main talking point against Democrats. They were arguing that Democrats are trying to restore eligibility for Medicaid to illegal immigrants. Now it’s become a general takedown of the Affordable Care Act and arguing that in urging continuing the expanded tax credits for ACA premiums, Democrats want to throw good money after bad, because the ACA has made health care more expensive.
First off, it has not. There’s lots of evidence that the ACA has actually held down health spending increases, although other factors have pushed it up. But more to the point, do Republicans still not get that the expiration of these additional tax credits are going to hurt their voters more than it’s going to hurt Democratic voters? I see arched eyebrows.
Edney: It doesn’t seem like they get that yet, but I’m not in those strategy rooms, so a little tough to say what their line will be with this game of chicken. They basically are allowing firings of federal workers to continue to go forward in a way that they hope maybe will turn the tide and attention. It doesn’t seem to be working. So I don’t know if they’re having these conversations quite yet, but I know that the notices are starting to go out to some people in some states about these increases, and so it really might depend on what that backlash is from people who are going to see much higher costs for their health care.
Rovner: Yeah, apparently open enrollment began in Idaho on Wednesday. I didn’t realize that they started early, and so there’s just that one little state where people are actually able to see what these premium increases look like, assuming that they do not continue these extra subsidies. I’m wondering sort of about the Republican strategy of, We couldn’t get any traction with the illegal immigrants, so we’re just going to move to “The ACA is terrible.” Joanne.
Kenen: Well, I mean, we talked about this a couple of weeks ago. And Julie linked to the story, and I wrote about the politics of this. And one of the issues is [President Donald] Trump is a master of deflection. Are these people going to think it’s really Republican policy? Or are they going to think it’s greedy insurers, leftovers of the flaws of Obamacare itself, it’s Biden’s fault? And also concentration, I mean where the voters are in these states. Are there enough of them who actually are going to turn out to make a difference? They’re not going to flip Texas, right?
Are there enough of them in swing states or closer-margin states to make any difference? Are there enough in a single congressional district to make any difference? I mean part of it, I think they’re just sort of banking on that they won’t get the blame, that it’s really easy for us to get mad at our insurers. And I think that’s part of what they’re hoping, that they can just say: Blame them. Blame the structure of Obamacare. Because it’s not our fault. So, whether that works as a selling tactic remains to be seen. If they thought it was a huge political risk, they wouldn’t do it.
Rovner: True. Lauren.
Weber: I’ve been fascinated to see [Rep.] Marjorie Taylor-Green come out and say, Wow, these are some expensive premiums. And her in general, her seeming split from some parts of the Republican Party, is fascinating to watch for many reasons. But it’s just a lot of money that these people could be staring down. I mean, there was an analyst quoted in some coverage that was, like, people will have to decide between groceries and rent. I mean, if you are paying over a thousand dollars more a month, for some of these folks, I mean, that is a significant amount of cash. So, I do feel like people vote with their pocketbooks more than they vote with anything else. But to Joanne’s point, I mean, will they attribute the blame? I’m not sure.
Rovner: So, Politico was reporting on some possible options for a deal on those subsidies, which lawmakers are apparently talking about quietly behind closed doors, since actual negotiations are not yet happening. Two of those possibilities seem like real potential common ground. Minimum premiums — so, people who are now not paying any premiums, and the argument from some Republicans is that that’s pushing fraud, because some people, if they’re not paying premiums, don’t even know that they’re enrolled, and that the brokers are making money, which my colleague Julie Appleby has written about ad nauseum. So that seems like a possible place for compromise, to have a minimum $5-a-month premium so people would know that they have insurance. And maximum incomes for the subsidies. I know that people are floating, like, $200,000 a year or something like that.
Then there are two possibilities that at least strike me as less likely. One of them is grandfathering the subsidies, so only people who are getting them now could continue to get them, which would be problematic at a time when the economy seems to be shedding jobs, and changing the abortion language, which I don’t even want to start with. So, I’m seeing the first two as a real possibility. The second two, not so much. I’m wondering what you guys think.
