KFF Health News' 'What the Health?': Nutrition Programs Face Their Own Shutdown
The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Health programs are feeling the pinch of the ongoing government shutdown. Funding for the Supplemental Nutrition Assistance Program, or SNAP, and the food program for women, infants, and children, WIC, is likely to run out in November, and cuts at the Centers for Disease Control and Prevention are keeping the agency from carrying out some of its primary public health functions.
Meanwhile, the Trump administration’s immigration crackdown is also leading to health consequences, and the Department of Homeland Security is trying to bolster its medical staff to cope with the large number of people in its custody.
This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Alice Miranda Ollstein of Politico, and Rachel Roubein of The Washington Post.
Panelists
Shefali Luthra
The 19th
Alice Miranda Ollstein
Politico
Rachel Roubein
The Washington Post
Among the takeaways from this week’s episode:
- As the federal shutdown continues, some are facing the startling possibility that their SNAP and WIC benefits soon will be cut off. Lawmakers remain in a stalemate over renewing the enhanced Affordable Care Act subsidies that are set to expire, and the roughly 24 million people with such plans — about 90% of whom benefit from the subsidies — are starting to learn what they will owe next year without them.
- With a key weekly government report on morbidity and mortality halted amid the shutdown, the New England Journal of Medicine and the Center for Infectious Disease Research and Policy announced they will team up to publish public health alerts. While others are stepping in to fill the gap left by the Trump administration’s pullback from public health, the federal government’s data and ability to access information are not easily replaced.
- It’s unclear whether the Trump administration’s plan to make in vitro fertilization more accessible will yield a substantial improvement in access to fertility treatments. Some employers already offer supplemental IVF benefits, and so far there are few details, such as how generous the Trump proposal would require coverage to be.
Also this week, Rovner interviews KFF Health News’ Katheryn Houghton, who wrote the latest “Bill of the Month” feature, about a broken elbow and a nearly six-figure bill.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: ProPublica’s “The Shadow President,” by Andy Kroll.
Shefali Luthra: The 19th’s “More People Are Freezing Their Eggs — But Most Will Never Use Them,” by Shalini Kathuria Narang, Rewire News Group.
Alice Miranda Ollstein: Brown University’s “New Study: AI Chatbots Systematically Violate Mental Health Ethics Standards.”
Rachel Roubein: The Washington Post’s “Errors in New Medicare Plan Portal Mislead Seniors on Coverage,” by Dan Diamond and Akilah Johnson.
Also mentioned in this week’s podcast:
- Politico’s “ICE Is Hiring Dozens of Health Workers as Lawsuits, Deaths in Custody Mount,” by Alice Miranda Ollstein and Ruth Reader.
- The 19th’s “ICE Keeps Detaining Pregnant Immigrants — Against Federal Policy,” by Shefali Luthra and Mel Leonor Barclay.
- The Associated Press’ “Anti-Science Bills Hit Statehouses, Stripping Away Public Health Protections Built Over A Century,” by Michelle R. Smith and Laura Ungar.
Click to open the transcript
Transcript: Nutrition Programs Face Their Own Shutdown
[Editor ‘s note: This transcript was generated using both transcription software and a human ‘s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest reporters in Washington. We’re taping this week on Thursday, Oct. 23, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Today we are joined via videoconference by Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hi there.
Rovner: And Rachel Roubein of The Washington Post.
Rachel Roubein: Hi.
Rovner: Later in this episode we’ll have my interview with my KFF Health News colleague Katheryn Houghton, who reported and wrote the latest “Bill of the Month” about a broken elbow that cost nearly six figures to fix. But first, this week’s news.
So, today is Day 23 of the government shutdown, and there is still no discernible end in sight. But even though the Trump administration is playing fast and loose with the law that’s supposed to ban most spending without the consent of Congress, more ramifications to the shutdown are starting to be felt. It appears that both big federal nutrition programs — food stamps and WIC, which serves pregnant and breastfeeding women and the youngest children — will soon run out of money, which someone on social media pointed out would mean people going hungry on Thanksgiving, which is not a great look for the government. Yet both Republicans and Democrats still think they’re winning this fight. Really?
Ollstein: I feel like every week we’re like: Yep, still shut down. Yep, no real meaningful progress on negotiations. And we’re just in a “Groundhog Day” time loop here.
Rovner: And now the president’s off to Asia in addition to everything else.
Ollstein: Yes, but he wasn’t really super engaged on the shutdown and the reopening. Actually, some lawmakers in both parties have been begging him to get involved, saying it’s really the only way for this to work itself out and to strike some sort of deal on the Obamacare subsidies, is for President [Donald] Trump to be the leader of the Republican Party and tell them to get in line, basically. But that has not happened, and without that happening we haven’t seen a ton of real progress.
Roubein: I mean, I think one thing we’re all looking for is we’ve obviously started seeing rates in some states go up.
Rovner: For the ACA [Affordable Care Act]. Yeah.
Roubein: Yes, for the Obamacare exchanges, due to the impending expiration of the subsidies. But—
Rovner: And the impending open enrollment that starts Nov. 1.
Roubein: Exactly. And so we’ve not yet seen posted on HealthCare.gov, the federal site that some states use, those rates. So I think everyone’s also watching and waiting to see those rates, which are expected to go up.
Rovner: Well, we’ll get to the ACA in a minute, but first I want to talk a little bit more about some of the things that are actually happening because the government is shut down. Over at the CDC [Centers for Disease Control and Prevention], where furloughs have been followed by firings that may or may not be legal, remaining staff are unable to attend this week’s big international meetings on infectious diseases, which feels like something you’d want public health professionals to be kind of up to date on.
And with the so far temporary stoppage of the CDC’s Morbidity and Mortality Weekly Report, which is kind of the weekly bible of public health, now the New England Journal of Medicine and CIDRAP [the Center for Infectious Disease Research and Policy], the public health institute at the University of Minnesota, announced at that same infectious disease conference that they would begin publishing their own public health alerts to try and fill the void of the MMWR. It’s not clear to me if this is intended to be temporary and will stop if and when MMWR is back up and running. Or is RFK [Health and Human Services Secretary Robert F. Kennedy Jr.] actually succeeding in his quest to dismantle the CDC and leave public health up to states and private funders? Is this sort of the decline and fall of the federal role in public health?
Ollstein: I mean, I think it’s a step in a trajectory we’ve been seeing for a few years. It’s not brand-new. I mean, it reminds me of how during the peak of the covid pandemic, outside institutions, academic and otherwise, were setting up their own trackers and other data tools because they did not trust the federal government. And we’re sort of back in that same situation. It’s both a lack of trust in the federal government and the people running it, as well as this new slashing of resources and institutions and a desire to build sort of independent ones that can’t be sort of subject to these political whims in the future.
Although the idea was that the MMWR was protected from political whims, but that is maybe no longer the case. And so it’s tough because building these independent outside versions, they just won’t have the same resources. They won’t have the same access to data that the federal ones that they’re trying to replace had. So it’s not like a one-to-one. And again, seeing the splintering of trust. And so there’s a portion of the public that doesn’t trust the federal government right now, but there’s going to be a portion of the public that won’t trust this alternative setup, either. So it’s just very hard to have a gold standard fount of data that everyone can agree on.
Roubein: Just in sort of the public health space, we’re seeing this really particularly in vaccine policy. It’s starting to fracture along state and political lines. We’re seeing states in the Northeast and the West with their own coalitions to make shot recommendations. We’re seeing groups trying to, like major medical associations, putting out recommendations and saying that they don’t trust the new ACIP [Advisory Committee on Immunization Practices]. So that’s, I mean, I think a kind of tangible spot there.
Rovner: I would say, since I have all three of my abortion experts here, I mean one of the things that we’ve seen since the fall of Roe is that every state now has a completely different policy on reproductive health. Are we moving to the point where every state is also going to have a completely different policy on these public health issues?
Luthra: I think that’s really plausible, but just thinking about Rachel’s point about vaccines in particular, one of the most important differences there is that vaccines are effective when more people use them. And with abortion, we have seen these sort of patchworks take effect. People can travel. People can get pills mailed to them. And there’s a strain on this system. But if someone doesn’t get an abortion in Texas, that doesn’t necessarily affect the health of someone a few states over. But if we see some people have ready access to vaccines and trust in the system that enables them to get that kind of preventive health care and in other parts of the country we don’t, eventually what happens is that there is broader spread of disease and worse public health consequences for all of us.
Rovner: Which is kind of why we have a national public health infrastructure in the first place. We’ll clearly come back to this, but let’s move back to what’s driving this shutdown in the first place, as you mentioned, Rachel, which is the high and growing cost of health care. The Paragon Institute, which is providing what seems to be most of the Republicans’ talking points on health care these days, is pushing a new argument that the expiration of the additional Affordable Care Act tax credits are only a small piece of the increasing premiums for 2026. And that’s true. The CBO [Congressional Budget Office] said in its estimates that insurers are raising premiums slightly to make up for the loss of policyholders who are likely to drop their coverage, which will raise costs for everybody else. But the bigger reasons that premiums are going up are things like tariffs and industry consolidation and the general increase in health care cost.
But I’m wondering if that very semantic point, that the subsidy expiration is only a tiny part of the premium increase is going to make much difference to the people who are going to see their out-of-pocket costs double or more, because while the premium might only be going up a few percentage points, the expiring tax credit will dwarf that, because now they’re going to have to pay the whole premium instead of just a portion of the premium. It’s like your employer’s premiums are going up 5%, but your employer is cutting its contribution in half. That doesn’t seem like a very big solace to people who were — even though the expirations are a little bit of the premium increase, you’re still going to see a bill that says a thousand dollars a month instead of $200 a month, right?
Ollstein: I think we’re seeing that realization take hold. I mean, I know we’ve talked on the podcast before about a small handful of Republicans coming out and saying: Look, my kids’ premiums are going up. We really have to do something, people. Including some members you might not expect, like [Rep.] Marjorie Taylor Greene, very, very conservative folks who say: Look, I’m no fan of Obamacare, but we have to act. This is really bad. Meanwhile, you still have other lawmakers downplaying it, saying, Oh, those subsidies, that was a covid thing and covid’s over, so we don’t need that. But I think the more the plans and the costs start to solidify and people start getting these notifications, the political pressure will continue to build, but build towards what we’re not really sure at this point.
Rovner: Yeah, we’ve seen, I think we’re starting to actually see these premiums in a dozen states. And Rachel, as you mentioned, we will see the federal premiums soon and that might spur something. Meanwhile, the Democrats have a new talking point as well to counter the Republican complaints that the subsidies for the ACA coverage are exceedingly high. They point out that all other forms of health insurance coverage are also heavily subsidized by the government, Medicare and Medicaid by the federal and state governments and employer coverage by the tax exclusion that makes premiums tax-free for both employers and employees. So why, they say, should the individual market be the only one that is not highly subsidized? Effective or a little bit too complicated for this?
Roubein: I mean, I think in general, like at the sort of macro level, we tend to see this in health care. When there’s some benefit or there’s a new policy, it is hard to change that. A lot of things that are supposed to sort of, in Congress they’ll do for a few years, tend to just get extended on and on because it then becomes a pain point.
Rovner: So in the end, I mean, do these subsidies get extended or we still have to wait and see how painful this pain point gets?
Roubein: Who’s to say? I don’t like to always predict what Congress will do, so—
Rovner: Certainly not this year.
Luthra: One thing I will add in there is that we did some polling recently at The 19th just looking at broad economic concerns among other issues, and health care costs are a very serious concern for just a huge majority of Americans. It’s not even, I mean, across the board, this is true. It’s even more true for women. We know that the subsidies had and have had a really meaningful impact for a lot of specific demographics. Women are one of those, so are a lot of more conservative-leaning voters. And I just think that we may not know what will happen with the subsidies, but what we can say is that it’s a really big deal to a lot of people who will be affected, and it’s hard not to imagine that affecting how they think about their representation and ultimately whether government is working for them when they look at their health care getting more expensive.
Rovner: I don’t carry around a lot of numbers in my head, but the numbers that I carry around include 24 million people who are getting ACA coverage, 90% of whom are getting subsidies. So, it’s a lot of people, as we’ve said many times, in a lot of pretty Republican states. So we’ll see when the yelping really starts. Well, I want to talk a little bit about immigration and health because we have two excellent stories about health care and immigration this week, written or co-written by two of our panelists. How convenient. Alice, tell us about your story about ICE [Immigration and Customs Enforcement] hiring more health workers.
Ollstein: My co-worker and I noticed that all of these jobs were posted for doctors, nurses, pharmacists, therapists, health care workers to work specifically in ICE detention. And we were interested in, why go on this hiring spree? I mean, we’re in a government shutdown. It’s not exactly hiring season. But once we started looking into it — well, one, the federal government did not respond to our questions about why they’re hiring and what they hope to achieve. But we saw that the detainee population has exploded to record levels and the number of deaths has gone way up. We are approaching the number of deaths, just in 10 months this year, almost as much as occurred over the four years of the Biden administration. Now, the actual rate isn’t as high because there’s just so many more detainees, but it’s very troubling and people are dying of both sort of acute and chronic factors.
And so there’s all these lawsuits right now about medical neglect and poor access to medical care in ICE detention. There are multiple hunger strikes going on in multiple states related to We’re being denied access to health care. And so all of this is sort of building to a crisis point. And people are being held in facilities that weren’t meant to hold people, let alone this many people, these sort of tent cities they’re standing up very quickly. Facilities are overcrowded, which makes it hard to control the spread of disease. Just a lot of issues going on. And so we talk to people about what could hiring some new medical personnel, what could that help address and what is it not likely to address in terms of the conditions.
Rovner: Yeah, I mean it seems when you have that many people in detention, hiring a couple of dozen of health workers is going to not really solve the problem.
Ollstein: Right. So, one, we don’t know if and when these people will be hired, but even so, again, a few dozen compared to they’re trying to grow the population of detainees by tens of thousands. The numbers don’t really add up.
Rovner: Well, Shefali, you have a story that kind of follows onto that, about women who are pregnant or nursing being taken into immigration custody, which is a change from prior practice, and the sometimes tragic outcomes of that. What did you find?
Luthra: So this story came because we just kept seeing individual lawsuits and single reports of someone saying: I was detained while I was pregnant. Here are the conditions I was held in. Some people reported miscarriages. Some people just reported really substandard care. And it came to become clear to us that this appeared to be somewhat of a trend, is these women were being detained, sometimes for short periods, sometimes for longer periods, and they were having adverse health consequences.
And so we did some digging. We learned that there actually was a policy put in place that said you are not supposed to detain people who are pregnant, who are nursing, who are a year postpartum, unless there are really extenuating circumstances. We looked everywhere to see: Had this been rescinded anywhere? And it hadn’t been. And that was just so striking to us because this policy is technically still in place. ICE is not supposed to be detaining these people, and every doctor you speak to will say: Well, we can’t study. There’s no randomized control trial of being detained versus not and pregnant and what happens to you.
But we know what is good for pregnancy and what is not, and we can say that the best practices are you shouldn’t detain people where access to prenatal care is sporadic at best, maybe not in the language that you speak. The food will not work for you, especially if you have these strong aversions. You may not be able to talk to someone right away if you suspect you are miscarrying. There’s a lot of psychological and physical stress. And then at the same time, the government has stopped reporting just how many of these cases there are.
And so there’s a lot of efforts underway to try and figure out as detention gets broader and broader, they try and, as Alice said, really increase the number of people being detained. We are seeing more women in particular, more pregnant, postpartum nursing women, being detained, and the numbers will just not be able to give us that clear sense of who they are or also what the health consequences can be.
Rovner: We’ll try to keep an eye on it there. I will post links obviously to both of your stories. I want to talk about MAHA, Make America Healthy Again. The AP [Associated Press] has a series out this week tracking the organized campaign by those with financial interest in the MAHA movement to, in the words of the story, quote, “strip away protections that have been built over a century” in public health. The reporters, including KFF Health News alum Laura Ungar, tracked 420 anti-science bills introduced in 43 state legislatures around the country focusing on vaccines, fluoride, and raw milk. They also tracked back those pushing the legislation to the supplement and wellness product sellers, raw milk farmers, and others who stand to profit from focusing on the MAHA priorities. For all of Secretary Kennedy’s accusations about the health care industry being in the pocket of Big Pharma or Big Food, can’t it also be said that many of his allies are in the pocket of Big Wellness?
Ollstein: I think that it has been fascinating that the wellness industry, the supplements industry, these aren’t being seen as the big capitalist forces that they really have become. And they’re far less regulated than the industries that the movement rails against, like food and like the pharmaceutical industry. And yet it sort of has this sheen of virtue that is — it’s gotten a lot less scrutiny and a lot less questioning. And so I wonder if that changes as this power shift happens at the state and federal level.
Rovner: Yeah. I think the raw milk producers I think really probably shocked me the most, maybe because I knew about the other ones, but sort of the power of the burgeoning raw milk industry. By the way, if you don’t pasteurize milk, you can get all kinds of bacteria and viruses and other bad things from drinking raw milk. It’s one of those things, like many of these things, that sounds great until you actually look into it. Rachel, you wanted to add something?
Roubein: Oh yeah, I was just going to say that I think in general, this push from the Make America Healthy Again movement, its allies into state legislatures, has been very coordinated. This is a big goal of the MAHA movement. Allies aligned with Kennedy are pushing a range of bills. They’re also pushing bills around food that did pass the state legislatures last year, such as barring SNAP [Supplemental Nutrition Assistance Program] recipients from using their benefits to buy soda or cracking down on artificial dyes in the food supply. But in general, Kennedy has not put sort of sweeping regulations, new regulations, around food, around pesticides, etc. And instead, a lot of allies are seeking to use the states, particularly when it comes to food, to sort of pressure companies and then be able to kind of pressure into a sort of federal, a more kind of national push.
Rovner: That’s kind of this administration’s theme, right? It’s: We’re not going to regulate, because we don’t like regulation. We’re just going to do individual deals with individual companies. I mean, certainly that’s what Trump’s doing with tariffs and other things, and it looks like that’s what Kennedy’s doing too, right? Seeing nodding.
Well, moving on. Like pretty much every week, there is news on the reproductive health front. Late last week, President Trump unveiled his plan to improve access to IVF [in vitro fertilization] for people hoping to get pregnant. During the 2024 campaign, he very specifically promised to make IVF free, either by having the government pay for it or requiring insurers to cover it, quote, “because we want more babies,” he said. But his plan doesn’t really do either of those things, right? It doesn’t make it free. I’m seeing shaking heads. Someone explain what it actually does do.
Ollstein: So there’s two pieces of this. One is a voluntary agreement with a pharmaceutical company to lower the cost of one fertility drug. It’s not a drug that every single person who goes through the process uses, but a lot of people do use it. I will also note that out of the total cost of IVF, the cost of these drugs is just like a fraction of it. Less than a quarter is what I was told when I talked to experts. So this doesn’t do anything to lower the cost of the consultations, the egg retrievals, the egg storage, the embryo implantation. All of those costs are unchanged. So there’s the drug crisis — yeah.
Rovner: I would say basically if you don’t have coverage for IVF and you can’t afford it on your own, lowering the cost of the drug is nice but it’s not going to make you able to afford it. Right?
Ollstein: Likely not. Likely not. But the other piece of it is we’re still waiting for the exact text of what this guidance and regulation will consist of, but just going off of what they’ve said, they want to make it easier for employers to offer supplemental IVF coverage that’s separate from the regular health plan. Now, I’ve talked to some experts who are really skeptical that that will make a difference. One, employers can already do that. Politico offers supplemental IVF coverage.
Rovner: So does KFF Health News.
Ollstein: There you go. And so it’s not clear what this guidance, which comes with no funding, no incentives, no mandates, why an employer that didn’t already offer it would choose to offer it now. It’s not totally clear. But also making it this separate supplemental thing, you get into this adverse selection situation where the only people who are going to sign up for it are the people who plan to use it, and that doesn’t spread the cost around and bring it down like regular insurance does.
Luthra: And I think it’s worth noting, if we even — to Alice’s point, we don’t have a lot of details yet about how these plans would work — but going off of everything they said in their remarks, looking through what documentation has been put out so far, one thing we keep hearing about from administration officials is the flexibility within these plans and the ideas that employers could offer benefits that match their values.
Which I think is really interesting because when you talk about fertility benefits, some people do have moral objections to IVF, and when you talk about matching their values, there’s a real question there: Are these plans actually required to cover IVF with multiple embryos, created with embryos discarded? We also heard a lot of chatter about offering benefits that would address the root causes of infertility. And this has become somewhat of an allusion to other forms, regimens, ideas of what fertility treatment can be that conservatives call restorative reproductive medicine.
And I think as we get more details, a really important question to see is, how generous do these plans have to be, or are they in practice? Do they actually cover IVF in a way that is meaningful and actually addresses people’s needs? Or do they instead offer limited coverage of something that is less effective, maybe already covered, and certainly already affordable for a lot of Americans?
Rovner: So one would assume that this plan is sort of meek because the administration is trying to be sensitive to the portion of the anti-abortion movement that opposes IVF because, as you say, you often create multiple embryos and then don’t end up using them and they end up getting destroyed. So is the politics of this going to satisfy both sides or going to dissatisfy both sides of this fight?
Luthra: The anti-abortion movement seems to understand that it could have been worse for them, but they are not thrilled about it, either. You mentioned, when we were discussing this part of the show, the Vox article, which I thought had a really great headline, by Rachel Cohen Booth, which was “Trump Manages To Disappoint Nearly Everyone With His New IVF Plan,” which I think is about right. I mean, this is not what people who want broad access to IVF would actually hope for, and this is certainly not what conservatives who oppose IVF would hope for, either, because they want something that is more sweeping in its criticism of IVF as it’s practiced. They want something that more full-throatedly endorses what they support instead. And it’s neither of them. It’s just sort of trying to find something that pleases everyone and, as a result, not necessarily changing that much.
Rovner: Politics as usual. Well, meanwhile, Bloomberg has a really provocative story this week about the limbo that many Planned Parenthood clinics find themselves in. You may or may not remember that as part of the Republicans’ big budget bill that passed earlier this year, the organization lost all of its federal Medicaid funding for a year. But because of the shutdown, HHS has not yet issued guidance on which Planned Parenthoods — many of which have stopped providing abortions or never provided abortions in the first place — are covered by this funding cutoff. Making everybody uncertain and unable to plan appears to be the overall strategy for this HHS, doesn’t it?
Ollstein: Well, and on top of that, Planned Parenthood affiliates that were getting Title X family planning money had that withheld, had that frozen, and they’re still waiting to learn the fate of that portion of money. And so it’s just uncertainty piled on top of uncertainty.
Rovner: Yeah. This I imagine is not going to impact what sort of the big abortion fight is going forward, which is going to be about abortion pills sent through the mail. But one would assume that it is going to impact people who are looking for services that don’t have anything to do with abortion, that have to do with cancer screenings and STD [sexually transmitted disease] screenings and just regular, routine gynecologic care. I mean, that’s what these Planned Parenthoods are providing using Medicaid funds and using the Title X funds, neither of which can be used for abortion.
Ollstein: Right, and a lot of the clinics that have shut down in recent months — I’m thinking of the ones in Louisiana and Texas and Iowa — abortion is banned in those places. Those clinics were not providing abortions. So I’ve been seeing a lot of folks on the right celebrating those clinic closures. But again, those clinic closures don’t mean less abortion. Those clinic closures mean less access to these other services.
Rovner: All right, well, that is this week’s news, or at least as much as we have time for. Now we will play my “Bill of the Month” interview with Katheryn Houghton, and then we will come back and do our extra credits.
I am pleased to welcome back to the podcast KFF Health News’ Katheryn Houghton, who reported and wrote the latest KFF Health News “Bill of the Month.” Katheryn, welcome back.
Katheryn Houghton: Thank you so much.
Rovner: So, this month’s patient had insurance but ended up dropping it because she could no longer afford the premiums, an all too common story, and then two months later slipped and fell and broke her elbow. Tell us who she is, what kind of care she got, and how much she was told it was going to cost.
Houghton: Sure. So her name is Deborah Buttgereit. She had fractured her left arm near the joint. So this was a humerus break, and it shattered a bit. So she needed surgery to kind of piece the bones back together, and that’s pretty key to, say, be able to move her arm. So she was told it was going to cost $50,000 or just a little bit more than that, and all of that would be out of pocket because, like you said, she didn’t have health insurance.
Rovner: Yikes. So, she had the surgery. Presumably her arm is better. And then the bill came. How much did it end up being?
Houghton: A lot more than $50,000. It was more than $97,000. Though it is important to say the hospital applied a self-pay discount, which left her with a $78,000 bill.
Rovner: So what was the explanation about why it was so much more expensive than the original estimate?
Houghton: The original estimate is just that, and the way that hospitals put it is: It is our best guess of what you are going to have to pay. If there’s some sort of complication, it could cost more, and there is a small fine print in any good-faith estimate that says that. So for Deborah’s case, the hospital said there were surprise complications, which means surprise costs. Her doctor said they encountered complications kind of mid-procedure, so her bones shattered into more pieces than they expected. That meant more time in surgery, that meant more skill to fix the break, and that also meant more tools to fix the break. And all of that comes with more costs.
Rovner: Yes. So Ms. Buttgereit decided that she did not wish to pay, even though, what, $78,000 that they were hoping that she would, and found that eventually she could appeal the bill under a provision that I didn’t know was included in the federal No Surprises Act, which I thought only applied to people with health insurance. Tell us about this little not well-known piece of the No Surprises Act.
Houghton: Yeah, exactly. I mean, fair thought on it being surprising, because a lot of people don’t know this exists. Some of the policy experts I talked to were like, Oh, this exists. A little-known fact about this is the No Surprises Act also created a formal dispute process for uninsured patients or those paying completely out-of-pocket for a planned procedure, so even outside of that emergency care situation. And this process, you’re eligible for it if you’re paying out-of-pocket and your final tab is $400 or more than the initial estimate.
Rovner: Which this clearly was.
Houghton: By quite a bit.
Rovner: So in the end, she decided not to use this appeal process. Why?
Houghton: So the appeal process, the floor of a process starts at the good-faith estimate, and Deborah had said, more time to think pain-free, she started to question that $50,000 bill and started using online price comparison tools and saying: You know what? This all seems overpriced. I don’t want that to be the floor. So she’s been going back and forth and doing negotiations with the hospital. But honestly what I’m hearing from the policy experts that I spoke with for this story was there’s just not a good process or system for patients paying out-of-pocket to fight a big bill. And this dispute process is one of the only options that they see out there.
Rovner: And I take it this fight about what she’s eventually going to be required to pay is still ongoing.
Houghton: Last I heard it was still ongoing. She was still going back and forth with the hospital, which was standing by their price tag, and she was working on setting up a payment plan no matter what the final tally came to. But if it stays at that final $78,000 range, a payment plan means she would face payments for 60-plus years.
Rovner: And she’s already in her 60s, right?
Houghton: Yes. Yeah. She would be paying off this for the rest of her life.
Rovner: So it’s probably in the hospital’s interest to find a better solution. What’s the takeaway here for other patients who end up with an accident and a big bill and no health insurance?
Houghton: The takeaway is if you’re going to push back on a price, starting at the good-faith estimate is key. So once you’ve already gone through the procedure, that’s almost like acceptance of what that floor price would be. And so if you’re going to fight back, fight at the very beginning. That’s hard when you’re going through a, say, painful break and you don’t have a lot of the energy to deal with anything other than trying to be OK with yourself and take care of yourself. The other thing to know is just if you are uninsured, if you are paying out-of-pocket, there is this dispute process if you get to that point.
Rovner: Great. Katheryn Houghton, thank you so much.
Houghton: Thanks so much.
Rovner: OK, we’re back. It’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Shefali, you have a story that’s related to reproductive health and IVF and all of those other good things. Tell us about it.
Luthra: Sure. So this was written by Shalini Kathuria Narang, written for Rewire News Group, co-published with the 19thnews.org. The headline is, “More People Are Freezing Their Eggs — But Most Will Never Use Them.” And I thought this was so interesting. It delves into a study that showed that 6% of people who froze their eggs between 2014 and 2021 had actually come back and used them within seven years.
There’s a Q&A with the author. But what’s so striking to me about this is, I mean, I definitely felt in the 2010s there was this huge conversation around egg freezing among especially young women who were working, this idea that this is a benefit that is being made available to you, this could actually make it much easier for you to ultimately have children if it’s something you want to do later in life when it gets harder.
And I just think this is so fascinating that this was a benefit that was really promoted, an alternative that a lot of people turned to, and that it seems that a lot of people aren’t necessarily using it. I really wonder why. I’m curious how much money has been spent on this and what this means and sort of how it helps us understand people’s reproductive choices moving forward. I just am so excited to see where this research takes us and how we better understand people’s reproductive choices.
Rovner: Yeah, it was interesting. I mean, one of the things that I found really interesting about this story was that it’s actually too soon to really know how many of them get used, because we did see this increase in young women having their eggs retrieved and frozen, and those young women, many of them are still young and not yet ready to use them. I mean, they still could, in other words.
Luthra: And many of them who froze them may not have to use them, because they froze them thinking, Oh, this is for much later, and then it turns out they actually can get pregnant without using them to begin with.
Rovner: Yeah, it’s a really provocative story. Alice.
Ollstein: Yes. So I chose this new study from Brown University. It’s titled “AI Chatbots Systematically Violate Mental Health Ethics Standards.” So the number of people who turn to ChatGPT and these other AI tools for therapy, either just chatting with it or specifically prompting it to provide therapy — that’s an increasingly common practice.
But if you read this study, you might not want to do that. This says that exhibited 15 ethical risks, including failing to refer users to appropriate resources or responding indifferently to crisis situations, including suicidal ideation. The chatbots exhibited gender, cultural, or religious bias. They used what they called deceptive empathy. They created a false bond between the bot and the user. They reinforced negative thoughts and beliefs. So this is yet more evidence that therapy is best provided by a human being who was trained and not a language predictor tool.
Rovner: Maybe it’s just that I’m old, but I don’t think I want to take personal advice from anything that learned everything it knows from the internet. That’s just me. Rachel.
Roubein: My extra credit this week is a story by my colleagues Dan Diamond and Akilah Johnson at The Washington Post. The headline is “Errors in New Medicare Plan Portal Mislead Seniors on Coverage.” So Medicare open enrollment began Oct. 15, and ahead of that, the Trump administration created this directory that was aimed at helping millions of seniors try and look up what doctors and medical providers accept which insurance.
But the portal, when it first opened, it was focused just on Medicare Advantage plans, and what my colleagues found is it frequently produced erroneous and conflicting information, and that led to a scramble inside the federal government to try and fix it. Dan and Akilah wrote about the backstory, too, which is that the Trump administration announced these plans for a national directory, but then in August they said it would be a temporary directory limited to just Medicare Advantage or private plans. After Dan and Akilah raised the problems that they were writing about to the Centers for Medicare & Medicaid Services last week, officials said that they were working to address the errors and seek potential solutions.
Rovner: People in other countries that have national health insurance must laugh at us about the fact that we can’t even have accurate directories of which providers take which insurance. But this has been a long-standing problem dating back as many years as we’ve had networks of doctors. Someday someone will solve it. I don’t know, maybe AI can do it.
My extra credit this week is from ProPublica. It’s called “The Shadow President,” by Andy Kroll. It’s about the rise of Russell Vought, whose name most people don’t know unless you listen to podcasts like ours, but who is the head of the White House Office of Management and Budget, the man behind lots of Project 2025, and the person calling most of the shots for the domestic policies of Trump 2.0. Trump actually proudly introduced him this week at a lunch for Republican senators as his personal Darth Vader.
What I really like about this story, though, is not just the detail of how Vought came to his beliefs, which is interesting enough, but how OMB is so intricately in charge of just about everything an administration does, which I think most people do not appreciate. This story is part of a year-long investigation with The New Yorker, and it is well worth your time, even though it’s pretty long.
All right, that is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me still on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Shefali?
Luthra: I’m on Bluesky, @shefali.
Rovner: Alice.
Ollstein: Mainly on Bluesky, @alicemiranda.
Rovner: Rachel.
Roubein: I’m on X, @rachel_roubein. Bluesky, @rachelroubein. LinkedIn, etc., Signal.
Rovner: You can find us wherever you look. We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': 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.
Panelists
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.
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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
The Washington Post
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
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Sandhya Raman
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Among the takeaways from this week’s episode:
- The federal Office of Management and Budget on Wednesday night sent a memo to government agencies asking for contingency plans in the event of a government shutdown starting Oct. 1. Such a memo isn’t unusual when it comes to pre-shutdown planning. This time around, it took an unprecedented turn in informing agency personnel that they should prepare for mass firings of employees whose programs lack alternative funding sources or who are working on a program whose mission doesn’t directly align with Trump’s priorities. Though federal RIFs, or reductions in force, and government shutdowns have each happened before, the combined RIF/shutdown threat is a first.
- It seems we are headed for a shutdown. Before adjourning until after the fiscal year ends Sept. 30, the House approved a stopgap funding measure. But, because House members do not plan to return to Washington until Oct. 6, that leaves the Senate in a jam. If senators change anything in the bill, it would require another House vote, which, because of the House schedule, might not happen before the month ends.
- There’s also interparty strife. Republicans say they want a clean bill to provide short-term funding, while Democrats have other ideas. Their prevailing attitude is that they went along with this approach in March and got burned. This week, Trump also canceled a meeting with Democratic leaders. The bottom line is that both sides are jockeying for a position that would allow them to cast shutdown blame across the aisle. Some call it a game of three-dimensional chess, while others call it a game of chicken. Either way, there will be consequences.
- Confusion and chaos have emerged as buzzwords to describe two recent events: last week’s meeting of the CDC’s Advisory Committee on Immunization Practices and this week’s White House press conference about autism. Both were marked by mixed messages. At the White House event, for instance, Trump warned pregnant women not to take Tylenol. But the FDA information that shortly followed downplayed the Tylenol risk.
- The Trump administration’s new $100,000 fee for H-1B visas could have an impact on health care. Such visas are often used by graduating medical students and other health professionals who come to the U.S. for training, then stay to practice. That $100,000 fee is steep and generated an almost immediate backlash from hospitals and health systems, especially those in rural areas — a reaction that caught administration officials off guard. Administration officials have suggested that health professionals would qualify for an exemption from this fee. What is not yet clear is what hoops the sponsoring hospitals would have to jump through to qualify for it.
