The Host

Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

Read Julie's stories.

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

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

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

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

Panelists

Rachel Nuzum
The Commonwealth Fund

Berenice Núñez Constant
AltaMed Health Services

Anish Mahajan
Los Angeles County Department of Public Health

Click to open the transcript

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

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. We have a special episode today, direct from the annual meeting of the Association of Health Care Journalists in Los Angeles, where I moderated a panel called “Shock and Awe in Federal Health Policy,” featuring some pretty impressive guests. This was taped on Friday, May 30, at 1 p.m. Pacific time. As always, things might have happened by the time you hear this. So, here we go. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Núñez Constant: Unsatisfactory immigration status. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: NIH funding never used to be political. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Unidentified speaker: That’s very kind. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

USE OUR CONTENT

This story can be republished for free (details).

At the Department of Homeland Security, a man was led off the elevator in handcuffs.

But the area housing the regional office of the Department of Health and Human Services was eerily quiet.

In March, HHS announced it would close five of its 10 regional offices as part of a broad restructuring to consolidate the department’s work and reduce the number of staff by 20,000, to 62,000. The HHS Region 2 office in New York City, which has served New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands, was among those getting the ax.

Public health experts and advocates say that HHS regional offices, like the one in New York City, form the connective tissue between the federal government and many locally based services. Whether ensuring local social service programs like Head Start get their federal grants, investigating Medicare claims complaints, or facilitating hospital and health system provider enrollment in Medicare and Medicaid programs, regional offices provide a key federal access point for people and organizations. Consolidating regional offices could have serious consequences for the nation’s public health system, they warn.

“All public health is local,” said Georges Benjamin, executive director of the American Public Health Association. “When you have relative proximity to the folks you’re liaising to, they have a sense of the needs of those communities, and they have a sense of the political issues that are going on in these communities.”

The other offices slated to close are in Boston, Chicago, San Francisco, and Seattle. Together, the five serve 22 states and a handful of U.S. territories. Services for the shuttered regional offices will be divvied up among the remaining regional offices in Atlanta, Dallas, Denver, Kansas City, and Philadelphia.

The elimination of regional HHS offices has already had an outsize impact on Head Start, a long-standing federal program that provides free child care and supportive services to children from many of the nation’s poorest families. It is among the examples cited in the lawsuit against the federal government challenging the HHS restructuring brought by New York, 18 other states, and the District of Columbia, which notes that, as a result, “many programs are at imminent risk of being forced to pause or cease operations.”

The HHS site included a regional Head Start office that was closed and laid off staff last month. The Trump administration had sought to wipe out funding for Head Start, according to a draft budget document that outlines dramatic cuts at HHS, which Congress would need to approve. Recent news reports indicate the administration may be stepping back from this plan; however, other childhood and early-development programs could still be on the chopping block.

Bonnie Eggenburg, president of the New Jersey Head Start Association, said her organization has long relied on the HHS regional office to be “our boots on the ground for the federal government.” During challenging times, such as the covid-19 pandemic or Hurricanes Sandy and Maria, the regional office helped Head Start programs design services to meet the needs of children and families. “They work with us to make sure we have all the support we can get,” she said.

In recent weeks, payroll and other operational payments have been delayed, and employees have been asked to justify why they need the money as part of a new “Defend the Spend” initiative instituted by the Elon Musk-led Department of Government Efficiency, created by President Donald Trump through an executive order.

“Right now, most programs don’t have anyone to talk to and are unsure as to whether or not that notice of award is coming through as expected,” Eggenburg said.

HHS regional office employees who worked on Head Start helped providers fix technical issues, address budget questions, and discuss local issues, like the city’s growing population of migrant children, said Susan Stamler, executive director of United Neighborhood Houses. Based in New York City, the organization represents dozens of neighborhood settlement houses — community groups that provide services to local families such as language classes, housing assistance, and early-childhood support, including some Head Start programs.

“Today, the real problem is people weren’t given a human contact,” she said of the regional office closure. “They were given a website.”

To Stamler, closing the regional Head Start hub without a clear transition plan “demonstrates a lack of respect for the people who are running these programs and services,” while leaving families uncertain about their child care and other services.

“It’s astonishing to think that the federal government might be reexamining this investment that pays off so deeply with families and in their communities,” she said.

Without regional offices, HHS will be less informed about which health initiatives are needed locally, said Zach Hennessey, chief strategy officer of Public Health Solutions, a nonprofit provider of health services in New York City.

“Where it really matters is within HHS itself,” he said. “Those are the folks that are now blind — but their decisions will ultimately affect us.”

Dara Kass, an emergency physician who was the HHS Region 2 director under the Biden administration, described the job as being an ambassador.

“The office is really about ensuring that the community members and constituents had access to everything that was available to them from HHS,” Kass said.

At HHS Region 2, division offices for the Administration for Community Living, the FDA’s Office of Inspections and Investigations, and the Substance Abuse and Mental Health Services Administration have already closed or are slated to close, along with several other division offices.

HHS did not provide an on-the-record response to a request for comment but has maintained that shuttering regional offices will not hurt services.

Under the reorganization, many HHS agencies are either being eliminated or folded into other agencies, including the recently created Administration for a Healthy America, under HHS Secretary Robert F. Kennedy Jr.

“We aren’t just reducing bureaucratic sprawl. We are realigning the organization with its core mission and our new priorities in reversing the chronic disease epidemic,” Kennedy said in a press release announcing the reorganization.

Regional office staffers were laid off at the beginning of April. Now there appears to be a skeleton crew shutting down the offices. On a recent day, an Administration for Children and Families worker who answered a visitor’s buzz at the entrance estimated that only about 15 people remained. When asked what’s next, the employee shrugged.

The Trump administration’s downsizing effort will also eliminate six of 10 regional outposts of the HHS Office of the General Counsel, a squad of lawyers supporting the Centers for Medicare & Medicaid Services and other agencies in beneficiary coverage disputes and issues related to provider enrollment and participation in federal programs.

Unlike private health insurance companies, Medicare is a federal health program governed by statutes and regulations, said Andrew Tsui, a partner at Arnall Golden Gregory who has co-written about the regional office closings.

“When you have the largest federal health insurance program on the planet, to the extent there could be ambiguity or appeals or grievances,” Tsui said, “resolving them necessarily requires the expertise of federal lawyers, trained in federal law.”

Overall, the loss of the regional HHS offices is just one more blow to public health efforts at the state and local levels.

State health officials are confronting the “total disorganization of the federal transition” and cuts to key federal partners like the Centers for Disease Control and Prevention, CMS, and the FDA, said James McDonald, the New York state health commissioner.

“What I’m seeing is, right now, it’s not clear who our people ought to contact, what information we’re supposed to get,” he said. “We’re just not seeing the same partnership that we so relied on in the past.”

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its newsletters here.

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

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

Read Julie's stories.