Kenen: I mean, I’ve talked to some Republicans who claim that the current structure of the subsidies would enable families who are making $600,000, which all of us would agree is a fair amount of money. When I was told that, I went on a whole bunch of different calculators and pretended I was making $600,000. And could I actually get the subsidies? And I kept being laughed at by these calculators. I think there are probably some cases where this has happened. It’s a complicated formula where 8% of — we don’t have to get into the technicality. There may be—
Rovner: But it is a percent of your income. You only get a subsidy if it’s more than — yeah.
Kenen: And you’d have to have a premium that’s, like, an extraordinarily rich premium. I mean, it has to be in a really, really, really, really high number. Can this exist under current law? Several reputable Republicans have told me yes. Or conservatives — they’re not all necessarily Republicans. Conservative on this issue, at least — have said yes. I mean, if that’s the kind of thing that you want, to set an income cap, that was probably what was intended. I would take that out of the nonstarter and into the starter pile. I don’t think that’s enough, but I think that’s a reasonable discussion for both sides to have. I don’t think the intention was to subsidize people who were really not lower-middle, middle class.
Rovner: The people who got the big tax cuts.
Kenen: Right. They’re getting other tax cuts. I thought that was an interesting piece with some interesting options, but I’m also hearing escalating rhetoric, back to 2014 kind of rhetoric, back to repeal kind of rhetoric, that everything that you hate about the health care system is the fault of Obamacare, nothing in Obamacare works. We’ve got a really — they’re not saying “repeal,” but they’re saying reform it, and I’m hearing more and more of that. It’s just in the air now. So, and Jon Cohn had a really good piece in The Bulwark about some of the background of this. I think it could mean that this becomes a more intense tug-of-war that does not bode well for a quick resolution of the shutdown.
I don’t think we necessarily get into a yearlong repeal fight, even if you call it reform. But I think that these demands and this rhetoric about, Well, high-risk pools worked. Well, no, they didn’t. That, This is why your insurance costs have gone up. No, there’s a whole bunch of incentives and structures and bad stuff in our health care system. It is, Obamacare fixed certain problems. Those of us, we all have employer insurance, I believe, and all of us face cost increases and frustrations and hitting our head against brick walls and delays. And things are not perfect by any means, but it’s not because of these subsidies in Obamacare.
Rovner: And it’s not because of Obamacare. [Barack] Obama himself this week was on a podcast and said it was intended as a start, not as the be-all, end-all. I was surprised. I mean, I think one of the reasons that Republicans, I mean, this is now in their talking points about, We’re going to go after Obamacare. And [Rep.] Mike Johnson, the speaker, had kind of a rant on Monday, I mean, which sort of opened this up. And I think some of the Republicans were also talking about it on the Sunday shows. But I can’t imagine that Republicans don’t remember that the last time they had this big fight against Obamacare, Obamacare won. That was in 2017, and if anything, it’s even more popular now because there’s twice as many people on it, which was kind of the way I set up my first question.
Kenen: Right. But the dynamic of a year’s worth of repeal votes while other things are actually functioning in government versus a fight about this when Trump holds a lot of the cards in a shutdown — it’s comparable but not the same.
Rovner: Anna?
Edney: Well, and I also have to wonder if an actual extended replace, or reform, whatever we’re going to call it, fight is what they want, or if this is a strategy to help blame the increases in premiums that are coming on Obamacare in general directed towards the Democrats, right?. I mean, you can see how that line could be drawn. And so if they just keep bashing Obamacare, it’s Obamacare’s fault that Obamacare’s premiums got higher, not because they didn’t vote on extending the subsidies.
Kenen: And we’re also talking about Obamacare again. We had been talking about the Affordable Care Act. It had gone from Obamacare, which is politically toxic, to Affordable Care Act, which was sort of a subtle acknowledgment that it had bipartisan popularity among people getting benefits. And now we’re back to Obamacare, which sort of tells me, yes, we’re back into some of this endless loop of political fights about Obamacare.
Rovner: Yeah.