- Trump has given 17 drug companies a Sept. 29 deadline by which they will have to commit to adopting his “most favored nation” pricing policy. It’s intended to increase the cost drugmakers charge in other countries while lowering prices in the U.S. Talks between the administration and the drugmakers are ongoing. So far, indications are that Trump might end up with half a loaf. Some large drugmakers have announced they will raise the prices of specific medications in other countries but have not agreed to reduce prices in the U.S.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: NBC News’ “RFK Jr. Has the Federal Vaccine Court in His Sights. Attacking It Could Threaten Vaccine Production in the U.S.,” by Liz Szabo.
Anna Edney: The Washington Post’s “Do State Abortion Laws Affect Women’s Recruiting? That’s Up to Athletes,” by Kevin B. Blackistone.
Sandhya Raman: ProPublica’s “Psychiatric Hospitals Turn Away Patients Who Need Urgent Care. The Facilities Face Few Consequences,” by Eli Cahan.
Also mentioned in this week’s podcast:
- Axios’ “Drugmakers Meet Trump Only Halfway on Pricing Plan,” by Peter Sullivan.
- Bloomberg Law’s “White House Says Doctors May Win Reprieve From H-1B Visa Fee,” by Rachel Cohrs Zhang, John Tozzi, and Jessica Nix.
Click to open the transcript
Transcript: Public Health Further Politicized Under the Threat of More Firings
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Sept. 25, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this, so here we go.
Today, we are joined via videoconference by Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning.
Rovner: And Anna Edney of Bloomberg News.
Anna Edney: Hey, everybody.
Rovner: So we’re going to do something a little different today. I got a chance to speak on Wednesday with Dr. Demetre Daskalakis, the former head of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases. I asked him to respond to the White House announcement on autism and last week’s rather muddled meeting of the Advisory Committee on Immunization Practices. So we’ll play that interview first, and then we’ll come back for our panel discussion. Here’s the interview.
I am so pleased to welcome Dr. Demetre Daskalakis to the podcast. Until last month, Dr. Daskalakis was the head of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases in Atlanta. He quit, along with three other senior career CDC officials, after Health and Human Services Secretary Robert F. Kennedy Jr. fired their boss, Susan Monarez, for refusing to approve in advance changes to the childhood vaccine schedule. Dr. Daskalakis, thank you so much for joining us.
Demetre Daskalakis: Thank you so much for having me.
Rovner: So, for those who haven’t been plugged into the public health doings over the past month, remind us what exactly your job was at CDC and why you felt you needed to resign following the dismissal of Dr. Monarez.
Daskalakis: So CDC is made up of centers, and so I ran one of the centers, called the National Center for Immunization and Respiratory Diseases. CDC’s not known for its pithy titles. So what that is is the center that is responsible for a lot of what you think about when you think about vaccines and vaccine-preventable diseases. That includes the resources that go out to local jurisdictions.
Rovner: And when Dr. Monarez was fired, what did that signal to you?
Daskalakis: Yeah. I think the last eight months had been hard. I think that we had other things that happened before Dr. Monarez’s resignation. I think we saw the Advisory Committee on Immunization Practices be zombified into something that was not science, we saw recommendations around covid vaccine come out on Twitter rather than through any scientific process. So those were the things that were on the way. But as ACIP was made zombified — and what I mean by that was CDC has nothing to do with it, these folks who have been installed, who are frankly anti-vaxxers for the most part, they’re the ones that are driving the agenda, the membership, all of it — so it wasn’t really doing anything of scientific consequence anymore.
But when Dr. Monarez was there, we had a scientific leader whose job it was to really be a diplomat to Secretary Kennedy and Health and Human Services, but also to really make sure that the science is what leads the policy. And so, when I saw that organization, the Advisory Committee on Immunization Practices, become some strange ideology machine, and then also saw that I wouldn’t have a scientific leader at CDC who would be able to defend the science, the game was over for me, because I couldn’t see any way that we would be leading with science. Instead, I could only see ideology. I read RFK’s books, and I know what’s coming, which is the dismantling of vaccines for the United States.
Rovner: So can you talk a little bit about how the career scientists and doctors at the CDC normally interact with the political appointees at the agency and the political folks at the top of HHS, and how that was so different in this administration?
Daskalakis: Yeah. I worked with — now that would be — four CDC directors and two secretaries of health. And so, the way that we normally interacted as career scientists was that we would produce materials; if there were questions, we would create memos and other materials to be able to present to our politicals around those issues. We would be responsive to any issues that they wanted to talk about. So for instance, if somebody said, “I want to talk about the birth dose of hepatitis B vaccine,” we would create briefing materials and opportunities for the politicals, both at HHS and CDC, to be able to have time with career scientists to really learn about the story. And that’s not what’s happened in this newest regime.
Now, let me be clear, Dr. Monarez did ask for briefings, and she did get them, so that is not the person I’m talking about. Above that, the secretary had never been briefed by anyone from the National Center of Immunization and Respiratory Diseases while I was there, so he never heard about measles, never heard about bird flu, didn’t hear about covid, though he made decisions about covid, didn’t hear about any of the things that we normally brief about. Didn’t hear anything about seasonal flu, RSV, and covid. We had been briefing folks on a monthly basis, because this was the epidemic that we have every year. So to say that there’s a glitch in the matrix is an understatement. This is an extremely atypical environment, where the head of people’s health for America doesn’t talk to people who know the science.
Rovner: So I want to ask you about the ACIP meeting, but since then, we’ve had the White House announcement on the causes of autism and a potential new treatment for it. Can you give us your take on that entire event, both the press conference announcing it and the documentation, such as it was, that was provided afterwards? I have to say, I watched all of the covid press conferences with President [Donald] Trump in 2020, and this made even my eyes cross a little bit.
Daskalakis: So let’s rehash what happened with the acetaminophen and autism issue. So they took one study and elevated that study and did this Orwellian doublespeak around it, where they said that it showed that there was a link, quote, “link,” between acetaminophen and autism. The study didn’t show that; the study showed that there was an association, and so an association does not mean cause. And so, my example that I use is when you are meeting people who have lung cancer and you ask them if they have matches in their pocket, they very often do. It’s not the matches that cause the lung cancer, it’s the tobacco; it’s the smoking.
So very similarly, there’s an association with acetaminophen, that’s the matchbook. Autism is a spectrum and it’s not a disorder or a disability for some people, it’s just part of their normal neurocognitive story, but it’s like the equivalent in my analogy of lung cancer. And so, there’s something in between there that we don’t really see, and that could be genetics and other environmental exposures. So they put all of their eggs in one basket that should make nobody feel comfortable that they have the answer for autism because they found an association that people kind of already knew about and made an announcement, mainly because the secretary promised a September announcement. And so, science can’t be rushed, this was a rush job, and I don’t like my policy fast and loose, and that’s what you’re seeing, fast-and-loose policy.
They also talked about leucovorin, which is a drug that I think many people use or know about, usually used in cancer chemotherapies that involve some kind of antifolate, so it is a rescue. So if people are getting a medicine that makes their folate low, the folinic acid is kind of like super folate that really replaces the deficiency. And so, they made big statements about this being a potential treatment for autism, but then subsequently in the writing that they put out, they were very focused on a very specific circumstance of people who have some sort of cerebral folate deficiency.
So that’s the big picture. They announced a bunch of stuff, and it didn’t go through any process, we don’t know the quality of the data, the entirety of the data was not reviewed in any systematic way, and then announcements were made without any process of actually demonstrating what work was done to get there. We’ve all been in math class — the answer to an equation isn’t just 25, you have to show the work to get there, and so it’s like they just said, “The answer is 25.”
Rovner: And in this case, this could cause all kinds of actual consequences for people, particularly for pregnant women who have pain or fever.
Daskalakis: Which is associated with poor outcome for the pregnant woman, as well as for the fetus or the child after they’re born. So there’s that reality, that it’s not inconsequential, and then you have someone saying, “Avoid it, don’t do it, at all costs, don’t do it,” and then what the FDA puts out that says, “Should use judiciously.”
So I’m going to answer the second part of your question, what did I think of the press conference? I’m going to be honest, I don’t blame the president for anything that he said. I blame RFK Jr. and the other people on that stage. Their job is to make sure that their principal knows what they’re talking about, and so they have failed their job because what happened was we had a principal who was talking about things that were, I think, beyond his scope. And then also, we thought we were just talking acetaminophen, and then all of a sudden, in a non sequitur, we heard about the vaccine schedule for kids with some very strange places that we visited, including the notion that hepatitis B is a sexually transmitted infection, and rather than the birth dose that prevents vertical transmission, mother to child, as well as household transmission, we should wait until age 12, which will manifest itself as liver cancer, liver transplant, and cirrhosis for a lot of children, especially those who maybe are at higher risk because of their social circumstance.
So that’s what I thought. I was, like, poor guy, he’s being briefed by people who don’t know anything, and so maybe they should take care of him.
Rovner: All right. Well, I want to also ask you about your reaction to the Advisory Committee on Immunization Practices’ meeting last week, where the committee voted to change recommendations for both the measles-mumps-rubella and chickenpox vaccines and the covid vaccine. At the end, it felt like everyone was confused, including the members of the committee. What stood out to you about that meeting?
Daskalakis: I felt like an oracle, because in my resignation letter, I told you this was going to happen, and it’s exactly what I thought. And so, what happened was they did no process and just did stuff. And so, let me just give you what normal is, because that’s really important, and then I’ll walk you through each one and tell you why they were abnormal.
So generally speaking, something happens, and there’s a question related to vaccine policy, there’s a new vaccine, there’s new data around safety, something happens. And that’s elevated either by ACIP members, CDC, or the working groups that live within the ACIP that do all the work on the side before the meeting. So that question comes to the work group, and the CDC folks work really hard and poll all the data in the world about the question. They in effect work to do what is, for lack of a better word, a meta-analysis, a study of studies, and they go through a process called GRADE, where they look at all the data and say, “This is good data, this is OK data, there’s bias,” really to contextualize all of the data. They then put that onto a clear table that tells you what’s happening. Now, they did that for a couple of things.
The next thing is that there are long discussions. They’re long because they’re complicated, and they go through something that’s called an Evidence to Recommendations Framework. Now, that’s jargony, but what it means is that there’s this process where they ask, “Is this an important public health question? What are the implications for equity? Do the risks and the benefits … what is the equation there? Is there more harm or more good? Is this something that is going to improve the health of people? And is this cost-effective?” There’s a lot of domains, but they go through it really methodically because they want to get all of the domains that are needed for decisions. Once they do that, they produce a recommendation. That is taken to ACIP and it’s discussed. And then they vote.
So what happened was that they didn’t do it, because RFK Jr., I know this from the inside, said, “I want on the agenda hepatitis B birth dose and MMRV.” What you saw there was politicization of the committee, ideology dominating, conspiracy theories being elevated to the level of data, and then decisions being made based on that. So if the data’s no good, if the foundation of the house is rotten, that house shouldn’t be standing, so that’s what we saw.
And I want to go back to that hepatitis B thing. So they may go and do something that’s more process. But one of the reasons that I left was that CDC is not allowed to dictate who is on the work group anymore. So if they stack the work group with people that are anti-vax people, who are naysayers, who are not basing conversations on data, but on the anecdote or unvetted studies, it won’t matter, because that process will also be rotten if there’s not a diversity of opinion and scientific expertise on the work group. So that’s what happened at ACIP.
Rovner: So following some pretty unusual public health actions just in the week since you’ve resigned, what’s your biggest concern about public health going forward?
Daskalakis: So I think that there’s a couple of things that happened that I didn’t talk about yet that are very concerning. I’ll tell you that the book that I picked up to start reading when I finished my time at CDC was [George] Orwell’s “1984,” and the reason that I picked it up was because really soon after I left, I have nothing to do with stopping it or starting it, but just saying temporally speaking, CDC changed their webpage, that was the “About CDC” webpage, into, in effect, what is a manifesto as opposed to a description of an agency that is supposed to be balanced and scientific. So it really, in effect, speaks about compliance to ideology as the principal motivator for what CDC is and will do. There were other things wrong with that document, but we don’t have the time to go into that one.
And so, I feel like — first chapter of “1984” that talks about ministries that are using doublespeak to be able to say what they do, I think we are now living it. And so that’s my fear, that everything that’s going to be coming out of CDC is going to be colored by ideology, or that data is going to be released from CDC without scientists able to explain it so that it can be used for other means or that will allow folks who are more ideologically motivated to be able to make conclusions based on inadequate analyses. So that’s what I’m worried about.
Rovner: So how do we proceed from here, both public health professionals and Americans who are just looking for health guidance?
Daskalakis: Yeah. I think we’re at a dark time, but I also think that there’s going to be light in the darkness, it just may not be today. So the first thing is trauma-informed care, your feelings are valid: This is not normal, something not good is going on, and it’s hard to figure out who to trust. And so, my recommendation to people is, and I know that this is a hard one because not everybody has access to care, is if you do have access to care, you really need to lean into your doctors — doctors, nurses, nurse practitioners, physician assistants, pharmacists — taken widely and broadly, health care professionals. So even if you don’t have a primary care doctor, you have a pharmacist, and so go to that pharmacist and talk to them. It’s not as good as having one word for the land, as had been standard for CDC, but in this environment, I think you need to go with people that you trust.
I’ll also say one of the things that should be a red flag for everybody out there is — I’m a doctor, I take care of patients — and I do actually believe that the relationship between a clinician, a health care provider, whoever they are, and their patient is very sacred. And so, whenever you hear anyone in the world trying to destabilize that relationship, saying that, “Doctors don’t know what they’re talking about, don’t listen to the pediatricians,” that is not someone you should be taking medical advice from, because they’re actually at their core trying to get you to not listen to the people who are your best allies and advocates in the health space.
Rovner: Dr. Demetre Daskalakis, thank you so much for joining us.
Daskalakis: My pleasure.
Rovner: OK. We are back with our panel, and I want to ask both of you about your reactions to the ACIP meeting and the autism announcement. But let’s turn first to the breaking news about the potential government shutdown that’s less than a week away. Last night, the Office of Management and Budget, which traditionally sets the rules for who stays on the job in a shutdown and who doesn’t, issued a memo of the sort I’ve never seen before. Rather than directing agencies to prioritize which activities are needed to preserve, quote, “life and property,” and thus who’s required to work without pay for the duration and who gets furloughed until funding is restored, this memo basically says if the activity doesn’t have another source of funding and it’s not within the administration’s priorities, agencies should prepare to fire not furlough workers. This is obviously a big ramping up of this shutdown. I know this just happened, but what kind of reaction are you guys seeing?
Raman: This to me just seems very, very highly unprecedented. We’ve had shutdowns, we’ve had near shutdowns, many of them in the past, and it has not escalated to this at any time that I’ve seen.
Rovner: Forty years, I’ve been doing this 40 years, I have never seen anything quite like this. We’ve had rifts and we have shutdowns, but we’ve never had them combined.
Raman: Yeah. And so, I think it’ll be really interesting how the next few days play out. The Senate is in for a couple of days before we would hit the shutdown, if there’s anything they can come together on. It is really difficult when you escalate to this level when they’ve been trying to negotiate so far. It’s hard. The House isn’t supposed to come back until Oct. 6.
Rovner: Oops.
Raman: So if the Senate changes anything or wants to change anything compared to what the House had passed, they’re stuck. Either the House has to come back in or they shut down until they come to a compromise on something. So I think from everyone that I’ve been talking with over the past few weeks, it seems like we’re really headed to a shutdown. It’s possible they get a few Democrats to fold and go with what’s there, but I think this last move, and then also President Trump saying that he was going to meet with Democrats earlier this week, and then saying, “No, I don’t want to,” they’ve been saying there’s not good-faith efforts to negotiate, so they’re in a pickle at this point.
Rovner: Let’s get real: This is about not whether we’re going to have a shutdown, but who gets blamed for the shutdown. Traditionally, it’s been the Democrats, and the Republicans keep saying this, who say, “Look, we’re just having a clean extension of funding, we’re just going to basically roll out the clock, kick the can down the road, so we can continue to negotiate over funding for next year. Why won’t Democrats go along with that?” And Democrats are responding, “Well, we went along with it in March, and look at what’s happened in the interim, and our base didn’t like that, so we think we should fight this time.” And then, you had the president agreeing to meet with Democratic leaders, but then the Republican leaders in Congress telling the president, “No, don’t meet with them.” It’s all strategy at this point. You’re nodding, Anna.
Edney: Yeah, yeah. I was just thinking, I think a lot of times, talking about this administration, people are saying, “There’s no plan.” But I do see the 3D game of chess at this point, and that letter very clearly mentioned if the Democrats shut down the government, that was lobbying that into the court of the Democrats saying, “This is your fault if it happens.” And I do think that the Democrats were burned last time in the sense that it seemed like they might allow a shutdown and then backtracked pretty quickly and the base just didn’t like it, and I think we’re seeing a lot from the, I don’t know what exactly to call them, thought leaders on the more liberal side saying, “Just do it, let it rip.” If it shuts down, they’re going to try to find a way to blame it on the Republicans.
So I think it’s a game of chicken at this point, but there are real consequences. These are people’s jobs who aren’t necessarily going to all want to come back to the government if things suddenly, it works out. These are activities that we rely on for everyday life that will be hurt.
Rovner: Yeah. We’ve already seen the administration trying to hire back some of the people that they laid off earlier this year because it turns out they were needed to do important jobs. I saw House Democratic Whip Katherine Clark this morning on CNN describing this letter as, “The beatings will continue until morale improves.” This really is playing with the lives of government workers who basically have come to these jobs because either they believe in them or because they usually have been stable jobs. They might, may be able to make more in the private sector, but government jobs tended to be secure, and boy, that’s not what’s happening right now. They don’t seem to be guilty parties in all of this, and yet they’re the ones who are being used as pawns.
Raman: I think one thing that I have been thinking about in reading that OMB memo is that it says that the rifts are going to affect people that aren’t also really aligned with carrying out President Trump’s priorities and mission. What does that entail? Within HHS, what falls in that bucket? We have some ideas based on previous executive orders and things that he’s made some remarks on, but there’s plenty that we don’t know.
Rovner: They could theoretically shut down the entire NIH [National Institutes of Health] or the entire CDC, which I think Secretary Kennedy might not mind.
Raman: How that would go about, I don’t know. I think that we’ll all be really looking to see what kind of contingency documents they put out. They usually put those out before, when we’re in this waiting period about a shutdown, and it would definitely be very different than the ones that we’ve had in the past for a department down or agencies. What that’ll say, I just don’t know.
Rovner: Yeah, that’s right. To be clear, the OMB memo is to the agencies saying, “Send us your contingency plans.” Normally, that would’ve happened by now, it usually comes out a couple of weeks ahead of a potential shutdown and everything. We’re playing brinksmanship here. Anna, you wanted to say something before we move on?
Edney: Oh, I don’t remember what that was. But just on the last point, I think the agencies, they usually have that contingency plan at the ready, but they can’t — I don’t think that this would’ve been the one that they had drawn up. I think they have to tear that up and start over again. And like you mentioned, the CDC, the NIH, you can, through this mandate, possibly see how you could just wipe out an entire agency.
I think on the FDA side, I just wanted to add, there are some user fees on that side that may keep the drug review side afloat, anything where they’re looking at approvals and things like that is funded, at least for a while. If this devolves for months and months, that’s not the case. But there are a lot of other parts where they’re doing inspections and keeping the drug supply and the food supply safe that could be impacted.
Rovner: Yeah. And we should point out that this does not affect things that have mandatory funding, like Medicare and Medicaid and Social Security, and, as you say, user fee funding, like the review activities at FDA.
Well, while we’re on the subject of things that are unprecedented, let’s turn back to that ACIP meeting and the White House autism announcement. One of the things that ties them together is the fact that both leave the public with more confusion than clarity over what to do about vaccines and Tylenol and, once again, leaves Americans wondering who or what they can trust. What’s the biggest takeaway from each of you? Anna, why don’t you go first, about both the autism announcement and the ACIP meeting?
Edney: Yeah, I think there just is a ton of confusion. I can’t count how many times people are like, “Remind me again, who can get a covid shot and who can’t? And what are we doing with RSV now?” There was a lot of talk before the ACIP meeting about hepatitis B and that even the ACIP members were confused.
So I think that one thing that I think this makes crystal clear is that when I know that this administration and many of the people at the top in health care don’t appreciate the medical establishment and they don’t feel that it is operated in a way that is open to modernization. But you can’t just break it all and then start over, these are guidelines and things that people rely on, and it has to be, I think, a much more thoughtful process than what we’re seeing right now. You have a lot of people who are pregnant or have young children who are freaking out, because they’re like, well, I took Tylenol for three days because I had a fever, and I think that it creates more fear-mongering, because the guidance really isn’t that different, what the FDA actually said isn’t that different from what was already out there, you’re just really scaring people now.
Raman: So I think I would say something along similar lines, the mixed messaging and the confusion of that both events is pretty stark. So I think the thing that struck me with ACIP is just the second day, we have a re-vote on something that you voted on the first day, and if you watch just one, you would assume that what happened there is done, and then going back, it’s just very unusual and makes it even more confusing.
And I think the second thing that struck me was that we had this whole shake-up of ACIP in general to be like, we don’t want conflicts of interest, we want people that are able to vote on everything. And then, here, when we have the votes, we have someone on ACIP not be able to vote on something because they’re disclosing a conflict of interest. So it struck me that we went through this whole process that was to eliminate that, and then here we are back to that, which people have been saying for a long time, it’s difficult to find anyone in this space that doesn’t have other things that are connected to vaccines.
For the autism announcement, the thing that was really interesting to me was that this was done on the White House level rather than just HHS is having an event, it’s with some agency folks there, and then them putting out information, whatever they’re talking about. This was predominantly Trump speaking in a much more aggressive, this is what is what tone, compared to the agency folks who mostly were downplaying a little bit of what he’s saying. He repeatedly said, over and over again, “Don’t take Tylenol, don’t take Tylenol, no Tylenol for pregnant women.” And then, even when you look at the FDA release that came out a little bit after really downplayed it, it said that there was an association, but there wasn’t a causal relationship that they had found between acetaminophen and autism in children. It goes back to that mixed messaging, where even if the majority of scientific professionals are saying that this goes against what a lot of the research that they’ve been doing, you’re going to be confused.
Rovner: Yes. Another thing that seems to tie together both the ACIP meeting and the autism announcement is to basically put all medical responsibility on individuals, which many consider to be blaming the victim and increasing stigma by basically saying, “Whatever you decide, whatever happens is your fault.” I feel like we’ve careened from maybe too much reliance on experts to too little. That was certainly the president’s message at that press conference, it’s like, “Well, this is just common sense.” It’s like, I thought we were supposed to be relying on gold-standard science.
Edney: That was a very stark point, where it was like, what do you mean you feel this? It’s like, I think you’re supposed to know that through research and scientific data.
But I wanted to go back, you mentioned blaming the patient, I think specifically on the autism side, this is something we see with expecting mothers a lot, because I interviewed professor Emily Oster about the autism announcement, and she dives very deep into data on a lot of things parents are concerned about, and she was telling me about “refrigerator moms” in the 1950s, and I didn’t realize this, but apparently women were blamed for different mental illnesses if they were too cold, not freezing-cold, but emotionally not available for their children enough, and so they must be causing their schizophrenia and there was a big link to that. And that continues, they’re telling the women, “If you have a fever or enough pain that you would consider popping a Tylenol, then that’s on you, just either deal with it or be responsible for the fate of your child.”
I think that’s what the medical establishment has been trying to avoid, is giving women options, and there are a lot of reasons you need to take care of that fever or you need to take care of that pain, and some of them have to do with the health of the child, the baby that they’re carrying, so …
Rovner: Right, fever is also a potential cause of problems.
Edney: Exactly.
Rovner: All right. Well, in a health-related story that doesn’t seem like a health-related story, the Trump administration late last week announced a new $100,000 application fee for H-1B visas. Now, those are usually associated with tech workers, but it turns out that an awful lot of medical professionals, particularly doctors from other countries, use them to come here to fill residency positions that American medical school graduates don’t fill — often low-paying primary care slots in rural areas. And, according to reporting from your colleagues at Bloomberg, it seems that medical personnel might be exempt from this new fee, but it’s not clear how many hoops hospitals might have to jump through to get those exemptions. At best, it doesn’t feel like this was very thoroughly thought through, particularly for an administration that says that rural health is a priority.
Edney: Right, yes. I think they may have been a little surprised by the amount of pushback from the hospital and doctor associations, saying, “We really rely on these to get doctors to rural areas.” And they almost immediately tried to massage that and say, “Oh, well, they could be included in exemptions.” But that’s all we know, “can be included” is not extremely reassuring. It’s not saying, “We’re giving you a blanket waiver for doctors,” or anything like that, and nobody knows, like you said, the hoops they might have to jump through. I would say it’s a start, and maybe they’re thinking about it, more aware of it, at this point.
Rovner: Sandhya, is there any pushback from Congress? Can the president even do this?
Raman: I think the pushback I’ve seen has been broader, not just on how this is going to affect hospitals that clearly cannot afford this in the same way that maybe some of the Big Tech companies may be able to. But I will be really interested when they come back just how lawmakers might look at this, because hospitals are the biggest employer in so many congressional districts, that if they’re pushing back, I could see people that normally don’t push back on this kind of thing saying, “If the biggest employer in my district is going to tank because of this,” it rises up as an issue for them.
Rovner: On the other hand, we haven’t seen a lot of pushback from Congress for things that we expected to see pushback on, so I guess we’ll have to watch that space.
Raman: Yeah.
Rovner: Well, finally this week, there’s good news and bad news on drug prices, which President Trump has vowed to reduce by, and I looked this up to get the quote correct, 1,400% to 1,500%. He said it many other ways, by the way. The idea of his, quote, “most-favored-nation” executive order that he issued last spring is to get drugmakers to lower U.S. prices to those charged in other countries that have price controls that we don’t have. Well, Trump is getting half of what he wanted, according to Axios. Several large drugmakers say they’re going to equalize what they charge here and overseas, but not by lowering prices for Americans, rather by raising them for Europeans and others. On the other hand, there’s still a few more days until the Sept. 29 deadline for them to do this. Anna, are you hearing anything new on this?
Edney: I haven’t heard anything new. I think we just saw, like you mentioned, what Bristol Myers Squibb did, which was a newer schizophrenia drug they raised, they said they were going to introduce that in the U.K. [United Kingdom] at the same price in the U.S., extremely convenient for the pharmaceutical companies to be able to have this reason to raise prices elsewhere. But then, of course, they can find reasons not to bring them down so far in the U.S., and we’ve seen — the only other company I can think of was Eli Lilly did this earlier this summer, saying they would do the same for their drug Mounjaro, and there was maybe some hoarding that started because people in Europe don’t want to pay the higher price.
Rovner: Mounjaro being a diabetes drug that is also the weight loss drug.
Edney: Right, right, yeah, so the weight loss drugs have seen a lot of ups and downs. But you’re right, there’s only a few days left, and it’s interesting that it hasn’t leaked … any kind of plan that the pharmaceutical companies are talking about or anything like that. Sometimes, I feel like because this administration is operating more by telling people through letters and demanding it at the podium rather than doing actual regulations — remember, the most-favored-nation policy did not work out well after challenged in court the first administration. So I think they’re often happy to get half of what they asked for in a way. But this could be tough, because it lets Trump say, “We’re no longer carrying all the water,” but it doesn’t let him say, “We decreased prices for the American people.” So we’ll have to see …
Rovner: By 1,400% to 1,500%.
Edney: Right, right, get those economists to figure that out. But we’ll just have to see what’s going on even … so much. The shutdown may take all his fire.
Rovner: Yeah. This is one of those issues that is bipartisan, that it is popular on Capitol Hill, and that lawmakers keep saying they’re going to do something about, but so far, we’re not seeing it, are we?
Raman: I think that there’s so much that they have on their plate right now and just so much that they have been at odds with each other right now, it’s something that would’ve gotten more attention in normal times, has just gotten really delayed at this point.
Rovner: These are definitely not normal times.
Raman: Yep.
Rovner: All right. Well, that is the news for this week. Now, it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read too. Don’t worry, if you miss it; we will put the links in our show notes on your phone or other mobile device. Anna, why don’t you go first this week?
Edney: Sure. So mine is in The Washington Post, and it’s: “Do State Abortion Laws Affect Women’s Recruiting? That’s Up to Athletes.” It was a really interesting look at basically how women athletes, specifically in basketball, and they discuss others lower down, are choosing college based on abortion laws — the states where they have less restrictive abortion laws, or more abortion rights, I guess I should say — then they’re tending to go there. And then, you have the schools more in the South, where they’re more restrictive, where they’re choosing not to go there for the four years of their college life. And it was something that I think was just a really interesting look at a topic that has been on everyone’s mind, but with so much going on, not exactly focusing on it. And it talks about other trends in college admissions and things too. So something to think about.
Rovner: Yeah. I know we’ve talked a lot about health workers avoiding states with abortion restrictions. This is the first time I’ve seen this link to younger women and sports and college, and we’ll see whether some of the states react to that. Sandhya?
Raman: My extra credit is called “Psychiatric Hospitals [Turn Away Patients Who Need Urgent Care. The Facilities Face Few Consequences],” and it’s in ProPublica by Eli Cahan. And I think what drew me to this is EMTALA [the Emergency Medical Treatment and Labor Act] has been one of those things where we have been thinking about it a lot in terms of abortion, when we’ve seen it in the news in the last few years, it’s been very abortion-focused. But this story looks at a psychiatric hospital in Colorado that got taken to task for not providing stabilizing care to patients at risk for suicide, and CMS [the Centers for Medicare & Medicaid Services] didn’t penalize them in reducing funding or imposing any penalties. It’s part of a broader thing, where over 90 psychiatric hospitals have violated EMTALA in the past 15 years. I don’t want to give away the whole thing of the story, but it goes more into this.
Rovner: Yeah, it’s a really good story. All right. My extra credit this week is from NBC News by my friend and former colleague Liz Szabo, and it’s called “RFK Jr. Has the Federal Vaccine Court in His Sights. Attacking It Could Threaten Vaccine Production in the U.S.” It’s a really good roundup about what’s likely to be the HHS secretary’s next target: the program that compensates the very small number of Americans who are injured or killed by vaccine side effects. There are risks to all vaccines, although they are very much outweighed by the benefits, and this program was created by Congress during the Reagan administration to compensate those who have suffered from those rare adverse reactions.
The program was created to keep vaccine manufacturing alive in the United States because product liability suits were threatening to shut it down entirely, while the program also makes it easier for those who are injured to receive compensation. The program is far from perfect and it could use some revisions, which Congress has tried and failed to do over the last couple of decades. But it seems clear that that’s not what Secretary Kennedy has in mind. It’s a great preview of what the next likely battle is going to be in the vaccine wars.
OK, that is this week’s show. Thanks this week to our editor, Stephanie Stapleton, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks these days? Sandhya?
Raman: At X and on Bluesky: @SandhyaWrites.
Rovner: Anna?
Edney: Same places, @annaedney or @annaedney.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Ousted CDC Officials Clap Back at RFK Jr.
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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.
Fired less than a month after being confirmed as head of the Centers for Disease Control and Prevention, Susan Monarez appeared at a dramatic Senate hearing this week alongside another ousted CDC official and directly contradicted Health and Human Services Secretary Robert F. Kennedy’s earlier testimony about why she was fired.
Monarez told the Health, Education, Labor, and Pensions Committee that Kennedy ordered her to agree to approve changes to the childhood vaccine schedule soon to be recommended by a CDC advisory panel, regardless of scientific evidence, and to fire senior career scientists who the secretary felt did not share his vaccine views.
Meanwhile, Republicans and Democrats in Congress are at a standoff over government funding, with less than two weeks to go before a potential shutdown. Democrats — whose votes are required to pass a bill in the Senate — say they won’t vote to keep the government open unless Republicans agree to extend expanded subsidies for Affordable Care Act insurance plans that otherwise expire at the end of the year. Republicans are so far resisting those calls, although some are concerned that the resulting premium spikes would affect their own voters.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Alice Miranda Ollstein of Politico, and Margot Sanger-Katz of The New York Times.
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Joanne Kenen
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Alice Miranda Ollstein
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Margot Sanger-Katz
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Among the takeaways from this week’s episode:
- Sen. Bill Cassidy (R-La.) — who, as chairman of the HELP Committee, called the hearing and is a gastroenterologist — found himself pushing back on some of his GOP colleagues, particularly on the importance of vaccinating newborns against hepatitis B. Cassidy, who is up for reelection next year and faces a primary challenge, is in a delicate position regarding the oversight of the Trump administration’s health policies.
- The hearing showcased broad, across-the-aisle agreement that trust in the CDC has eroded — along with a stark divide over the cause and who’s at fault. Democrats point at Kennedy and the Trump administration, while Republicans blame the agency’s handling of the covid-19 pandemic. Historically, Americans have tended to trust public health officials; now, states are starting to create a patchwork of policies.
- Congress is struggling to agree on even a stopgap measure to keep the federal government funded, increasing the chances of a government shutdown on Oct. 1. Democrats are pushing to extend enhanced federal ACA subsidies as part of a deal, but that issue could be kicked down the road, injecting uncertainty into this year’s open enrollment process, which begins Nov. 1.
- And more details are emerging about the $50 billion rural health fund inserted at the eleventh hour into Trump’s major domestic policy law. As the federal government begins soliciting applications for funding from states, it’s becoming clear that there are strings attached — and that the funding isn’t entirely designated for rural hospitals after all.
Also this week, Rovner interviews Troyen Brennan, former chief medical officer at Aetna and CVS, on his new book about primary care, “Wonderful and Broken: The Complex Reality of Primary Care in the United States.”
Plus, for “extra credit,” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:
Julie Rovner: The New York Times Magazine’s “Trump Is Shutting Down the War on Cancer,” by Jonathan Mahler.
Margot Sanger-Katz: ProPublica’s “Programs for Students With Hearing and Vision Loss Harmed by Trump’s Anti-Diversity Push,” by Jodi S. Cohen and Jennifer Smith Richards.