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

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

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

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

Panelists

Anna Edney
Bloomberg News

@annaedney

@annaedney.bsky.social

Read Anna's stories.

Maya Goldman
Axios

@mayagoldman_

@maya-goldman.bsky.social

Read Maya's stories

Sandhya Raman
CQ Roll Call

@SandhyaWrites

@SandhyaWrites.bsky.social

Read Sandhya's stories.

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned in this week’s podcast:

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

click to open the transcript

Transcript: Cutting Medicaid Is Hard — Even for the GOP

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 8, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via a videoconference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Great to be here. 

Rovner: And Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

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

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

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

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

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

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

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

Goldman: Yeah. 

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

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

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

Goldman: And President Trump has said that as well. 

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

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

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

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

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

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

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

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

Edney: That’s where. 

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

Edney: Right. 

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

Edney: Yeah. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: We’re importing other countries’— 

Edney: —prices. 

Rovner: —price limits. 

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

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

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

Goldman: If I’m remembering— 

Rovner: But I think they won. 

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

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

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

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

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

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

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

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

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

Raman: From both sides— 

Rovner: Go ahead, Sandhya. 

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

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

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

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

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

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

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

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

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

Rovner: He hasn’t yet. 

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

Rovner: Face-saving for Kennedy or for Cassidy? 

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

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

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

Lauren Sausser: Thank you. Thanks for having me. 

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

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

Rovner: And how big was the bill? 

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

Rovner: Which is a lot. 

Sausser: A lot. 

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

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

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

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

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

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

Rovner: So what eventually happened with this bill? 

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

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

Sausser: Right. 

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

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

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

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

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

Sausser: Thank you. 

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

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

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

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

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

Edney: “Creative” is a nice word. 

Rovner: Sandhya. 

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

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

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

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

Rovner: Anna. 

Edney: X and Bluesky, @annaedney. 

Rovner: Maya. 

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

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

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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

Members of Congress are back in Washington this week, and Republicans are facing hard decisions on how to reduce Medicaid spending, even as new polling shows that would be unpopular among their voters.

Meanwhile, with President Donald Trump marking 100 days in office, the Department of Health and Human Services remains in a state of confusion, as programs that were hastily cut are just as hastily reinstated — or not. Even those leading the programs seem unsure about the status of many key health activities.

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.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories.

Among the takeaways from this week’s episode:

• How and what congressional Republicans will propose cutting from federal government spending is still up in the air — one big reason being that the House and Senate have two separate sets of instructions to follow during the budget reconciliation process. The two chambers will need to resolve their differences eventually, and many of the ideas on the table could be politically risky for Republicans.
• GOP lawmakers are reportedly considering imposing sweeping work requirements on nondisabled adults to remain eligible for Medicaid. Only Georgia and Arkansas have tried mandating that some enrollees work, volunteer, go to school, or enroll in job training to qualify for Medicaid. Those states’ experiences showed that work requirements don’t increase employment but are effective at reducing Medicaid enrollment — because many people have trouble proving they qualify and get kicked off their coverage.
• New reporting this week sheds light on the Trump administration’s efforts to go after the accreditation of some medical student and residency programs, part of the White House’s efforts to crack down on diversity and inclusion initiatives. Yet evidence shows that increasing the diversity of medical professionals helps improve health outcomes — and that undermining medical training could further exacerbate provider shortages and worsen the quality of care.
• Trump’s upcoming budget proposal to Congress could shed light on his administration’s budget cuts and workforce reductions within — and spreading out from — federal health agencies. The proposal will be the first written documentation of the Trump White House’s intentions for the federal government.

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’ “As a Diversity Grant Dies, Young Scientists Fear It Will Haunt Their Careers,” by Brett Kelman. 

Joanne Kenen: NJ.com’s “Many Nursing Homes Feed Residents on Less Than $10 a Day: ‘That’s Appallingly Low’” and “Inside the ‘Multibillion-Dollar Game’ To Funnel Cash From Nursing Homes to Sister Companies,” by Ted Sherman, Susan K. Livio, and Matthew Miller. 

Alice Miranda Ollstein: ProPublica’s “Utah Farmers Signed Up for Federally Funded Therapy. Then the Money Stopped,” by Jessica Schreifels, The Salt Lake Tribune.  

Margot Sanger-Katz: CNBC’s “GLP-1s Can Help Employers Lower Medical Costs in 2 Years, New Study Finds,” by Bertha Coombs.  

Also mentioned in this week’s podcast:

• MedPage Today’s “Trump Order Targets Med School, Residency Accreditors Over ‘Unlawful’ DEI Standards,” by Cheryl Clark.
• Stat’s “Despite Kennedy’s Stated Support, Funding for Women’s Health Initiative Remains in Limbo,” by Elizabeth Cooney.
• CBS News’ “FDA Head Falsely Claims No Scientists Laid Off, as Agency Shutters Food Safety Labs,” by Alexander Tin.
• The New York Times’ “F.D.A. Scientists Are Reinstated at Agency Food Safety Labs,” by Christina Jewett.

click to open the transcript

Transcript: 100 Days of Health Policy Upheaval

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 1, at 10:30 a.m. As always, news happens fast and things might change by the time you hear this. So, here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: 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, everybody. 

Rovner: Later in this episode we’ll have a special report on the first 100 days of the second Trump administration and what’s happened in health policy. But first, as usual, this week’s news. 

So Congress is back from its spring break and studying for midterms. Oops. I mean it’s getting down to work on President [Donald] Trump’s, quote, “big, beautiful” budget reconciliation bill. For those who may have forgotten, the House Energy and Commerce Committee is tasked with cutting $880 billion over the next decade from programs it oversees. Although the only programs that could really get to that total are Medicare and Medicaid, and Medicare has been declared politically off-limits by President Trump. So what are the options you guys are hearing for how to basically cut Medicaid by 10%, which is effectively what they’re trying to do? 

Sanger-Katz: I think it’s a bit of a scramble to decide. My sense is, there’s been for some time a menu of changes that would pull money out of the Medicaid program. There’s also kind of a small menu of other things that the committee has jurisdiction over. And as far as I can tell, all of the various options on that menu are kind of just in a constant rotation of discussion with different members endorsing this one or that one. The president weighs in occasionally or voices from the White House, but I think the committee is waiting on scores from the Congressional Budget Office, so they have to hit this $880 billion number. And so it’s kind of a complicated puzzle to put together the pieces to get to that number and they don’t know what they need. But I also think that they are facing some really difficult politics inside their own caucus in trying to decide what to do and how they can message it in a way that kind of checks everyone’s boxes. 

There are some people who have made promises to their constituents that they’re not going to cut Medicaid. There are some people who have said that they only want to do things that would target fraud and abuse. There are some people who have said that they want to make major structural changes to the program. And all of those people are sort of disagreeing about the exact mechanisms. 

Rovner: The phrase I keep hearing is that the math doesn’t math. 