Kenen: And trying to get the Guinness Book of World Records for repeal votes on a single piece of legislation.
Rovner: Well, meanwhile — and I said this last week and I think the week before — that even if there is a deal on the tax credits, the bigger problem for Democrats right now is that if they make a deal on spending levels for fiscal 2026, which is what this fight is actually over, the administration can simply undo it, and Congress can ratify that undoing with a simple majority of just Republican votes. This week, even Republican [Sen.] Lisa Murkowski wondered aloud why Democrats would do a deal like that. So, I’m still wondering how they get out of that box, even if they were to get some kind of a compromise on the ACA subsidies. I certainly don’t know how Democrats get out of that box. I think the Republicans don’t know how they get out of that box.
Kenen: They don’t realize they’re both in the box. That’s one of the problems. This is a large box.
Rovner: It’s Schrödinger’s shutdown. We will have to see how that plays itself out. In the meantime, I’m not holding my breath. Well, moving on, despite laws against it, as Anna already mentioned, the Trump administration began firing federal workers last week, and the cuts hit particularly hard at the Department of Health and Human Services and agencies like the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration. The cuts appeared both sweeping and devastating, at least at first, including the entire staff of the CDC’s news journal and lead public health source of information, the Morbidity and Mortality Weekly Report. Though by the end of the weekend, many of the firings had been rescinded. It’s not clear whether that really was a coding mistake, as was the official explanation, or an effort to continue to put federal workers, quote, air quotes here, “in trauma” as OMB [Office of Management and Budget] Director Russell Vought famously promised before he took office for the second time. Whichever, it’s not really the way to get the best work out of your workforce, right? Telling you: You’re fired. No, you’re not. Maybe you are? Go ahead, Lauren.
Weber: I would like to go back to the story I wrote in April when a bunch of fired health workers were told to contact an employee who had died. I don’t think, based on the coding error or some of these past things, it does not seem like these layoffs are being done in any sort of organized way. It doesn’t seem like they have up-to-date records. It seems like, also, are these layoffs even legal, based on some of the litigation that’s been filed? I think there’s going to be a lot that has to shake out there. But, I mean, to be quite honest, it is very striking to see a bunch of CDC employees continue to get laid off after, again, this is an agency that got shot at with hundreds of bullets. Police officer—
Rovner: Yeah, literally shot at.
Weber: Literally shot at with hundreds of bullets, and a police officer died responding to that, due to a shooter who had been radicalized in part, it seems, from his father’s account, by information that was wrong about the covid vaccine. So, to see more of those employees get laid off, I mean, you just have to wonder who’s going to want to work at these places. Morale is just completely, as we understand it, terrible. But yeah, I also question if that was a coding error or what exactly was happening there, because there were a lot of priorities of folks that were seemingly let go that are allegedly Make America Healthy Again priorities, but that’s also been true for many months of policymaking, so—
Rovner: Yeah, there’s a lot of right hand not seemingly knowing what left hand is doing in all of this, which may be the goal. I mean, I think you put your finger on it. It’s like, who would want to work at these places after what’s being done? And I think that’s the whole idea of the Russell Vought strategy of, Let’s shrink the federal government to a point where it’s so small that you can just sort of put it in a box and put it under the bed. That’s essentially where we are. Well, Lauren, as you mentioned, Wednesday afternoon, a federal district court judge ordered the administration to pause the firings. But will they actually obey that? And do we even know what offices have been most affected at this point?
I mean, we heard a lot of things like the entire Office of Population Affairs at HHS, which runs Title X, has apparently been reduced to one person. The people who do a lot of the statistics and survey work at CDC. All these people sort of appear to have been laid off, but we’re not quite sure, and we’re not quite sure what’s going to happen from here.
Kenen: I’m not sure if they know they’ve been laid off and rehired, because if you were laid off, you lost your access to your work email, and then if you get an email in your work email saying, Oops, you’re hired. I mean, I guess people sort of may just see if they have access again, but I’m not really sure how the actual notification of this somewhat chaotic layoff, no-layoff thing is.