Alice Miranda Ollstein: The New York Times’ “I Have Dental Insurance. Why Do I Pay So Much for Care?” by Erica Sweeney.
Joanne Kenen: Politico Magazine’s “Why Voters Will Feel the Impact of GOP Health Cuts Before the Midterms,” by Joanne Kenen.
Also mentioned in this week’s podcast:
- NBC News’ “Data Investigation: Childhood Vaccination Rates Are Backsliding Across the U.S.,” by Erika Edwards, Jason Kane, Stephanie Gosk, Mustafa Fattah, and Joe Murphy.
- The Washington Post’s “Why 1 in 6 U.S. Parents Are Rejecting Vaccine Recommendations,” by Lauren Weber, Scott Clement, Emily Guskin, and Lena H. Sun.
- Politico’s “The Rural Health ‘Hunger Games’ Are Underway,” by Alice Miranda Ollstein.
Click to open the transcript
Transcript: Ousted CDC Officials Clap Back at RFK Jr.
[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’et cetm 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. 18, at 10:30 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: Margot Sanger-Katz of The New York Times.
Margot Sanger-Katz: Good morning, everybody.
Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.
Joanne Kenen: Hi, everyone.
Rovner: Later in this episode, we’ll have my interview with Troyen Brennan of the Harvard T.H. Chan School of Public Health, who has a brand-new book out on the past and future of primary care, aptly called “Wonderful and Broken.” But first, this week’s news.
So, ousted director of the Centers for Disease Control and Prevention Susan Monarez testified before the Senate HELP [Health, Education, Labor, and Pensions] Committee on Wednesday, and the hearing did not lack for drama. As she wrote earlier this month in The Wall Street Journal, Monarez disputed HHS [Department of Health and Human Services] Secretary Robert F. Kennedy Jr.’s account of what led to her firing and repeated that she was asked to “rubber-stamp” whatever changes the secretary’s handpicked vaccine advisory committee suggests at their meeting, which is starting just as we tape today. Monarez also told the committee she was ordered to fire senior career people who were not aligned with the secretary’s anti-vaccine views.
But unlike last week’s hearing with RFK Jr., which was before the Finance, not the HELP, Committee, this hearing, with few exceptions, was a lot more partisan, with Republicans who literally just voted to confirm Monarez in July trying to undermine her credibility and Democrats apologizing for doubting her integrity. We’ll talk about HELP Chairman Dr.-Sen. Bill Cassidy separately in a second. But this hearing struck me as evidence that most Republicans are still firmly supporting RFK Jr., at least for now. Is that the impression that you guys got? You all watch the hearing, too?
Ollstein: Yeah, I was in the room. There was an interesting divide among Republicans. I mean, Democrats were pretty uniformly outraged about what was happening, praising Monarez for attempting to stand up to Kennedy even if that cost her job. Some Democrats even apologized for doubting her and said, “When you came for your confirmation hearing, I was really tough on you. I wasn’t sure you were going to stand up to Kennedy, but you proved me wrong. You did,” which I thought was interesting. And then on the Republican side, you had the folks you would kind of expect — Susan Collins, Lisa Murkowski — expressing concern about the implications for public health, asking Monarez what happened and who said what and who made what decision.
And Cassidy was in that camp as well, and Cassidy even, at multiple points, pushed back on his own Republican colleagues. He did that on this issue of whether or not there was a secret recording, which we can talk about. He did that on just the basic science of the hepatitis B vaccine. He used his own medical credentials to say, “Look, I know what I’m talking about. The recommendation that newborns get vaccinated for hepatitis B is a good one.” And this was with Rand Paul, who’s also a physician, but doesn’t specialize in hepatitis like Bill Cassidy does, was sort of fact-checking that.
Rovner: Yes. Rand Paul’s an ophthalmologist, just for the record.
Ollstein: Right, right. And so there were some really interesting moments with that divide in the GOP.
Rovner: I thought to a little bit of an extent, and I know I’m jumping ahead here, Cassidy kind of threw Monarez under the bus because it looked like several of the Republicans had the same talking points, accusing her of having tried to banish the political appointees from her suite of offices — things that had not, I went searching around for, gee, is there some story that I missed and I didn’t find anything. I’m sure that there was something there. But Cassidy, he was responsible for bringing her in — and we should say Debra Houry, who was one of the senior people who quit after Monarez was fired. Cassidy brought them both there and then let some of his colleagues run roughshod over them.
Kenen: Yeah, but he also — I thought he dropped some hints of support. You’re right, he didn’t embrace her, but he kept saying, “We have to hear from the secretary, too.” But the fact that he really ended it on such a “I’m a doctor and I know,” I thought that was a very validating thing for her in a way. Then, when we get to the mystery tape, he said one thing that if you were paying careful attention was quite interesting, potentially helping her.
Rovner: Let’s talk about the mystery tape. This was Sen. Markwayne Mullin from Oklahoma, who was, I guess, you would say, the most hostile questioner basically.
Kenen: Well, [Ashley] Moody, what was her name? The last hour was bonkers.
Rovner: Yeah. So anyway, so Mullin basically accused Monarez of lying about what happened in the meeting with her and the secretary, where she says she was told to basically pre-rubber-stamp the ACIP recommendations, and Kennedy said he asked her if she was trustworthy, and she said no. And Mullin said that this meeting was recorded, and I think you’re not telling the truth. And then, apparently — I was not there, Alice, you were — when we went out into the hallway to vote, he said, “Well, maybe it wasn’t recorded.” And then all hell broke loose.
Kenen: It was six minutes. I checked the time between the time when Cassidy said, “What tape?” And then when Cassidy then interrupted to say, “Oh, by the way, he’s now telling everybody there’s not a tape.” So what text did he get to remind him that he didn’t remember in those six minutes?
Ollstein: We also got a statement from HHS saying there is no tape. The tape does not exist. So that’s the official word from the agency. That was a weird little — but I mean, I think it all goes back to the bigger tussle over how do we make this anything other than a “he said, she said.” I mean, we even had senators say we don’t want this to become a “he said, she said.” But in the absence of a tape or supporting documentation or other eyewitnesses, how are they going to get past “he said, she said”?
I mean, clearly Monarez was trying to argue that they should believe her, but now they’re going to have Kennedy come back and give his rebuttal to her rebuttal. And so where does this end? Cassidy said that he had been requesting supporting documentation from HHS and hasn’t gotten it yet. So how do we get past this?
Rovner: Well, but I want to talk about Cassidy because that’s where this all sort of hinges. I mean, you could see from the talking points of the more conservative Republicans that they clearly are taking RFK Jr.’s side of this in the “he said, she said.” Cassidy, as he has been since he voted reluctantly to confirm RFK Jr., kind of on both sides. At some point, does he have to fish or cut bait on this?
Sanger-Katz: He’s in a very difficult political situation. I think the fact that he held this hearing is actually a little bit surprising and in some ways the most meaningful thing that happened. I mean, Congress would not have brought these people to come testify if not for him. I think almost certainly. And I think giving voice to these ousted officials at CDC, giving them an opportunity to tell their side of the story, represents new information and a new spotlight on these disputes within the CDC and HHS that we would otherwise not know about.
But this was the week of profiles of Bill Cassidy as the man in the middle. And I do think he is in a very delicate position, where he is up for reelection. He is being primaried in his home state. He is not seen as being entirely loyal to the president. He voted for President [Donald] Trump’s impeachment, for conviction of an impeachment the second time around in the first Trump term.
Rovner: After January 6th.
Sanger-Katz: After January 6th, yeah. And yeah, I guess it was not his term anymore by the time he voted. But I mean, I think he is seen as maybe not fully MAGA, not fully loyal, and I think he’s worried about losing his job. On the other hand, he is a physician. I think he does care about vaccines. He certainly seems to care a lot about this hepatitis vaccine that he was pretty forthrightly defending at this hearing.
And he clearly does not like everything that Kennedy stands for and is trying to achieve. And he tried to bridge that divide by obtaining a bunch of personal guarantees from Kennedy before he was confirmed, that he wasn’t going to do various things, that he was going to do various things. And I think the track record really shows that Kennedy has broken a lot of those promises.
And so again, I just think this puts Cassidy in a difficult bind, where I think he does not seem like the kind of person who’s ready to really come out against the Trump administration and Secretary Kennedy. At the same time, I think he’s trying to find a way to stand up for some of these medical values that he’s held and express some minor disappointment that promises that were made have not been kept.
But I think anyone who’s looking for him to suddenly break free and become extremely strident on these things is probably going to continue to be disappointed.
Rovner: We can wait. Well, in the meantime, even as RFK Jr.’s newly reconfigured Advisory Committee on Immunization Practices meets, it seems more and more that CDC itself is losing its place as a source of trusted scientific advice. AHIP, the health insurance industry group, announced on Tuesday that its members would continue to cover vaccines recommended by AHIP as of Sept. 1, 2025, through 2026.
Basically, whatever they decide at this meeting, we’re going to ignore. And, as we discussed last week, many states are bypassing CDC recommendations and going with their own health department rules for obtaining covid and other vaccines. The West Coast states made their consortium formal just this week. No matter what happens going forward, is CDC’s day as the nation’s trusted source of scientific advice over?
Kenen: Well, it depends on who’s doing the trusting. It used to be that the country trusted the CDC. And now the new CDC, and we don’t know who it’s going to be or what they’re going to do, but it’ll be in the mold of Kennedy. We’re past the time, at least for now and hopefully not forever, when half the country trusted the CDC as it was and half the country has lost trust.
So it’s going to flip. So you can’t even talk about the CDC being trusty without saying, for half of America, for those who watch certain TV stations. So it’s a whole different scenario about trust and distrust, unfortunately. Certain basic things are no longer shared values and beliefs.
Rovner: Is it really half of America, or is it a very loud minority?
Kenen: America’s a really distrustful country and has been for a really long time when you go back to what you thought was a more trustworthy era. No, we’ve been really a suspicious bunch for decades. But the division over the CDC and over public health and the messaging, it might not be 50-50, but it is bigger and bigger and bigger. It is not all completely hard-line. And just look what’s happening with vaccines. But that shows that this is eroding, right?
It’s eroding deeply and fast, and it’s eroding from something that people assumed to be true and helpful and lifesaving in this 180[-degree] flip. So I just think unfortunately, no, I may have overspoken by 50-50, but it’s a lot of people, and we cannot talk about trust in this country the way we used to talk about trust in this country, other than maybe sports. It’s the only thing that people agree on, right?
Rovner: It’s not even that always. Alice, want to say something?
Ollstein: Yeah. So at the hearing yesterday, there was pretty broad agreement across the board about plummeting public trust in the CDC and health agencies, but they disagreed on who was to blame for that. And so you had Monarez and several senators saying, “Look, the things Kennedy has said about his own agency and workers, calling them corrupt, saying that they are responsible for deaths, etc., that is what is eroding trust.”
And you had several conservative Republicans say, “No, what the CDC did during covid that is responsible for the eroding trust.” Now, Monarez was not the head of the CDC during covid, but they still tried to pin it on her. And you had senators even tell her, “You are the problem for the eroding trust,” which I thought was pretty interesting.
Rovner: Yeah, I did too.
Sanger-Katz: This feels to me almost like the culmination of polarization on these issues about trust in public health authorities and in vaccines, in particular. As Joanne said, historically, we were a suspicious country, but I don’t think there was a real partisan divide over these questions. There were certain people who were worried about vaccines, who were suspicious of public health advice generally, but I think overall Americans tended to trust public health authorities.
And we started to see that breakdown during covid, where we saw more and more right-leaning Republican people who were suspicious of the public health advice, who felt like they were being misled or that it was politically motivated. And I think Kennedy and Trump have heightened that.
There has been all of this messaging from the president, in particular from the health secretary, questioning the long-standing public health advice that the agencies have been giving people and telling them that they shouldn’t trust them and that there needs to be a major overhaul. But I think what we see now is left-leaning states basically freelancing and doing their own public health advice.
And I think that furthers the sense that these central public health authorities a) are not to be trusted, and b) that there’s Republican public health message and a Democratic public health message. And I think we’ve seen this kind of polarization across lots of other areas of public policy and social values in our country over the last few decades. But this does feel to me new and starting to become a complete polarization about public health advice and who you should trust about the right way to stay healthy.
That does seem like it could have pretty long-standing impacts in how people go about their lives, as there are threats and as there are ongoing drives to get people to get vaccinated and other things.
Rovner: And I do, and I think this is all so accelerated just this year because HHS, for all its lots of controversy to cover — we’ve all covered HHS for a long time — most of HHS has been pretty apolitical, the general functioning of the CDC and the NIH [National Institutes of Health] and FDA [Food and Drug Administration] and CMS [Centers for Medicare & Medicaid Services]. I mean, you’ve got career people that have been there through multiple presidents of multiple parties and multiple administrators and multiple HHS secretaries, and it just hasn’t been that controversial. And now it feels like everything is highly controversial and loaded and polarized. But I did want to mention —
Sanger-Katz: And partisan, like divided along the party lines in a way that I don’t think it was before. Yeah.
Rovner: Right. I see so many career people who are just mystified and their heads are exploding. It’s like, this is not what I’ve been doing for 30 years, and this is not what I signed up to do. I did want to mention the poll out this week from The Washington Post and my own polling colleagues here at KFF that found that most parents do still support childhood vaccines, but that poll also found that 1 in 6 parents has delayed or skipped a vaccine for their children.
And of those parents, they’re more likely to identify as white, religious, Republican and under 35, so younger and more partisan. At the same time, a data investigation by NBC News and Stanford University found that not only are vaccination rates falling in general, but in more than two-thirds of U.S. counties, the vaccine rate for the measles vaccine is under the 95% required for herd immunity. That’s what prevents outbreaks from spreading. When does this actually become a public health emergency or is it one already and the public just hasn’t noticed yet?
Kenen: And the other thing about those numbers is they’re getting bigger fast. If you did that poll again in two months, I mean, the trajectory is sharp. The trust is just falling and falling. It’s not like itsy-bitsy. There are counties where childhood vaccine rates are now like 80, 82. It’s a cliché to us, but not to necessarily to all of our listeners, is that the problem with public health is like when it works, you don’t see it. And then you say, why do we need that, why should we pay for that? etc. It’s sort of the same thing for vaccines. When they work, these diseases have basically almost vanished and we’ve forgotten or we never know.
Ollstein: They’re a victim of their own success.
Kenen: Right. People don’t think, oh, measles actually kill you or leave you vulnerable with all sorts of other neurologic and other problems. Do most kids get better? Yes, but it’s a bad thing, something you should not want your child to have. And we’ve forgotten that. So the fear is that the only way we’re going to recognize their value is when it’s too late for some people who’ve already been hurt or died.
And I won’t say that’s inevitable, but it’s on the table. This is a very real possibility. Now, we just had this huge outbreak in Texas. Two kids did die. And it was sort of like, well, it’s only two, or maybe it was something else, or et cetera, et cetera, et cetera. None of us want to see something terrible happen and yet something terrible could happen.
Sanger-Katz: And also, measles is the most contagious of these childhood diseases for which we have historically had widespread vaccination. And so that means we’re going to see measles outbreaks the fastest. But, as Joanne said, measles is not the most dangerous of the diseases that we vaccinate children for. And so if you’re seeing 1 in 5, 1 in 6 parents skipping a vaccine, we will see it in measles outbreaks first.
But a couple of cases of polio, you could end up with a very high percentage of children with very bad outcomes, and some of these other diseases really are more dangerous. So it really becomes a question of when some of these other diseases that have really, really bad outcomes start finding their way into these populations that are not vaccinated. And I think it’ll become immediately more clear that these vaccines are doing something important.
Rovner: In other words, we’re going to have to learn the hard way. Moving on, as of this taping, we are 12 days away from a possible government shutdown if Congress doesn’t agree on a temporary spending bill, and it’s looking like they might run right up to the deadline, as usual. Democrats are still insisting that Republicans do something to extend expiring tax credits for Affordable Care Act insurance plans. Republicans continue to say no way, basically daring Democrats to shut the government down. How’s it looking as of Thursday morning?
Ollstein: Well, we have competing CRs [continuing resolutions], which is never a good sign. You have the Republican CR that Democrats say is unacceptable, and now you have a Democrat CR. Either of these would just be kicking the can down the road just less than a couple months. So clearly they haven’t yet addressed the fundamental underlying disagreements, and now they can’t even agree on the stopgap.
Rovner: There’s new numbers out from the CBO [Congressional Budget Office] this morning that we’re not going to talk about in-depth, but one of the things I did notice is that the Democrats are asking for the extension of these ACA credits, and one of the things that CBO said is that even if you do it by Sept. 30, you’re not going to get back all the people who are going to lose insurance because insurers aren’t going to necessarily lower their premiums.
So I mean, this is going to happen no matter what, at this point. There’s going to be sticker shock. The question is how big the sticker shock is going to be. And the longer this debate goes, the harder it’s going to be to have any real impact on. I mean, so it’s not just keeping the government open, it’s like the future of the Affordable Care Act.
Ollstein: A lot of the chaos is fueled by the fact that they’re kicking the can on resolving what’s going to happen with the ACA subsidies into the middle of open enrollment. And so what does that even mean? I have sources asking me how are plans going to respond? Are consumers going to be notified that the price is going to change? Can it even change? Or they have to pay the full price even if the subsidies come through? These things have to be worked out in advance, not in the middle of the process, but that’s where we are.
Kenen: The rates haven’t all been finalized in all the states, and there’s also an appeals process. So you could end up with just this very messy prolonged rate-setting. I mean, if you’re an insurance plan and you’ve put in your rates high and this situation changes in terms of ACA subsidies, you might decide you want to come down because you’re afraid your competitor is going to come in — I mean, we don’t know how all that’s going to play out. It’s complicated and time-consuming.
But yeah, a lot of people are going to hear this isn’t available anymore, and people don’t pay attention. We all get stuff from our health plan that we do not click on, and we are health reporters. So there’s going to be people who are entitled to things that don’t realize they’re entitled to things just as there are people who under the current scenario think they’re entitled to things and are going to get an unpleasant shock when they find out that they’re not. So it’s a whole lot of confusion.
Rovner: I’ve been saying for the last couple of weeks that when are Republicans going to wake up and notice that these are going to be largely their constituents who are going to get this sticker shock? I mean, it’s in a lot —
Kenen: Well, [Sen. Tommy] Tuberville [R-Ala.] said so yesterday.
Rovner: Right, right. That’s what I was getting at. So we’re starting to see Republicans notice. Is it too late? Margaret, you wanted to say something?
Sanger-Katz: Yeah. Well, there’s two things I wanted to say. One, to that point, I did a story last week with my colleague Catie Edmondson, who covers the Hill. And I actually think a lot of Republicans already know this. And I think it’s one of the reasons why it is interesting to me that this is the ask that the Democrats are making as part of their negotiations over the spending bill.
I think there has been a lot of consternation among Democrats since the last spending fight, that they didn’t fight hard enough, that they didn’t stand up to Trump, that they didn’t shut down the government to prove a point. And they have a long list of grievances with the Trump administration, and their voters are upset about a lot of things. And there are a lot of fights that the Democrats could have chosen to pick and say, We will not fund the government unless …
And I think we can imagine what many of those things could be, and some of them actually could be related to the budget itself, but that’s actually not what they chose here. What they basically chose is they said, We will fund the government if you do these health care subsidies. And then again, I want to come back to what have Republicans been saying about that?
So I think there has actually been quite a lot of openness, a surprising amount of openness among Republicans, including quite conservative Republicans like Tuberville, to considering changes that would extend the subsidies. And we see in the House, 10 relatively vulnerable members sponsored legislation to extend the subsidies for one year. And then in the Senate, there’s almost a dozen members who either said, Yes, we should do this in some fashion or Anything’s on the table, I’m open to considering it.
Now, that was, of course, before there was the standoff, but I do think that the Democrats are trying to put forward an offer that could result in a deal, which doesn’t mean that there won’t be a shutdown and it doesn’t mean that there won’t be a lot of negotiation, but there could be a deal, I think, on this. This was a choice that they made maybe to get a policy win and not to get maximum conflict.
Rovner: Yeah. I mean, there are those who say that the Democrats shouldn’t do this because they should let the Republicans reap the whirlwind of what they did by not extending the subsidies when they could, should, would have, back in the summer when they did the big bill.
Sanger-Katz: And I think potentially I’m sure there’s a cynical political calculation that would’ve said, OK, let them do it. Let them own it. We’ll run on the fact that everyone’s premiums went up and lots of people don’t have insurance anymore. I think they’re making a different choice here. They’re making a choice where they say, maybe we could get to a deal on this. If we can’t get to a deal on it, we’ll run on how the Republicans raised your insurance premiums. But we do see some kind of cracks in the armor. There are some Republicans who would like to do this. Maybe there’s an opportunity to work together.
And then on the marketplaces, I just want to say I did a fair amount of reporting on this, talking to insurers and state officials and various other actors in this. I think the really crucial deadline to think about is Nov. 1. So that’s when open enrollment starts. We’re talking about a CR that needs to be passed by the end of this month in order to avoid a shutdown.
Now again, we could get a shutdown. It certainly could be that these negotiations push out closer to that Nov. 1 deadline. But in general, Nov. 1 is when most people are going to go onto the website and start window-shopping and see what is insurance going to cost me? And while I think the insurer-calculated rates may be cooked by that point, they are probably not that important if the subsidies get extended.
Because what the subsidies did is they provided financial assistance for almost everyone who buys their own insurance, such that they are not really vulnerable to changes in the overall price. And there are all these various mechanisms that can work it out on the back end. If there are no subsidies, then there really is this double whammy for consumers. A) premiums are going to be higher because the insurers think the risk pool is going to be worse. So they’ve increased prices around 4% to account for the fact that some healthier people are probably going to drop out. They’ve raised them a whole bunch more for other reasons that are unrelated to this. And b) people who were getting a plan for free are suddenly going to get a plan for 30, 50 bucks a month. People who were getting a heavily subsidized plan in some cases might have to pay hundreds of dollars more a month on that for the older, higher-income people.
So if people come in Nov. 1 and they see suddenly my plan that was free is 50 bucks a month and I can’t afford that, I think those people may just not come back. I think that is really the concern that the insurers have that a lot of policymakers have, even if it gets worked out on the back end.
But I think if they get a deal before Nov. 1, and when people go to the portal the first time, they see that their subsidies are subsidizing as much of their premium as they were expecting, I think there really could be an ability to mitigate some of the really big drop-offs in coverage and panic among consumers that the insurers and other policymakers are concerned about.
Rovner: Well, we will continue to watch this space. I do want to move on. Remember that $50 billion that Congress added to the summer’s big budget bill to offset the much larger cuts in that bill to rural hospitals? Well, now we know how HHS plans to distribute it, and there are so many strings attached and such a short time frame that Politico is cheekily calling it the rural health “Hunger Games.” Alice, you took a closer look at this. Why are there so many oops here?
Ollstein: So this was a creation of Congress at the last minute in order to buy votes, essentially. Things were going sideways with the “One Big Beautiful Bill,” and there was a lot of anxiety on both sides of the aisle about the proposed reductions to Medicaid. And this was aimed at alleviating those fears. It’s a new $50 billion fund for rural health.
It is not specifically for rural hospitals. It has been mischaracterized as such, including by members of the Trump administration who have described it that way. Under the way it is written, it’s possible for none of the money to go directly to rural hospitals, although they are supposed to benefit indirectly. And, really, there’s just going to be such broad discretion — partially in the hands of governors and partially in the hands of Dr. [Mehmet] Oz — about who’s going to get this money.
And so right now, states have just a few weeks to put together an application for a piece of this pie, and there are some basic structural disadvantages some states will have. So, for one, half of the money is going to be divided up like the Senate, not like the House, which means every state that applies is going to get an equal amount, whether they’re California or whether they’re Idaho.
Now, as you know, there are a lot more people in California. There are a lot more hospitals. There are a lot more rural hospitals. And so that’s a structural disadvantage these big states have. But on top of that, there are some criteria that CMS created that people feel is more partisan and designed to reward states that align themselves with the Trump administration’s policy priorities.
So states will get scored higher if they adopt changes that the administration wants to see, like banning people on SNAP [the Supplemental Nutrition Assistance Program] from using it to buy soda and candy and whatever. They just call it non-nutritious food, which, again, who defines that, etc. But also, why are you using a rural health fund to incentivize that change? There are other policy provisions as well.
And so there’s just a lot of anxiety about who’s going to get this money. And even if all of it does go to the rural hospitals that are struggling so much, according to a report by Manatt, it will not make up for the hit they’re set to take from the rest of the bill, from all of the Medicaid cuts. And even that is a big if, them getting the money.
Rovner: Yeah, we will also watch this space. All right, well, turning to reproductive health, Alice, we have a really confusing and curious story out of Belgium this week regarding something we talked about months ago, this $10 million worth of contraceptives — pills, shots, implants, and IUDs — that may or may not have been incinerated after the Trump administration decided that providing birth control as part of foreign aid programs is not “lifesaving,” despite the fact that it’s been part of U.S. foreign aid for decades. And while it appears that stockpile has not yet been destroyed, we do know that the administration has refused to sell the supplies to several nonprofits that offered to buy them and distribute them themselves. What is the issue here?
Ollstein: Yeah, so we don’t know what the actual fate of these contraceptives are, but what’s been really notable is that the administration gave reporters a statement calling them “abortifacient birth control.” Now, none of these contraception devices or medications are abortifacients, but again, this is part of a much bigger blurring of the line between preventing conception and ending a pregnancy.
You see this in court cases going back to Hobby Lobby and probably before, and continuing to this day in other court cases. You’re seeing it in state policy, in federal policy, just misinformation online. There’s been misinformation about contraception spreading on TikTok, etc. So, to be clear, if you are already pregnant, it will not work. It prevents pregnancy.
It does not end a pregnancy. And so there’s been a lot of concern about the administration parroting those talking points that you’re hearing from conservative activist groups on that front.
Rovner: All right. Finally, this week, the on-again, off-again defunding of Planned Parenthood is apparently on again after a federal appeals court overruled a lower court that had blocked the defunding — a triple-quadruple negative. What happens now?
Ollstein: We don’t know if there is going to be an appeal, so we will have to see there. But for now, the defunding is happening. And even when it was put on pause by lower courts, you started to see clinics close all around the country. In Ohio, in Michigan, in Vermont, in New York, there’ve been Planned Parenthood clinics closing because they were already on the edge and they can’t take the uncertainty of not knowing if the funding is going to be there. And so I think even if, and I think this isn’t likely, even if the money is restored, then it could come too late for a lot of these places.
Rovner: That seems to be a theme running throughout today’s podcast of things that even if they get reversed, might be too late. All right, well, that is this week’s news. Now we’ll play my interview with Troyen Brennan about primary care, and then we will come back and do our extra credits.
I am so pleased to welcome Dr. Troyen Brennan to the podcast. If ever there was an all-purpose utility player in health policy, Troyen Brennan would have to be it. He’s worked as a physician, a Harvard researcher and professor, and as an executive in several health care companies, including as chief medical officer for Aetna and CVS Health. But he spent the past two years talking to people about the paradox that is primary health care in the U.S., which he’s chronicled in his brand new book, “Wonderful and Broken: The Complex Reality of Primary Care in the United States.” Troyen Brennan, thank you so much for joining us.
Troyen Brennan: Thank you very much for having me.
Rovner: So when I say primary care is a paradox, I really, really mean it. At the same time, we see pretty much universal agreement that primary care is the very foundation of a well-functioning health care system and that good, personalized primary care is something that every patient yearns for. We see more and more primary care practitioners leaving the profession or opting not to join it in the first place when they end their medical training.
And who can blame them? Primary care providers today are overworked, underpaid, and pulled in dozens of directions at once, leaving many feeling they’re letting themselves and their patients down. How did we get to a point where primary care is, as you say, both wonderful and broken?
Brennan: Well, I kind of lay it at the structural role of health care financing, a fee-for-service mechanism, which you well understand, I think most of your readers and viewers would understand, is being paid on the piece. And the more you can do a procedure and get an expensive piece of equipment involved or use an operating room, you can earn a good deal of money in our health care system.
But it’s not a payment structure that’s designed for long-term, continuous relationship with individuals and trying to keep them healthy and promote their health and get them involved in their own decision-making and help them make sense of what is a complicated health care system. So a fee-for-service just doesn’t fit with primary care. And primary care kind of evolved out of general practice at the same time that our health care system really began to change 50 to 60 years ago, and it just has not done well.
And each year, it’s worse and worse as a result of being stuck in this particular approach to paying for health care services. And we don’t take much active intervention in the health care system. I mean, it is a heavily regulated industry, that’s for sure. But it’s been very difficult for policymakers to come up with new solutions for primary care.
Rovner: So, for the students in our audience, can you lay out what exactly you mean when you talk about primary care? It’s not just doctors, right?
Brennan: No, it’s not just doctors. Primary care is any provider. And it’s important to note that more increasingly the people who you’re going to see as your primary care provider could be trained as nurse practitioners or physician associates in addition to being physicians. But I think that there have been experts who’ve laid out what the characteristics of primary care are over the years.
Barbara Starfield, who was the long-term professor at Johns Hopkins University, a pediatrician, who in many ways did almost all the important initial research in primary care, thought that the important aspects of being in primary care were that you were going to be patient-centered, the patient was going to be an active participant in the care, but it was going to be ongoing and continuous over the lifetime of the patient. So it was a long-term relationship, unlike a lot of the other smaller and shorter-term relationships you would have with specialists — that you were concerned about the patient’s overall health and that you were promoting their health. So that list has been extended by Tom Bodenheimer and others who write about primary care, but I think it’s still pretty much a matter of I’m a member of a provider’s panel. This is who I see when I have a health care problem. I’m going to rely on this person long-term. They’re going to help me make that are going to ensure that my care is both cost-efficient and that I’m going to avoid illnesses when at all possible.
Rovner: So you write about Primary Care 1.0, Primary Care 2.0, and Primary Care 3.0, which is the goal for a better-functioning system. What are the differences between those things?
Brennan: Well, Primary Care 1.0 is just what I would say is a standard idea of primary care where you’ve got a relationship with an individual provider and that individual provider is an independent primary care doctor, kind of like the old “Marcus Welby” model. I mean, I may be dating myself by using that term, but I think people still try to refer to the primary care provider of old as Marcus Welby.
The second, Primary Care 2.0, was really a result of the efforts by the Clinton administration, both President [Bill] Clinton and the first lady, to change health care. And they basically spooked most of health care into thinking we were moving into a managed-care situation. And as a result, at most hospitals, and I was a hospital administrator at this time, we thought we had to get a big base of primary care doctors in order to get the referrals we needed to feed the rest of the operation.
And so we hired lots of primary care doctors, and that was Primary Care 2.0, primary care doctors in integrated delivery systems working with the integrated delivery system. Primary Care 3.0 is really a move to value-based care, where no longer you’re dependent on a fee-for-service mechanism, that is a doctor billing their evaluation and management codes, but they’re getting paid prospectively to try to keep the patient healthy. And it’s certainly more modern. And, in many ways, I think most people in health care, the health care policy cognizant, think it’s a much better approach to primary care. It fits with this notion of continuity, health promotion, prevention of disease, much more so than a fee-for-service mechanism does. But we’ve had a lot of difficulty getting to significant momentum around value-based care in our health care system.
Rovner: How do we get more students into primary care in all the professions? I mean, I know we’ve even seen that majorities of physician assistants are going into specialties. Some of these medical schools that were created to turn out primary care physicians are finding that a majority of their graduates are wanting to become specialists. It’s still pretty bleak out there if you’re a primary care practitioner. It’s really hard work.
Brennan: It is hard work. Really two things, I think. One is you have to pay more. You have to put more money into the system on the primary care side. And there’s a variety of different ways in which you would do that. I would do it through a value-based approach, but some people think you need to do it through a reordering of the fee structure that’s overseen by the RVS Update Committee, the so-called RUC.
The second thing is I think you have to open more, and there has been movement in this direction, more training programs that are community-based primary care. And there is debate amongst the experts in the physician and nurse practitioner workforce area about exactly what that should look like. Some say there are enough training programs. But at least in my observation, if there were more training program slots available, there would then be more students, because there’d be more development of osteopathic hospitals and more development of hospitals overseas. And the foreign medical graduates and the osteopaths really take up a huge portion of our primary care slots today.
Rovner: So over the past decade, we’ve seen lots of big companies try to move into the primary care space only, as you point out in the book, to back right back out again. Why is it so hard for these big companies to actually fix what ails primary care? And if they can’t, who can?
Brennan: Well, I don’t think they have much expertise at it, and I think they go at it in a variety of different relatively ham-handed ways. I mean, I would say Walmart never, at least from the outside — and there’s lots of smart people at Walmart, far smarter than I am, and I’m sure they knew what they were doing — but at least on the outside, they tried a variety of different kinds of things, but you could never tell exactly what their strategy was going to be.
Walgreens invested in a company, VillageMD, which had expanded in size from something like 12 physicians to 1,200 physicians over a two-year period of time. That’s a big warning signal that maybe something’s going wrong there with that kind of rapid expansion. And what I see is a very good primary care practice and, in some cases, thriving.
Now, I do raise in the book, and as you well know, there’s big questions about whether or not those kinds of practices, which are oriented towards Medicare Advantage, are going to thrive as we take dollars out of Medicare Advantage by changing the overall coding structure.
So it’ll be very interesting to see. But I’ve been at it a long time. I know you have, too. And what we see with regard to things like Medicare Advantage is sort of a sinusoidal wave, but overall increasing predominance in the health care system. So I don’t think we’ll set that back.
Rovner: So everybody seems to be pretty grim about the future of the health care system, but you’re optimistic at least about primary care after doing this project, aren’t you?
Brennan: Well, you go out and talk to a bunch of people who are taking care of patients, and especially when you’re talking to people at federally qualified health centers who are taking care of very sick, impoverished patients and extraordinarily committed to their welfare, it’s hard not to be optimistic. And I went to places where the physicians were completely burned out.
But even though they’re burned out, charred in many ways, there’s still a flame of enthusiasm for care of patients. And I found that to be overwhelming in the travels that I did. And so you can’t help but be optimistic about it. But I think from a policy point of view, we could do a far better job of supporting those people than what we’re doing today.
Rovner: Well, we shall see how things go forward. Dr. Troyen Brennan, thank you so much.