Sanger-Katz: Yeah. I also think some of them are going to be surprised when the Congressional Budget Office gives them the scores. I think that the leadership has been reassuring a lot of these members, when they voted on these earlier budget bills that were more vague, more theoretical. I think that there were promises that were made to them that, Don’t worry about this. We’re going to solve your problems. This isn’t going to be a huge political headache for you. And I think the reality is is a) The cuts are going to have to be big. That’s what $880 billion means. And b) I think that they are going to be estimated to have pretty big effects on health insurance coverage, because if you’re going to cut $880 billion from Medicaid, that probably means that fewer people are going to be covered. I think some members are going to be surprised by that. 

And the other thing is, I think they’re going to start to see in the analyses and hear from local people that some states are going to get hit harder than others. I think there are some states that these members come from where the cuts are going to disproportionately fall. Now we could talk more about the options on the menu. I think some of them will hurt some states more and others will hurt other states more. And I think that is part of the politicking and debate that’s happening as well, where each of these legislators is trying to figure out how they can hit this target, keep their promises, and also protect their own districts to the best of their ability. 

Rovner: It seems like one of the things at the top of every Republican’s list that would be quote-unquote “acceptable” would be work requirements. And I heard numbers this week that the CBO is estimating something like more than $200 billion over 10 years in work requirements, which would be pretty strong work requirements. But Alice, you’re our work requirements queen here. We know that the stronger those work requirements are, the more people end up falling off who are still eligible, because most people on Medicaid already work, right? 

Ollstein: Yes. The only places in the country that have implemented work requirements for Medicaid have found that it does not increase employment, but it does kick people off the program who should qualify, either because they are working or they have a legitimate reason, they’re a full-time caretaker, they’re a student, they have a disability to not be able to work, and they lose their coverage anyway because they can’t navigate the bureaucracy. And I think what Margot is really getting to is, the fundamental dilemma that Republicans are facing right now as they try to put this together is that the proposals that are most politically palatable to them, like work requirements, won’t get them anywhere near the amount of money they need to cut, that they’ve promised to cut, that they’ve passed a bill pledging to cut in this space. And so that will mean that other things will have to be considered. 

And again, I feel like I say this every time, but we really have to be paying very close attention to semantics here. What one person considers a cut when they say the word “cut” is not necessarily what all of us would consider a cut. What some people in power are labeling waste, fraud, and abuse is people getting health care under the law legitimately. They think they shouldn’t, but they do. And so I think we really need to scrutinize the exact language people are using here. 

Rovner: There does seem to be kind of a zeroing in on what we call the expansion population, the population that was added to Medicaid under the Affordable Care Act, which were people who were not the traditional welfare moms and kids and people with disabilities and seniors in nursing homes. These were people who were otherwise low-income but didn’t have health insurance, which is kind of the point. That’s why we say most of these people are already working. You’re not going to live on your Medicaid benefits. There’s no cash involved. The cash goes to the people who provide the actual health care or in some cases the insurers. But that seems to be when — you were talking about semantics — you see Republicans talking about protecting the most vulnerable. That sounds like they really do want to go after this expansion population. But Margot, as you said, a lot of this expansion population is in red states, right? 

Sanger-Katz: Yeah. I think there’s another dynamic that’s going on right now that is important to keep track of, which is we’re at the sort of beginning of this process. So both the House and Senate have passed budgets. Those lay out these numbers, and they’ve laid out this very high number. It’s a high threshold for the Energy and Commerce Committee in the House. They have to find this $880 billion. After they do that, the entire House has to vote on the entire reconciliation package, which includes not just these changes to Medicaid but also a series of tax changes, changes to defense and homeland security spending, probably reductions in SNAP [the Supplemental Nutrition Assistance Program] and education funding. Then the whole thing goes to the Senate and the Senate has to do its own version.  

And the budget itself is a very weird document. Usually what you see with these budgets is that what the instructions are for the House and the Senate match. In this case, they do not. So the House still has to find these very large Medicaid cuts that I think will be politically problematic for certain House members. But the Senate actually doesn’t. It’s very unclear what the Senate’s plan is and whether they are going to try to go as far. And so I think it creates a difficult dynamic where I think some of these House members may not want to take a hard vote on major budget cuts, that could be politically costly to them, if it’s not even going to become law. And so I think that there’s a lot of kind of meeting of reality that is happening right now, which I think doesn’t mean that they won’t come up with a plan. It doesn’t mean that they won’t pass a plan, and it doesn’t mean that they won’t pass a plan that will affect those budgets of their home states. 

But I do think that they are in a little bit of a politically uncomfortable position right now, where they’re being asked to vote for something that is going to be unpopular in some quarters and where they don’t even really know if the Senate is going to hold their hand and go along with it. 

Ollstein: Just one point. We talk a lot about red states and blue states, but it’s important to remember that blue states have a lot of districts represented by Republicans, and that’s arguably the reason they even have a House majority. And so if they pass something that really sticks it to New York and California, there’s a lot of Republican House members who might be at risk. 

Rovner: Yes. And they’re already making noise. And that’s what I was going to say. The last time Republicans went hard after Medicaid after the expansion was during the effort to repeal the Affordable Care Act in 2017, obviously, and we have a brand-new poll out today from KFF, shows that, if anything, Medicaid is even more relevant to Republicans than it was eight years ago. Today’s poll found that more than three-quarters of those polled say they oppose major cuts to Medicaid, including 55% of Republicans and 79% of independents. Those are pretty big numbers. I guess it helps explain why we’re seeing so many Republicans who are looking — there’s so much hand-wringing right now when they’re trying to figure out how to get to these numbers. Go ahead, Joanne. 

Kenen: The other thing, it’s not just people who have increasingly, across party lines, grown in their affection for Medicaid, which is paying for all sorts of things. It’s paying for long-term care. It’s paying for almost half the births in this country. It’s paying for postpartum care. It’s paying for kids. It’s paying for the disabled. It is paying for a lot of drug and opioid treatment and substance abuse. It is paying for a lot of things. But in addition to the politics of individuals and families relying on — they call it an entitlement for a reason. People feel entitled to it. But once you give it to them, they don’t want to give it away. And it’s hard for politicians. They don’t want to give it up, and it’s hard for politicians to take it away. But the other thing is it’s also incredibly important to health care providers, specifically hospitals, because nursing homes are not going to get cut the way hospitals are vulnerable. 

Rural hospitals, urban hospitals — this is just a, particularly in areas where hospitals are already closing and rural states, it would be devastating to hospitals. You’re beginning to hear them talk more and more and more. Ultimately, I think this is going to come down to three syllables: Donald Trump. We are hearing all sorts of things, right?. He is really good at getting what he wants in the House, even if it’s politically difficult. Someone says, I can’t vote for it, they go back, Speaker [Mike] Johnson goes back in wherever he goes back with them and they come out and vote for it, right? It can take a day, it can take a few hours, but Trump hasn’t lost anything on the floor on the budget so far. We’ve gotten to this point. If Trump decides that he’s going to bite this bullet and go for the $800 [billion], he can probably get it through the House if he really decides that that’s what he wants. Unless they really convince him that it’ll cost the Republicans in the House, and then he has to believe them. He has to think that he really is vulnerable and that the Republicans can lose. And there’s all sorts of questions about what elections are going look like in two years. 