Rovner: It has been chaotic. I think that’s a good word to describe all of this. Well, one reason it was relatively easy for the administration to go after the CDC is that it doesn’t have a leader — or even a nominated leader — at the moment, after the firing of Susan Monarez in August, less than a month after her Senate confirmation vote. Another high HHS position that remains vacant is that of surgeon general, although that office at least has a nominee, Casey Means. She’s the sister of RFK [Robert F. Kennedy] Jr. top aide and MAHA associate Calley Means and more than a little bit controversial. Lauren, you did a deep dive this week into the prospective surgeon general. What’d you find?
Weber: Yeah, my colleague Rachel Roubein and I did a deep dive into her background. And she’s, look, she’s a fascinating example, really, of MAHA today. And you could argue she really wrote the manifesto to MAHA with her book “Good Energy” that she authored with her brother, Calley Means. But basically she’s a very accomplished person in the sense that she went to Stanford undergrad; she graduated from Stanford med school; she had a very prestigious residency in ear, nose, and throat surgery; and then she resigned. She left and decided she wanted to take a different path and has become a bestselling author, a health products entrepreneur, and has also worked, as her financial disclosures have revealed, to promote a variety of products in some of her work. Financial disclosures revealed that she had received over half a million dollars over basically the last year and a half promoting a variety of different supplements, teas, elixirs, diagnostic products, and so on.
And several of the medical and scientific experts I spoke to said that they worried that she spoke in too absolute of terms about health, and they were really concerned that as someone who would be the surgeon general that she would use that bully pulpit and speak in terms not necessarily grounded in evidence. They pointed to some of her remarks about how cancer and Alzheimer’s and fertility was within one’s power to prevent and reverse, and they felt like that language went a step too far. And looking at her history, they are concerned about what that could mean for the health of the nation if she is directing it.
Rovner: She doesn’t even have a confirmation hearing scheduled yet, does she? Well, the Senate’s in so they could.
Weber: She is pregnant, so I think that is playing into the timing of some of her stuff. But yes, she does not have it scheduled. Her forms seemingly were pretty delayed. And then obviously there’s other things going on. I mean, I think the CDC firing also sucked a lot of health air out of the room of what people want to deal with and spend their political capital on, I suspect. But yes, we shall see.
Kenen: Yeah, she has to go before the [Senate] HELP [Health, Education, Labor, and Pensions] Committee, which is, Sen. [Bill] Cassidy is the chair. He is not a happy camper at the moment, from his public statements, and we do not know what the private conversations he is having at this point in time.
Rovner: And of course, that committee will also have to pass on the new CDC nominee when there is one.
Kenen: Yes. And the last CDC hearing, which all of us watched, I think he’s clearly concerned and displeased by lots of things going on at the federal health agencies. So, none of us are in those rooms, but they’re probably interesting conversations.
Rovner: As I like to say, we will watch that space. Well, turning to reproductive health, The New York Times has a story this week about something that we’ve talked about before on the podcast, arguments by anti-abortion activists that abortion pill residue in wastewater might be contaminating the nation’s waterways. Notwithstanding that there is no evidence of that, the Environmental Protection [Agency], acting on a request from anti-abortion lawmakers in Congress, ordered scientists to see if they could develop methods to detect the drug in wastewater. Now, the groups that originally pushed this say they were concerned about pollution. But if such a detection method is successfully developed, abortion rights supporters worry that it could be used to trace users in particular buildings in order to enforce abortion bans. This is basically another step in this sort of, Let’s try and shut down abortion nationwide. Is it not? And Anna I see you nodding.
Edney: Well, I mean that was my feeling when I read this really good piece that you’re talking about. And it’s a little bit lower down in the piece when they do start talking about using this to target maybe buildings or places where someone might have used an abortion drug. And I kind of was like, Yes, this is what I assumed they were trying to do, as I read this. And the reason for that is not just because I feel like there’s always a vindictive motive or something, but it’s because there are lots of drugs that are in our wastewater, and people are taking far larger amounts daily of many more things that is all going into our wastewater. So, particularly, why you would want to track that one, which is not used by millions of people for a chronic condition on a daily basis, it seems like there would be an ulterior motive.