Brennan: Thank you very much for having me, Julie. I really appreciate 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 post the in our show notes on your phone or other mobile device. Joanne, why don’t you go first this week?
Kenen: Well, actually, this is a story I published in Politico Magazine this morning, “Why Voters Will Feel the Impact of GOP Health Cuts Before the Midterms.” There is this conventional wisdom in Washington and perhaps beyond that — since the Republicans push most of the health provisions, not the ACA subsidies, most of the things in the “One Big Beautiful” Bill law, most of them are after the midterms, November 2026, most of them are starting in Jan.27 and subsequent years — that they protected themselves from political backlash.
And I basically just made the case that no, they didn’t. We don’t know how people were going to vote. We don’t know who they’re going to blame, but people are beginning — notifications in both the political advocacy and just the bread-and-butter health plans having to tell people what’s changing and who’s at risk and all that. We’re going to be hearing a lot about this.
State governments are going to have huge holes in their budgets because of the changes to provider taxes that help them finance Medicaid. And those debates are going to start beginning in January. So basically, I just wrote that, no, this is not a 2027 story. This is a right-now story, and the political ramifications are going to start soon.
Rovner: Yeah. Alice.
Ollstein: So I have a piece from The New York Times called “I Have Dental Insurance. Why Do I Pay So Much for Care?” And it asks the question, Is the entire concept of dental insurance a scam? And there are some mixed views on whether or not it is a scam, but I think everyone, all the experts they quoted in the piece, agree that it is, in general, way less generous and protective than health insurance. People often have to pay a ton of money out-of-pocket for procedures. They hit their annual limits really quickly.
One procedure can knock out all of your insurance benefits for the entire year. And if you need another one, better be willing to pay for it yourself. And it is just, in general, not created in a way that incentivizes people taking good care of their teeth. And it just made me think about how long the health of your teeth has been a class marker for just this reason. Basically, only the wealthy can really afford to get everything they need on that front.
Rovner: And, boy, has dental care gotten expensive. Margot.
Sanger-Katz: I wanted to highlight a story from ProPublica called “Programs for Students With Hearing and Vision Loss Harmed by Trump’s Anti-Diversity Push.” And these reporters found that the cancellation of a number of Department of Education special education grants has led to really big potential cutbacks in services for this very vulnerable population, relatively small population of children who are both deaf and blind and who obviously need very specialized educational assistance to teach them to read and communicate.
And I like the story because it was a good reminder that DEI — diversity, equity, and inclusion — inclusion policies are often targeted at people with disabilities. And I think this is a population that is often not thought about and not talked about when that term, that DEI moniker, is thrown around as a turn of phrase. So these are some students who really seem like they’re going to lose out on very much-needed and specialized educational services as a result of these cancellations.
And in some cases, it appears that their grants were canceled because of word-search-type reasons, where there were just some words, like “privilege,” in their grant application that flagged them for cancellation because they were seen as undesirable.
Rovner: Presumably unintended consequences. Well, my extra credit this week is from The New York Times Magazine, and it’s called “Trump Is Shutting Down the War on Cancer,” by Jonathan Mahler. And I know we’ve talked about this repeatedly, but here in one place is a really good take on just how the administration is, perhaps unwittingly, undoing decades of biomedical advances, but doing it for really no particularly, at least no stated, reason and what the implications could be going forward. It’s a really good and thorough explanation in one medium-length read.
All right, that is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me at X, @jrovner, or on Bluesky @julierovner. Where are you folks hanging on social media these days? Joanne?
Kenen: I’m more on Bluesky and LinkedIn.
Rovner: Margot?
Sanger-Katz: You can find me @SangerKatz in all the places and on Signal at SangerKatz.01.
Rovner: There you go. Alice.
Ollstein: On Bluesky @alicemiranda and on X @AliceOllstein.
Rovner: We’ll be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Countdown to Government Shutdown
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Oct. 1 is the start of the next fiscal year, and unless Congress reaches agreement on continued spending, big parts of the government could shut down that day. Democrats, whose votes will be needed in the Senate, would like Republicans to extend the Biden-era extra tax credits for Affordable Care Act insurance plans as part of a compromise, but so far Republicans don’t seem willing.
Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. released his much-anticipated “Make America Healthy Again” blueprint to improve children’s health, but the report contained few specifics on how his goals would be reached.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.
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Anna Edney
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Lauren Weber
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Among the takeaways from this week’s episode:
- Congress has less than three weeks to approve federal government spending for the new fiscal year and avert a shutdown. Democrats are pushing for the legislation to include an extension of enhanced subsidies for those covered by ACA plans, which otherwise will expire at the end of the year and contribute to an increase in premium costs. But that proposal is already getting bogged down in longtime fights over abortion funding.
- The Department of Health and Human Services is expected to cite the use of Tylenol during pregnancy in a pending report on the causes of autism — despite a lack of definitive scientific evidence. And the remade Advisory Committee on Immunization Practices is scheduled to meet next week, while some Americans are struggling to access the covid vaccine.
- The lack of teeth in the MAHA report — along with the White House’s lengthy review before publication — suggests industry officials helped shape the final product. Plus, its calls for things like healthier meals in schools and hospitals amid federal funding cuts raise an important question: Who will pay for these policy changes?
- And the Trump administration is seeking changes to federal regulations on pharmaceutical advertising that could effectively kill drug ads on television, though free-speech rights could complicate that effort.
Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:
Julie Rovner: NPR’s “What Kind of Dairy Does a Body Good? Science Is Updating the Answer,” by Will Stone.
Anna Edney: Bloomberg News’ “The Implants Were Supposed to Dissolve. They Didn’t,” by Anna Edney and Tanaz Meghjani.
Sandhya Raman: The Texas Tribune’s “Texas’ New Parental Consent Law Leaves School Nurses Confused About Which Services They Can Provide to Students,” by Jaden Edison.
Lauren Weber: ProPublica’s “‘Just Let Me Die,’” by Duaa Eldeib.
Also mentioned in this week’s podcast:
- The New York Times’ “As Trump Weighs I.V.F., Republicans Back New ‘Natural’ Approach to Infertility,” by Caroline Kitchener.
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Transcript: Countdown to Government Shutdown
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Sept. 11, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Today we are joined via videoconference by Anna Edney of Bloomberg News.
Anna Edney: Hey, everybody.
Rovner: Lauren Weber of The Washington Post.
Lauren Weber: Hello, hello.
Rovner: And Sandhya Raman of CQ Roll Call.
Sandhya Raman: Hello, everyone.
Rovner: No interview this week, but plenty of news. So let us dive right in. As of today, we are less than three weeks away from a government shutdown if Congress can’t pass all 12 spending bills — spoiler, that is not going to happen — or pass some sort of continuing resolution to keep the government funded while lawmakers continue working on the spending bills. Now, even though Republicans control the House, Senate, and the White House, it will take Democratic votes, at least in the Senate, to make any of this happen, because appropriations bills, unlike that budget reconciliation bill that passed earlier this summer, require 60 votes to pass rather than just 51. So how’s it all going, appropriations watchers? Sandhya, you’re there on the Hill.
Raman: It’s a work in progress. You know, I think there are a lot of different options kind of being floated around right now to try to avoid a government shutdown. So something our budget reporters reported yesterday is that House Republican leaders are trying to bring a clean CR to the floor next week, so the same spending levels that we have now through late November, early December. But that would include the ACA [Affordable Care Act] subsidy extension that the Democrats want.
There’s also, in the works right now, they’re voting as we speak, kind of, in the House on advancing three of the spending bills, but not HHS [the Department of Health and Human Services] and maybe attaching a clean CR for the rest to that. And whether or not that could eventually include something else that the Democrats want is unclear. Or it’s still in play where just now Democrats were speaking about how they want a very bipartisan — they won’t come to the table unless they’re getting their voice at the table. So it’s unclear if any of these three options are going to happen, just because so much is in flux right now and we’re still a couple weeks out from their deadline. And you know how Congress can be about this.
Rovner: Yes, three whole weeks — why should they do anything? Let’s talk about those ACA subsidies for a minute. We talked about them last week. Republicans are finally realizing that if they don’t extend the Biden-era tax credits that it’s going to be a lot of their voters who are going to see these sort of eye-popping premium increases. And the Democrats would like to sort of do a deal, but so far I’ve seen Republicans saying, Nope, not going to happen. At least not as part of this, keep-the-government-open continuing resolutions. That where they still are?
Raman: I think it depends on who you talk to. When you talk to some of the more hard-line Republicans, they just don’t want this continued. It’s something that you have to offset with a lot of money, and so they’re not on board at all. There are some of the more moderate Republicans in the House that have signed onto a bill last week that would extend it for a little bit, and so others have been a little bit more wishy-washy. But where they fall, I think that complicates things. We also have a new breakdown in the House right now where the Republicans only have a two-person majority, so it just makes it even more narrow for them to get something across if not everyone is aligned on this.
Rovner: And of course, because this is the Affordable Care Act we’re talking about, we’re going to have an abortion fight with this too, right?
Raman: You know I was just saying earlier that everything old is new again, that anytime that we get into this, we get into the debate of whether or not we include some sort of Hyde Amendment kind of language to say no federal funding for abortion except in rare circumstances. And so the anti-abortion groups have signed on and said, You should not support any sort of ACA subsidy extension that doesn’t have that language. Some of the Democrats have already come out saying that that’s a no-go. In the past, generally when we’ve had funding for health care, either if it’s in the approps cycle or something separate, there has been that language, so I’m not sure where that will land if they get to an extension. Just 15 minutes or so ago, House and Senate Democrats had said they really want to get to a bipartisan deal, but they didn’t kind of draw a line in the sand that if the ACA subsidies weren’t in whatever spending deal we get in the next few weeks that that would be a deal-breaker. So it’s complicated in terms of where the cards may land in the next few weeks.
Rovner: Long way to go.
Raman: Yeah.
Rovner: Well, meanwhile, the House Appropriation Committee this week approved its version of the bill that would fund the Department of Health and Human Services along with the Departments of Labor and Education. The House committee bill cuts HHS funding, but by far less than the Trump administration had asked, but still by a lot more than the more bipartisan bill approved by the Senate Appropriations Committee just before they left for the August recess. What is the outlook for HHS funding going forward?
Raman: I don’t think that we’ll see, whenever we get to some sort of deal, something super close to what we had advanced by House appropriators today, but I also don’t think that we’re going to see something identical to what the Senate did before recess. My guess would be a little bit more aligned with what the Senate did. They’re both run by Republicans, but that one did get, in the Senate, bipartisan support, and since they do need Democrats to pass it in the Senate, I could see it being a little bit more aligned there.
The Senate one had slightly higher spending and didn’t have as many of the new riders as in the House related to abortion and trans health and things like that. But we are in kind of a weird circumstance in that, earlier this year, instead of doing new funding, they renewed funding at the same level as last year for another year. So that’s also a possibility, which is not something that happens super often, in the past, and I don’t really see we’re getting a lot happening in either chamber until we get kind of a deal, just because they don’t have an agreement on any of the other funding really, either.
Rovner: One of the things that we do see particularly appropriators complaining about with, and we’ve talked about this, is this whole pocket rescission thing, the idea that they’ve appropriated this money, they’ve gotten a deal to pass this spending, Congress is supposed to be in charge of spending, and the administration isn’t spending money that’s been appropriated. Is there some possibility of putting in some kind of You must spend this money guarantee, or at least an effort to make a guarantee, in one of these bills? Or are they just sort of tiptoeing around this?
Raman: They’ve kind of tiptoed around that. I mean, they’re supposed to spend money. If they don’t, they can have the impoundment issues that they’ve had this year where they aren’t spending the money and get told that you’re violating the Impoundment Act, but that hasn’t seemed to stop some of these cases. I think there’s also a lot of things happening in this that haven’t happened before. We’ve had Russell Vought just kind of say that appropriations should be less of a bipartisan process than it has been. So I’m not sure if even adding that kind of language would necessarily mean that that wouldn’t happen or there wouldn’t be different ways around that.
Rovner: And of course, Russell Vought, the head of OMB [the Office of Management and Budget], is just itching to take this to the Supreme Court so that they can say that the Impoundment Act is illegal and that the administration can decide whether or not it wants to spend money that Congress has appropriated, which is obviously something that we will get to at some point with the Supreme Court, but I think we’re not quite there yet.
Well, moving on, the fallout continues from efforts at the Department of Health and Human Services to translate Secretary Robert F. Kennedy Jr.’s anti-vaccine views into policy. We now know that the ousted director of the Centers for Disease Control and Prevention, Susan Monarez, is scheduled to testify before the Senate HELP [Health, Education, Labor, and Pensions] Committee next week. That’s the committee chaired by Sen. Bill Cassidy, the Republican doctor who cast the deciding vote to confirm Kennedy back in the winter. The meeting of the CDC’s advisory committee on vaccines is also scheduled for next week. Do we know if that’s going to happen? I know several officials, including Cassidy, have called on it to be postponed. Anna, are you planning for it to take place?
Edney: I think, so far, planning for it to take place, but maybe not so sure what they’re going to discuss and whether the covid vaccines will be something that they’ll vote on, at least, because that’s what a lot of people are waiting on. That’s what has caused a lot of confusion is that the FDA [Food and Drug Administration] gave its limited approval to some of these, and then we haven’t heard ACIP’s [the Advisory Committee on Immunization Practices’] vote on that, or it hasn’t been held. And so insurers are finding ways not to cover those vaccines for some people, and people are confused whether they can get them. Pharmacies in some states need prescriptions to be able to give them out. So there’s just a lot of confusion around and people — the middle of September is already late, and so people were hoping, at least people who are interested and, once the confusion cleared up, were hoping that this will come up. But no indication for sure yet.
Rovner: One of Kennedy’s most stubborn pushbacks at last week’s hearing at the Senate Finance Committee was that he has not prevented people from getting the covid vaccine. Except in the ensuing days we’ve seen story after story about people who should be eligible for covid boosters but still haven’t been able to get them or, and as you said, haven’t been able to get them covered by insurance, even in some states where governors have tried to intervene to make them more available. I had a note from a friend in Oregon whose 80-plus-year-old husband couldn’t get the vaccine. I mean, obviously over 65 and couldn’t get a prescription from his doctor to get the vaccine because — and, of course, one of those states that doesn’t have MinuteClinics where you can go and get a nurse practitioner to give you the vaccine. I mean, what are you guys hearing about people’s ability to actually get this vaccine? We’ve now been sort of conditioned to: OK. it’s September. Kids are back to school. We should go and get our flu shots and our covid boosters.
Edney: Yeah, I think that Secretary Kennedy had said everyone can get it, and maybe there’s a tiny kernel of truth in there in the sense that if you knew all the work-arounds you could do it. Maybe you could find a way to get someone to put the shot in your arm. Who would pay for it, though? I mean, we’ve heard of people postponing because they’re hoping that insurance will cover it. They’d rather not pay $200. So essentially this is causing a lot of people to gamble with their health because they’re hoping in the next few weeks they don’t get covid while they’re waiting on insurance to possibly cover it and on direction.
So it’s not true that just anyone can get it if they want to, I don’t think, or those aren’t the stories that I’m reading, that I’m seeing, or even hearing. There was a colleague, actually, she had an interesting story. Her husband had, instead of signing up on the website for a pharmacy, because you have to answer the questions if you have any preexisting conditions, a lot of people don’t if they’re under 65. He just walked in and he said: Well, the pharmacist didn’t ask me anything there. They just gave it to me. So, I mean, people are finding ways, but it doesn’t mean that everyone can do it or pay for it.
Rovner: I feel like Kennedy has sort of conflated the I didn’t ban it with the Everybody can get it. Those are two very different things. Lauren, yes.
Weber: I mean, Kennedy also has previously said that the covid vaccine is the deadliest vaccine ever made and then claimed that [President Donald] Trump should get the Nobel Peace Prize for Operation Warp Speed. So there is a lot of dissonance between the secretary’s statements and sometimes with the reality.
Rovner: And I will note, actually going back to our budget discussion, that there was a bipartisan amendment at the House Appropriations Committee to restore the money for mRNA vaccine research that Kennedy cut. Who knows whether we’ll ever see that into law, but I was interested to see that Republicans joined with Democrats to sort of push back at that.
Edney: Yeah, I think mRNA has a lot of applications beyond vaccines that even hard-line anti-vaxxers could see. Is curing cancer a good idea, or treating it? I mean, it has a lot of other things that mRNA really is meant for.
Rovner: Yeah, and also the speed with which, I mean, that was what made Operation Warp Speed work was the speed with which you can actually make vaccines using the mRNA technology. Well, now, apparently, at least according to The Wall Street Journal, HHS is planning to link Tylenol taken in pregnancy to the rise of autism. Just the story appearing on the website tanked the stock of the drugmaker that makes Tylenol last week and has prompted quite the pushback from doctors and researchers as well as drugmakers. What do we know about the links between Tylenol, acetaminophen, and autism?
Edney: I think what we know is that there are mixed results in studies out there, that no one has definitively linked it. No one has definitively, either way. I think there’s sort of confusion. But the big study that they’re using out of Harvard to kind of say that Tylenol use during pregnancy causes autism, even the study’s authors say: That’s not what we were saying. We were saying that there is an association, but that doesn’t mean causation. I think that’s something we always come back to when we’re talking about studies. And in this sense, I think it’s unfortunate that the discussion is happening without more definitive answers.
Because when you’re talking about pregnancy, and if acetaminophen is the only thing a pregnant woman can take when she has a very high fever, then high fever can cause a lot of problems as well, and you’re scaring women off from, even, it can cause birth defects if the fever is high enough. The March of Dimes actually says there is concern that a high fever during pregnancy in the first trimester is linked to autism. So you just have this circle that nobody actually has any answers, and unfortunately I don’t anticipate that the autism report is going to provide them. It might provide more fear for pregnant women.
Rovner: Lauren, you want to add something
Weber: Yeah, I mean, Robert F. Kennedy Jr. has promised to have the cause of autism by September, which, many medical experts and autism researchers have cautioned, seems like that may not be a complete report, as this is something that has been examined for many years and it seems to be multifaceted. But I think it’s worth noting that in the lead-up to this report being due, we at The Washington Post, in looking at MAHA influencers, noticed that Tylenol has been 15 times more likely to be mentioned by these influencers in August as opposed to April. So there seems to be a lot of MAHA contingent around the Tylenol hypothesis that also potentially could be driving some of this, but we’ll see what happens when we see more of the report.
Rovner: So where exactly is President Trump on this whole vaccine issue? On the one hand, he’s been pro-vaccine in some of the comments that he’s made since Kennedy’s confrontational appearance last week at the Finance Committee. But he also posted on, he the president, also posted on his social media a video pushing the long-since discredited accusation that autism is linked to the vaccine preserved with thimerosal, which hasn’t even been in most childhood vaccines for the last two decades. I feel like the president’s kind of walking this fine line waiting to see which way public opinion falls.
Weber: I think that’s right, Julie. I think also we have to go back. The president has a history of making vaccine-skeptical comments. I mean, in presidential debates he’s asked questions about vaccines being too big for a horse for children. I mean, he’s said, certainly, things that are of vaccine-skeptical rhetoric. That said, I think he and others have seen polling recently that shows that vaccines are overwhelmingly popular. The vast majority of Americans do vaccinate their children, and while he is conscious that Kennedy and the MAHA movement brought him voters, I think he’s maybe being counseled by others that he could lose voters if he goes too far. So if anything, the man has a shrewd assessment of what’s going to win him political points. So it seems to me that it’s a messaging to both sides of the fence and it’s kind of a You pick the message you want to hear so you can stay in the tent kind of vibe is how I am interpreting it.
Rovner: Yeah, that’s my impression, too. And as we know, he’s very good at being on all sides of an issue until he actually has to come down one way or the other. Well, there was a lot more from the Department of Health and Human Services this week than just vaccine news. Secretary Kennedy issued the second part of his long-awaited Make America Healthy Again strategy to improve children’s health. It didn’t mention some of the biggest threats that we know about for children’s health, like gun violence, climate change, or tobacco. It did mention things Kennedy has talked about a lot, like exposure to chemicals and ultraprocessed food, but it didn’t really lay out concrete plans for how the administration plans to address those concerns. So what does this report say? And do we think it got watered down by the White House? Do we think it might’ve been stronger at some point?
Edney: I think with what I saw with the report when I read the report is sort of a list of a lot of the things that Kennedy would like to focus on that he sees as the biggest threats to children. Although it got watered down, I think, for sure throughout this process and certainly potentially as the White House held it for about a month or so from coming out. But a lot of people have made the point that Kennedy had to work with the heads of the EPA [Environmental Protection Agency] and the Agriculture Department on this, who are in many ways more aligned with the chemical companies and the big farmers than Kennedy himself might be or had wanted to be in this.
So you kind of lost any ability to maybe go after chemicals in the food supply or things like that. And so there weren’t a lot of concrete things that it would do or ways forward, which I would expect in a large administration report like this is kind of more of the next steps, not just the list of what’s going on. And I imagine we’ll talk about it, but there was one piece in that with drug ads that it kind of simultaneously came out with the report.
Rovner: Yes, we’ll get to that next.
Edney: Yeah, so I assume we’ll talk about that. So maybe they have some plans on some things that we just don’t know about yet. But I think that that has, for me, been a struggle in covering and watching this administration is there’s been a lot of talk and it’s hard to know what the rhetoric is versus what is actually being done. And I kind of see that continuing, and even with drug ads, when we talk about that and get there.
Rovner: Yeah. Lauren, you’ve obviously been following the MAHA movement pretty closely. What was your take from this report?
Weber: Well, my takeaway from this report is I was fascinated there were no footnotes, so there could be no AI conversation like the last time we talked about this on the podcast. But no, my other takeaway was, clearly, as Anna pointed out, it seems like industry influence had watered down some of the big pushes of the MAHA movement around pesticides. And I also, my biggest takeaway is: Who’s paying for all of this? I mean, they promised healthy, nutritious foods in schools, VAs [Department of Veterans Affairs facilities], hospitals. These are things that nutritionists have wanted for a very long time. There was talk of MAHA boxes. Where’s the funding? I mean, as far as I understand, all the funding’s getting cut everywhere I turn around. So I’m curious where the funding for this transformation of America’s health care is coming from. And I also think it’s worth noting that in there there was a conversation around some pet projects among folks that are involved in the Trump administration. I’m very curious. Right now it was basically a bullet points with no action plan. So as Anna smartly pointed out: When will the rhetoric become reality? We shall see.
Raman: I was just going to agree with Lauren. That was kind of exactly my takeaway is that if you’re calling for more research and this and this and then the White House at the same time, when they put out their budget proposal, they called for a 40% decrease in NIH [National Institutes of Health] funding. It just seems counterintuitive. And even thus far in the appropriations process, the Senate didn’t even have money for MAHA in theirs. The House did. But we don’t know if that happens. And so I am very curious how they would get to do some of these things that they’re exploring, because it really did seem more like an executive order in the formatting, is like: This is early on. Explore this issue. Rather than Here are concrete things we need you to do.
Rovner: And I would just, to underscore something that Lauren said, a lot of talk about how to improve nutrition for kids and things about the SNAP [Supplemental Nutrition Assistance Program] food stamp program, then at the same time that the “Big Beautiful Bill” cut food stamps. So there is sort of right hand not recognizing what the left hand is doing. Well, Anna, as you mentioned, on the same day, the administration issued its not-so-earth-shaking MAHA report, the president signed an order that could end those annoying direct-to-consumer TV ads for pharmaceuticals, at least as we know them.
This is the moment where I get to repeat the fact that the U.S. and New Zealand are the only developed countries that allow drugmakers to advertise their products on TV. The executive order purports to return to the status quo before 1997, when drug companies basically couldn’t advertise on TV, because they were required to talk at so much length about possible side effects and contraindications. Now, I think both Republicans and Democrats in the past 28 years would’ve loved to have taken this same action. Drug ads aren’t exactly popular with the public. But there’s a First Amendment issue here, right? Something about commercial speech?
Edney: Yes. Yeah, certainly. It seems like long ago the train left the station on banning these pharmaceutical ads completely, because the free-speech protection seems to have encompassed this and it feels like no getting rid of them. There’s been no successful effort. So what the Trump administration has said that they’re going to do is change that regulation that allowed them, the drugmakers, to water down their statement in those ads on all of the awful side effects that can happen to you by taking drugs. And so right now in a drug ad, they can just say, Talk to your doctor and visit this website to see what the side effects are.
And so they want to roll that back and so be able to take it back to having to list all of them, which if you’ve looked at a drug pamphlet, a prescription drug pamphlet, I mean, that could take several minutes to get through, and so effectively possibly killing a lot of these advertisements. I think this is still a situation that where the devil’s in the details. We haven’t seen the regulation. And I feel like this happens pretty often where they say they’re going to roll back a huge thing and then it becomes a little bit different than that when the actual regulation is out. But you never know. I mean, I would love — I’m not a fan of drug ads, either, so it’s not like I need to listen to them on the—
Rovner: Yeah, could they at least get rid of the jingles?
Edney: Right. So you don’t say them all day in your head.
Rovner: Yes.
Edney: But yeah. And then they said that, the FDA commissioner said, they were going to be sending out warning letters to potentially thousands of companies, and Just to let you know, we’re going to be cracking down on this, because that’s not something the FDA has done a lot in recent years, making sure that they’re complying with regulations in their advertisements. But they made it into more of a — a warning letter’s a very strong thing that the FDA can do. What this is is more of a form letter saying, Just to let you know we’re going to, not that you specifically violated it, but we’re going to start cracking down on this. So I’ll be curious to see where this lands. They also want to go after more of the social media influencers because they don’t fall under these regulations, so bring them more in line with the idea that they need to talk about the side effects and not just how much weight they quickly lost or something along those lines.
Rovner: But certainly we would expect the drug companies, if not TV networks, to sue to protect the right to run these ads, in cases of the networks to get paid to run these ads.
Edney: Definitely. I think that there’ll be some litigation over this, and that first requires the regulation to be made, and so that also takes some time. So this could be a kind of a long haul.
Rovner: Yeah, it was actual big news. Well, last week we caught up with some but not all of the reproductive health news that happened over our break. One thing I didn’t want to leave out is that lawsuit that the Supreme Court threw out earlier this summer, challenging the FDA’s approval 25 years ago of the abortion pill, mifepristone. It is not dead yet. While the justices said the anti-abortion doctor group that sued originally did not have standing to sue, since then three states — Missouri, Kansas, and Idaho — have replaced the group as plaintiffs, and now Texas and Florida are asking to join the suit as well. Sandhya, the original suit sought to wipe away the FDA’s original approval. That’s now off the table. But the states do want the courts to effectively end the mailing of the pills and return to the FDA’s tighter rules that were enforced before the pandemic, right? Just that could have a major impact.
Raman: It really could, just, if you look at in the last few years, how much of it, abortion, is medication abortion, how much of that has been telehealth after covid, and if you look at what’s happening in some of the states right now. Texas has cracked down on it. But then there’s [Texas] Attorney General [Ken] Paxton last year had sued a doctor in New York for allegedly mailing medication abortion to Texas. And then just this week, the attorney general of New York, Letitia James, has intervened in that lawsuit. So it’s going to be a battle between two of probably the most front-and-center attorney generals, especially in these kinds of issues. So I think with those odds, it’s something that I would definitely watch to see does this go back to the Supreme Court at some point. Even if it’s not this case, this issue is rising up again.
Rovner: Yeah, that’s right. That’s what I was going to say. I mean, at some point the Supreme Court is going to have to adjudicate this question about these blue-state shield laws. Not only has Texas gone after this doctor in New York, Louisiana, I believe, has indicted this doctor in New York, has tried to charge her criminally, which Attorney General James in New York is also trying to prevent. So I mean, we’re going to see this come to the Supreme Court at some point, right?
Raman: I do think so. Just because of how front and center this within the whole movement has kind of become, and especially I think even if we look past, in the past few weeks, how much more mifepristone has come up is something that Republicans want HHS to look into. RFK Jr. has brought it up. There could even be changes on that level that spur a lawsuit, or I think that there’s a lot going on, and so even if it’s not this specifically, something else will nudge it that we see that elevate.
Rovner: Well, meanwhile, anti-abortion groups, or should I say anti-in-vitro-fertilization groups, are now promoting something called “restorative reproductive medicine” as an alternative to IVF. According to Caroline Kitchener writing in The New York Times, quote, “the concept addresses what proponents describe as the ‘root causes’ of infertility, while leaving I.V.F. as a last resort,” close quote. Groups that support IVF are not amused. The American Society of Reproductive Medicine, which represents doctors that treat infertility, calls “restorative reproductive medicine” and “ethical IVF,” quote, “misleading terms that threaten access.” Sandhya, is this yet another effort to ban reproductive technologies that have pretty broad political support by basically rebranding bans?
Raman: You know this one is interesting because it also, to me, has a tinge of kind of what we see in MAHA in that it’s kind of pointing to We’re doing this whole-person thing to elevate health care in the same way that they’ve said: It’s not that you’re having these issues because of something you need medicine for. It’s the food. It’s the chemicals and that kind of stuff. So I’m curious, A, if this gets kind of elevated more just because there’s similar thinking in both of those, but also just kind of how the messaging plays out. When we’ve had some of these IVF battles, we’ve had people walking kind of a fine line because maybe they’ve used it themselves or someone in their lives had but that they know that some of the people in their base do have some issues related to if all the embryos get used and things like that. So elevating this does seem like something that would be politically easier for certain people to message on, but I’m not sure.
Rovner: Lauren, you want to add something.
Weber: Yeah, I mean, I think we talked about Trump toeing a political line earlier in this podcast, and I see this as a similar version of that. I mean, this is the president who vowed to expand access to IVF, but some of his hard-right conservative base has issues with it. They see it as potentially interfering with life itself. And so I think offering up this alternative health care strategy, which, to be clear, there could be good things in there — treating women with endometriosis, investing in the root causes of infertility. There’s nothing inherently wrong with that. In fact, there’s a fair amount of lack of information where it becomes questionable and where I—
Rovner: There’s also, I said, there’s nothing inherently controversial about any of that.
Weber: No, I think there’s a lot of people that would be very excited about that. I think where it hits a line that’s confusing and that Caroline’s story kind of gets into is, is it at the expense of — that’s usually the entry point, which a lot of these health organizations have made clear. Those are all great things to do, but at some point there is potentially a need to hit the next step, and there is concern that this movement could replace the push for IVF. And so I think that tension point and how Trump and the administration is kind of toeing that line with both the MAHA group and the far right is really interesting.
Rovner: Yeah, I mean, I would add that IVF is expensive, involved, unpleasant. It’s not something that people turn to as a first choice anyway, so I was a little bit sort of taken. It’s like, yes, I would think that people with infertility do explore most of their other options first. But yes, what’s wrong with having more research to try and solve the problem before you actually have to resort to IVF? We will watch this one as well.
All right, that is this week’s news. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Anna, why don’t you go first? You have your story, which I’m really glad you’re doing.
Edney: Thank you. Yeah, I appreciate that. So mine was from last week: “The Implants Were Supposed to Dissolve. They didn’t.” So I did an investigation into this device called BioZorb that’s made by a company called Hologic. And they have a huge women’s health division and a breast division that — so a lot of mammogram machines that they sell and things like that. But they were selling BioZorb. It was supposed to revolutionize breast cancer treatment because, at least the idea, this isn’t what they had FDA approval for, but what it was talked about as is something that could help women when they were healing, that their breasts would grow back after a tumor was taken out. Their breasts would grow back more, heal more full-looking, not have dips and maybe other deformities that can happen with a lumpectomy. And instead, these women have experienced all kinds of awful infections, and some people actually had the device poking through their breasts because it was supposed to dissolve, but it was years where some people still had it.
A woman I talked to, it shattered inside of her. So there were 24 pieces of plastic, sharp shards in her breast that were causing immense pain. A lot of people complained about pain, but the key to this is that Hologic and a company that invented the device and sold it early on, called Focal, were hiding these complaints. They were not handing them over to the FDA as they should have, and some for as long as 10 years. So nobody knew what was going on, but women were still being implanted with the devices. I think it’s just a bigger story about oversight of devices and also how devices come to market, because this device was never studied in humans, in women, despite it being implanted inside of them. And that’s actually really typical to how devices make their way through the FDA.
Rovner: Really important investigation. Thank you. Sandhya.
Raman: So my extra credit is called “Texas’ New Parental Consent Law Leaves School Nurses Confused About Which Services They Can Provide to Students,” and it’s at The Texas Tribune, by Jaden Edison. And I picked this because I thought it was something really interesting that I’d never really thought about before, but there’s a new law in Texas that you have to get parental consent before the nurse or whoever at the school can do health services for students. And they’re getting more confused about if they would also be penalized for handing out Band-Aids or ice packs or just first aid. And school districts are required by the law to discipline violations of the law, but how it’s kind of being done across the state is a little varied, and some places have been saying they’ll only even intervene if it’s life-threatening. So I think it’s interesting as part of the parental consent movement of when is this something that is debilitating and if someone doesn’t have a form signed, how that’s going to affect kids at school.
Rovner: Yeah, a lot of good discussion about thinking things all the way through. Lauren.
Weber: Mine is titled “‘Just Let Me Die,’” by ProPublica, written by Duaa Eldeib. And it is just a heartbreaking tale, one that ProPublica has been doing really well, where they examine the fact of prior authorization and what it means for patients. And it’s about a gentleman who was trying to get approved for mental health stays after several suicide attempts. It’s a gutting story. And the reviewer at the end of the appeal process, he was so appalled by what had happened that he called the wife of the man who had been trying to get these appeals. And it’s an important read, especially as Congress is weighing things on prior authorization and as [Centers for Medicare & Medicaid Services Administrator Mehmet] Oz has vowed to expand prior authorization for some things. So a lot here to be unpacked. And ProPublica, again, big props for how they’ve covered the prior auth issue in the last couple of years.