But I think that the providers, they’re lobbying in ways that we can see and they’re lobbying in ways that we can’t see. So that’s a part of it. And then the other thing is that there’s a really interesting dynamic with the expansion of states. The states that have not expanded Medicaid tend to be mostly, not all, in the South, Republican states. Their people are not covered. The people who fall in the gap are still not covered. So they don’t have such a dog in this fight. But as we’ve already mentioned, places with a lot of working-class Republicans, the irony is to order, to get states to accept Medicaid expansion in the first place under the ACA, the federal government gave a lot of money — 90%, right? There was more originally. They’re still paying 90%. And that cost the federal government a lot, but states don’t want to give that money up. It’s free dollars. 

And another layer of weird dynamics is a lot of the conservative states that did expand Medicaid did so with what they call a trigger. If the payment changes, the Medicaid expansion collapses. It’s gone. So there’s this weird dynamic of the states who were most skeptical of Medicaid expansion, ended up making it safe by putting in those triggers because no one wants to pull or press the trigger. 

Sanger-Katz: Can I say one more thing— 

Rovner: Yes, go ahead. 

Sanger-Katz: —about the state-by-state dynamics? Because I’ve actually been thinking about this a lot and doing a lot of reporting on this. Joanne is a 100% right. There are these states that have these triggers. They are predominantly Republican states. So those are states where, again, you’re going to see a lot of people losing coverage, because the state is just going to automatically pull back on all of the coverage for these working-class people who are getting Medicaid because they have a low income. But that’s not universally the case. I did a story a couple of weeks ago. There are three Republican states that actually have constitutional amendments that they have to cover this population. So even more so than the blue states— 

Rovner: We talked about your story, Margot. 

Sanger-Katz: Yeah? I love it. I love it. But even more so than the blue states, these are states that are really locked in. Those state governments and those state hospitals, to Joanne’s point, are going to face some really, really tough choices if we see the funding go away. And then another option that’s on this menu — and again we don’t know what they’re going to choose — but one possibility that I think a lot of the kind of right-leaning wonks are really pushing is to get rid of something called provider taxes, Medicaid provider taxes. And we don’t need to get into, fully into the weeds of how these work, because they are sort of complicated. But what I will say is that because of the way that Medicaid is financed and because of the history of how these taxes have proliferated and expanded across the country, there are quite a few Republican-led states that would be disproportionately harmed by that policy. 

So I just think all of this is a little messy. I think there’s not an easy way — even setting aside the point that Alice made that of course there are Republican lawmakers from blue states. But even if you’re only concerned about the red states, say you’re only concerned about getting the Senate votes and not the House votes, I still think it’s pretty tricky to come up with one of these policies that’s sort of just taking the money out of states where you don’t need votes. 

Rovner: Well, they’re supposed to, the committee is supposed to, start marking up its bill next week. I am dubious as to whether that is actually going to happen on time, but we shall see. Obviously much more on this to come. But I want to move on to news from the Trump administration. Last week we talked about threatening letters sent by the interim U.S. attorney in Washington, D.C., to some major medical journals, including the New England Journal of Medicine. This week we have another story from our friends over at MedPage Today about the administration going after medical student and residency accreditation agencies for their DEI [diversity, equity, and inclusion] efforts, because both organizations have long had robust programs to require medical schools and residency programs to recruit and retain racial and ethnic minorities who are underrepresented in medicine. Now, this isn’t about being woke. Racial and ethnic representation in the health care workforce is an actual health care issue, right? 

Kenen: There’s data. There’s a fair amount of data that shows that this kind of representation, patients having providers that they feel can identify with and understand them and come from a similar background. They’re not always a similar background, but there’s this perception of shared understanding. And there’s a ton of data. Not one or two little studies. There’s a ton of data that it actually improves outcomes. I’m actually working on a piece about this right now, so I’ve just read a bunch of it. 

Rovner: I had a feeling you would know this. 

Kenen: And it’s been pointed out, there was some research in The Milbank Quarterly, too. And I should disclose that Milbank is one of my funders at Hopkins, but they don’t control what I do journalistically. When the courts ruled against DEA in admissions, DEI in admissions, they were looking at sort of the intake, who comes in. And they really weren’t looking at the data of what happens to health care when the workforce is diverse. So there’s a lot of numbers on this, and they looked at one set of numbers and they didn’t look at another pretty solidly researched for many years, like: What is the impact on patients and what is the impact on American health? So if you’re talking about making America healthy again and you want everybody to be healthy, there’s really a good case to be made for a diverse, a competent, well-trained — we’re not talking about letting people in because they’re a token but getting people in who could become qualified doctors, nurses, respiratory therapists, whatever, right? And that data was sort of ignored. The outcomes, the down-the-road impact on health was ignored in that court case. 

Rovner: Also, the practical implications of this are kind of terrifying. Yanking accrediting responsibilities from these groups could make a big mess out of training the health care workforce. These groups have decades of experience devising and enforcing guidelines for medical education, much more than just DEI — what you have to teach, what they have to learn, what they have to be competent in. If the administration takes away these organizations’ recognition, it could raise real questions about the uniformity of medical education around the U.S., not to mention deprive lots of programs of lots of federal funding, because programs have to be accredited in order to draw federal funding. This could turn into a really big deal. 

Kenen: If they go away, what happens? 

Rovner: There would be alternate accrediting bodies. 

Kenen: But I have — when I read about the threats on the current accreditation bodies, I did not see, in what I read last night, I did not see: Then what? That blank was not filled in as far as I am aware. 

Rovner: I don’t think there is a then what. There are some efforts to stand up alternate accrediting bodies, but I don’t think they exist at the moment. And as I said, these are the bodies that have been doing it for now generations of medical students and medical residents. All right, well we also learned this week that the Government Accountability Office, the GAO is investigating 39 different cases of potentially illegal funding freezes, except the agency’s director told a Senate committee, the administration is not cooperating. I think I’ve said this just about every week since February, but there is a law against the administration refusing to spend money appropriated by Congress. And it feels pretty clear in many of these cases that the administration is violating it. 

Why aren’t we hearing more about impoundments and rescissions? The administration says they’re going to send up a rescission request, which is what they are supposed to do when they don’t want to spend money. They have to say: Hey, Congress, we don’t think we should spend this money. Will you vote to let us not spend this money? And yet all we do is talk about all of these cases where the administration is not spending money that’s been appropriated. 