Rovner: And has not been shown to do any harm, even if it is showing up in trace amounts in the wastewater. Although presumably that’s what the EPA scientists were also tasked with trying to figure out.
Kenen: I mean, it’s really hard to get rid of a drug you no longer take. I mean, pharmacies don’t want to take it back. In my neighborhood, there is a pharmacy at a supermarket that does have a take-back, which is great, but it’s always broken. If you have any drug that you want to get rid of responsibly and not have it end up — Anna’s right, I mean, there’s just a lot of stuff in our water. It’s really hard to do. And this is not the only drug that is an issue with.
Rovner: Although if you Google it, there are a lot of places where you can actually take back drugs.
Kenen: It’s hard. It’s limited hours, limited access, and the machines are often—
Rovner: Yeah. Yeah.
Kenen: I’ve been trying for a couple of them for a few months, actually.
Rovner: You do have to actually take some steps actively to do it. Well, turning to drugs, and drug prices, there was so much other news, you might’ve missed this, but President Trump last Friday afternoon announced a deal with a second drug company to bring back manufacturing, in order to avoid tariffs. This deals with AstraZeneca, which promised to build a plant in Virginia. But Anna, is there any promise to actually bring down prices for consumers in any of this?
Edney: Minimally, possibly. It’s a lot like the Pfizer deal, and we saw that focus largely on Medicaid, that already has extremely steep discounts that are required by law. And so how much they’d actually be slashing to offer the “most favored nations” pricing that Trump wants to the Medicaid program, it seems like that probably isn’t a huge leap, and certainly we saw that Wall Street didn’t react with any hair on fire. They’re not worried about the bottom lines of these companies when these deals come out, and they’re avoiding tariffs for three years. So, kind of net positive, seemingly. We don’t have all the details of the deal—
Rovner: Like with the Pfizer deal where we never got all the details.
Edney: Yeah, exactly. So, there’s some stuff that we still don’t know, but Medicaid is the main focus. Then they’ll offer, again, some of their drugs on TrumpRx. So, maybe if your insurance doesn’t cover something, or if you don’t have insurance, and you want to get a drug, that might be helpful. But most people I think are going to opt to pay their lower copay than the cost of a drug that is discounted but still full price.
Rovner: Well, in case you’re looking for a reason why it might be a good thing to reshore some drug manufacturing, the World Health Organization this week warned of potentially poisonous cough syrup made in India. According to one of your Bloomberg colleagues, Anna, 22 children have died in the central Indian state of Madhya Pradesh — I hope I’m pronouncing that close to right. And this is far from the first time poisonous substances have been found in medications made in India, right? You’ve done a lot of reporting on this.
Edney: Yeah, for sure, and these are really tragic stories that now seem to keep, particularly with these kind of cough medicines, keep popping up. And thankfully the FDA did put out a message saying these cough medicines in this round were not sold in the U.S., but there have been times where India has imported some of these. There were children in the Gambia that died last time — this was a few years ago. Because what’s happening is some of the drugmakers in India are supposed to be purchasing a solvent. It’s propylene glycol. Well, that solvent, that helps the medicine kind of all mix together. It can be a lot cheaper if you buy something that looks like it but is actually deadly, diethylene glycol. And so that’s what some of these companies are doing, is saving money and substituting a deadly ingredient. And so we see that this is a problem a lot of times with some of the drugmakers, and it’s happened, unfortunately, particularly in India, where the cost-cutting, the corner-cutting has actually affected people’s lives, and in this case, tragically, children.
Rovner: Yeah. There is reason to kind of want to keep drug manufacturing where the FDA can keep an eye on it, which I know you will continue to report on.
Edney: For sure.
Rovner: Because that has been your specialty, I know, of late.
Edney: Yes.
Rovner: All right, that is this week’s news. Now we will play my Medicare open enrollment interview with Louise Norris, and then we’ll come back with our extra credits.