Rovner: Yeah, it’s been fodder for a lot of — really a lot of — good stories. All right. My extra credit this week is from NPR by Will Stone. It’s called “What Kind of Dairy Does a Body Good? Science Is Updating the Answer,” and it’s a really clear story about how it turns out that full-fat dairy, at least in some cases, isn’t nearly as bad for you as other high-fat animal products appear to be. It looks at this one case where science is working as it’s supposed to, with researchers continually updating and refining what they know and recommend. Bottom line seems to be that full-fat cheese and yogurt — probably not bad for you, maybe even good for you. But butter? Still not great. It’s too bad for me. I like butter. Also, what matters is what else is in your dairy products. It’s one of those really well-done pieces that it’s like: OK, this is what we know. This is what we’re trying to find out. This is what’s new. This is the kind of consumer-helpful information we should have more of.
OK. That is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Sandhya.
Raman: On X and on Bluesky, @SandhyaWrites.
Rovner: Anna.
Edney: Same places, @annaedney.
Rovner: Lauren.
Weber: Same spots, @LaurenWeberHP. The HP is for “health policy.”
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': On Capitol Hill, RFK Defends Firings at CDC
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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.
Just days after his firing of the brand-new director of the Centers for Disease Control and Prevention, a defiant Robert F. Kennedy Jr., the U.S. secretary of health and human services, defended that action and others before a sometimes skeptical Senate Finance Committee. Criticism of Kennedy’s increasingly anti-vaccine actions came not just from Democrats on the panel but from some Republicans who are also medical doctors.
Meanwhile, members of Congress have only a few weeks left to complete work on spending bills or risk a government shutdown, and time is also running out to head off the large increases in premiums for Affordable Care Act health plans likely to occur with additional Biden-era government subsidies set to expire.
This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of Pink Sheet, and Alice Miranda Ollstein of Politico.
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Jessie Hellmann
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Sarah Karlin-Smith
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Alice Miranda Ollstein
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Among the takeaways from this week’s episode:
- The FDA approved this year’s covid booster for people older than 65 and for younger people with serious illnesses. Previously, it had been recommended more broadly. All eyes will now turn to the CDC’s Advisory Committee on Immunization Practices, which is scheduled to meet Sept. 18. Usually this panel would endorse these recommendations and perhaps offer more guidance on the booster’s use for specific populations. But it is not clear whether it will do so — or whether it might even impose more limitations.
- Kennedy’s firing of CDC Director Susan Monarez and the subsequent resignation of multiple senior scientists is raising questions about the agency’s future. Many staffers who were already on the fence about staying now are increasingly likely to leave. Many of these career scientists associate Kennedy’s history of harsh criticisms of public health workers with the recent CDC shooting in Atlanta. But since the shooting, Kennedy seems to have doubled down on his position.
- At the hearing before the Senate Finance Committee, even those Republicans who were critical of Kennedy were careful not to criticize President Donald Trump. There’s some speculation that this duality is meant to drive a wedge between Kennedy and the White House, and to communicate that the HHS secretary could be politically damaging.
- With vaccine policy in flux, red and blue states alike seem to be doing their own thing. Some, like California, Oregon, and Washington — which formed what they’re calling the West Coast Health Alliance — appear to be taking steps to protect access to vaccines. Red states could move in the other direction. For instance, this week, Florida Surgeon General Joseph Ladapo announced an effort to undo all statewide vaccine mandates, including those that require certain vaccines for children to attend school. If more states follow suit, it could lead to a geographic patchwork in which vaccine availability and requirements vary widely.
- This month is lawmakers’ last chance to reup the federal ACA tax subsidies. If Congress doesn’t act to extend them, an estimated 24 million people — many of whom live in GOP-controlled states like Georgia and Florida — will see significant increases in their health insurance premium costs. There’s some talk that Congress could opt for a short-term or limited extension that would postpone the pocketbook impact until after the midterm elections. But insurers are already factoring in the uncertainty as they set rates for the upcoming plan year.
- The Centers for Medicare & Medicaid Services announced a Medicare pilot program beginning next year that will use artificial intelligence to grant prior authorization decisions for certain procedures. There is irony here. United Healthcare and other private plans have already gotten into a lot of trouble for doing this, with AI systems often denying needed care.
Also this week, Rovner interviews KFF Health News’s Tony Leys, who discusses his “Bill of the Month” report about a woman’s unfortunate interaction with a bat — and her even more unfortunate interaction with the bill for her rabies prevention treatment.
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 “Gutted: How Deeply Trump Has Cut Federal Health Agencies,” by Brandon Roberts, Annie Waldman, and Pratheek Rebala.
Jessie Hellmann: KFF Health News’ “When Hospitals and Insurers Fight, Patients Get Caught in the Middle,” by Bram Sable-Smith.
Sarah Karlin-Smith: NPR’s “Leniency on Lice in Schools Meets Reality,” by Blake Farmer.
Alice Miranda Ollstein: Vox’s “Exclusive: RFK Jr. and the White House Buried a Major Study on Alcohol and Cancer. Here’s What It Shows,” by Dylan Scott.
Also mentioned in this week’s podcast:
- The Washington Post’s “Florida Moves To End All School Vaccine Mandates, First in Nation To Do So,” by David Ovalle and Lori Rozsa.
- The 19th’s “Texas Passes Bill Banning Abortion Pills From Being Mailed to the State,” by Shefali Luthra.
- The New York Times’ “Medicare Will Require Prior Approval for Certain Procedures,” by Reed Abelson and Teddy Rosenbluth.
click to open the transcript
Transcript: On Capitol Hill, RFK Defends Firings at CDC
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, Sept. 5, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Rovner: Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: And Jessie Hellmann of CQ Roll Call.
Jessie Hellmann: Hi there.
Rovner: Later in this episode, we’ll have my interview with my KFF Health News colleague Tony Leys, who reported and wrote the August “Bill of the Month” about a patient’s unfortunate run-in with a bat and an even more unfortunate run-in with the bill for rabies prophylaxis. But first, this week’s news.
Well, it is safe to say that there has been quite a bit of health news since we last met in mid-August. Health and Human Services Secretary Robert F. Kennedy Jr. testified before the Senate Finance Committee yesterday, which we will talk about in a moment. But first, I want to catch us up on what you might’ve missed. Our story starts, kind of, with the FDA’s [Food and Drug Administration’s] approval of this year’s covid boosters, which are only being licensed for those over age 65 and those who are younger but have at least one condition that puts them at high risk of serious illness if they contract the virus. That leaves out lots of people that many doctors think ought to be boosted, like pregnant women and children. Sarah, what’s supposed to happen after the FDA acts? The next step happens at CDC [the Centers for Disease Control and Prevention], right?
Karlin-Smith: Correct. So right now the CDC’s Advisory Committee on Immunization Practices is scheduled to meet Sept. 17 to 18, 18 to 19, but about two weeks from now. And they would typically vote on sort of endorsing use of these vaccines and, again, have like sort of a second chance to weigh in on which populations they would be used for. And that’s often important for triggering insurance coverage without copays. And also many states rely on the CDC recommendations for various state laws that say, again, who can get the vaccine or whether you can get it via a pharmacist or only at a doctor’s office, do you need a prescription, and things like that. So the CDC and FDA, I would say, in general is a little bit behind this year. I could think a lot of people have been trying to go out and get these new shots even though those steps haven’t happened yet.
Rovner: That’s right. I mean, it is early. Even if there was nothing else going on, there is that little bit of a lag between when FDA acts and when the CDC acts, right?
Karlin-Smith: Yeah, there usually is. I think in the past they’ve tried to have both FDA approval and the CDC act so that the vaccines could start rolling out more like late summer, early September. So they’re definitely behind, and there’s been a number of reports of covid kind of slowly rising as the summer winds down and school gets back in session.
Rovner: Yeah, so there’s a lot of other things going on. Well, in the meantime, nothing that was supposed to happen has happened yet, and we still don’t know all the details, but it certainly appears that Susan Monarez, who was just confirmed by the Senate to lead the CDC a month ago, was fired after she refused to override her scientific advisers and approve the new restrictions on covid vaccine availability, even before the ACIP met. In turn, four top CDC leaders resigned as well, going public to warn that the agency is being politicized by the secretary. How much of a mess is the CDC in right now? And how long is it going to take to put the pieces back together?
Karlin-Smith: I think they’re in a pretty bad place, because not only did they lose their director really quickly, but after she resigned, about I think it was eight or nine senior CDC leaders resigned last week as well. And so, really critical people to various parts of the operation that you don’t just replace very easily. And Kennedy has slotted in Jim O’Neill as the temporary director of the CDC and kind of indicated he wants to remake the agency. And I think there are questions as to how that remaking shapes both its priorities and how it handles public health throughout the U.S.
Rovner: And of course, morale at CDC is awesome, in part because, as we discussed the last time we met, a gunman came and shot up the place, killing a policeman and leaving the staff pretty upset. And that gunman, who then took his own life, was later found to have had some discontent with vaccines. So things are just really bright and cheery there in Atlanta at the CDC. Alice, I see you nodding.
Ollstein: These things kind of snowball, you know? I think there are likely to be a lot of staff who were already on the fence about staying and decided to stay because they trusted these pretty senior leaders with a lot of decades of expertise and institutional knowledge. And that was sort of the thread they were hanging on as well, at least: I’m with these people. And now that they’ve left, I think that could trigger a bigger exodus on top of the exodus that was already underway.
Rovner: And it’s important to say — even though we say it, I think, every time — that these are career scientists who’ve worked for Democrats and Republicans over the years. These are not generally political people. They’re not political appointees. And they basically do their jobs. And until fairly recently, public health wasn’t this partisan, so it wasn’t that hard to be a career public health official just working for public health. That’s just not the case anymore, is it?
Karlin-Smith: I think there’s been a lot of insult to injury added with what happened with the shooting at the CDC, because there is a sense that the kind of rhetoric that Kennedy in particular has used over the years, even before he came into HHS [the Department of Health and Human Services], on sort of his movement has sort of amplified the criticism of public health workers and put them in this situation where they’re dangerous. And Kennedy, instead of really acknowledging that and maybe apologizing or giving any sense that he was going to shift in a different direction, has actually really kind of doubled down on it. And even in some of the pieces he’s written recently about how he wants to reform the CDC, he kind of keeps criticizing the rank-and-file employees and so forth. So there’s a lot of tension between the political leadership and the career staff, I think, at this moment.
Ollstein: And in normal times, most of the American public would not even know the names of these people. They’re not public figures. They’re just very behind-the-scenes scientists doing their work. And now their personal photos are being combed through and shared to attack them because they’ve criticized the administration. They’re getting threats. It’s just this whole level, like you said, of politicization that we haven’t seen before.
Rovner: Well, so, in kind of a coincidence, Kennedy had already agreed to appear on Thursday before the Senate Finance Committee, which by the way doesn’t have jurisdiction over the CDC or the rest of the public health service. But no matter — a Senate hearing is a Senate hearing. And let’s just say it didn’t go that well for the secretary. Democrats were kind of withering in their criticism of Kennedy’s eight-month tenure so far. Here’s Colorado Sen. Michael Bennet.
Sen. Michael Bennet: This is the last thing, by the way, our parents need when their kids are going back to school, is to have the kind of confusion and expense and scarcity that you’re creating as a result of your ideology.
Rovner: Republicans weren’t that impressed, either, particularly the Republicans on the committee who are also doctors. [Sen.] Bill Cassidy, a doctor who’s on Finance but is also the chairman of the Health, Education, Labor, and Pensions Committee and is facing a primary challenge in Louisiana, seemed to tread pretty carefully. More surprising, at least to me, was Dr. Sen. John Barrasso of Wyoming, who’s also in the Senate leadership.
Sen. John Barrasso: So over the last 50 years, vaccines are estimated to have saved 154 million lives worldwide. I support vaccines. I’m a doctor. Vaccines work.
Rovner: I was super impressed that even the Republicans who criticized RFK were careful not to criticize President [Donald] Trump. In fact, there were several suggestions — this was clearly a talking point — that Trump should be given a Nobel Prize for his work overseeing Operation Warp Speed, just so the senators could kind of bifurcate their complaints. What impact, if any, is this hearing going to have on RFK’s future as secretary?
Ollstein: Well, I think there was an attempt to, I think, what you just mentioned. That like dual criticism with praise of Trump was meant to drive a wedge and to get Trump to question RFK’s leadership. That does not seem to have worked so far. We don’t know what’s going to happen in the future, but I think it’s an attempt to get the message to Trump that RFK’s reputation and actions could be damaging to the administration overall. And there was some reporting that polling showing that most people do support vaccines was circulated amongst Republican members before the hearing. And so, I think it’s trying to, yeah, get the message that this is both damaging in a public health sense but also potentially damaging in a political sense as well.
But so far, the reporting is that Trump is standing by RFK, that he liked how combative he was. And so I don’t know where those attempts to drive a wedge will go in the future, but like you said, it was notable that if folks like Barrasso, [Sen. Thom] Tillis, who’s not running for reelection, was also more vocally critical, and a couple others, not a lot. We’re not seeing a great dam breaking yet. But I think there’s more cracks than there used to be on the GOP side.
Rovner: I did notice that Trump, he had a very strange Truth Social post earlier in the week that basically said that CDC is a mess and it has to be fixed. Kind of just Trump being the omniscient observer. And then, apparently at a dinner with tech titans after the hearing, he said that he had not watched the hearing but that he heard that Kennedy did well, which is not exactly what I would call a ringing endorsement. I feel like Trump is giving himself some runway to go either way depending on sort of how things continue to shake out. I see nodding.
Karlin-Smith: Yeah. I saw a lot of people reposting that clip on social media last night who are frustrated with Kennedy and using it to try and ramp up their banks and say: Keep calling. Keep pressuring. This shows we have an opening. I think it’s really always hard to read the tea leaves with Trump and his language and words. He’s a harder person to interpret. But I also thought it was really interesting that in some ways Cassidy and some of the other Republicans were throwing RFK a bone and saying: This is your president. This was his greatest achievement. Can you support it?
And RFK couldn’t even really twist himself into doing that. He sort of tried to, but he could never square it with the bulk of his remarks at the hearing, which were incredibly critical. MRNA vaccines and vaccines in general — he defended the massive cuts in this area for research. He defended people who have really said very untrue things about the harm caused by these vaccines. So in some ways I felt like Cassidy was trying to give him one more chance or something, and RFK couldn’t even take it when it was couched as this Trump achievement.
Rovner: I can’t help but wonder if this is playing to Trump’s advantage because it’s distracting from Trump’s other problems, that perhaps Trump likes that there’s so much attention on this because it takes attention away from other things.
Ollstein: Yeah. Although I do find the eagerness of Democratic members of Congress and other folks to wave away certain things as a distraction as a little bit questionable. This is all part of the agenda of the administration, and dismantling government bureaucracy is clearly a core, core part of the administration’s agenda, and so—
Rovner: And flooding the zone.
Ollstein: Exactly. Well, it might also serve as a distraction. I think that it should be considered a serious part of what they actually want to do as well.
Rovner: So there were a couple of things that we learned about RFK Jr. from his confirmation hearings back in the winter. One is that he’s not at all deferential to elected officials, even calling them liars, which is pretty unheard of. And that he doesn’t really know how his department works. And it appears that eight months later, neither of those things have changed. How does he get away with being so rude? I mean, I’ve just never seen a Cabinet official who’s been so undeferential to the people who basically put him in office. Is it just me?
Karlin-Smith: I think it’s part of the times where politics is really trumping behavior or policy, right? Even though there were a few Republicans that we’ve talked about who have kind of started to get frustrated with RFK and his vaccine policies. You saw at the beginning of the hearing, Chairman [Mike] Crapo was asked by the ranking Democrat, Sen. [Ron] Wyden, to basically swear Kennedy in because Wyden has felt like Kennedy has lied to the committee before. And Crapo just basically brushed that away and dismissed it. And I think, so, in many ways a lot of the Republicans on the committee endorsed Kennedy’s behavior kind of, maybe not overtly but indirectly, and that’s sort of been how they’ve been operating. It’s more of a political theater thing, and they’re OK with sort of this disrespect, of its sort of political fight that somebody on their side is taking up.
Ollstein: I also think Congress’ unwillingness so far to actually sanction or take action in any way about anything RFK has done seems to have emboldened him. I think the fact that he has broken all these promises he made to Cassidy and other senators and there have been basically no consequences for him so far feeds into that. He kind of has a What are you going to do? attitude that was very evident in the hearing.
Rovner: Yeah, I think that’s fair. Well, there were, as always, parochial question from senators about home state issues, but one topic I don’t think I expected to see come up as many times as it did was the future of the abortion pill, mifepristone, which is about to celebrate the 25th anniversary of its original approval by the FDA. Alice, what are you hearing about whether FDA is going to rein the drug back in, which is what a lot of these anti-abortion Republicans really want to see happen?
Ollstein: Yeah, so I think there was nothing new in the hearing this week. What he said was what he’s been saying, that they’re looking into it, that they’re evaluating. He made no specific commitments. He gave no specific timelines. He said basically enough to keep the anti-abortion people thinking that they’re cooking up some restrictions but not explicitly promising that, either. And so I think we’re just where we were before. They continue to reference data put forward by an anti-abortion think tank that was not peer-reviewed and claiming that it is this solid scientific evidence, which it is not, about the risks posed by the pills, which many actual, credible, peer-reviewed studies have found to be very safe. And so we just don’t know what’s going to happen. I think any nationwide restrictions, which is what they’re mulling at the federal level, which would impact states where abortion is legally protected, that would be a potentially politically damaging move. And so it’s understandable why they might not want to pull that trigger right now. So, right.
Rovner: And Trump has said, I mean, Trump has indicated that he does not really want to wade into this.
Ollstein: Correct. But again, he’s also very good about not making hard promises in either direction and sort of keeping his options open, which is what they’re doing. The anti-abortion activists, this is not their only iron in the fire. This is just one of many strategies they have going on. They also have multiple pending lawsuits and court cases that are attempting to accomplish the same thing. They’re pursuing new policies at the state level, which we’ll probably talk about, Texas and others.
Rovner: Next.
Ollstein: And so yes, this pressure on FDA and HHS to use regulation to restrict the pills is only one of many ongoing efforts.
Rovner: Well, you have anticipated my next question, which is that while we are on the subject of the abortion pill, Texas, because it is always Texas, has a new bill on its way to the governor for a signature to try to outlaw telemedicine prescribing of the abortion pill. What exactly would this Texas law do? And would it work? Because, obviously, this has been the biggest loophole about stopping abortion in these states that have banned abortion, is that people are still able to get these pills from other states via telemedicine.
Ollstein: Yeah. So in one sense, nothing’s changed. Abortion was already illegal in Texas, whether you use a pill or have a procedure. And so this is just layered on top of that. The groups who backed this explicitly said the attempt is to have a chilling effect. What they’re hoping is that no lawsuits are even needed, because this just scares people away from ordering pills and scares groups in other states away from sending pills. One concern that I saw raised is that the law criminalizes simply the shipping of the pills. Somebody doesn’t even have to take them for a crime to have been committed.
And so that’s raising concerns that anti-abortion activists will do kind of sting operations, sort of entrapment-y things where they order the pills solely in the interest of bringing a lawsuit. Because there is a cash bounty that you can get for filing a lawsuit — there’s an incentive. So that’s a concern. And then just the general concern of a chilling effect and people who are using less safe means than these pills to terminate their pregnancies out of fear, which studies have shown is already on the rise, people injuring themselves taking herbs and other substances, chemicals. So that’s a concern as well.
Rovner: We’ll continue to watch this, but back to vaccine policy. With the status of federal vaccine recommendations in limbo, states appear to be going their own way. Blue states California, Washington, and Oregon are banding together in a consortium to make official recommendations in the absence of federal policy, and several blue-state governors are acting unilaterally to make sure covid vaccines, at least, remain available to most people. At the same time, some red states are going the other way, with Florida Surgeon General Joseph Ladapo, who we have talked about before, now vowing to get rid of all vaccine requirements for schoolchildren. Sarah, that would be a really big deal, right?
Karlin-Smith: Right. I think the big fear then is that the school requirements is kind of what gets us to close to, in many cases, universal vaccine uptake in the country, because everybody needs their kids to be in school. Unless you’re homeschooled, you really must follow these vaccine requirements. And it not only hurts the kids who don’t end up getting vaccinated individually, but it can really hurt the idea of herd immunity and the protection we need for these diseases to disappear in the community. So there’s—
Rovner: And protection for people who can’t be immunized for some reason.
Karlin-Smith: Right. Who either can’t be immunized or don’t have an adequate response to the immunization because they’re going through cancer treatment or they have some other medical reason that their body is immunocompromised.
Rovner: So, I mean, is this going to end up like abortion, where it’s availability absolutely depends on where you live?
Karlin-Smith: I think that’s hard to say. I think that a policy like what Florida is trying to implement could very quickly and easily go wrong, I think, and be reversed, as we’ve seen, like what’s happening in Texas now, with measles outbreaks. You know you only need just very small fractions of decreases in vaccination to create huge public health crises in places. And so I think it would be more sort of visible, in a way, to some of these states and their populations, the potential harm that could be caused, than maybe it is to them the abortion harm. But we definitely are seeing some sense of, right, the Democratic-controlled states trying to implement policies that help people get better access to vaccines, even when the federal government is trying to maybe harm that, and red states not caring as much.
So there is going to be some more of a patchwork. And I feel like, in talking to just sort of people outside of the health policy space, there is a lot of confusion about: Where can I get my covid vaccine? Am I going to have to pay? Do I qualify? Especially being in D.C., which has less generous, I guess, pharmacy laws, because of this. So people are confused. If I go to Maryland, which is really close, does that matter even though I live in D.C.? And it’s just all these things we kind of know end up leading to less people getting vaccinated. Because even if they want to do it, the hurdles end up driving people away.
Rovner: Yeah, I think something you’d said earlier about the fact that we’re seeing kind of a covid spike, so people are anxious to get covid vaccines, I think, a little bit earlier than normal. It’s usually kind of a fall thing and it’s only the beginning of September, but I think there’s just this combination, this confluence of events that has a lot of people very excited about this right now.
Karlin-Smith: Yeah, I think it does. And covid has been, I think there’s been lots of hope in the public health world that covid would become a little bit like the flu, where we could predict a little bit more when it would really peak and get everybody vaccinated around the same time as they’re getting flu vaccines. Just again, because we know when we make it easier on people to get vaccinated, if you could just one-and-done it, it would be good. Unfortunately, covid has tended to also still have summer peaks, and this year again it’s kind of a late summer peak. And a lot of people, including seniors, are still recommended really actually to get two vaccines a year. So many people are kind of coming due for that second update right now.
Rovner: Well, we’ll keep watching that space. Moving on, as we kind of pointed out already, Congress is back in town, with just a couple weeks to go before the start of fiscal 2026 on Oct. 1. This was the year Congress was really, truly going to get all of its spending bills passed in time for the start of the new year. How’s that going, Jessie?
Hellmann: It’s going great. I’m just kidding. There’s a lot of friction on the Hill right now. The White House budget chief is talking about doing more clawbacks of foreign aid, which is frustrating both Democrats and Republicans. It’s about $5 billion, and we’re seeing Democrats kind of start to put their neck out there a little more than they did earlier in the year when they were also kind of making noise about government funding. And they’re now saying that Republicans are going to have to go this alone and they’re not going to support partisan spending bills. So it’s kind of difficult to see where we go from here. And then—
Rovner: Are we looking at a shutdown on Oct. 1? I mean, that’s what happens if the spending bills aren’t done.
Hellmann: It’s hard to say. There might be a short-term spending bill, but anything longer-term than that, it seems really difficult at this point. And there are just massive differences between the health bills that the House came out with and the Senate came out with. I mean, there’s differences in all the other appropriations bills, too, but I was just going to focus on health.
Rovner: Yes, please.
Hellmann: The Senate bill would allow an increase for HHS, and the House bill would cut it pretty significantly. So it’s kind of hard to see how they could do anything more substantive when there’s so much light between the two.
Rovner: Yeah. I mean, on the one hand, we have both the Senate and the House subcommittee that’s marked up the Labor HHS [Labor, Health and Human Services, Education, and Related Agencies] appropriation on record as not supporting at least the very deep cuts to the National Institutes of Health that were proposed by President Trump. But on the other hand, as you mentioned, we still have the administration, primarily budget office chief Russell Vought, making the case that the administration doesn’t have to spend money that Congress appropriates. And from all we can tell, at least as of now, there’s a lot of money that won’t be spent as of the end of the fiscal year, despite the fact that that is illegal. It’s known as a pocket rescission, a term I think we’re about to hear a lot more about. Alice, you referred to this earlier: Is Congress just going to quietly ignore the fact that the administration is usurping their power?
Ollstein: I think that in many areas of politics, there is a faction that wants to play hardball and really use whatever leverage is possible and there’s a faction that wants to play nice and try to get what they can get by negotiation. And I think both parties always fear being blamed for shutdowns, and so that drives a lot of it. But I think there’s mounting frustration with Democratic leadership about not playing hardball enough. I mean, the jokes I hear are Democrats like to bring a spreadsheet to a gunfight, just seen as being unwilling, in the face of what many see as lawlessness, being unwilling to really put a check on that using the levers they have, including this federal spending. But I think we’ve seen that there are risks no matter what they do, and so I think people make reasonable points about the pros and cons of various strategies.
Rovner: Well, we know that [Sen.] Susan Collins, who’s now the chair of the Senate Appropriations Committee, is very, very concerned — because Susan Collins is always very, very concerned. But she’s the one whose power is basically being thwarted at this point. People have gotten a lot of gray hair waiting for Susan Collins to stand up and be combative, but one would think if there was ever a time for her to do it, this would be it. Jessie, are we seeing, I was going to say, any indication that the appropriators are going to say, Hey, this is our job and our constitutional responsibility, and you’re supposed to do what we say when it comes to money?
Hellmann: They are saying these things. I feel like we are seeing more Senate Republicans, at least, express discomfort with what the Trump administration is doing, saying things like: This is Congress’ job. We have the power of the purse. And then they are passing some of these spending bills through committee. But what else are they supposed to do? Unless Susan Collins wants to get on Fox News and start screaming about government funding, which I don’t really see happening and I don’t know if it would be effective, you kind of just wonder: What other options do they have at this point?
Rovner: Yeah. Well, we’ll sort of see how this plays out over the next few weeks. Meanwhile, it’s not just the spending bills that Congress is facing deadlines for. This month is basically the last chance to re-up those, quote, “expanded subsidies” for Affordable Care Act plans before the sticker shock hits 24 million people in the face. Not only are premiums going up by an average of 18% from this year to next — that’s for a lot of reasons: increasing costs of health care, tariffs, drug prices — but eliminating those additional subsidies, or actually letting them expire, will cause some people to have to pay double or triple what they pay now. And it’s going to hit folks in red states like Georgia and Florida and Texas even harder because more folks there are on the Affordable Care Act plans, because those states didn’t expand Medicaid. Do Republicans not understand what’s about to happen to them?
Hellmann: I think they understand, but they keep acting like there’s no urgency to the situation. They keep saying: We still have time. We have till the end of the year. Which I guess is technically true, but we’re already seeing insurers proposing these giant rate hikes. And it’s not easy to just go back and make changes to some of this. I guess the idea is—
Rovner: So they really don’t have until the end of the year, though. Because people are going to get, they’re going to see the next year’s premiums that they have to start signing up in November. So, I mean, they basically have this month.
Ollstein: If there’s uncertainty, they’re going to price very conservatively, aka high. They don’t want to be left holding the bag. And so, yeah, you and Jessie are exactly right that there isn’t time. These decisions are being made now. Even if they pass something to kick the can until after the midterms, I think some damage will already have been done.
Rovner: Yeah. Jessie, I cut you off, though. I mean, the idea is that sort of their one chance to maybe do this before people actually start to get these bills, or at least see what they’re going to have to pay, would be wrapped into this end-of-fiscal-year continuing resolution. And maybe they can kick the appropriations down the road until November or December, but they can’t really kick the question of the subsidies down the road until November or December.
Hellmann: Yeah. I think something would have to happen really quickly. We’re seeing some politically vulnerable Republicans, in the House, specifically, say that they want at least a year-long extension. It’s just a really difficult issue. We know, obviously, the Freedom Caucus is already making threats about it. They hate the ACA, maybe more than anything. It’s going to be really interesting how this turns out. I’ve also heard that maybe there might be a paired-back version of an extension that they could do, maybe messing with some of the income parameters. But I don’t know if that kind of compromise would be enough unless Republicans work with Democrats, which as we already said is complicated for other reasons. So it’s just a mess right now.
Rovner: I love September on Capitol Hill. All right, finally this week Medicare has announced it will launch a pilot program next January to test the use of artificial intelligence to perform prior authorization for Medicare fee-for-service patients in six states. The program is aimed at just a handful of services right now that are considered to be often wasteful and of dubious value to patients. So, honestly, what could possibly go wrong here? This is a serious question. I mean, isn’t using AI to do prior authorization what got a lot of these private health plans in trouble over the last year?
Karlin-Smith: Yeah, they did. UnitedHealthcare I think is sort of infamous for that. There was a lot of irony when they first announced this concept of doing a little more prior auth, essentially, in Medicare. It came right after they made another announcement where they were trying to say, We’re actually going to crack down on prior authorization for a health plan. So there’s a bit of, and I think they were trying to not have the, in this second announcement, not have the words “prior auth,” so that they kind of could get wins on both levels. Because I think they know that prior authorization is generally not popular with health consumers. People see it as kind of a barrier to care that their doctor has said they need and is largely stopped because of cost reasons. And then I think once you add in this idea that artificial intelligence is doing it, not a human being, I think people have less trust that it’s being done in the proper way and really that they’re stopping inappropriate care.
Rovner: Well, to paraphrase RFK Jr. at the Senate Finance hearing, who said many times, both things can be true, even if they are contradictory. All right, that is this week’s news, or at least as much as we have time for. Now we’ll play my “Bill of the Month” interview with Tony Leys, and then we’ll come back and do our extra credits.
I am pleased to welcome back to the podcast KFF Health News’ Tony Leys, who reported and wrote the latest KFF Health News “Bill of the Month.” Tony, welcome back.
Tony Leys: Glad to be here. Thanks, Julie.
Rovner: So this month’s patient got a literal mouthful when she went to photograph the night sky in Arizona. Who is she and what happened?
Leys: While Erica Kahn was taking photos at Glen Canyon last summer, a bat flew up, landed on her, and jammed itself between her camera and her face. Kahn screamed, as anyone would, and the bat went into her mouth. It only was in there for a few seconds, and she didn’t feel a bite. But she feared it could have infected her with a rabies virus, which bats frequently carry.
Rovner: Yeah, not a great thing. So as with any run-in with a bat, Erica wisely reported to the nearest emergency room for preventive rabies treatment, which we know from previous “Bills of the Month” can total many thousands of dollars. How much did her treatment cost?
Leys: Nearly $21,000, mostly for a series of vaccinations and other treatments, over the course of two weeks, aimed at preventing the deadly virus from gaining a foothold.
Rovner: Yikes.
Leys: Yikes, indeed.
Rovner: Now, the problem here wasn’t so much that she was charged as what her insurance status was. What was her health insurance status?
Leys: Well, Kahn had been laid off from her job as a biomedical engineer in Massachusetts, and she had turned down the COBRA [Consolidated Omnibus Budget Reconciliation Act] plan, which would’ve allowed her to stay on her employer’s insurance plan. The plan would’ve cost her about $650 a month, which seemed too much for her. And she was a young, healthy adult who was confident that she would quickly find a new job with health insurance. She also thought that if she became ill in the meantime, she could buy a private plan that would cover preexisting health conditions.
Rovner: Yeah. That was the big problem, right?
Leys: Right.
Rovner: So what did she do? And then what happened?
Leys: So before she went to the hospital for rabies prevention treatment, she signed up for a policy she found online. The policy, which she thought was full-fledged health insurance, apparently wasn’t. But she says the company selling it told her it would cover treatment of a life-threatening emergency, which this sure seemed to be. But the company later declined to cover any of the bills, citing a 30-day waiting period for coverage.
Rovner: Yeah. Now, I mean, you can’t generally buy any kind of insurance after an insurable event happens. You can’t buy fire insurance the day after a fire or car insurance the day after an accident. Health insurance is no different. Although in her case, she could have actually resumed her previous coverage through COBRA, right? How would that have worked?
Leys: So after you lose coverage from an employer, you generally have 60 days to decide whether to sign up for COBRA coverage, which would be retroactive to the day your old policy lapsed. Khan was within that period when the bat went in her mouth. So she could have retroactively bought COBRA coverage, but she didn’t know about that option.
Rovner: Yeah. A lot of people, they initially lose their job or they leave their job and they don’t take COBRA, because it’s really expensive, as a rule — because it’s employer insurance and employer insurance is usually pretty generous — and they think they don’t need it. But this is one of those cases where she actually probably could have gotten it covered, right?
Leys: Right, right. And in fairness, I’d never heard about that 60-day thing, either, and I’ve covered this, so—
Rovner: I had, but I was there when COBRA was started. So what’s the takeaway here about people who don’t have insurance or think they can buy it at the last minute?
Leys: Well, two things. One is you should have health insurance.
Rovner: Because you never know when a bat’s going to fly in your mouth.
Leys: And that a bat in the mouth does not count as a preexisting condition.
Rovner: True.
Leys: We know that now.
Rovner: And what happened with this bill?
Leys: She is still trying to get it worked out.
Rovner: And presumably she’s going to be paying it off for some time to come.
Leys: That’s what it sounds like. Yep.
Rovner: But she won’t get rabies.
Leys: Nope.
Rovner: So happy ending of a sort. Tony Leys, thank you so much.
Leys: Thank you for having me. Appreciate it.
Rovner: OK, we’re back. And now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Sarah, you were the first to come up with your extra credit this week. Why don’t you tell us about it?
Karlin-Smith: I picked a piece that ran in NPR from KFF’s Blake Farmer, “Leniency on Lice in Schools Meets Reality,” because it’s about the one-year anniversary of my family getting lice from school. And I actually was exposed to this new reality, which is since I was in school, and it’s, I guess, a broader national policy that they no longer kick kids out of school once you see lice and make it kind of difficult before you can go back to school. And I guess the public health rationale is generally that lice is actually, while it’s quite itchy, it’s not really harmful. So trying to think about the best way to cause the least harm, letting kids stay in school while you treat the infection is seen as most appropriate now.