Ollstein: You’re seeing it in grants, and you’re also seeing it in the mass layoffs of agency employees who are in many cases working on congressionally mandated programs, some of them signed into law by President Trump himself in his first term. I’m thinking of the 9/11 health program, some of the firefighter health and safety programs through NIOSH [the National Institute for Occupational Safety and Health]. So this is something I’ve been looking into. But when the enforcement mechanism is really the court’s rule and hope that the rulings are followed, and when they’re not, we’re really running into what people are calling a constitutional crisis, where the normal checks and balances are not working. And we’re finding out that a lot of it has really been on an honor system this whole time. 

Rovner: Margot. 

Sanger-Katz: I was just going to say, I think this is a huge constitutional issue that this administration is facing down. There’s this question about who gets to decide how the money is spent? The Constitution seems to say that it’s Congress. The administration is saying, no, the executive has a lot of authority to just ignore those appropriations requests. There are several cases in the courts right now on this issue related to various programs that the administration has declined to fund. But courts move pretty slowly. There have been some preliminary rulings. I think the preliminary rulings have tended to say that the money should be continuing to flow. But this is one of these issues that is absolutely a thousand percent headed to the Supreme Court and hasn’t gotten there yet. And I think the intensity of the constitutional crisis that Alice is warning about will really become more evident when the court decides. 

But I feel like I can’t talk about this issue without also talking about Congress. Because the Constitution is very clear that Congress has the power of the purse. And Congress has passed these appropriations bills over many years that include very specific funding levels. There’s a whole process. There’s a lot of people that do a lot of work. And Congress has been very weak in asserting its constitutional authority to ensure that this money is spent. We have heard very little, a few little peeps about specific things. But in general I would say the congressional leadership, and the leaders of the Appropriations Committee who have made this their lives’ work, have just not been screaming and yelling and jumping up and down about how their constitutional power has been usurped by the executive. 

And so I think that is also part of the reason why this is continuing to go on, because you see this acquiescence where Republicans in Congress are basically saying to Trump: Okay. Like, please send us a rescission package, but like we’ll go along with this for now. So I do think that we’re sort of waiting on the Supreme Court to try to issue some really definitive legal ruling, and that that is when we’re going to probably have the bigger conversation about who really gets to decide what money is spent. 

Kenen: Susan Collins, who’s the chairman of the Senate Appropriations Committee, did put out a statement yesterday that is stronger than her usual, what we’ve heard to date. But it wasn’t a line in the sand, like, I’m not going let you do this, and I’m going to go to the Supreme Court. So it was more of a toe in the water than I had seen from her before. 

Rovner: I watched that hearing, because I wanted to. This was the first hearing in the Senate Appropriations Committee this year, so the first time they’ve had a formal chance to speak. And it was on biomedical research and the state of biomedical research. And I was the one that was yelling and screaming because neither Susan Collins nor Patty Murray, the ranking Democrat, they both talked about how terrible these cuts are, without saying that they could do something about it. It’s like, you’re the Senate Appropriations Committee. This is your power that they’re taking away, and you’re both saying this is awful without suggesting that You’re taking this from us. So I got a little bit of exercise just watching it. 

Kenen: They put out a statement highlighting— 

Rovner: I know. I heard her, listened. She read the statement. 

Kenen: But what they, how they framed it in the statement was a little bit more pointed. But no, I agree it was not a call to arms. 

Rovner: No. 

Kenen: It was a statement that I hadn’t seen yet. 

Rovner: I watched it live. It didn’t come across as: Hey, this is our responsibility. We passed these bills. You’re supposed to spend this money. I’ve seen a little bit of that coming from the House. I was surprised to not see it coming more from the Senate. We do have to move on. Meanwhile, HHS [Department of Health and Human Services] Secretary Robert F. Kennedy Jr. continues to make headlines for his questionable takes on science and medicine. In an interview this week on the “Dr. Phil” show, Kennedy said that parents, quote, should do their “own research” before having their children vaccinated. And he said that, quote, “new drugs are approved by outside panels,” which they most certainly are not. Those outside panels make recommendations that the FDA [Food and Drug Administration] usually follows but sometimes doesn’t. Yet there’s still not much in the way of opprobrium coming from Republicans inside and outside the administration. Is it just not news anymore when the secretary of health and human services says kind of outlandish and false things? Is it baked in? 

Kenen: Well, we’re waiting. So far. They approved him, and Sen. Bill Cassidy of Louisiana said, I’m going to be in close contact with him, and we’re going to be talking, and I’m going to make sure nothing terrible happens. And lots of things have happened. So at this point, yeah, he’s doing what he wants without — they have said they are going to call him, but I haven’t seen a date set for the hearing. 

Rovner: There’s not a date set for the hearing. 

Kenen: Right. So at some point, at some place, he will eventually be asked about something or other maybe. But at this point, no. He’s MAHA-ing his way through HHS and cuts galore and really things that they were started before he took his job, stuff that Elon Musk started. But now that the team of FDA, C— well, not CDC [the Centers for Disease Control and Prevention] but FDA and NIH [National Institutes of Health] leadership is there, it’s going Kennedy’s way. They’re not standing up and saying, It’s my institute, and I’m going to run it the way I see fit. It’s very, particularly FDA, people who thought that he was the least radical of the officials to be appointed. 

Rovner: He, Marty Makary, the FDA commissioner. 

Kenen: Yes. Some of what he said about vaccines just this week has shocked people who thought he would be a little bit more, not a traditionalist but more traditional in how the FDA did its business. 

Rovner: More science-based, might be a fair way to put it. Well, I want to talk about the continuing cuts at HHS because things are, in a word, confusing. Last week we talked about the cancellation of the Women’s Health Initiative. That’s a decades-old project that has led to a long list of changes in how women are diagnosed and treated for a wide range of conditions. Late in the week, former California first lady and longtime women’s health advocate Maria Shriver announced on social media that she convinced her cousin, RFK Jr., not to cancel the study. But this week Stat reports that Women’s Health Initiative officials around the country have not been officially notified that the cancellation has been rescinded, so they’re kind of frozen in place and can’t really plan anything. 

Similarly, on April 25, The New York Times reported that the FDA had reversed a decision to fire scientists at its food safety lab. But that was days after FDA Commissioner Marty Makary insisted that no scientists had been terminated. Quoting from the CBS News story on Makary’s claims, quote: “‘That just made me so mad … he said no scientists were cut,’ said one laid-off FDA scientist, a chemist who had worked at the agency for years.’” Which kind of leads to the question: Are they just confused at HHS, or are they trying to sort of obfuscate what’s really happening there? I’m hearing department-wide about claims made by spokespeople about funding that’s been, quote, “restored” but that’s still not flowing, according to the people who are trying to get it. Margot, I see you nodding. 