I am so pleased to welcome to the podcast Louise Norris. She’s a health policy analyst at Medicareresources.org and at Healthinsurance.org and the author of some of the most helpful guides to health insurance out there — and the person who keeps track of all the changes for health reporters like me. Louise, so happy to welcome you to “What the Health?”
Louise Norris: Thank you so much, Julie. It’s a pleasure to be here.
Rovner: So, we’ve talked a lot these past few months about how the Affordable Care Act and its potentially skyrocketing premiums for 2026 is about to happen, but we haven’t talked as much about some of the changes to Medicare, for which open enrollment began this week. Now, most years it’s probably OK for Medicare recipients just to let whatever coverage they have kind of roll over. But that’s not the case this year, right?
Norris: Well, I feel like it’s never the best idea to just let your coverage roll over, because there’s always plan-specific changes that people just really need to pay attention to. And even though averages might be fairly steady in terms of premiums and benefits, that doesn’t mean your plan will have a steady premium or benefits. And for 2026, we’re seeing in the Medicare Advantage and Part D —stand-alone Part D — drug plans, there are fewer plans available on average and actually a slight average decrease in premiums. But I feel like if people see that as the headline, they might be sort of lulled into complacency, of like, Oh, I just don’t need to look, when in reality there’s quite a bit of variation from one plan to another. So, although the average stand-alone Part D plan premium is actually decreasing slightly, some plans are increasing their premiums by as much as $50 a month. So, you need to really pay attention to the notice you got from your plan about what’s happening for 2026 and then comparison-shop. Comparison-shop is always in your best interest every year.
Rovner: Right, because, I mean, people don’t realize that maybe your doctor’s been dropped from your Medicare Advantage plan or your drug has been dropped from your Part D plan. So, I mean, even if your premium doesn’t change that much, your coverage might be changing a lot, right?
Norris: Exactly. And you don’t want to find that out when you go to the pharmacy in January to fill your prescription and then you’re locked into your Part D plan for all of 2026. It’s definitely better to know all those details at this right now during open enrollment.
Rovner: Now there are some coverage changes that people are starting to feel from really a couple of years ago, yes?
Norris: There are. So, there’s some basic changes like, for example, the maximum out-of-pocket cost on Part D plans, which just went into effect in 2025 under the Inflation Reduction Act, it was a $2,000 cap on out-of-pocket costs for Part D. That is indexed for inflation. So for 2026 it goes up to $2,100. So not a huge change but definitely a change people should know about. And you do still have the option to work with your plan to spread that out in equal payments across all 12 months of the year instead of having to meet it right at the beginning of the year, if you take an expensive medication. There’s this change in the maximum Part D deductible, just like there is every year. This year it’s, for 2025, it’s $590 is the maximum deductible. It’ll be $615 next year. That doesn’t mean your plan will have a $615 deductible, but it might.
But there are also plan-specific changes that vary from one plan to another. So, for example, your Medicare Advantage plan might be adding or subtracting supplemental benefits. They might be changing the amount of your deductible or changing the amount of your inpatient hospital copay. There’s all sorts of changes that aren’t necessarily broadly applicable but that apply to your plan. And then, like you were saying, whether or not your doctor and hospital are still in the network, whether your prescription drug is still covered and covered at the same level, plans can move prescription drugs from one tier to another. So, those are all the sorts of things you really need to pay attention to now so that you can comparison-shop and see if something else might be a better option.
Rovner: And we are seeing plans starting to sort of drop out. I mean, I know at one point there was concern that there were too many plans for people to choose from, that it was, just, it was too confusing. But now are we running the risk of having too few plans in some places?
Norris: Well, I think the concern about too many plans is definitely valid. For a while, there were — it could definitely be overwhelming for people shopping for coverage. For both Medicare Advantage and Part D, we do have, overall, an average of a reduction in how many plans are available for next year. There are a few states where the average beneficiary will actually see more options for Medicare Advantage, but that’s rare. But the average beneficiary will have access to more Medicare Advantage plans than they did before 2022, for example. It’s just been in the last few years that it has decreased, but it still hasn’t decreased below the level that it was in 2022. So it’s still a lot. I believe it’s an average of 32 plans. And then in the Part D, for people who buy stand-alone Part D coverage, everybody has between eight and 12 plans to pick from.