But there’s been, as a story goes into, some pushback from parents who feel that then it’s just getting them in these cycles where they’re constantly getting lice and having to deal with it. And dealing with getting the shampoos and stuff for lice can be kind of costly. So I thought it was a slightly lighter health care story for people to think about in these times.
Rovner: Yeah. Risks and benefits. Classic case of risks and benefits. Alice.
Ollstein: Well, this is definitely more on the risks than the benefits side of things, but I have a very good piece from Vox. It’s an exclusive. It’s called “RFK Jr. and the White House Buried a Major Study on Alcohol and Cancer.” And so they talked to these scientists who were commissioned to compile all of the data about the risk of drinking alcohol to having cancer. And it was compiling high-quality data that was already out there. And it really shows that no amount of drinking is totally safe. Even a very small, moderate amount of drinking includes a cancer risk, and that goes up the more you drink.
And now, according to this report, the administration is not going to publish this. The authors turned it in in March, and they’ve just been sitting on it and they said they have no plans to publish it. And this is coming as the alcohol industry does a lot of lobbying to try to prevent stuff like this from being put out in the public consciousness. I just found this really fascinating. Already the younger generations are drinking a lot less. And so there does seem to be a growing awareness of the health risks of even moderate drinking. But I think that anything that keeps people from seeing this information is worrying, although this report did say that they are planning on publishing it in a peer-reviewed medical journal, which they were always planning anyways. But not having the federal government’s backing is a big deal.
Rovner: It’s not exactly “radical transparency” is what they’ve been talking about. Jessie.
Ollstein: And it’s not exactly “MAHA” [“Make America Healthy Again”]. They’re talking MAHA. They’re talking about lifestyle stuff. They’re talking about what you eat, but apparently not about what you drink.
Rovner: Jessie.
Hellmann: My story is from KFF Health News, from Bram Sable-Smith. It’s called “When Hospitals and Insurers Fight, Patients Get Caught in the Middle.” It is about what happens when providers and insurers have contract disputes. The one example in this story is in Missouri, and it kind of focuses on this family that’s caught in the middle of a dispute between the University of Missouri Health Care system and Anthem. And it means patients don’t get care. There’s not a lot of protections for them. There are provisions that were in the No Surprises Act kind of intended to ensure there was some continuity of care in these situations. But at least for this couple, they weren’t really able to access those protections. So unclear if those are working as intended.
I just thought it was really interesting because it’s not a new problem, but it’s definitely something that we are hearing more and more. It just happened in the D.C .area a few weeks ago. It just happened in New York. And it kind of raises questions about: What are policymakers going to do about this? They complain about rising health care costs, but they don’t often do very much. They complain about competition and consolidation, and this is one of the effects of that. People lose access to care. So I thought this was a really interesting story.
Rovner: Yeah. These are all the policy issues that policymakers are not working on but could be. My extra credit this week is from ProPublica. It’s called “Gutted: How Deeply Trump Has Cut Federal Health Agencies,” by Brandon Roberts, Annie Waldman, Pratheek Rebala, and Sam Green. And it’s a deep data dive that found that more than 20,500 workers, or about 18% of the Health and Human Services Department workforce, have left or been pushed out in the first month of Trump 2.0. That includes more than a thousand regulators and safety inspectors and 3,000 scientists and public health specialists. The agency, in its official response to the story, said, quote, “Yes, we’ve made cuts — to bloated bureaucracies that were long overdue for accountability.” I guess we will have to see if America gets healthier. In the meantime, it’s good to have some data on where we were and now where we are at HHS.
OK, that’s this week’s show. Thanks to our fill-in editor this week, 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. As always, you can email us your comments or questions at whatthehealth@kff.org, or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging out these days? Sarah.
Karlin-Smith: Kind of everywhere. At Bluesky, X, LinkedIn — @SarahKarlin or @sarahkarlin-smith.
Rovner: Alice.
Ollstein: Mostly on Bluesky, @alicemiranda, and still on X, @AliceOllstein.
Rovner: Jessie.
Hellmann: I am on X, @jessiehellman. I’m also on LinkedIn.
Rovner: We will be back in your feed next week. Until then, be healthy.
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KFF Health News' 'What the Health?': Happy 60th, Medicare and Medicaid!
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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
On July 30, 1965, President Lyndon B. Johnson signed landmark legislation creating Medicare and Medicaid. Sixty years later, the programs represent a fifth of the federal budget and provide coverage to nearly 1 in 4 Americans. In addition, the way Medicare and Medicaid structure and pay for medical care has set the standard for the private sector as well.
On this week’s special episode of KFF Health News’ “What the Health?” podcast, host Julie Rovner interviews two experts on the history, development, impact, and future of Medicare and Medicaid.
First, Rovner talks with Medicare historian and University of North Carolina health policy professor Jonathan Oberlander. Oberlander is the author of the book “The Political Life of Medicare” and a former editor of the Journal of Health Care Policy, Politics and Law.
Then, Rovner chats with Sara Rosenbaum, professor emerita at George Washington University. Rosenbaum has spent nearly her entire career working on Medicaid policy and has helped shape key priorities at the federal and state levels.
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Transcript: Happy 60th, Medicare and Medicaid!
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to this special episode of “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m usually joined by some of the best and smartest health reporters in Washington. But this week we’ve got something special for you. It’s an episode marking the 60th anniversary this summer of Medicare and Medicaid, the twin government health programs that have largely shaped the way the U.S. pays for and delivers health care for the past half-century. To bring us the story, I sat down with two of my favorite experts on the subject, University of North Carolina professor Jonathan Oberlander and George Washington University’s Sara Rosenbaum. Here are my chats, starting with Jonathan Oberlander on Medicare.
I am so pleased to welcome Jonathan Oberlander to the podcast. He’s a professor of social medicine, professor of health policy and management, and adjunct professor of political science at the University of North Carolina School of Medicine in Chapel Hill and one of the nation’s leading experts on Medicare. John, welcome to “What the Health?”
Jonathan Oberlander: Great to see you, Julie.
Rovner: So Medicare, to me at least, remains the greatest paradox in the paradox that is the U.S. health care system. It is at once both so popular and so untouchable that it’s considered the third rail of politics, yet at its core, it’s a painfully out-of-date and meager benefit that nevertheless threatens to go bankrupt on a regular basis. How did we get here?
Oberlander: Wow. Let’s talk about the benefits for a minute. And I think one of the things we can say about Medicare in 2025 as we mark this 60th anniversary is it still bears the imprint of Medicare in 1965. And when Medicare was designed as a program — and the idea really dates back to the early 1950s — it was not seen as a comprehensive benefit. It was intended to pay for the most consequential costs of medical care, for acute care costs. And so when it was enacted in 1965, the benefits were incomplete.
And the problem is, as you know very well, they haven’t been added to all that much. And here we have, all of us know, as we get older, we generally don’t get healthier. I wish it was true, but it’s not. And older persons deal with all kinds of complex medical issues and have a lot of medical needs, and yet Medicare’s benefits are very limited, so limited that actually a very small percentage of Medicare beneficiaries have only Medicare. Most Medicare beneficiaries have Medicare plus something else, and that may be an individual private plan that they purchase, called a Medigap plan, or maybe a declining number of people have retiree health insurance that supplements Medicare. Some low-income Medicare beneficiaries have Medicaid as well as Medicare, and they’re dual-eligibles. And some Medicare beneficiaries have extra benefits through the Medicare Advantage program, which I’m sure we will have a lot to say. So the bottom line, though, is Medicare has grown. What, about 70 million Americans rely on Medicare. But the benefit package — with some intermittent exceptions that are significant, such as the addition of outpatient prescription drugs in 2006 — really has not kept pace.
Rovner: So let’s go back to the beginning. What was the problem that Medicare set out to solve?
Oberlander: Well, it was both a substantive problem and a political problem. The origins of Medicare are in the ashes, the failure, of the Truman administration proposals for national health insurance during the mid- and late 1940s. And after they had lost repeatedly, health reformers decided they needed a new strategy. So instead of national health insurance, what today we would call single-payer, a federal-government-run program for everybody, they trimmed their ambitions down to initially just hospital insurance, 60 days of hospital insurance for elderly Social Security beneficiaries. And that was it. And they thought if they just focused on older Americans, maybe they would tamp down the controversy and the opposition of the American Medical Association and charges of socialized medicine, all things that had really thrown a wrench into plans for national health insurance.
It didn’t quite work out as they thought. It took about 14 years from the time Medicare was proposed to enacted, and there was a big, divisive, controversial debate about Medicare’s enactment. But it was fundamentally a solution to that political problem of: How do you enact government health insurance in the United States? You pick a more sympathetic population. Now, there was a substantive problem, which was in the 1940s and especially 1950s, private health insurance was growing in the United States for Americans who are working-age. And that growth of employer-sponsored health insurance really left out retirees. They were expensive. Commercial insurers didn’t want to cover them. And the uninsured rate, if you can believe it, for people over age 65 before Medicare was around 50% — not 15% but five-zero, 50%. And so here you had a population that had more medical needs, was more expensive, and they had less access to health insurance than younger people. And Medicare was created in part to end that disparity and give them access to reliable coverage.
Rovner: So as you mentioned, Medicare was initially just aimed at elderly Social Security recipients. What were some of the biggest benefit and population changes as the years went by?
Oberlander: So in terms of populations, in 1972, Medicare added coverage for persons who have end-stage renal disease. So people who need dialysis, no matter what the age — it’s a lifesaving technology — they can qualify for Medicare. It didn’t really make sense to add it to Medicare. It’s just it was there. So they added it to Medicare. And also a population we don’t talk nearly enough about, younger Americans with permanent disabilities who are recipients of Social Security Disability Insurance for a couple of years. They qualify for Medicare as well and are a very important part of the Medicare population. Beyond that, Medicare’s covered population has not really changed all that much since the beginning, which actually would be a great disappointment to the architects of Medicare, who thought the program would expand to eventually cover everybody.
In terms of benefits, the benefit package has been remarkably stable for better and actually probably for worse, with the exception of, for example, the addition of outpatient prescription drug coverage, which came online in 2006, the addition of coverage for various preventive services such as mammography and cancer screenings. But Medicare still does not cover long-term stays in nursing homes. Many Americans think it does. They will be disappointed to find out it does not. Medicare does not cover, generally, hearing or vision or dental services. Traditional Medicare run by the government does not have a cap on the amount of money that beneficiaries can spend in a year on deductibles and copayments and so forth. So really its benefits remain quite limited.
Rovner: Even to this day we keep hearing about “Medicare for All,” “Medicare for All,” “Medicare for All.” Why has this never happened? And might it?
Oberlander: Medicare was never intended just to be for older persons. The original vision was enact federal health insurance for the elderly, demonstrate that it works, then expand it to children next. And that way you have people towards the end of life and at the beginning of life covered. And after you do that, carry out essentially a pincer movement and cover the rest, the middle ages, and bring them into Medicare until it’s Medicare for all.
And so that was their aspiration, and it did not happen that way. Some of it has to do with the costs of Medicare and the unexpectedly high cost at the beginning of the Medicare program. And when Medicare was seen as a fiscal problem, there wasn’t a lot of political space to expand it. Some of that has to do with just history. If you look at the late 1960s when the Johnson administration was considering expanding Medicare to children, which might’ve changed the trajectory of Medicaid and actually of all of U.S. health care policy, the Vietnam War was raging and the costs were really high and they didn’t want to add the expense of that, so they chose not to do it.
Part of it has to do with a shift in the political winds. And Medicare was enacted at a very liberal time in American political history. And in the 1970s, American politics shifted to the right, so that arguably Jimmy Carter, a Democrat who became president in 1976, he was arguably more conservative on a health policy than Republican Richard Nixon was, the president that preceded him. So as American politics shifted to the right, the idea of Medicare for all through this incremental strategy sort of vanished. And in fact, Democrats largely abandoned that, and they went in a different direction, which eventually culminates in the Affordable Care Act. They went to building on Medicaid and building on private insurance.
What’s interesting is you have seen in the last decade this resurgence of “Medicare for All,” and of course pushed most famously by Bernie Sanders in the Senate and through his presidential campaigns. And it has a lot of appeal. You look at the public opinion polls, it actually polls pretty well. I think a lot of that is really an indictment of U.S. health care and dissatisfaction with all kinds of things about American health insurance. But it faces so many obstacles. If it was easy to do, it would’ve been done already. And interest group opposition, having to raise taxes, which is not easy in the United States, allegations of socialized medicine in a country that has a strong libertarian focus, dislodging around 160 million people with private insurance and putting them into Medicare — there are just enormous obstacles to Medicare for All. So I suspect it’s going to continue to be part of the debate, but we are a long way from it.
Rovner: Medicare is also the biggest single payer in the nation’s health care system and for decades has set the standard for how private insurance covers and pays for health care. Is that still the case?
Oberlander: It is in many ways. Medicare, at the beginning, had very permissive payment policies. It was essentially a blank check to the health care industry, to physicians and hospitals. And not surprisingly, as a result, Medicare’s cost ran up really high in its first decade. When you get into the 1980s, Medicare becomes an innovator in payment reform in the United States. And in the early 1980s, it starts with hospitals and adopts what we call prospective payment for hospitals in the early 1980s, and then a fee schedule for physicians later on at the end of the decade in the 1980s. And Medicare has continued to be an important innovator. It is the home today for experiments in accountable care organizations and other innovations that we would term value-based purchasing.
And really, if you look at, for example, how many commercial insurers pay, they use Medicare’s physician fee schedule. Now they don’t pay the same amount, because they’re not as big as Medicare. They don’t have the same leverage. And in fact, hospitals on average are paid about twice as much by commercial insurers than Medicare and physicians about 20% to 30%. Commercial insurers use the fee schedule that Medicare has, and then they adjust the dollar amount because they simply don’t have the same kind of influence that Medicare does.
Rovner: I was going to say we hear a lot about administrative costs for health insurance. Medicare actually has among the lowest administrative costs, right?
Oberlander: Yeah, Medicare is fairly low in administrative costs. And of course administrative costs are one of the reasons American health care is so much more expensive than other countries. And if you think about it, once you enroll in Medicare, you’re generally enrolled for the rest of your life. And that contrasts with private insurance. It also contrasts with Medicaid, where people turn on and off and it creates all kinds of instability. Medicare is a program that is federally administered, although of course a large share of the program is now delegated out to private insurers, and that is changing the complexity of administrative arrangements in Medicare, among other things.
Rovner: We should probably go back and talk about how Medicare has so many pieces, A and B and C and D. How did that happen? I mean, I like to say it was not made confusing on purpose, but it was definitely made confusing.
Oberlander: Yeah. So at the beginning, Medicare was created with Part A and Part B. Part A really was insurance for inpatient services and hospitals, Part B for outpatient and physician services. And there were two reasons for that. One is they were marrying the standard and a lot of private insurance at the time. So we had Blue Cross for hospitals and Blue Shield for physicians, and that was just like Medicare Part A and Part B. The other reason is the original Medicare proposal was really just Part A, as we mentioned before, just for hospital insurance, funded by payroll taxes through the Social Security system.
Part B, the idea that you would have this insurance that beneficiaries could obtain for physician services that was going to be funded by paying premiums and general revenues, that was added very, very late in the Medicare debate. And so it came at a different time. So it got it added on as Part B. And then eventually we added Part C, which are private plans that beneficiaries can choose now, called Medicare Advantage, HMOs [health maintenance organizations] and PPOs [preferred provider organizations], and the whole alphabet soup, as an alternative to traditional Medicare. And then Part D, and Part D is prescription drug coverage. So I think we may be running out of the letters. We certainly have enough to confuse everybody.
Rovner: We certainly do. So we keep hearing about how Medicare is going broke. Is that true? And can it be fixed? And how hard would it be?
Oberlander: People have been worried about Medicare going broke since about 1970. And my philosophy on this is if you’ve been worrying about something being unsustainable for a half a century and it’s still here, you’re probably worrying about the wrong thing. So the chances of Medicare literally ever going broke and going away are, if not zero, as close to zero as you can get. What this has to do with is the way that Medicare is funded. And so Medicare Part A, hospital insurance, is funded almost entirely by what we call an earmarked payroll tax, the payroll tax that workers and their employers pay just for that.
Rovner: And it’s part of the Social Security tax, right?
Oberlander: And it’s part of the Social Security tax that people pay. And each year, the actuaries from Medicare project: How much money are we taking in? How much do we have in balances for Part A? And what do the expenditures look like? And so when you hear people say the Medicare trust fund is going to go, quote, “bankrupt” in now it’s about a decade, I think, projected from now, what they really mean to say is: OK, when we get to 2036, Medicare right now is not projected to have 100% of the funds it needs to pay for Part A services. We’ve had multiple periods during Medicare’s political history when we’ve gotten down to seven years, five years, four years. And Congress has never let that trust fund go insolvent. Politically, think about it. If there’s one thing we know about members of Congress, they want to be reelected. There are 70 million people in Medicare. I’m pretty sure a good way not to get reelected would be to get to say, I don’t know, October in 2036 right before the 2036 midterm elections, and say: We’re sorry. Medicare is just going to stop paying.
So the good news is things can change. Congress can adopt policies, which they have in the past, that extend Medicare’s finances and strengthen its finances. So I think there is good reason to be concerned about how do we stabilize Medicare financing. But in terms of what keeps me up at night, Medicare going bankrupt, I wouldn’t let that bother me, and I wouldn’t let it bother you.
Rovner: So how have the politics of Medicare changed over the years? I mean, at the beginning it was very— it was supported by Democrats and opposed by Republicans, and now it’s President [Donald] Trump who says, Thou shalt not touch Medicare.
Oberlander: There’ve been some twists and turns. If you look at the vote on Medicare enactment in 1965, it was not the vote on Obamacare in 2010. There were some Northern Republicans, moderate liberal Republicans, who voted for it, and conservative Democrats who voted against it. So it was mainly a partisan debate but not exclusively a partisan debate. And I would say in between 1965 and it passed in 1995, the politics of Medicare were consensual. There was a lot of bipartisanship. If you think about the payment reforms in Medicare that we have today and that shape Medicare today, the prospective payment system, the Medicare fee schedule, those were sponsored by Republican presidents and supported by bipartisan majorities in Congress.
And as you will vividly remember, because I know that you covered this, the biggest benefit —attempted benefit — expansion in Medicare’s history at the time in 1988 was sponsored by [President] Ronald Reagan, a conservative Republican. In 2003, the expansion of prescription drug coverage was under a Republican president, George W. Bush. So the partisan tides have not flowed in predictable ways, but I do think it’s fair to say, since 1995, there has been an erosion of bipartisanship in Medicare and a real breakdown. And the reason I choose that year as a demarcation point is for the first three decades of Medicare’s life, it never lived under a Republican-majority Congress. And in 1995, after Republicans swept the ’94 elections that brought [Rep.] Newt Gingrich to the speakership in the House and a Republican majority in the Senate, was the first time you had Republicans in Congress as a majority governing Medicare, and they pursued ambitious Medicare reform plans. And in the decades since then, Democrats and Republicans have disagreed very sharply over Medicare and over the future of Medicare.
Now, Donald Trump has thrown a wrench in the politics in Medicare, as he has in many things, because he is not a traditional Republican in many senses, including on Medicare. And he said explicitly when he ran for president the first time that the effort by [Rep.] Paul Ryan, who was chair of the Budget Committee, also speaker of the House, to really reform Medicare and accelerate privatization and make large cuts in Medicare, he said it was politically stupid. Why would Republicans want to do that? And so he has moved the Republican Party to a different place in Medicare, and you can see it in this budget bill that just passed that did all kinds of things to Medicaid and very little to Medicare. I think the question is whether that Trump effect is going to endure past Trump. And so when we get out to, oh, I don’t know, 2029, 2030, what is the Republican consensus in Congress going to be? Have they actually moved in that direction? Or, particularly with the soaring budget deficits, is it going to go back to really a debate between Democrats and Republicans about the future of Medicare?
Rovner: So let’s talk about privatization. Medicare Advantage, the private health plan alternative to traditional Medicare, is now more than half the program, both in terms of people and in terms of budget. Is this the future of Medicare? Or will we look back in many years and see it as kind of a temporary diversion?
Oberlander: I think it’s the present and probably the future. The future is always so hard to predict, Julie, because it’s unwritten. But, I mean, this is really a shocking outcome historically, because what Medicare’s architects expected was that the program was going to expand government health insurance to all Americans, first with the older population, then adding children, then adding everybody. Did not turn out that way. The original aspiration was Medicare for all through any incremental means. Instead, 60 years later, we don’t have Medicare for all, but Medicare is mostly privatized. It’s a hybrid program with a public and private component that increasingly is dominated by private insurance. And the fact that over half of Medicare beneficiaries are enrolled in these private plans is a stunning development historically, by the way with lots of implications politically, because that’s an important new political force in Medicare that you have these large private plans, and it’s changed Medicare politics.
I don’t think Medicare Advantage is going anywhere. I think the question is: How big is it going to get? And I’m not sure any of us know. It’s been on a growth trajectory for a long time. And the question is: Given that all the studies show that Medicare Advantage plans are overpaid, and overpaid by a lot, by the federal government and it’s losing a lot of money on Medicare Advantage and it’s never saved money, is there going to come a point where they actually clamp down? There have been some incremental efforts to try and restrain payments. Really haven’t had much effect. Are we actually going to get to a place where the federal government says: We need savings, yeah. This 22% extra that you’re getting, no, we can’t do that anymore?
So I think it’s an open question about: How big is it going to get? Is it going to be two-thirds of the Medicare program, three-quarters of the Medicare program? And if so, then what is the future, turning the question on its head, of traditional Medicare if it’s that small? And that’s one of the great questions about Medicare in the next decade or two.
Rovner: So for all the needs that Medicare does pay for, one huge hole that remains is its lack of coverage for long-term care, which I think you mentioned at the outset. I wrote my first story on Medicare’s lack of a long-term care benefit in 1986 when I was in my 20s. Now I am in my 60s, and we still haven’t solved the long-term care dilemma. Why has this one thing been so very difficult to address?
Oberlander: It is the issue that will not speak its name. It’s such a huge problem, and we don’t talk about it. And the way we organize and pay for long-term care in the United States is really terrible. The costs of long-term care in nursing homes has skyrocketed. It’s, as anybody who knows who’s had a family member deal with this, it is absolutely a staggering cost to pay for somebody to stay in a nursing home. And I think, paradoxically, one of the reasons we don’t talk about it is actually because of that cost, because the budgetary implications of this are so high that members of Congress and presidential administrations just don’t go there. And what we’ve done instead is we’ve created a kind of de facto nonsystem where people spend down, often in not very ideal ways, to qualify for Medicaid. So we’ve got Medicaid as a major payer for institutional long-term care.
We have expanded home health, long-term care, both in Medicare and Medicaid, and that’s a growing part of the system. Private insurance has never really developed. It’s not very stable. The insurance is expensive and hard for people to afford and often not very good. And I think as the baby boomers age, of course the need for long-term care just keeps growing and growing, and yet we paid more attention to it when you were in your 20s. Not to date you, but you did it first. I mean, we paid much more attention, I think you would agree, to this issue on the national stage back when [Sen.] Claude Pepper was in Congress, what, 40 years ago, and it is not really talked about anymore. We’ve kind of swept it up under the rug. And the result of that is a lot of Americans are left with terrible situations when somebody needs a long-term care stay.
Rovner: And 40 years later, people still don’t know that Medicare doesn’t cover most long-term care.
Oberlander: And yes, people still don’t know. And yeah, they assume that: Medicare, of course, it’s a program for older persons. Of course it must cover long-term care. And unfortunately it does not.
Rovner: So one other thing that Medicare does do that most people don’t realize is educate most of the health care workforce, certainly doctors. People don’t realize the way that Medicare subsidizes the training of doctors. Is that something that we’re going to have to look at going forward?
Oberlander: Medicare does play a huge role in subsidizing medical education, and I think — you ask: Is it something we have to look at? It’s something that of course provides a lot of social value. I think that the issue for Medicare, and not just for graduate medical education but for all of Medicare, is this: We have a federal budget deficit that was already enormous. We just added to it and added to it a lot in the so-called One Big Beautiful Bill. So we have red ink as far as the eye can see. And my prediction, which I don’t think takes a lot of courage, is that sooner or later, probably sooner, members of Congress are going to look up and see: Wait a minute. We have this gargantuan deficit. And they’re going to say — it’s a deficit that is going to have exploded because of the tax cuts — but they’re going to say: Oh, look at this deficit. We’ve got to tame government spending.
Well, OK. Where does the government spend money? And of course, why did Willie Sutton rob banks? That’s where the money was. That’s what he famously quipped. Well, where does Congress go for budgetary savings? And this has been true for 40 years now. They go to Medicare. So I think there is a reckoning coming where Congress will look for major savings in Medicare as a result of the broader fiscal picture in the United States, and that is going to have implications for all parts of Medicare.
Rovner: So last question. I know you don’t want to predict the future. Is Medicare going to be around in another 60 years when you’re ready for it?
Oberlander: I’m going to be ready for Medicare closer to six years than 60 years. I won’t be around in 60 years. Yes, yes. The most important thing to say about Medicare is that retirement in the United States today is unimaginable without Medicare. Medicare is a cornerstone of health security, of retirement security, in the United States. It is absolutely unthinkable that we wouldn’t have the Medicare program. And for all the problems and challenges that it has, it’s also important at the end of the day to remember the successes it’s had and the vital access to medical care that it’s provided. And to think about what the world would look like for older Americans and persons who have permanent disabilities who did not have Medicare, what would happen if Medicare was not there? So I think there’s no question that Medicare is going to be here in 60 years. The question is: What form is Medicare going to take?
Rovner: Excellent. Jonathan Oberlander, thank you so much.
Oberlander: It was great to be with you, Julie.
Rovner: I am so pleased to welcome Sara Rosenbaum to the podcast. Sara is professor emerita of health, law, and policy at George Washington University, one of the, if not the, leading experts on Medicaid. She’s also the person who has taught me at least 80% of what I know about the program. So I am extra thrilled that she’s agreed to come be our guide. Sara, welcome.
Sara Rosenbaum: Thank you for having me. It’s such a pleasure to be on the show.
Rovner: Let’s start at the beginning. Medicaid was kind of an afterthought to Medicare when they were both created 60 years ago. How did Medicaid come to be?
Rosenbaum: Yeah, it’s a really interesting question. This is, of course, the lore, that Medicaid was an afterthought. If you look at the original act — which of course was an outgrowth of an earlier law, the Kerr-Mills Act, which had been enacted about five years before — and you read the original statutory language, which we lawyers revel in doing, you are amazed. This was not such a big afterthought. I would say that Wilbur Cohen and Wilbur Mills and Lyndon Johnson and everybody else had a good idea of what they were doing. They knew that they were planting the seeds for a program that ultimately would come to be the foundation of health insurance for low-income people across the United States, as well as, of course, specific categories such as people with very severe disabilities.
Rovner: Why don’t you remind us what Kerr-Mills was?
Rosenbaum: Yeah. So Kerr-Mills was an earlier, a limited, federal grant program, very much structured the way Medicaid is structured today, open-ended grants, but it really focused on the elderly. And of course it predated Medicare. And Kerr-Mills kind of helped make the case for Medicare, because it was obvious that it was such a limited program in its reach. It could not do what a universal insurance program for people who had attained a certain age, and ultimately also who become disabled, would do.
Rovner: So what was the difference between Medicare and Medicaid supposed to be when they were signed into law 60 years ago?
Rosenbaum: Yeah. So Medicaid was very much structured in the classic style of a state grants program. It has come, of course, to be so much more than that. But it was a grant to states, and states would set up state plans. This is all language that has become very familiar to us. And they would provide medical assistance, as it was called, to certain categories of poor people. And the theory was that the program would start with these people, but tucked into the — the categories were cash welfare recipients — but tucked in there were a group of people known as the medically needy, in the early days.
And the medically needy, I always felt, was sort of the first seeds of something much bigger, because the point was that it was a program for people who were low-income, who couldn’t afford their medical care, but didn’t get cash welfare. So the theory was exactly the theory that has carried the program for 60 years now. And originally the thought was that it would really — and of course this has turned out to be the case — that that would enable people who had very serious health care costs for things that Medicare did not cover — nursing home care, home health benefits ultimately, those kinds of really big-ticket long-term care items outside of Medicare, because Medicare was really sort of like Blue Cross Blue Shield for old people like me.
Rovner: You weren’t old at the time, though.
Rosenbaum: I was not. I was just a kid. But the program was meant to replicate what folks had had through, during their working years. And so it was very important and very profound, but limited.
Rovner: So Medicare’s long been the more politically popular of the two programs—
Rosenbaum: Yes.
Rovner: —primarily because of the political clout of older voters, which is how it was created. How was it that Medicaid became the program that grew so much?
Rosenbaum: Well, I believe that Medicaid, and this is I think what Wilbur Cohen understood—
Rovner: And you might remind us who Wilbur Cohen was.
Rosenbaum: Wilbur Cohen was the genius behind so much of the early social welfare thinking who sort of was a bridge between the academic thinking about assistance, the legal thinking about assistance. By then, by the time Wilbur Cohen was working his magic in the Johnson administration, maybe the single most important article on social welfare policy ever written had been written by Charles Reich, “The New Property.” That sort of spelled out how Americans had come to expect help from the government as a right. So he was the brain trust, the one-man band behind thinking through, with members of Congress, what Medicare and Medicaid would look like. He was really the architect.
Rovner: He was the secretary of health, education, and welfare at that point, right?
Rosenbaum: Yeah. Well, I think he was actually the deputy, but you could be correct. I don’t remember whether he ever assumed the top position or whether he in fact was second in command. It’s worth checking. But he was the guy. He knew that what would propel Medicaid forward is that, unlike Medicare, which is tied to a premium structure, Medicare is funded through premium payments, which is great, but premium payments are quite unique because they are actuarially based. They are sort of a very tightly controlled form of financing, because you’re asking — whether it’s the government or now, of course, private insurers that contract with the government — you’re asking them to take on a lot of financial risk. And so everybody wanted the — like it was really going to work that way — wanted the assurance of premium structure.
Well, Medicaid was not. Medicaid is a classic public health statute. It’s general revenue. And so every time something happened that required an intervention by the federal government where health care was concerned, you could just add a few pages to the Medicaid statute and end up with, voilà, a fix. So I was very privileged. I began my career in the first decade of Medicaid’s existence, shortly after the first great leap had happened when we created, in 1972, the Supplemental Security Income program, for people with profound disabilities or the elderly who were very, very poor. And that, of course, was accompanied pretty much by Medicaid. People were entitled to Medicaid.
And by the time I came along, everybody was looking at another great leap. And that great leap, under the Carter administration, because of a lot of people’s work along the way, was children. Interestingly, the original statute — and this is what I mean when I say, “You go through the statute” — there’s all kinds of stuff that tells you where everybody knew this thing was going. There was the used-to-be-famous Ribicoff Amendment. Sen. [Abraham] Ribicoff of Connecticut offered an amendment to give states the flexibility to cover low-income children without regard to whether they lived in families that received cash welfare. And not too many years later, along comes the Department of Health and Human Services, based at HEW, that says, You know what? And of course this is way before the reproductive health politics of today. Somebody said, You know, if we added an unborn component to the Ribicoff child option, then you could cover poor pregnant women.
And the original Ribicoff child program, therefore, including its the-unborn component, which was regulatory, were incredibly important. But they were tied to cash welfare assistance, and of course cash welfare assistance began to sink and sink and sink and sink. And by the mid-’70s, people said, Well, what if we decoupled this category from cash welfare funding levels and just let poor children have Medicaid? And there then ensued essentially a decade-long effort to add poor children and pregnant women as groups in their own right to the Medicaid program. And—
Rovner: That was when I started covering it.
Rosenbaum: Yes.
Rovner: I was going to say it was almost sort of a stealth expansion, because it happened bit by bit by bit. But that was the strategy.
Rosenbaum: That was the strategy. And of course the architect of that strategy — there were many, many parents of that strategy — but the true hero of that strategy was Congressman Henry Waxman and his extraordinary staff, who were so brilliant, not only in thinking through what they would be able to get done in the House — he was of course a chair of the [Energy and Commerce] health subcommittee at that point in the House — but also what those of us working outside of government would have to do by way of delivering support in the Senate. And so every year became sort of, at the beginning of the year, a strategy session with the singular Karen Nelson, who was the staff director for the health subcommittee. And we would all sit and say: OK, this year we’re going to do X. And so we’ve got to round up — this is what you could move in the House, and this is what we have to go round up in the Senate, and these are the outside groups.
It was, they were amazing that way — I mean, political athletes. And their political athleticism was used to achieve this extraordinary breakthrough, not just for children but later on for long-term services and supports for the elderly, for people with disabilities. We all have that kind of amazing legislative prowess to thank, and they sent the program on its way. So by the turn of the 21st century, we had a Medicaid program in which it was a given that low-income children and pregnant women would have coverage. It was a given that the program was propelled — of course, there were many other things along the way — but would be a much more robust responder to long-term care needs, and to adults, to working-age adults, because we recognized parents as a group of people who could be helped.
So all these seeds were here. And Medicaid had done amazing other work in the early 21st century, like enabling a response to the catastrophe of New Orleans, because it’s a general revenue program, or the World Trade Center attacks, where suddenly thousands of people needed health insurance. And so Medicaid was constantly the first responder, whether it was a structural first responder like coverage for poor people or whether it was a first responder to naturally occurring or man-made disasters. And that was the brilliance of the early years.
Rovner: I was going to say also, Medicaid was used, I know in the last 30 or so years, to basically give states more money during economic downturns.
Rosenbaum: Absolutely. This is one of the things that everybody was so sensitive to, that as the program was building, building, building, what the federal government could — now see, just how much debt the federal government can manage to work under — what the federal government could absorb in the way of spending in order to advance social welfare policy. States, because their economies are very differently structured, as are their political and legal systems, could not. And so, many times — many times — preferred financing has been used to make it possible for states to do all kinds of things. And look, we could go back to Sen. Russell Long, not exactly a civil rights icon, who was the father of Medicaid’s extraordinary family planning benefit, who made sure, along with Sen. [Herman] Talmadge, who similarly was not exactly a civil rights pioneer—
Rovner: Couple of Southerners.