Sanger-Katz: I think there’s just a great deal of confusion. There’s a lot of people missing, too. So I think that just some of the kind of basic mechanics of how you turn things on and off is a little bit broken. But I also think that there are disagreements among the decision-makers about what they want to turn on and off. And we have seen this throughout the Trump administration, not just at HHS but in other places where top officials have said that they’re going to restore funding that was cut or a court has ordered them to restore funding that has been cut, and then, lo and behold, the money doesn’t turn back on. So I just think there’s — this is why it’s a good time to be a journalist. I think it really bears a lot of reporting and follow-up and checking on whether they’re doing the things that they say they’re doing. Some of these things might just be confusion — it’ll take a minute. And some of them, maybe they’ve changed their minds. 

Kenen: Or like the AID [U.S. Agency for International Development] global AIDS money, which they said they were restoring, and it’s questionable still. It’s unclear how much. We certainly know not all of it’s been restored, and it’s unclear. I haven’t done any firsthand reporting on this, but from reading, it’s just uncertain how much. Some is getting through but not what they said they were going to do. I sent an email to some at the CDC yesterday asking, and I had to say: Excuse me. I’m not being facetious. It’s just hard to keep track. Is your division still there? So yes, he was still there. I couldn’t find a master list of which CDC departments are still functioning and which are not. What Elon Musk said was, We’re going to move fast and break things, which is the Silicon Valley mantra, and that We can always fix it. We’ve seen them moving fast, and we’ve seen them breaking things, but we’re waiting on the fixing it. 

Ollstein: And I think it’s been interesting that Secretary Kennedy has said publicly now, on more than one occasion, that these cuts, these program eliminations, certain ones are a mistake. He didn’t even know they happened. He said this in interviews. And then with some of the ones that they’re claiming, they’re restoring, the national firefighters union, the IAFF [International Association of Fire Fighters], said that when they met with HHS leadership, they were told that the HHS blamed mid-level bureaucrats for incorrectly canceling some of these programs. All of this sort of begs the question: Who’s in charge over there? Who’s making these decisions? Is the secretary even in the loop on them? Is this all coming from DOGE [the Department of Government Efficiency]? Yeah, and so I think Margot’s absolutely right about we just really need to keep reporting and not take what they say at face value. And we should do that for any administration. 

Sanger-Katz: The president is scheduled — any day now, we don’t know — to release his, what they’re calling the skinny budget. So this is a document from the White House that says what their spending priorities are for the next fiscal year. We think it’s just going to deal with discretionary spending, but I think it will give us some really good clues about what parts of the various cuts in HHS and other parts of the government were sort of part of the plan or will continue to be part of the plan going forward and which of the cuts were made randomly or haphazardly or at the behest of someone who hadn’t talked to the White House. I definitely am very interested to see that document when it comes out, because I think it is the first time that we’ll really see, written down in one place, what it is that the White House is intending to cut in the federal government. 

Rovner: Yeah, the appropriations committees are very interested in seeing that document, too, so they say. Also the other thing that getting a budget will trigger is having to have some of these people come to Capitol Hill to justify their budget and having Congress get a chance to ask questions. 

Finally, in this week’s news, we haven’t talked about abortion in a while. Not that there isn’t news there, it’s just been eclipsed by all of the bigger news. So I want to catch up. Well, speaking of funding being restored, Alice, you were the first to report that the Trump administration has quietly resumed Title X family planning funding to Oklahoma and Tennessee, even while it’s still frozen for some other states. Not so coincidentally, Oklahoma and Tennessee had their Title X money cut off during the Biden administration, because they were out of compliance with the Title X rules requiring women with unintended pregnancies to be counseled on all of their options, including pregnancy termination. I guess this shouldn’t be surprising except for the fact that the grant notices to these states said the money was being restored pursuant to settlement agreements that apparently don’t exist? 

Ollstein: Yes, these states are still not complying with the Title X requirements. That’s what they went to court about. Those cases have not been settled. These states weren’t even expecting this money and were surprised about it and now have to come up with how to actually administer it, because the money was going to other groups in those states that were providing services. And so, it’s really thrown everyone for a loop. And this is coming at a time when grants for a lot of other Title X providers who say they are following the rules have been indefinitely frozen. They’re allegedly being investigated for violating orders on DEI and immigration, but they have heard nothing about where that investigation stands, whether the money is coming. And in the meantime, a lot of people, hundreds of thousands, according to the National Family Planning and Reproductive Health Association, that represents all these providers, are said to lose services. And again, this is access to birth control for low-income people, STI [sexually transmitted infection] testing, a lot of things people need. 

Rovner: So, when we last visited Texas, abortion opponents and women who’d had pregnancy complications were fighting over a bill that was supposed to clarify that the state’s 2022 ban would allow pregnancy terminations in emergency medical situations. Well, apparently they reached a rapprochement, because the Texas Senate this week passed a bill by a 31-0 vote. Alice, what broke the logjam? And will this bill ultimately get signed by the governor? Is there a deal here? 

Ollstein: Well, we’ll have to see. Medical experts have been very skeptical about the provisions here and don’t trust Texas lawmakers to have patients’ best interest in mind, given the impact of previous policies on this front. And so just given the makeup of the state legislature and the officials in power, it’s definitely very possible it will become law. There could be court challenges. We’ll just have to see how it plays out. 

Rovner: Well, this is obviously not any kind of sign that Texas is going soft on abortion, because the Senate also this week passed a bill that would basically extend the state’s bounty hunter abortion law, that lets private individuals sue doctors or others who help people get abortions, would extend that to manufacturers, mailers, and deliverers of abortion pills. Alice, this would be a pretty big step in the state’s efforts to curtail abortions, right? 

Ollstein: Yeah, I think we should think about bills like this like a lot of other bills that are already in place, in that it’s not possible to fully enforce them. It’s not possible to prevent — short of opening everyone’s mail and surveilling everyone in the state — it’s not really possible to prevent medication abortion being mailed. And in the case that’s already in court about a New York doctor who is providing pills to patients in Texas and other states under a shield law, New York has said: We are not turning over this doctor. We are not going to enforce. What she’s doing is legal in our state. It’s legal in the place where she is doing the action, so you can’t have her. 

So I think the main issue here is the chilling effect. It’s a law that makes people more afraid potentially to go and order these pills online or over the phone. And so they’re hoping that that deters people, because, I think, it’s totally possible that, like the New York doctor, we’ve already seen, they pick a few cases to make an example of people and to further that chilling effect, because it’s not possible to go after everybody. 

Sanger-Katz: It just really highlights, I think, the challenges of President Trump’s approach to this issue, which is, he basically said: Let’s just leave it to the states. Let’s not have a lot of federal policy on abortion. Now, there are things that are being done through the Title X funding and everything that affect reproductive health. But in general, there just does not seem to be an appetite for big sweeping regulations that would make abortion substantially harder to get everywhere or any kind of law that would ban or restrict abortion nationwide. And the problem is is if you’re a Texas legislator and you were trying to prevent abortions in Texas, it’s a really frustrating situation, because the state boundaries are just so porous. And particularly because of these abortion pills that can be easily smuggled in through various ways, through mail or someone walking across the border or someone going and coming back, there are still a lot of abortions that are happening in Texas. 