So, if your plan is ending, you obviously need to shop for new coverage. If you’re on a Medicare Advantage plan and you don’t shop for new coverage, you’ll just be automatically moved to original Medicare on Jan. 1. If you’re on a Medicare Advantage plan that’s ending, because your carrier is exiting the market or pulling out of your area and your plan can’t be renewed, you can pick any other Medicare Advantage plan that’s available in your area. But you also can do, you can switch to original Medicare, and you’ll have guaranteed issue access to Medigap, which is not normally the case. During this open enrollment period, people have guaranteed issue access to Medicare Advantage and Part D but not Medigap. So, for other folks whose Medicare Advantage plan is continuing, obviously they have the option to switch to original Medicare. But depending on how long they’ve been on their Advantage plan and what state they’re in, they do not have guaranteed issue access to Medigap. So, that is an important thing for folks to know if their plan is actually ending, is that they can make that choice if they want to.
Rovner: We’ve seen a lot of increases in health care costs overall, and I guess that’s true for Medicare, too. I mean, why should people who aren’t on Medicare care about what happens to Medicare and what happens to the Medicare market?
Norris: First of all, hopefully all of us will eventually be on Medicare. Almost everyone by the time they’re 65 is on Medicare. But even if you’re a long ways away from that, it is important to know how much the whole Medicare sphere, in terms of the insurance companies and the regulations, how that sort of trickles down to the rest of the commercial insurance sector. Drug price negotiation, for example, that will have a trickle-down effect into what the insurance companies in the rest of the commercial market pay for drugs. When regulations come out for Medicare, they oftentimes, the insurance companies follow suit in the private market, or states will follow suit in terms of how they regulate the private market. So, it certainly does matter for everyone, even if it’s not a direct effect.
Rovner: So even if you’re not 65 or helping somebody who’s over 65.
Norris: Exactly, yes, and that’s the other thing is a lot of folks who are younger are helping a parent or a grandparent navigate this, and so it really does affect most people.
Rovner: Yeah, it is one of the autumn tasks for many people.
Norris: Absolutely.
Rovner: Helping Mom and Dad or Grandma and Grandpa navigate their Medicare coverage for the following year.
Norris: And I do think, like you were saying earlier, as far as just letting it ride, obviously if you comparison-shop and you’re happy with your coverage and you’ve determined that it is still the best option, then, yes, you do not need to do anything. You just, assuming it’s still available for renewal, you just let it renew. But oftentimes I think people don’t comparison-shop, simply because the process seems overwhelming and they just figure, I’ll just keep what I have. And of course, if you’re in that situation, you might be one of the people who’s on a Part D plan that’s increasing by $50 a month next year, or you might find out in January that your doctor’s no longer in-network with your Advantage plan.
So if you get those notices from your plan and something doesn’t make sense or you’re confused, it’s much better to reach out to someone who can help you, whether it’s a family member or friend, asking them for help, or call 1-800-MEDICARE. Call the Medicare SHIP in your state. Every state has a State Health Insurance Assistance Program that’s staffed with people who can answer your questions. Contact a Medicare broker in your area. Just asking questions and finding out the answers is a much better approach than just assuming things will work out if you just let your plan renew.
Rovner: I’ll put a link to your site also.
Norris: Yeah, Medicareresources.org. We do have an open enrollment guide where we list all of the changes that are happening for 2026, the broad changes, and we’ll continue to update that. For example, we don’t yet have the Medicare Part B premiums for 2026, so as those numbers come out, we’ll update that guide with everything people need to know.
Rovner: Louise Norris, thank you so much.
Norris: Absolutely. Thank you so much for having me, Julie.
Rovner: OK, we’re 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. Joanne, why don’t you go first this week?