Rosenbaum: Yes. That the family planning benefit not only would be expansive but would be paid to the states at 90% federal financing. So this idea goes all the way back to the early years, and you’re absolutely right that the financing has been used to make it possible for states to do things, to make it possible for states to maintain their programs during downturns, right up through the covid pandemic, of course. And that’s been a tremendously important part of the story, just like Medicaid has been used to support the health care safety net, both hospitals through its disproportionate-share hospital payment program, its other elements that give states the ability to fund their public health systems, county-operated public health systems, through Medicaid, and of course one of the most interesting stories of all, which is the extent to which Medicaid literally took a few dozen experimental clinics from the Great Society years that were struggling to survive — there were a few hundred by the time it happened — and created the financing system that today has created community health centers which serve 32 million people. So, I mean, Medicaid is the powerhouse. It is the powerhouse.
Rovner: Today we think of Medicaid, as you were saying, in terms of this major population — seniors in nursing homes, low-income moms and kids, people with disabilities. But Medicaid’s also become the nation’s leading provider of things like drug treatment and rehabilitation and mental health care. How much has that been overlooked in the modern Medicaid discussions?
Rosenbaum: Well, I think all of these things tend to get overlooked until they’re threatened, right? So all of a sudden, for the past six months, everybody’s had a 101 into what Medicaid does, because every few years we find we go through the same thing. This year was tougher than any we’ve faced before. But I put all of Medicaid’s contributions to mental health and addiction treatment in the category of long-term services and supports that Medicaid, because of its financing structure, has been able to essentially wrap around of a terribly deficient private insurance system and Medicare system that just do not, they’re not structured to fund these things. Somebody’s got to fund these things. And Medicaid has stepped up each time. And that’s why I think the battle over Medicaid that we have all been living through since January of this year is so profound, because the achievements of the program sort of reach into everything — chronic health, public health, insurance coverage. I always tried to explain to my students that there was no one thing that Medicaid does. You can’t just describe Medicaid as insurance. It’s way more than that. So you are absolutely right to point this out.
Rovner: I feel like in 2017 in the fight over the repeal of the Affordable Care Act, that was sort of a big change for Medicaid. I think people had finally realized that Medicaid had grown larger than Medicare, that it was not just a program for the poorest of the poor, that it did all of these other things that you’re talking about, and that really a lot of, I guess, the stigma had been taken away. And yet this Congress felt comfortable — I don’t know if I’d say “comfortable” — but a majority of them voted to make these really deep, profound changes. I mean, what is that going to mean going forward both to the health care system and to the political system?
Rosenbaum: Well, I’ve spent a lot of time thinking in the post-enactment period about: When was the die cast? When was the die cast that set everybody spinning? And I think they, congressional leaders and the White House leadership, understood the fatal error they’d made in 2017, which was separating the tax reforms from the spending reforms, because of course we were then able to battle the spending reforms on our own turf, right? Here, because of the decision that was made back, I’m sure, almost a year ago—
Rovner: Literally the idea to do one “big, beautiful” bill.
Rosenbaum: Yes. And that meant that Medicaid, along with food stamps, or SNAP [the Supplemental Nutrition Assistance Program], along with everything else, just became pay-fors. They just became offsets. And the name of the game then became beating back every attempt to deprive Congress of pay-fors to do the thing that it really wanted to do, which was tax reform. And so we were all reduced to — “we” in the sense of people who worked on social welfare policy, including a lot of my friends who work on tax policy but as a social welfare concern — we were all reduced to bystanders in this effort to get to a trillion dollars.
Rovner: A trillion dollars in cuts.
Rosenbaum: A trillion dollars in cuts. And therefore it opened the door to extraordinary things. I mean, for example, if I could take just a second on it, on the work requirements. The experiments from Arkansas and New Hampshire and other states, that formed the basis for so much of the opposition to work requirements, were very destructive. But the way they worked was people who were on Medicaid would then have to report in if they were working, which was not good, because they couldn’t navigate the red tape and fell off. But the model that has been passed, that’s been enacted, is like dropping a hydrogen bomb, because you will no longer be able to enroll in Medicaid if you cannot navigate the red tape. And so many of us kept pointing out that this was a terrible idea in any event, but to impose this at the point of enrollment meant that you were not just simply destabilizing coverage for people who had it, you were preventing people from getting it.
And the way the statute is written, literally every person on Medicaid today who’s an affected person, the working-age adults in expansion states, is going to have to reapply for the benefits. It is huge. Huge. And because you can’t have Medicaid at the point of enrollment unless you could meet these requirements. And so I had many, many disputes along the way with people who thought it would be 3 million or 4 million or 5 million people losing their coverage. It’s potentially 20 million people, 20-plus million, the expansion population, because while there are exemptions, you’re going to have to prove an exemption. And some of the exemptions will be easier than others. But interestingly, the way Medicaid works in expansion states, people just enroll as low-income people.
So whether you’re a parent, whether you have a disability and you’re waiting for Social Security to make the determination and you’re sort of on as a poor person while that’s happening, it doesn’t show up. What shows up is you’re a low-income person. And you’re going to be confronted with having to prove your worth to get health care. And when we tried to confront this, we were told quite bluntly that people were told: No, no, it’s the enrollment that’s going to remove everybody. That’s where the savings come from. And so it lost all of its humanity, and I think it drove home to me the point that this was all about the money and that’s why they were able to succeed.
Rovner: So obviously, I mean, I know a big source of enrollment for Medicaid is health care providers themselves. People show up, they’re uninsured, and there’s somebody smart there who says, Hey, you’re eligible for Medicaid, so we can get paid. This is going to have a huge impact on the provider community, isn’t it?”
Rosenbaum: Yes. And those providers that have, say, experience in trying to help their patients enroll in or keep their coverage will struggle mightily, because they’re losing huge amounts of revenue. We did a couple of quick analyses of just how much money, for example, community health centers stood to lose, and it’s over a five-to-seven-year period. It’s in the tens of billions of dollars. A friend of mine in Georgia told me that they’re about to lay off their entire — this is, We’re not affecting children, we were told. They’re about to lay off their entire child outreach staff, who help families with children all over Georgia enroll in and keep their coverage — for the children. And so they can’t afford them anymore.
Rovner: So what happens next? Does this happen? And if it happens, does it take out the underpinnings of the entire health care system? Or does Congress eventually realize what it’s done and change its mind?
Rosenbaum: Well, yeah, I mean, I think people are saying, Well, the two-year runway. It’s like two years until it becomes effective. The two-year runway is going to sort of make people forget about this, and then, boom, it’ll be upon us. I don’t think so. I think the two-year runway will end up shining a huge light on the fact that states cannot implement the whole system. I mean, while we are very focused on the number of people who will lose their coverage, the states are confronting an insurmountable problem here. They’ve never had to link Medicaid to work records. And Congress did everything it could to make matters so much worse. For example, they could have just said that: We’re going to import the same requirements that apply to SNAP to Medicaid. And so if you’re getting SNAP in your working age, then you automatically enroll in Medicaid. They didn’t do that. They didn’t do that. It’s a different-enough set of eligibility criteria and exemption categories. For example, SNAP ends, I think, at about 60, and the Medicaid work requirements go all the way to 65.
Rovner: Age 60 and 65. Yeah.
Rosenbaum: Yes, exactly. But I mean, the exemptions are different. The requirements are different. And so people are talking about, Oh, we’ll just align reporting systems. No, no, no, no. You are liable for all kinds of error rate penalties. If you just rely on SNAP, you can’t. So states have no way to deal with this, health care providers that will be called upon to literally provide the documentation. My guess is that Russell Vought, the head of OMB [the Office of Management and Budget], who is really the person in charge of implementing all of this, is not going to take attestations as evidence. They’re going to require documentary evidence and files about health exemptions and continuing health exemptions. This is all just to get some health care. It’s not like you can eat with your Medicaid card or pay your rent with your Medicaid card.
So the astonishingness, I don’t think that’s a word, but the astonishingness of this all, I think, is only going to build and build. And of course so much attention was paid to rural hospitals, and so they tucked in this little teeny-tiny rural hospital program. And quite frankly — I just did a post with my colleague Anne Reid about this at HealthAffairs — if you read the fine print — and Carole Johnson has an excellent one — if you read the fine print — we’re not so fine print — if you read the print of the statute, we noted that offsetting lost revenue is only one of 15 different activities. In fact, you can’t just go to the government and say, you can’t go to Russell Vought and say, Please give us our allotment so that we can offset, the way the fund worked back during covid. You have to spend your money. My favorite is that you have to spend your money on things like consultants to help you design payment reform strategies, payment reform strategies for people who are no longer injured. So there’s no mitigation strategy for this, and I think the hope is that Congress will call it back
Rovner: If it doesn’t, is this, I mean, the one sort of silver lining that I’d been sort of thinking about is, well, maybe if we tear down the health care system we’ll have to start again and build a better one. Is it possible that we could get there? Or are we just going to limp along?
Rosenbaum: I have those thoughts often, and then I stop and think, well, those of us with health insurance could sit there and say, Yeah, maybe we just tear down the health system to start again. Meanwhile, of course, we will have millions of people without health care. So interestingly, the Affordable Care Act, of course, was designed not to tear down the health care system but to strengthen the health care system. But it was the brilliance of the Affordable Care Act was that it saw the holes and it sort of tried to fix them. And if we’d left it alone, with everybody in this, what I consider to be, sort of an intermediate arrangement, we could have done exactly what you are talking about, with just about everybody in the United States covered. We could have begun to really do the serious work of moving to something more unified, better, and of course cheaper and more efficient. That’s right — far easier to use. But we have decided instead to tear the Affordable Care Act apart, both the access to the marketplace by rolling back the assistance and of course the Medicaid reforms.
Rovner: Well, happy birthday, Medicaid.
Rosenbaum: Happy birthday, Medicaid. Today’s the day.
Rovner: I know.
Rosenbaum: Yeah.
Rovner: Thank you so much, Sara Rosenbaum.
Rosenbaum: Thank you for having me. It was a — it was both uplifting and sad.
Rovner: OK. That’s this week’s show. I hope you enjoyed it. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. We’re going to take a short break to let our hardworking staff have some rest. We’ll be back in your feed the Thursday after Labor Day. Until then, be healthy.
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KFF Health News' 'What the Health?': Trump Further Politicizes Science
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
A new executive order from President Donald Trump has potentially broad implications for the future of the federal research enterprise by transferring direct funding decisions away from career professionals to political appointees.
And a gunman, reportedly disgruntled over covid vaccines, attacked the headquarters of the Centers for Disease Control and Prevention in Atlanta, highlighting how increasingly inflammatory rhetoric from health critics endangers the public health workforce.
This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.
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Among the takeaways from this week’s episode:
- Trump’s executive order highlights the tension between how Congress has directed federal science funding and what the administration can do to alter that course. Congress has traditionally set the parameters and experts have made the judgments for moving forward. The National Institutes of Health, considered an American crown jewel, specifically has remained apolitical. But this step opens the door to concerns about grant cancellation and adds to growing uncertainty in scientific research. Even investors are starting to hold back. The ripple effects could be much bigger than the Trump administration anticipates.
- Many CDC staffers blame Health and Human Services Secretary Robert F. Kennedy Jr. and other agency leaders for stoking the negative climate that led to last week’s attack. Kennedy appears to have doubled down on his language, however, announcing decisions and policies that continue to fuel vaccine opposition and hesitation.
- This week, Kennedy also made the unprecedented move of calling on the Annals of Internal Medicine, a medical journal, to retract a study that found that the aluminum adjuvant in many childhood vaccines did not cause harm. The journal refused to retract the study based on Kennedy’s scientifically unsubstantiated claims that the additive was damaging.
- More fallout is emerging about the GOP-backed sweeping budget law enacted this summer. Republicans have argued that its cuts to Medicaid — most of which will not kick in until after the midterm elections — would touch only waste, fraud, abuse, and people who weren’t entitled to the coverage. In reality, the sprawling nature of Medicaid is already becoming clear as institutions — ranging from hospitals to community health centers — prepare for cuts that could limit their ability to provide services.
- The CDC reported this week that Americans are eating less ultra-processed food but that it is still a big part of the American diet. The Trump administration has talked a big game about addressing this public health issue yet has seemed loath to require the food industry to do anything. Much of the administration’s efforts have focused on “voluntary” changes. Former FDA chief David Kessler this week highlighted a regulatory, legal way the administration could compel more action.
Also this week, Rovner interviews Aaron Carroll, president and CEO of the health services research group AcademyHealth, about how to restore the public’s trust in public health.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: ProPublica’s “Veterans’ Care at Risk Under Trump as Hundreds of Doctors and Nurses Reject Working at VA Hospitals,” by David Armstrong, Eric Umansky, and Vernal Coleman.
Alice Miranda Ollstein: The New York Times-KFF Health News’ “Why Young Americans Dread Turning 26: Health Insurance Chaos,” by Elisabeth Rosenthal and Hannah Norman.
Sarah Karlin-Smith: The New York Times’ “This Ohio Farm Community Is a Mecca for the ‘MAHA Mom,’” by Caroline Kitchener.
Shefali Luthra: Stat’s “Inside the American Medical Association’s Sudden Strategy Shift in Washington,” by Theresa Gaffney.
Also mentioned in this week’s podcast:
- The Washington Post’s “This Phrase Was Meant To Increase Trust in Science. It Backfired,” by Aaron E. Carroll.
- Stat’s “Former Surgeon General: The CDC Shooting Must Be a Wakeup Call,” by Jerome Adams.
- PBS NewsHour’s “Federal mRNA Funding Cut Is ‘Most Dangerous Public Health Decision’ Ever, Expert Says,” by Geoff Bennett and Karina Cuevas.
- The Washington Post’s “How Schools Could Be Hit by Medicaid Cuts,” by Terell Wright.
Click to open the transcript
Transcript: Trump Further Politicizes Science
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 14, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Good morning, everybody.
Rovner: Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: And Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hi.
Rovner: Later in this episode we’ll have my interview with Aaron Carroll, president and CEO of AcademyHealth. He’ll talk about how the public has lost trust in public health and how public health might win it back again. But first, this week’s news.
I want to start this week with a story that maybe hasn’t gotten as much attention as I think it should. Last week, President [Donald] Trump issued yet another executive order, this one called “Improving Oversight of Federal Grantmaking.” It really should be called “Implementing Political Oversight of Federal Grantmaking” because that’s what it does. Sarah, before we get into this, explain how federal science grants work now and the role of political appointees vis-à-vis career and outside experts.
Karlin-Smith: I guess I would say right now there’s very little political oversight. You have various scientific committees and federal experts that make the decision of how to reward the money, and it’s going to be very broken down by people’s areas of scientific specialty. So, and this order is really trying to put it more in the hands of political people that have a lot less scientific knowledge.
Rovner: That’s a polite way to put it.
Karlin-Smith: I think the reason why maybe it hasn’t gotten attention is this is sort of an extension of a lot of stuff they have tried to do throughout the administration, but they’ve either gotten pushback from universities or other parties or through the courts. And part of what seems to be going on here is they maybe have learned some lessons about their legal failures and they are trying to see if they can kind of adjust their strategy to maybe make it more foolproof. But there’s a lot of tension between how Congress has directed this federal funding to be spent and what the administration can really do to change the process around it.
Rovner: Yeah, I mean, I feel like until now this has been very much Congress setting the parameters and career people and outside experts making the judgments about what kind of science should be funded, right? Am I missing something here?
Karlin-Smith: I don’t think you are. I guess one thing that strikes me about this is I think that the U.S. scientific infrastructure and NIH [the National Institutes of Health] in general has not been political in the way I think other parts of our health system, our public health system in particular, have been over the years. Like, NIH, it’s gone through some periods maybe in the past decade or so where the funding wasn’t quite where people want it. But in general it’s been a pretty bipartisan priority. People do not want to mess with this system. It’s kind of a crown jewel of the U.S. that has helped spur both our universities and private industry and technology. So I think this is just a bit of a very different kind of strategy and approach from the Trump administration than we’ve seen from other administrations in terms of even trying to do this.
Rovner: It has been political in the sense of Disease Group A goes to members on Capitol Hill and say, Please fund our disease, and then they’ll put a line in the Appropriations Committee report to Please fund this disease. But when it comes to how, what specifically the kinds of research for that disease gets funded, that’s been left up to experts. So, under this order, not only will political appointees be in charge of potential funding announcement as well as grant approvals, but it also orders creation of a system to cancel ongoing grants for, quote, “convenience,” meaning apparently any reason that the administration might want to invoke. That’s something, as Sarah points out, that this administration has been doing since January, although various courts have pointed out kind of repeatedly that that’s not legal. But this could create so much uncertainty in scientific research so as to just basically bring things to a screeching halt. I see you nodding, Alice.
Ollstein: Yeah, I think that this is going to deter a lot of researchers from even embarking on the process, because why would you pour years of effort into writing these grants, recruiting subjects, setting up these labs when you know that the funding could be yanked at any time? That kind of uncertainty doesn’t comport with the years-long stability required to really get somewhere with this kind of research. And it’s no wonder that other countries right now are aggressively recruiting American scientists and American scientists are saying, Yeah, I would rather go abroad and have more stability, more of a guarantee that my research won’t be messed with and won’t be suddenly defunded, rather than stay here. And that’s going to be an enormous loss of knowledge here and an enormous loss of economic power over time.
Karlin-Smith: The other thing about, in talking to some of the groups that advocate for the universities here, that they were saying even prior to this order, with some of the earlier actions, what they were hearing, what was happening is is that other countries are actually recruiting scientists to work for them or fund them, but letting them stay in the U.S. And here so they’ve even come up with ways to even make it pretty easy for people to switch. But then the catch is probably that that research or IP [intellectual property] and so forth will actually belong to other countries, particularly China is one that is interested in that, in the many ways an adversary of the U.S.
Rovner: So, yeah, because I was going to say, one of the headlines I saw this morning was of investors who were starting to hold back because of all the uncertainty about the U.S. research establishment. I mean, this is a big chunk of the economy. I mean, it feels like the Trump administration trying to punish Harvard and Columbia and other universities, but I feel like the ripple effects of this could be much bigger than even they anticipate.
Ollstein: Well, absolutely, and I know we’re going to talk a lot about trust in health science and where that’s going, but I think there are two sides to people’s fears about this right now. One, that good, gold-standard, important research won’t get funded but also that shoddy or biased research will get funded. If you politicize that, you have both risks.
Rovner: Yeah, that’s true. Well, to segue, meanwhile, as if federal health officials aren’t uncertain enough right now, a gunman shot up the headquarters of the Centers for Disease Control and Prevention in Atlanta last week, killing a law enforcement official. Reports differ, but there’s evidence that the gunman, who apparently shot himself, blamed his covid vaccine for his mental health woes and wished to get back at the public health agency. To quote Jerome Adams, surgeon general in Trump’s first administration, in a Stat op-ed published over the weekend, quote: “One thing is clear: This tragedy is not an isolated event. It is a dire reflection of ever escalating threats public health workers face in a climate increasingly shaped by misinformation, politicization, and inflammatory rhetoric,” close quote. And it’s not just the shooting itself. Apparently the way higher HHS [Department of Health and Human Services] officials have tried to calm the nerves of CDC staff hasn’t really worked very well, from what we’re hearing.
Karlin-Smith: I mean, I think there’s a lot of CDC staff, and people in the public health space, blame the leadership of this current HHS for stoking these fears, and the rhetoric that they were using for a number of years prior to coming into office, for kind of creating a situation where this happened. And not only have they not really wanted to take that on head-on and talk about it or take any responsibility for it, they’ve sort of fueled the flames with comments HHS Secretary Robert F. Kennedy has made since the incident on news outlets, continuing to kind of double down on the language that suggested. And of course in the past few weeks they’ve made other decisions that have, I think, to people who have questioned vaccines and some of the technology that this person might’ve been upset about, sort of seem to back up their concerns, unfortunately, unscientifically, like pulling back on mRNA vaccine research funding.
Luthra: I was going to say, I think there’s another point that you made, Julie, that’s really important, which is looking at this in the broader context even of the past five years. And we’ve seen this real escalation of threats against public health workers across the country, and that really took off in a different way with the right-stoked skepticism around the covid vaccine, which we’ll talk about in a moment. But that’s had consequences already, whether that is people not wanting to enter public health, people leaving the profession, and it’s affecting our ability to monitor diseases, to do public health prevention, to do all those kinds of things that are becoming even more important and even more difficult as other parts of the health care safety net are being constrained.
Rovner: Yeah. And the mantra that we keep repeating is that public health, when it works, is invisible. Well, if it’s not there and it doesn’t work, it’s not going to be invisible anymore.
Ollstein: Well, and also this is coming at a time when a lot of people, if they’re not being straight-up laid off from these agencies, are feeling driven out in other ways by the uncertainty, by My department was cut, and then it was restored because of a lawsuit, and then it was cut again, and thinking, Why should I put up with this, the way the administration has disparaged bureaucrats, basically? But also these nonpartisan scientists who work for the government. And so this is coming on top of all of that. And so if someone was on the fence about, Should I stay and keep working for CDC or not? — this certainly isn’t going to convince them to stay, both the fear as well as the agency’s response to the incident.
Rovner: So HHS Secretary Kennedy was not very quick to respond to the CDC shootings, but he has been busy with other things this past week. One was an unsuccessful effort to get a prominent medical journal, the Annals of Internal Medicine, to retract a large vaccine study out of Denmark — and by “large” I mean 1.2 million children — that found that cumulative aluminum exposure to children via vaccines is not a safety risk. I honestly can’t remember an HHS secretary ever demanding a study be retracted because they disagreed with its finding. How unusual is this?
Karlin-Smith: Very unusual. I mean, I think the scientific basis for what he’s saying and pushing for. And the journal has already said, No, we are not retracting this, pretty bluntly. And this adjuvant has been something people have been worried about Kennedy going after. It came up a little bit the last CDC advisory committee on vaccines.
Rovner: Yeah, explain what aluminum adjuvant is.
Karlin-Smith: And it’s basically something they’ve been putting in vaccines since I think the 1930s. And it helps basically boost your body’s response to it. So it makes the vaccines better. And the last CDC advisory committee on vaccines, after Kennedy sort of overhauled the panel and put a lot of his people on there who don’t really trust vaccines very much, they removed thimerosal as an adjuvant for a flu vaccine, which I think was seen as problematic but won’t have huge, huge consequences, especially for the U.S. But they did—
Rovner: Because it had already been removed from most vaccines.
Karlin-Smith: Right. But they did also sort of tease that they were going to look at this adjuvant. And when I talked to people about that, they were much more concerned about it, because it’s in many more products and they don’t believe there’s really good alternatives for it. And it could basically be a move to push companies out of this space of making a lot of vaccines that children really need and benefit from.
Rovner: Or make vaccines less effective.
Karlin-Smith: Right. So they just don’t have good alternatives. So, yeah, it’s one thing people have been watching, is kind of the next step of where they go in vaccine politics here.
Rovner: What they’re going to go after. Well, meanwhile, the fallout continues over Kennedy’s cancellation of half a billion dollars in research on mRNA vaccines, which somebody mentioned earlier. This week, an international virologist group representing more than 80 labs reaffirmed their support for the technology. Michael Osterholm, one of the nation’s very top epidemiologists, said on the “PBS News Hour” that this was, quote, “unequivocally … the most dangerous public health decision I have ever seen made by a government body.” Why are scientists reacting so strongly to this particular policy change?
Karlin-Smith: One of the big reasons is because of how fast this technology can be used to develop vaccines and the ability for it to be helpful in a pandemic. So while we have other, older vaccine technologies, this one is really much faster in being able to update vaccines and make new vaccines. So that’s a crucial public health benefit to it, and that, I think, really scares people.
Rovner: Yeah, I know that the flu vaccine is still made using chicken eggs, right?
Karlin-Smith: Right. It’s grown in an egg. So, right, if you think about potential of flu pandemics, bird flu comes up. That’s one place where having the new mRNA technology would be really valuable. It’s also being studied for all different types of diseases outside of it, the infectious disease space, and cancer. And people are really excited about that, too. At this point, it doesn’t seem like the administration is as interested in cutting off that sort of funding.
Rovner: Yeah, well, we will have to see. Well, meanwhile, over at the FDA [Food and Drug Administration], we note the return of Vinay Prasad as head of the Center for Biologics. Sarah, didn’t he quit just, like, two weeks ago? What is going on over there?
Karlin-Smith: Strange times. Yeah, I think he was gone for maybe it might’ve been about 10 days. I don’t even think it was two weeks. He was kind of forced out. He drew attention from some right-wing allies of Trump, particularly Laura Loomer, after he halted the shipping of a gene therapy product after some safety events, some deaths. And that caused a lot of right-wing people that hadn’t really maybe paid much attention to the FDA or Prasad to look into his history. They pulled up some of his past, which was, he was probably, he was fairly Democratic and aligned with more of the left wing prior to maybe the covid pandemic. He had really strongly criticized Trump and made pretty, I mean, he’s quite a character in his colorful statements. So he had talked about having a voodoo doll of Trump, and I think if you know Trump, that’s not the kind of thing he’s probably going to personally stand for.
So it seems as if the White House pushed him out. But Martin Makary, the head of the FDA, and even HHS Secretary Kennedy seemed to eventually sort of convince the White House to let him back. And here he is. The question, I think, in a lot of people’s minds is does he have to sort of modify his decision-making or regulatory philosophy now that he’s brought back, whether it’s to sort of appeal to these right-wingers who basically have heralded Trump as this sort of head of a right-to-try movement, and this idea that there should be a more libertarian attitude toward regulation of medicine and people should basically have more options to try things.
Rovner: Yeah. It goes back to sort of the whole right-to-try thing and this drug for muscular dystrophy, right? Isn’t that sort of what prompted the big kerfuffle?
Karlin-Smith: Right. Right. So this Duchenne muscular dystrophy treatment has a really sort of long, complicated, controversial track record because Peter Marks, who used to have Vinay Prasad’s job before him, actually overruled a lot of his scientific reviewers in approving the product. And Prasad had a long history of criticizing Marks for doing that. And then right over the past few months it came out there had been some deaths in the space, mostly in non-ambulatory people. So this is a very devastating muscle-wasting disease, and eventually most people end up wheelchair-bound. And what ended up happening right before Prasad left is they agreed to let the drug back on the market for people that are still ambulatory, where they think the safety risk is less. And it’s still right now off the market for those.
But yeah, it’s sort of ironic because Prasad, while he’s sort of repeated a lot of the anti-vaccine rhetoric of Kennedy and Makary, particularly when it comes to covid vaccines, his philosophy, and what he was known for prior to coming to the FDA, was actually having kind of stricter standards for approval than many at FDA maybe had, or he would argue. And that doesn’t really align with the Trump philosophy or this libertarian, right-wing philosophy around this idea of right to try and people should have access to things if they’re willing to take the risks. So that’s where I think we’re watching moving forward, because actually outside of the covid vaccine space where he was sort of heavy-handed, he also made a number of decisions around gene therapies besides this one in his first, short stent at the FDA that did seem, again, a little bit more anti that right-to-try philosophy.
Rovner: Yeah. Well, we will definitely be watching that one closely. All right, moving on. We are seeing still more fallout of the big budget bill that passed earlier this summer. In rural New Hampshire, a community health center is closing at the end of October, citing Medicaid cuts, among other things. The Washington Post has a story this week about how the Medicaid reductions could lead to a decrease in services and an increase in wait times for things like counseling and speech therapy provided at schools for children with disabilities. I know Republicans were counting on these cuts not really having much of an impact prior to next year’s midterms. And they keep swearing that services won’t be cut except for people who are undocumented or who refuse to work. But that’s not how this is all playing out, right?
Luthra: There’s just no way that is how it can play out. And I think what we’re seeing in real time is how sprawling Medicaid is. It touches so many corners of so many people’s lives. There’s a reason it became this really sacred-cow component of things you can and can’t touch. And I think one thing that will be really interesting is, just again, as we think about something like community health centers, which Republicans also often tout as this really great model. We talk about that for family planning, especially. Oh, you can go there — you don’t need your Planned Parenthood, for instance. And what does happen when all of these places that so many people rely on are gone?
And I think one thing that you pointed out, Julie, that’s also so important is that many cuts may not be taking effect right away, but institutions have to make plans now. They are anticipating that that money isn’t coming back. And even if we don’t see some of the formal cuts having their start date until later on, it’s just not possible, I think, to imagine that we won’t see institutions have to adapt and scale back and see people navigate what that means.
Rovner: Yeah. If there are 10 million more people mostly without Medicaid, all of these places like community health centers who get a lot of their funding from Medicaid are going to lose a lot of their funding. I think this just didn’t carry through. I mean, we heard a lot from the hospitals, but it didn’t carry through to the other providers whose livelihoods basically depend on their patients having some form of insurance. And usually that’s Medicaid.
Ollstein: Right, and even with the hospitals, Congress was pressured into creating this kind of rural hospital slush fund to prop up the places that might be most impacted by this. But if all of the people who will be going to those hospitals lose their coverage, that might not be enough to make up for the loss, not to mention all of the hospitals that aren’t eligible for that money. And so I think Shefali’s absolutely right. The lesson in 2017 that Medicaid is not just the poor-people program was not learned. It didn’t stick. And now you’re seeing people relearning that, Oh, this impacts seniors in nursing homes. Oh, this impacts kids getting special services in schools. Oh, this impacts all of these groups that aren’t the working poor.
Rovner: Yeah, I think we’re going to continue to see this sort of spool out as we go. Well, finally this week, a priority for the Trump administration that’s shared by most of the public — cutting down on so-called ultraprocessed food. The CDC reported last week that Americans are eating fewer of their calories via ultraprocessed food, but it is still more than half of the calories consumed. And pushing for at least a partial solution is not the current FDA commissioner but a former one, David Kessler, who served under Presidents George H.W. Bush and [Bill] Clinton and has campaigned against processed food for pretty much as long as I can remember. While Trump administration officials have been urging food companies to do things voluntarily, Kessler this week filed a petition arguing that the FDA has the authority to declare certain ingredients used in ultraprocessed food as not, quote, “generally recognized as safe.” Making food companies prove these processed ingredients actually are safe could be a real tool in the fight against these foods, right? I mean, Sarah, this whole “generally recognized as safe” has been one of the big FDA loopholes over the years.
Karlin-Smith: Right. So, basically since the 1990s, due in some degree to probably staffing shortages and so forth, FDA has kind of allowed companies to self-certify that a lot of these ingredients are considered “generally recognized as safe.” And I think now there’s sort of some sense that maybe that wasn’t scientifically, and health, the best idea. So, Kessler’s basically saying you should give companies some cushion, maybe like 12 months or so, and say, Look, you either need to pull these ingredients out of your food or really, truly prove to us with the science that these are safe. Then he’s kind of calling Kennedy’s bluff a little bit and basically being like: Look, you keep talking about this. You’re really furious about the ultraprocessed food. Look, I found your regulatory hook, your legal way to do it. Now go do it.
And I think the food industry, like many other big industries in the U.S., are pretty powerful, as you said. Given the amount of food we consume with these ingredients, it’s a huge — it would be probably quite difficult to make these changes in a year or so forth. But Kessler’s pretty smart. He was the person that really led the regulation of tobacco at FDA. And so I think he’s basically trying to say, Look, here’s a strategy — now go do it, and see if they’ll really follow through on anything.
Rovner: Yeah, I was absolutely fascinated by this in terms of sort of calling the bluff, because that’s what you were saying. On the one hand, they’ve talked a big game on something that, unlike the Medicaid cuts, is popular with the public. On the other hand, they seem very loath to require the food industry to do anything.
Karlin-Smith: Right. I mean, their main food achievement so far is getting commitments on certain food dyes, which for the most part actually aren’t that used anymore. And I think even the safety concern around them is generally seen as pretty low. Now they’re not really adding anything to your food other than color. So there’s an argument that even if there’s just even some slight hypothesis that there’s the danger, you should get them out. But the theme, and we talked a lot about this a little bit last week in the podcast, is they’re talking a lot more than they’re actually making achievements so far in the public health space.
Rovner: I guess you can sum this up in: It’s less What color are your Froot Loops? than Should you be eating Froot Loops at all? Or, Should you be feeding them to your children?
Karlin-Smith: That’s perfect.
Rovner: Yeah. All right. Well, I’ll be fascinated to see if they actually follow up on this. All right, that is this week’s news. Now we’ll play my interview with AcademyHealth president and CEO Aaron Carroll, and then we’ll come back and do our extra credits.
I am so pleased to welcome Aaron Carroll to the podcast. Aaron is president and CEO of AcademyHealth, the leading national organization for health system researchers, in addition to being a top-notch health policy expert himself. Aaron is also a pediatrician and formerly a pediatrics professor and associate dean at the Indiana University School of Medicine. Aaron Carroll, thanks so much for joining us.
Aaron Carroll: Thanks for having me.
Rovner: So, I wanted to talk to you mostly about your op-ed published in The Washington Post last week. We will link to it in our show notes. It’s called: “This Phrase Was Meant To Increase Trust in Science. It backfired.” The phrase in question is “Follow the science.” Tell us why you think it backfired.
Carroll: Well, for a couple of reasons. The biggest is that I think it to some extent conflates science and policy, and it makes it sound like that once we have science that policy naturally follows from it and that anyone who is rational will know the right answer. The problem with that is that science is sort of a set of facts, or an explanation of the world as we best understand it, but policy should take good science, and then it has to incorporate societal values, people’s preferences, what I would call utility values almost, and all the trade-offs that come with policy. And so good science should inform policy, but good science is not the same as policy.
I provide a number of examples. One would be like, look, we have great science that shows vaccines are unsurpassed to preventing infectious disease. We also have science that shows that eating raw or undercooked eggs can cause salmonella. The first might justify vaccine mandates in schools. The second certainly doesn’t mandate banning sunny-side eggs. Just because something is true, you have to think about their differences when you come into policy. And too often we use that phrase almost as a cudgel to say: We have science, therefore this is the only policy that makes sense. And if you disagree, then you’re not following science. That’s just not the case.
Rovner: And that’s pretty much what happened during the pandemic, wasn’t it?
Carroll: Yeah. I mean there were so many times where we were making the best guess, because you have science, but the science isn’t terribly great and it’s not really up to date. So you have to make policy decisions from that. But different people are going to make different policies, and different groups, depending upon where they’re focusing, might make different policies. And that is OK. But we sort of fell into a trap where there could only be one voice, one truth. It really brooked no dissent, and it had to be sort of put out nationwide. And when there was pushback that the policy decisions didn’t necessarily follow from the science, everyone didn’t always react to that as well as they should have.