And so I think if you’re someone whose public policy goal is to restrict or stop abortions in Texas, you start having to have to think creatively about even some of these kinds of enforcement mechanisms that, as Alice said, are kind of hard to achieve and probably are going to have a selective enforcement approach. But I think they just haven’t really been able to achieve their goals. And you look at the national abortion statistics and when you look at some of the data on even the state of residency of people who are getting abortions of various types, there just haven’t been big declines. Even in Texas, even in this very big state that has very restrictive laws, there are a lot of women from Texas who are continuing to get abortions. And I think that’s why we’re seeing the state legislature continue to reach for more ambitious ways to curtail it. 

Rovner: Yes. Much to the frustration of the people who are making the anti-abortion laws in Texas. All right. That is this week’s news. Now I want to spend a few minutes trying to synthesize all that’s happened in health policy in the now 102 days since Donald Trump began his second term. I’ve asked each of the panelists to give us a just quick summary of some specific topics. Joanne, why don’t you kick us off with how public health has changed in these last couple of months? 

Kenen: Yeah. Basically if you — when I started writing it down, I couldn’t fit it on a page. If you name anything in public health, it’s been cut or reduced or put in jeopardy. We’ve talked extensively about what’s going on. And by public health, I’m talking about federal down to cities, because they’ve lost their money. So, whether you’re in a red state or a blue, you have less to spend, you’re not allowed to talk about certain things. HIV money has been affected. Global health has been affected. Obviously measles — we did not have whatever the number of measles cases, I believe it’s over a thousand by now. I haven’t seen the last number. Data has vanished. And that data, there are some nonprofits that are trying to collate it and make it available, but years and years and years of data, which was the foundation of data-based, reality-based, and measuring gains and losses in public health, that’s been obliterated. Things are being stopped at NIH. That’s the future of public health, right? 

If you’re stopping training, if you’re stopping universities, if you’re stopping postdocs, if you’re stopping graduate school funding, that’s not just public health today but public health as far as we can see in the future. The anti-smoking, anti-tobacco-use, the suicide helpline is in danger. Mental health, opioid treatment is being rolled back. Pretty much if you think of public health, it’s really hard to think of anything that has not been affected. 

Rovner: Thank you. That was a pretty good summation. Margot, if you had to write a one-page elementary school book report on DOGE and what’s happened at HHS, what would it be? 

Sanger-Katz: Well, I think it’s highly overlapping with a lot of what Joanne was talking about. I think we’ve seen these outsiders who came into the government and just started kind of hacking and slashing. They have eliminated a lot of functions of HHS that have existed for a really long time, not just individual people who have lost their jobs but whole offices that have disappeared, whole functions that existed for a long time and don’t exist anymore. I do think — I was talking about the skinny budget — we’re going to find out the president’s plan for this. I will give Secretary Kennedy some credit for releasing a sort of blueprint for what his goals were in trying to reorganize HHS. It seemed like they did have an idea in some cases of what they were trying to do — consolidate duplication, centralize certain functions, de-emphasize and reemphasize other priorities. 

Rovner: Cut NIH from 27 institutes to eight. 

Sanger-Katz: Right. Eliminate regional offices in various ways. But I think it is worthwhile to think about the DOGE effort in terms of what its goals are and whether those goals are really aligned with particular goals around health policy. In some cases, I do think Secretary Kennedy has directed them to do things that are in line with his goals for health policy, but I think a lot of this cutting was really just cutting for cutting’s sake, trying to hit certain budgetary target numbers, trying to reduce funding to some percentage of contracts, some percentage of grants. And of course, there has also been, from the White House, a desire to target particular political enemies of the president. So we’ve seen, all the NIH grants canceled to universities where he’s having feuds over other issues, huge categories of research funding just drying up because they’re at odds with various political priorities of the president. 

So there are multiple power centers that are all kind of wrestling over this future of HHS. You have the secretary himself, you have the White House, and you have this DOGE entity, which was kind of on the outside now and now is on the inside. And I think part of what we have seen is a real wrestling around that. And just very, very large reductions across all of the functions of what the department does. 

Kenen: Some of these things that Margot and I are talking about do have, in fact — they’re about chronic disease. So if Kennedy is trying to reorient our health system to fight chronic disease, then why are you cutting diabetes programs and why are you cutting long-term women’s health studies? These are chronic disease. Diabetes is the great example of a chronic disease that we really could do better on prevention, making sure people don’t get it. But not everybody — we could make gains there. And yet some of these key programs that are supposedly in line with his priorities are also on the cutting-room floor. And I will stop there. 

Rovner: And I have said, and I made this point before, but I will make it again here because I think it’s relevant, which is that I feel like HHS is part of the Jenga tower that holds up the nation’s health care system writ large, and that they’re kind of yanking pieces out willy-nilly. And I do worry that the whole thing is going to come crumbling down at some point. Obviously it hasn’t yet, but we’re going to see what happens when they take away a lot of these things. Like I said, yanking the ability of accreditation agencies to do their jobs, things that happen in the background that are going away, that won’t happen anymore. And we’re going to have to see what happens with that. 

Sanger-Katz: And I do think some of this really long-term research, both the collection of government data and also the funding of these very large longitudinal studies, I think those are the kinds of cuts that you don’t really see the effects of those right away. It’s the things that you don’t know in the future. And I think that we see a lot of cuts of that sort, where you see the DOGE team come in and they say: Oh, data. Oh, analysis. Like, we can do this better with our own tools. We have technical expertise. We don’t need this whole office of people that are doing data. And across the government, you’re seeing this real loss of long-term data collection and analysis, data sets and studies and surveys that have been conducted for decades, and there are just going to be holes in those. And we may not know the effects of those losses for some time. 

Rovner: I think that, too. Well, Alice, I don’t want to leave without touching on reproductive health. I’m actually a little surprised at all this administration has not done on abortion, as Margot was talking about, and other reproductive issues. So what have they done? 

Ollstein: Yeah, so I kind of have organized my thoughts into three buckets. So, it’s things they’ve done that the anti-abortion movement likes, things that the anti-abortion movement wants them to do that they haven’t done yet, and things that they’ve done that have actually pissed off the anti-abortion movement. These are not equal buckets — they’re just three categories. 

So, OK. What they have done: The anti-abortion movement was very pleased that the Trump administration rolled back a lot of Biden policies making abortion more accessible for veterans and service members. Also got reimposed the Mexico City policy, which restricts international aid for family planning programs that talk about abortion or refer people to abortion services. Of course, that’s been overshadowed by the just total decimation of foreign aid in general, but it’s still meaningful. I would say that the Trump administration switching sides in a legal battle over emergency room abortions was one of the biggest developments. We are still waiting to find out if they’re also going to switch sides in ongoing litigation over FDA regulation of abortion pills. That’s TBD but could be very big no matter which way they go. And the freeze on Title X funding that we’ve already discussed. The anti-abortion movement has been pleased by that because a lot of that has hit Planned Parenthood. Of course, it’s hitting providers beyond Planned Parenthood as well. 