Kenen: The piece I have this week is from Mother Jones, and it’s about Florida Surgeon General Dr. Joseph Ladapo. And the headline is “From Medicine to Mysticism: The Radicalization of Florida’s Top Doc,” by Kiera Butler and Julianne McShane. It’s a phenomenal read. He has stellar credentials — Harvard, Stanford. He was an academic medicine MPH [master of public health]. He’s public health and medicine. He had this stellar traditional career. He was widely respected. And now he is this leading voice. He’s trying to get rid of the vaccine mandates, childhood vaccine mandates, to the whole state of Florida. He has questioned all sorts of established public health practices. He is out there. And we’ve sort of all wondered: How do people get to this point?
And this story talks about his wife and her mysticism, and their guru healer, who walks on their thighs to the point that it’s painful. And they emerge from this foot-walking thigh-walking thing, and his mystical experiences with this whole different take on the human experience and the role of health. I cannot begin to capture it. And here it is. It is a long, detailed, and fascinating read on his wife, who he met on an airplane, and her beliefs in, we bring certain things on ourselves because of who we are and who are the ancestors that we carry. She sees auras and visions, and this is their current belief system. And it is not compatible with what most of us think of as science-based public health. Really good read. Really, really good read.
Rovner: Definitely MAHA to the max. Anna.
Edney: Mine was a guest essay in The New York Times, “The Drug That Took Away More Than Her Appetite,” [by Maia Szalavitz]. And I thought it was a really great look at how some of these obesity medications, the GLP-1s like Ozempic and others, can be used to treat addiction. And so it follows this woman who was addicted to different kinds of drugs at different times. And she lost her children and all sorts of horrible things and had tried over and over again to stop using, and then has been in this program that uses a version of these GLP-1s at a lower level — they don’t necessarily want you also losing weight — but to treat addiction, and just how it’s kind of been the only thing that’s worked for her. It stops the cravings, kind of as you think it might do for people with obesity as well.
I thought we don’t see this as much, and the companies that make these drugs aren’t extremely focused on this. So I thought the article did a good job of saying why this could be really important, and looking at the fact that right now it requires federal funding of research to keep the promise alive, and hope that at some point some pharmaceutical company will be more willing to pick it up.
Rovner: Right now, there’s a lot more money to be made in the obesity side of this. But yeah, it’s a really interesting story. Lauren.
Weber: I actually highlighted work from Rachana Pradhan and Samantha Liss from KFF Health News. The article’s titled “Senators Press Deloitte, Other Contractors on Errors in Medicaid Eligibility Systems.” It’s impact from their great reporting, which I think we talked about on this podcast earlier in the year, about how — talk about waste, fraud, and abuse — that there’s some questionable issues with how Deloitte manages Medicaid systems and how money’s being wasted through them. And the senators, it looks like, read KFF Health News’ reporting and have sent some letters about it. So, great work by the team over there, and eye-opening for sure to see, on some of the dollars, Medicaid, that are not going to patients.
Rovner: Journalism impact. My extra credit this week is a really thoughtful story from our fellow podcast panelist Alice Miranda Olstein at Politico. It’s called “RFK Jr.’s Got Advice for Pregnant Women. There’s Limited Data to Support It.” It’s about a topic that I have been covering for more than three decades — the difficulties of including women, particularly women of childbearing age, in clinical trials of drugs. As Alice outlined so well, the problem isn’t just ethical — an unborn fetus obviously can’t give informed consent to be part of an experiment — but it’s also a question of liability. Drugmakers are afraid of getting sued for bad pregnancy outcomes, and with good reason. That’s why it’s so hard to know what is and isn’t safe to take during pregnancy and what might cause birth defects or miscarriages. And despite the secretary’s promise to, quote, “do the science,” it is not that easy. It’s a really, really good read.
OK, 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 folks these days? Joanne?
Kenen: I’m either on Bluesky, @joannekenen, or on LinkedIn.
Rovner: Anna?
Edney: Bluesky or X, @annaedney.
Rovner: Lauren.
Weber: I’m on X or Bluesky, @LaurenWeberHP.
Rovner: 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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