Rovner: And now it’s being hung around people’s necks, whichever side they were on.
Carroll: Yeah.
Rovner: Even if the science has changed since then.
Carroll: Yeah. I mean, I helped to run Indiana University’s pandemic response, and we used to do at least a weekly webinar where we would answer questions, and all the time I would say things like: This is the best answer we have right now. That’s why we’re going with this. And let me explain to you why. And these are the trade-offs. We’re trying to do the best by everyone. These are the pros. These are the cons. Let’s talk it out. And if the data change in the future, we’ll change the policy. We’re doing the best we can. But that kind of nuance, that kind of long-form answer, was too often not acceptable or not possible during the pandemic, because we wanted things to be reduced to sound bites. We wanted things reduced to easy algorithms. We wanted everyone to sort of do whatever our chosen sort of arbiter of truth said. And if people disagreed, we really accused them of disagreeing with science. And there’s a real difference between science and policy.
Rovner: So, how do we start to win back that trust?
Carroll: I think a couple of ways. One is, I think, we have to start listening as well as we do speaking. I think too few of us actually are willing to spend time talking with people who truly disagree with us, and that’s going to limit our ability to enact good policy. I like to point to the fact that there are change management experts who will argue that there are three reasons people resist change. They don’t understand it, they don’t like it, or they don’t like you, which is really about trust. But we treat too many things as if they only fall into that first bucket. It’s a knowledge dissemination problem. And if we just speak out facts louder and louder and more stridently, then everyone will come and listen to us. So if we just keep broadcasting facts over social media, then everyone’s going to agree with us.
It completely ignores that there’s a section of people who are completely rational but don’t like the change, because of trade-offs. I hated wearing a mask. It fogged up my glasses completely. I would do it, but I hated it. And every time someone lectured me on how easy it was and I should just get over it, I got angry. We’ve got to be better about understanding there are trade-offs in policy, and we have to address those trade-offs. And of course there’s that huge third bucket of people that don’t trust us. That’s only going to come from slow, honest conversation with people who disagree with us. And we don’t want to do that, either. We want to shout at people over social media. We want to push people away who don’t agree with us. We want to belittle them.
That’s a problem. In the op-ed, I talked about that, as a pediatrician, I’ve been dealing with parents that don’t want to do what I tell them is best for decades. I don’t slap ’em. You have to build trust. You have to listen to them empathetically. You have to discuss the reasons why you might want to do something or not do something. And you have to build those kinds of relationships over time. It’s slow. It can be tedious. But that’s how you get people to change their mind, not by just shouting or belittling them. And we do that too often.
Rovner: One thing I’ve noticed over almost 40 years of doing this is that some of the best explainers of policy have been pediatricians — C. Everett Koop, David Kessler, Bill Roper, all pediatricians of one sort or another. What is it that they teach you that lets you communicate so well?
Carroll: I trained in Seattle. People were refusing vaccines back in the ’90s, and they weren’t the same people who are refusing vaccines today. You had to learn to deal with that. I would make recommendations about how to sleep, how to eat, how to control tantrums, how to do behavior change, how to parent. And I’m competing with Grandma, and I’m competing with other relatives who have very wildly different opinions about how things should be done. And you have to learn how to deal with that, with people who just don’t agree with you right away and who aren’t swayed by data and evidence but by trust. And people get more riled up about when they’re pregnant and, I think, when they have small children, than almost any other time in their lives, about they can’t make a mistake, they’ve got to do the right thing, and they’ve got to balance competing voices who are telling them very different information. Maybe we’re just better used to it or trained to it, but a lot of this stuff that we’re arguing about now, a lot of pediatricians have been dealing with for a long time.
Rovner: So, this administration, obviously, for anybody who’s listened to the podcast for more than five minutes knows, is not really helping matters right now, are they?
Carroll: I mean, we’re not doing a lot of really good communication and a lot of really good listening. I think we’re seeing a lot of top-down decisions that are not perhaps based on the best data and evidence, are not as justified as well as you might want to expect, and who are dismantling or removing many of the tools that we use to produce the data and evidence that can produce sound policy. No one would argue, I think, that the NIH couldn’t have reform. No one could argue that the USPSTF [U.S. Preventive Services Task Force] is perfect and never needs to be touched. ACIP [The Advisory Committee on Immunization Practices] could be refined. I think there were decisions made about covid vaccines and boosters that produced hearty debate years ago, and lots of decisions on ways that some of these organizations work could be refined. But we don’t want to throw out the baby with the bathwater. A lot of the infrastructure that we have in place is to make sure that things are nonpartisan, that we’re relying on the best evidence, that we’re doing the best job that we can to make sure that these things are not biased or partisan in any way.
And a lot of the steps, I think, that are being taken to wipe away a lot of this infrastructure are not going to reinforce trust. The answer isn’t to shut down discussion, which is happening too often around the country. It’s to move and lean into open dialogue. We have a meeting coming up in the next few months, Health Datapalooza, which really brings together lots of people from the current administration who should be there, plus lots of people from industry, plus researchers, plus health systems, and those who provide the care, coming together and having an open dialogue, open discussion, learning to listen to each other, and learning to realize we’re all really human beings and we need to be able to learn. Both ways is how we move forward. And unfortunately, we’re moving in a direction that tries to shut down that kind of debate and just shouting that the other side is wrong.
Rovner: I know AcademyHealth has been pretty outspoken about the disappearing databases at HHS in particular. I mean, what could that mean for public health? And, I mean, now it’s not just databases that are being taken down but there’s a concern about data being put up that’s not necessarily trustworthy.
Carroll: I mean, again, we can’t improve what we can’t measure, and we can’t make change if we don’t know where we’re starting from or where we need to go. And you can make an argument, I suppose, that a lot of these data would still be available without the federal government collecting it, but no one is as good or thorough or has the mandate of law to pull a lot of these data sources together in ways that people can use. And these aren’t just, like, esoteric research things. Some of these are, like, how public health officials monitor the health of their citizens. Some of these are about what clinicians might want to know to talk to their patients about what’s going on in their area, or what trends are in certain diseases, or how things work. People, clinicians, patients need these data. There are — a lot of them are mandated by law, and if we don’t have them up, people suffer.
This isn’t, again, like we’re just punishing researchers or scientists. This is punishing people, and, again, at AcademyHealth, our mission is to promote the creation and use of data and evidence to improve health and health care for all. You can’t do that without the data, and no one can do it if they don’t trust the data. So much of this, again, is about trust, which is about transparency, which should be a nonpartisan issue. We advocated for this same kind of thing under the Biden administration when they tried to restrict Medicare data and how researchers could get and use it. And we were out in front saying: That’s not OK. People need access to this data. And that the same thing is true under the Trump administration. We want more people to have more access to the best and most trustworthy data, always.
Rovner: Well, thank you for fighting the fight for good science and good policy. Aaron Carroll, thanks a lot.
Carroll: Thank you.
Rovner: OK. We’re back. And now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week?
Luthra: Absolutely. My story is by Theresa Gaffney from Stat News. The headline is “Inside the American Medical Association’s Sudden Strategy Shift in Washington.” I picked this because I knew Julie and I would both get a real kick. There’s just a lot of fun in following the political trajectory of the AMA, which as we know began as this more conservative political organization, has undergone this transformation in more recent years, becoming more interested in causes, sometimes aligned with more of the political left, whether that is expanding access to health care, whether that is opposing abortion restrictions, and then had really gone quiet when we saw this big attack on a lot of medical institutions from the new administration. And this story looks at how that is starting to shift and the AMA is now trying to actually act in response to all of the things that have been happening to scientists and health care providers, and where that is coming from within the medical community and what it could mean.
Rovner: It’s a really interesting story. And Shefali’s right. One of my hobbies is following the AMA’s political trajectory. Alice.
Ollstein: So I have a piece in The New York Times by some KFF stalwarts, and it’s called “Why Young Americans Dread Turning 26: Health Insurance Chaos.” So, it sets up that if Congress doesn’t renew the ACA [Affordable Care Act] subsidies that are expiring later this year, people are going to face an even worse cliff when they turn 26 and they have to start buying their own insurance. But the article talks about all of the ways that cliff is already worse now before that even happens, largely because there’s just less regulation of plans, and so people are buying crappier plans that don’t adequately cover them when they actually need them and get sick, and the process, because the navigators have been defunded, and there just isn’t a lot of outreach and promotion going on under the Trump administration.
People are very confused and overwhelmed by all of the options and are largely going without insurance. And I think what’s important from the story is you may think: Oh, this doesn’t affect me. I’m not a 26-year-old. I have my insurance. I’m fine. As we learned in the past, this impacts everybody. If young and healthy people are driven out of these markets, that impacts everybody’s costs and makes things more expensive for the rest of us. So definitely worth paying attention to.
Rovner: Yeah, it’s a really good piece. Sarah.
Karlin-Smith: I took a look at a piece in The New York Times by Carolyn Kitchener, “This Ohio Farm Community Is a Mecca for the” quote “‘MAHA Mom.’” And it’s about what is essentially sort of a — the story kind of describes it as the idea of the 1960s, 1970s, like, hippie farm commune but kind of MAHA [“Make America Healthy Again”] style, and maybe a bit more luxurious. And it’s essentially a look at how this community develops and operates and tries to live by some of the, quote-unquote, “MAHA principles” around how the foods you eat or grow. And it’s kind of a fascinating look as to what they’re trying to do and how they want to live their lives.
Rovner: Yeah, it’s the new age of the New Age. Fascinating. Well, my extra credit this week is from the “Who Could Possibly Have Seen This Coming” category. It’s from ProPublica. It’s called “Veterans’ Care at Risk Under Trump as Hundreds of Doctors and Nurses Reject Working at VA Hospitals,” by David Armstrong, Eric Umansky, and Vernal Coleman. And despite vows by Trump officials that they could cut tens of thousands of jobs at the department without harming clinical care, it turns out that the cuts are deterring clinical care workers from signing up to work at the VA [Department of Veterans Affairs] in the first place. It seems that 40% of doctors offered work at the VA in the first quarter of this year said no. That’s quadruple the rate of rejection from just the year before. And between January and June, the VA lost twice as many nurses as it hired.
While VA officials accused ProPublica of cherry-picking numbers, I will point out that separately this week, the VA’s inspector general, in its annual report, found that every one of the VHA’s [Veterans Health Administration’s] 139 medical centers reported staff shortages, with those reporting, quote, “severe shortages” for specific jobs up 50% from the year before. So, that doesn’t sound very much like cherry-picking.
OK. That is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our fill-in editor today, Stephanie Stapleton, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe where you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me still on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Shefali?
Luthra: I’m at Bluesky, @shefali.
Rovner: Alice.
Ollstein: On Bluesky, @alicemiranda, and still on X, @AliceOllstein.
Rovner: Sarah.
Karlin-Smith: Bluesky, X, LinkedIn — @SarahKarlin or @sarahkarlin-smith.
Rovner: We’re going to take a little bit of a summer break for the rest of the month. Next week we’ll have a special episode on the 60th anniversary of Medicare and Medicaid, and the week after we’ll be dark so our hardworking staff can have some time off. We’ll be back in your feed with all the news on the Thursday after Labor Day. Until then, be healthy.
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KFF Health News' 'What the Health?': Kennedy Cancels Vaccine Funding
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Emmarie Huetteman
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Emmarie Huetteman, senior editor, oversees a team of Washington reporters, as well as “Bill of the Month” and KFF Health News’ “What the Health?” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.
Health and Human Services Secretary Robert F. Kennedy Jr.’s announcement that the federal government will cancel nearly $500 million in mRNA research funding is unnerving not only for those who develop vaccines, but also for public health experts who see the technology behind the first covid-19 shots as the nation’s best hope to combat a future pandemic.
And President Donald Trump is demanding that major pharmaceutical companies offer many American patients the same prices available to patients overseas. It isn’t the first time he’s made such threats, and drugmakers — who scored a couple of wins against Medicare negotiations in the president’s tax and spending law — are unlikely to volunteer to drop their prices.
This week’s panelists are Emmarie Huetteman of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.
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Sarah Karlin-Smith
Pink Sheet
@sarahkarlin-smith.bsky.social
Sandhya Raman
CQ Roll Call
Lauren Weber
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Among the takeaways from this week’s episode:
- Explaining the decision to cancel some mRNA vaccine funding, a priority for vaccine critics, Kennedy falsely claimed that the technology is ineffective against respiratory illnesses. Researchers have been making headway into mRNA vaccines for maladies such as bird flu and even cancer, and the Trump administration’s opposition to backing vaccine development weakens the prospects for future breakthroughs.
- Trump’s insistence that big-name drugmakers voluntarily lower their prices underscores how few tools the presidency has to deliver results on this important pocketbook issue for many Americans. Medicare’s ability to negotiate drug prices took a hit under Trump’s big tax-and-spending law, which included two provisions advocated by the pharmaceutical industry that would delay or exclude some expensive drugs from the dealmaking process.
- A year after Trump promised on the campaign trail to secure coverage of in vitro fertilization, the White House reportedly is not planning to compel insurers to pay for those pricey reproductive services — a change that would require an act of Congress and could raise costs overall.
- And with Congress back home for its August recess and a late September deadline looming, the annual government funding process is in progress — but unlikely to resolve quickly or cleanly. Senate appropriators are further along in their work than usual, but the House of Representatives has yet to release its version, which is expected to cut deeper and hit social issues like abortion harder.
Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:
Emmarie Huetteman: KFF Health News’ “New Medicaid Federal Work Requirements Mean Less Leeway for States,” by Katheryn Houghton and Bram Sable-Smith.
Sarah Karlin-Smith: Slate’s “Confessions of a Welfare Queen,” by Maria Kefalas.
Sandhya Raman: CQ Roll Call’s “Sweden’s Push for Smokeless Products Leads Some To Wonder About Risks,” by Sandhya Raman.
Lauren Weber: The New York Times’ “‘Hot Wasps’ Found at Nuclear Facility in South Carolina,” by Emily Anthes.
Also mentioned in this week’s podcast:
- The Washington Post’s “How RFK Jr.’s mRNA Crackdown Affects Vaccinemaking and Future Pandemics,” by Carolyn Y. Johnson and Lauren Weber.
- The AP’s “Fact Focus: Trump Says He’s Cut Drug Prices By Up to 1,500%. That’s Not Possible,” by Melissa Goldin.
- The Washington Post’s “Medicare, Medicaid Plan To Experiment with Covering Weight Loss Drugs,” by Paige Winfield Cunningham.
- The Washington Post’s “White House Has No Plan To Mandate IVF Care, Despite Campaign Pledge,” by Riley Beggin and Jeff Stein.
click to open the transcript
Transcript: Kennedy Cancels Vaccine Funding
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Emmarie Huetteman: Hello, and welcome back to “What the Health?” I’m Emmarie Huetteman, a senior editor for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 7, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. Here we go.
Today, we’re joined via video conference by Lauren Weber of The Washington Post.
Lauren Weber: Hey, everybody.
Huetteman: Sandhya Raman of CQ Roll Call.
Sandhya Raman: Good morning.
Huetteman: And Sarah Karlin-Smith of the Pink Sheet.
Sarah Karlin-Smith: Hi, everybody.
Huetteman: It’s August, and here in the nation’s capital that means Congress has flown the coop, and a lot of the federal city has gone with them. No interview this week. And you may be wondering why you’re hearing my voice instead of the incomparable Julie Rovner. Julie’s out this week having surgery to repair her broken wrist. Good news: She’s on the mend and she’ll be back in your podcast feed very soon. Get well soon, Julie. Let’s get to the news.
On Tuesday, the Trump administration announced that the secretary of Health and Human Services, Robert F. Kennedy Jr., has canceled almost $500 million in federal grants and contracts to develop mRNA vaccines. That technology, of course, was responsible for the first covid vaccines, and researchers have been working on new ways to use mRNA, including against bird flu and even cancer. But in explaining his decision, Kennedy made false claims about mRNA vaccines, including that they do not protect against respiratory illnesses. Kennedy’s opposition to the covid vaccine, in particular, is well-documented. But before becoming health secretary, he advocated for federal officials to revoke approval for mRNA-based covid shots.
Sarah, you’re our pharmaceutical industry expert. What will this mean for vaccine development? Without this government funding, can that research continue?
Karlin-Smith: I think people are really concerned, particularly about the speed of vaccine development for pandemic situations. That’s a classic market failure in that companies aren’t that incentivized to work on developing products for hypothetical situations that may never come to pass, but we obviously want to be prepared for strains of the flu that can be particularly harmful and stuff. So I think that’s where people are really concerned.
I think, in general, this is just another mark in some of the vaccine actions that have taken place since this administration took over that makes people a little more nervous about just investing in the vaccine field, whether it’s mRNA or vaccines in general. FDA has made some unusual decisions around the indications for covid vaccines moving forward. The [Centers for Disease Control and Prevention’s] whole [Advisory Committee on Immunization Practices] has changed. So I do think there’s broader concern beyond the mRNA vaccines and our need to have this technology to really prepare for a pandemic about how confident industry will be in the places they normally would invest money on their own.
Huetteman: Lauren, you had a story yesterday about how Kennedy’s decision is intensifying concerns about our ability to fight future pandemics. Can you tell us what you’re hearing from public health experts?
Weber: Yeah. We spoke to a number of public health experts and vaccine experts, mRNA experts, who said, Look, this is the technology that you want to be spry, to be able to alter something, to fight potentially a bird flu. It’s also used in revolutionary ways to fight maybe even cancer here in the future. There’s a lot of fear about how this could have a chilling effect, as Sarah was pointing out, on the development pipeline and what that means in a pandemic situation.
I do think it’s important to note that just this morning, Trump was asked about this and said he was going to have a meeting on it at noon. Not sure exactly what that means, but potentially that could be something. Robert Malone, who’s an ACIP member, sent out an email trying to rally MAHA [“Make America Healthy Again”] supporters to make sure that they backed up Kennedy’s decision.
I think it’s also important to take a step back and look at Kennedy’s past remarks on mRNA, as you alluded to. This is a man who falsely called the covid vaccine “the deadliest ever made.” He’s described it as a poison in the past. Some anti-vaccine factions of MAHA have really been pushing to try and limit access to mRNA technology. You’ve seen this also in some Republican and far-right states, that are more right. You’ve seen some legislation suggested to remove access to mRNA technology. There’s a big question among some of the folks we talked to on if this is a bit of a signal to the base.
Karlin-Smith: I was going to say, ironically, the mRNA vaccines was probably the biggest success of the Trump administration’s first term in office. He was instrumental in spearheading the fast development of the vaccines for covid.
Huetteman: Right, Operation Warp Speed. Interesting how far we’ve come. To be clear, this isn’t all of the government’s mRNA contracts, right? This is just a piece of the research funding?
Karlin-Smith: This is a piece of it coming through BARDA [the Biomedical Advanced Research and Development Authority], which is particularly designed to help fill those market gaps in pandemic preparedness, but they’ve also cut other mRNA vaccine contracts previously in this administration, including a big one around bird flu, which people are concerned about right now. I’ve even seen some media reports where people, researchers in the cancer but mRNA space, were concerned about grants just being flagged just because they had the terminology. It’s not everything, but I think there’s certainly fears that this is just a step in a bigger process that is problematic.
Huetteman: Absolutely. We’ll be keeping an eye on that. And vaccine contracts aren’t the only thing that President Trump’s team is undoing this week. Under a new federal rule, VA hospitals would no longer be able to perform abortions in cases of rape, incest, or health endangerment. You may remember that the Biden administration introduced that policy at the Department of Veterans Affairs in 2022, after the Supreme Court ended the constitutional right to an abortion. The policy has allowed veterans and their relatives to obtain abortion services even while they are stationed in states with restrictions.
Meanwhile, lots of news to get to this week. In prescription drug news, late last week, President Donald Trump sent letters to more than a dozen drugmakers insisting that they drop their prices within 60 days. Specifically, the president demanded that pharmaceutical companies offer many American patients the same prices that drugmakers charge abroad. Over the weekend, Trump told reporters that his administration is dramatically lowering drug prices, “up to 1,500%,” he said — which, well, I think that technically means the drugmaker would pay you.
Anyway, Trump told drugmakers that if they don’t lower drug prices, “We will deploy every tool in our arsenal.” What can the president do to force drugmakers to comply?
Karlin-Smith: I think, in some ways, he doesn’t have as many tools in the toolbox as he probably would like to think. At least, not ones that are making the industry particularly fearful right now. He doesn’t have the power to just issue a regulation saying, “The Medicare-Medicaid reimbursement rates are tied to the rates countries are paying abroad.” That would have to be through legislation. And I think there are reasons that both Republicans and Democrats don’t really like this most-favored-nation approach to drug pricing. There is some sort of limited authority for them to do a demonstration project through CMS’ [Centers for Medicare & Medicaid Services’] Medicare-Medicaid Innovation Center. They could come up with a test of this in some kind of limited area. They tried to start implementing that [in] his last term and they got scuttled by lawsuits, so we’ll see if they have a way to avoid that problem this time.
But the ironic thing is that when the administration issued this executive order in May calling for this most-favored-nation pricing, he set this 30-day-ish deadline of saying, OK, we’ll tell you what prices we want, you guys lower them. If not, we’re going to do rulemaking. One thing that came up when he issued this letter, these letters on Friday, giving industry another 60 days is, Well, why are they not just going through with some kind of rulemaking or next steps? It almost seemed to some people like almost a more muted threat because they haven’t done the follow-through yet or come up with what the follow-through is here.
Huetteman: Now, where is the Medicare’s drug negotiation ability in this equation? Why isn’t the president doing more to leverage Medicare’s power to negotiate at this point?
Weber: Well, that’s really interesting because in the “Big, Beautiful Bill,” there were two provisions that a lot of people missed that limited the ability to negotiate on some key drugs, which has been estimated to likely cost the American taxpayer and the government billions of dollars over the next couple years.
Huetteman: Yeah, the CBO says that those changes will cost Medicare at least $5 billion in missed savings over 10 years.
Weber: Yes, that’s what’s called effective lobbying. Essentially, what happened is some pharma companies were able to tuck in provisions that key drugs, I think it was Keytruda, I’m not sure if I’m pronouncing that right, or Keytruda, which is used to treat cancer, it’s a drug by Merck. It had $17.9 billion in U.S. sales in 2024. That’s the kind of drug that they won’t be able to negotiate prices on for a bit.
Huetteman: Yeah, that’s right. Of course, that also means that Medicare patients will be subject to paying their percentage of those higher prices as well. On top of talking about this CBO score there, we’re talking about drug prices that real people are paying for their expensive cancer drugs right now. I guess I’m curious why Trump isn’t using the negotiation process in order to lower those drug prices?
Raman: I would add that something that makes this more difficult is that Trump has been very back-and-forth about a lot of his opinions on different things that he’s going to do throughout the last several months in this process. Even if you look at something like how we would deal with tariffs on the pharmaceutical industry, we’ve been a little bit all over the place. I think even if he’s not demonstrating the clear idea of which way he’d want to go, it makes it a little bit harder for the regulators, whether it would be in Congress or through the FDA, to do anything, given that he’s been changing a lot what he’s hinting at wanting to do.
Huetteman: Yeah, that’s right. Actually, Sarah, you brought up the CMS innovation option. There’s a story out about this this week. The Washington Post reports that the Trump administration is considering using that center to do a pilot project to expand access to GLP-1 drugs for weight loss purposes by allowing state Medicaid and Medicare Part D plans to cover them.
Now, insurance premiums are slated to go way up next year. If I’m not mistaken, the cost of covering GLP-1 drugs is one reason that insurers have cited for those premium hikes. If this happens, can we expect that the cost of those drugs would strain state and federal budgets?
Karlin-Smith: Actually, one I guess positive thing is that some GLP-1 drugs are slated to be subject to negotiation through the IRA [Inflation Reduction Act] program next year, so that there’s maybe positive news around the prices of those going down. Again, that’s obviously only for Medicare. But the problem on the back end is that, based on law, Medicare is not allowed in Part D to cover drugs for weight loss.
The Biden administration had tried through rulemaking to make an argument that weight loss drugs and drugs that treat obesity are two different things, hearkening back to — when that law was written we really didn’t understand obesity as a disease process and all the health problems it has on your body. We thought of weight loss as more of a cosmetic thing. The Trump administration actually pulled that rule, so this would be a much more small step in the direction of trying to get coverage. The report says it would be a “voluntary demo.”
The biggest question in my mind, which is again, knowing that these drugs, even with cheaper prices, would likely raise costs, is what is the incentive for health plans to voluntarily want to participate in this? What would the government have to do to incentivize this? Without some sort of push there for states and for Medicare Part D plans, I’m not sure the private plans are just going to pick up these products given the amount of people that would qualify for them. I think we need a lot more details from the Trump administration to know if they can actually make this feasible.
Weber: I just find this to be such a fascinating move considering [CMS Administrator Mehmet] Oz and Kennedy have such different opinions about weight loss drugs, as does MAHA as a whole. We at The Washington Post had reported previously that Oz does have financial ties to Ozempic through his show — they had to run a sponsored ad to some extent — and also through other means. It’s fascinating to see that clearly this is going forward, despite Kennedy having said repeatedly, often, constantly that he does not want to pay for these drugs, that he thinks other interventions, healthy diet and lifestyle, should be implemented. Which Oz has also really promoted as well. So fascinating to see how this experiment plays out. I agree with Sarah; I’m not sure where the incentives are, considering the cost that this will be to see it play out.
Huetteman: And one year after Trump promised coverage for in vitro fertilization services on the campaign trail, The Washington Post reports that the White House does not plan to require health insurers to cover IVF. The president had said that “if he were elected, the government would either pay for IVF services itself or require insurance companies to do it.”
What’s standing in the way here? What’s involved in making something an essential health benefit?
Raman: I think this whole process has been interesting. In February, Trump had put out an executive order directing his administration to come up ways to reduce the out-of-pocket costs for IVF. At the time, it’s pretty vague in terms of what that would entail. After the deadline passed, in part, I think a lot of people weren’t surprised because a) IVF is very expensive. And b) I think there are a lot of complicated nuances to some of his base and whether or not they fully support IVF. We had a lot of this last year, with people saying that they support it, but then also some of the folks that are more pro-life have some stipulations about not wanting embryos destroyed. It just complicated that some of the people that were talking to him about some of the other abortion-related issues were not on board with all of the IVF things. I think that has played definitely a factor in what they’re going to do with this.
But it’s also a hard thing to do, to just make this something that — even with prescription drugs, reducing the costs of those is not simple. In order for them to make it an essential health benefit, I think, is also more complicated given the issues that we’ve been having with preventative care, and just the concerns about the [U.S. Preventive Services Task Force] getting removed and what that’ll do to different things that are covered. It’s complicated and I wouldn’t really see this changing on IVF in the near future, at least from the executive level.
Karlin-Smith: It needs to go through Congress to be an essential health benefit. I think there’s a theme in some of the topics we’re coming up to today where Trump is clearly coming up to the limits of his bully power and his threats of negotiation. I think Martin Makary, the head of the FDA, said, “You get more bees with honey.” Well, unfortunately, sometimes it’s just not enough to attract these industries to make major changes.
Yes, they’ve gotten some sort of minor concessions, I think. I know they would like to think they’re transformative, but I think a lot of what they’ve gotten voluntarily is pretty minor, in terms of both health impact, and also how much it harms industry in terms of, like, food dyes. Or even the insurance companies saying, Oh, sure, we’ll do better on not going crazy on prior authorization.
I think Trump now has to actually double-down and work with policymakers on rule writing, or work with Congress. It’s more complicated, especially again, as Sandhya said, IVF is something that’s complicated for his base to support.
Huetteman: That’s right. This all came out of the blowback about how far towards banning abortion the country was going to go under Trump. This was a way to say, We’re preserving some parts of the reproductive health that are really important to people in our base, right?
Raman: Yet even when Congress has tried to look at any of the IVF legislation in the past, it’s fallen on party lines. There have been ones that have been more messaging on either side. I think the closest we’ve gotten is that, on the defense side, trying to consider measures there for folks with Tricare, but it’s difficult to get folks on board with things like this through Congress.
Huetteman: Well, speaking of Congress, Congress has left the building. August recess has begun and lawmakers are back home. Say, how is that government funding coming along. Sandhya?
Raman: I think we’re in a similar place to many years in that it’s August, they’re out. We need government funding by the end of September, and we’re nowhere close to getting that. I would say on the plus side, the Senate is further along than they usually are. Before they left, they did mark up the Labor, HHS, Education funding bill, and that was overwhelmingly bipartisan. It included some money that would be a boost for NIH [the National Institutes of Health], which I know was a big concern for a lot of folks given what was in the White House proposal. It maintains funding for some of the programs that would be cut under the White House, things like Title X, Ryan White HIV. It also has a little bit of a pushback on making sure that the agencies continue the staffing to keep up some of their statutory duties.
But again, it’s just the Senate. The House has not put out their bill. I would expect theirs to be a bit more conservative, given that the head of the Appropriations Committee in the Senate is Susan Collins, who’s been a little bit more moderate. The House is expected to release theirs and mark up theirs right after they get back. They meant to do it before recess but got pushed back because of reconciliation and that changing their schedule.
It depends what they say in theirs and how much difference there is. I would expect there to be a lot of differences. It seems like we’re headed toward the usual of at least some sort of temporary spending to kick it down the line. Whether or not that ends up being a year again, like we did this year, or a short-term thing, we’re not sure yet. It depends on where we are in September.
Huetteman: Right. And possibly preceded by a lot of fighting over social issues that get thrown into the health bill, and fights over the actual funding levels, if I had to guess, based on how House lawmakers have been talking about it so far.
Raman: Oh, no. I think just the fact that we had such a big rescissions debate this year and the fact that we might do that again, it has definitely left a sour taste for a lot of Democrats who are worried that if whatever they vote for here might just get clawed back later on down the line. That’ll be another thorn in it.
Huetteman: Awesome. Well, thanks for that take. That’s this week’s news. Now it’s time for our extra-credits segment. That’s where we each recognize a story we read this week that we think you should read, too. Don’t worry if you miss it; we’ll put the links in our show notes on your phone or other mobile device.
Lauren, why don’t you go first this week?
Weber: I have a doozy of a story from The New York Times titled “‘Hot Wasps’ Found at Nuclear Facility in South Carolina,” by Emily Anthes. Yeah, it’s the stuff of nightmares. It’s all about how wasps became radioactive — four wasps’ nests near a South Carolina nuclear facility.
Huetteman: Yikes.
Weber: If this gave you bad dreams, it definitely did for me. Essentially, what some of the researchers have posited is that wasps could have burrowed in some sort of bad wood or wood that was contaminated or other parts of the area that are contaminated. But this idea that it sounds like something out of Chernobyl, or something like that. But this idea that in the U.S., you could have a nuclear facility that is potentially transforming some of the near-wildlife is concerning in terms of cleanup efforts, and also concerning in terms of contamination control. Clearly, there’s more that needs to be dug into there. Hopefully everyone sleeps after hearing about this.
Huetteman: Woof, yeah. I might need to take an Ambien tonight. Sandhya, how about you go next?
Raman: My extra credit is from me in Roll Call. It’s my last dispatch from my reporting trip in Sweden earlier this year. And it’s called “Sweden’s Push for Smokeless Products Leads Some To Wonder About Risks.” It looks a little bit at some of the public health impacts as Sweden has really tried to reduce their smoking rate to become smoke-free. The U.S. is also at a low from smoking. Some of the things that public health experts are thinking about as people shift to other products and how they’re able to message to the remaining smokers that are not willing to give that up still.
Huetteman: Awesome. Thanks for telling us about your work there. And Sarah?
Karlin-Smith: I looked at a story from Slate, “Confessions of a Welfare Queen: I Study Poverty for a Living, and I Never Thought I’d Need Medicaid. Then My Child Was Diagnosed With a Terminal Illness,” by Maria Kefalas. It’s a personal story from a mother whose family needed Medicaid when their young child was diagnosed with an illness that was going to severely require intense medical care and limit her lifespan. They were able to take advantage of what are known as “Katie Beckett waivers” that were instituted by Ronald Reagan to allow states to voluntarily allow higher income requirements so that people could get Medicaid and care for their children at home. The original girl it was named for was otherwise basically going to be stuck living her life, and she lived until 34, in a hospital.
The purpose of the story is really to point out that now that the “Big, Beautiful Bill” has passed and there are $1 trillion in spending cuts to Medicaid, that these are some of the sorts of people and programs, because it is not a mandatory program, that may unfortunately be on the first for the chopping block. I think the piece does a good job of pointing out, while there’s been a lot of rhetoric around the people who are going to get hurt by this are people that are not working or somehow abusing the system, and the mother does a pretty good job of talking about how both she and her husband continue to work. Most of the families that need this program, to the extent they can, want to keep working. You just get a really human picture of the type of people that are at risk of losing services.
Huetteman: Yeah, for sure. It’s a really illuminating story. Thanks for talking about it. My extra credit this week is from my colleagues here at KFF Health News. The headline is “New Medicaid Federal Work Requirements Mean Less Leeway for States.” It’s by Katheryn Houghton and Bram Sable-Smith.
They report that at least 14 states are in progress designing their own work requirement programs. But now, with the passage of Trump’s law last month, which institutes federal work requirements, those states must make sure that their programs meet federal standards. In some cases, the states are actually going even further than federal requirements, my colleagues report. For instance, Arizona state law would institute a five-year lifetime limit on Medicaid coverage for “able-bodied adults.”
OK, that’s this week’s show. Thanks as always to our producer-engineer, Francis Ying, and to Stephanie Stapleton, our editor this week. If you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review; that helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on LinkedIn. Where are you guys these days? Sandhya?
Raman: I’m on X and Bluesky @SandhyaWrites.
Huetteman: Sarah?
Karlin-Smith: A little bit of everywhere, but X, Bluesky, LinkedIn @SarahKarlin or @sarahkarlin-smith.
Huetteman: And Lauren?
Weber: I’m at X and Bluesky @laurenweberhp. Yes, the HP is for “health policy.”
Huetteman: We’ll be back in your feed next week. Until then, be healthy.
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