So I also find it interesting that they have not done a lot of what the anti-abortion movement wants in terms of reimposing restrictions on abortion pills, saying they can’t be sent by mail, can’t be prescribed by telemedicine. So there’s a big push underway to pressure the administration to make those changes. Could still happen, but it has definitely not been something that they’ve prioritized at the beginning of the administration. 

And in this much smaller category of things they’ve done that have angered the anti-abortion movement, I’m thinking mainly of an executive order that didn’t actually do anything but purported to promote IVF [in vitro fertilization]. And he ordered his administration to study ways to make IVF more accessible and affordable. And a lot of anti-abortion groups view IVF as it’s currently practiced as akin to abortion, because some embryos are discarded. So, I sort of think of it like Trump has governed so far on abortion, a lot like he campaigns, trying to please the moderates and the conservatives and not really pleasing everyone fully and being a little all over the place. 

Rovner: Thank you. That was a great summary, and we’re on to the next hundred days. All right. That’s the news for this week. Now it is 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. Joanne, why don’t you go first this week? 

Kenen: Yeah. This is a pair of articles [“Many Nursing Homes Feed Residents on Less Than $10 a Day: ‘That’s Appallingly Low’” and “Inside the ‘Multibillion-Dollar Game’ To Funnel Cash From Nursing Homes to Sister Companies”] published by New Jersey Advance but in conjunction with papers in, The Oregonian in Oregon, MLive in Michigan, and in Alabama, and it’s by Ted Sherman, Susan Livio, and Matthew Miller. And it’s a really deep two-part investigation into, basically, greed at nursing homes. I don’t think they use the word “greed,” but that’s what it is. Feeding people, like, a food budget of $10 or less a day. Splitting the ownership so that there’s various interconnected businesses, so it looks like the nursing home doesn’t have enough money, because they’re actually paying somebody else for services provided at the nursing home that has the same owner, so it’s sort of financial gamesmanship. And just not taking care of people. Really well documented. They had thousands of pages of CMS [Centers for Medicare & Medicaid] files. They had university professors and data experts helping them analyze it. There’s never been an analysis, they say, this extensive. And it just shows tremendous abuse and just asks a What next? question and Why is this allowed to happen? question. 

Rovner: It’s a really good piece. Margot. 

Sanger-Katz: I want to highlight a piece from CNBC called “GLP-1s Can Help Employers Lower Medical Costs in 2 Years, New Study Finds.” I have some cautions about this study because the full study has not been made public. It has not been published in a peer-reviewed journal, and I still have lots of questions about it. Nevertheless, I read the story and I thought about it a lot and I have been thinking about it a lot since. And so I still feel like it is worth reading and talking about. This study was done by Aon, which is a big benefits consultant, and they pooled all this data from lots of employers who are covering these anti-obesity drugs for their workers. And basically what they say they found in the story is that among those people who continued to take the drug, who had what they called very high adherence to the drug, for two years, they actually found that their health improved so much that they saved their employers health plan money over that two-year period, even when compared to the very high cost of these drugs. 

So I would say this is a pretty surprising result. These drugs are expensive, and I think there was always an expectation that they were going to reduce people’s health care needs because they prevent diabetes and cardiac events and all of these other serious diseases. But I think there was always an expectation that the payback period would be much longer because the cost is so high. One more thing that jumped out at me in this study is there are some published studies from the clinical trials of Wegovy, the first anti-obesity drug that got approved by the FDA, that found that cardiac events among people taking those drugs were significantly diminished. But I think in a clinical trial where everything is perfect, you always expect those results to look a little bit better. 

This study, again, we can’t totally look under the hood, but they found 44% reduction in major cardiac incidents among working-age people who are taking these drugs in just two years. If that holds up, I think it just is additional evidence that these drugs are really, really promising for public health. Reducing heart attacks and strokes is just — and that’s compared to the standard of care. That’s compared to other people who had employer insurance who were of similar health, who were presumably taking statins and blood pressure drugs and the other things that you do to prevent cardiac events. So, I think, let’s not overinterpret this study. There could be something weird about it. But I do think it’s another promising indication that these drugs have the potential to have big public health impact and to potentially be a little less expensive for the system than we have been thinking of them. 

Rovner: And of course there are still efforts to lower the prices, which would obviously increase the benefit. 

Sanger-Katz: The big question I have is what percentage of people who are prescribed the drug are in this very adherent group, right? Because the companies are spending a lot of money giving people drugs who then stop taking them for various reasons or take them in a way that doesn’t produce these big health results. It could still be hugely expensive relative to the savings. But at least in this group that was taking the drugs, it seems like they’re getting healthier pretty quickly. 

Rovner: Interesting. 

Kenen: But if people aren’t taking it, if — adherence is often meant, like: Oh, I take it some days and not others, I forget to take my cholesterol drug, whatever. But if people stop taking it because there are side effects, then the cost also drops off. 

Rovner: Right. Yeah. We’ll see. Alice. 

Ollstein: So I chose a sad story from ProPublica. It’s called, “Utah Farmers Signed Up for Federally Funded Therapy. Then the Money Stopped.” And this is about a program through USDA [the U.S. Department of Agriculture] to offer to fund vouchers for farmers to be able to access mental health care. Farmers are notoriously very high-risk for suicide. There are a lot of challenges in that population. And this allowed people to, sometimes for the first time in their lives, to get these services. And the federal money has run out. There’s no sign it’s getting renewed. And while some states have stepped in and provided state money to continue these programs, Utah and some others have not, and people have lost that access. And the article is about the sad consequences of that. So, highly recommend. 

Rovner: All right. My extra credit this week is from my KFF Health News colleague Brett Kelman, and it’s called “As a Diversity Grant Dies, Young Scientists Fear It Will Haunt Their Careers.” It’s about a unique early-career grant program at the NIH, now canceled by the Trump administration, aimed at boosting the careers of young scientists from backgrounds that are underrepresentative, which includes not just race, gender, and disability but also those from rural areas or who grew up poor or who were the first in their family to attend college. It’s not only a waste of money — canceling multi-year grants in the middle essentially throws away the money that went before — but in this case it’s yet another way this administration is telling young scientists that they’re essentially not wanted and maybe they should consider another career or, as many seem to be doing, seek employment in other countries. As the old saying goes, it feels an awful lot like eating the seed corn. 

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

Kenen: I’m at Bluesky, @joannekenen, or I use LinkedIn more than I used to. 

Rovner: Margot? 

Sanger-Katz: I’m @sangerkatz in all the places, including on Signal. If you guys want to send me tips, I’m @sangerkatz.01. 

Rovner: Excellent. Alice? 

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

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

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

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

Congress returns from spring break next week and will get to work crafting a bill that would cut taxes and boost immigration enforcement — but that also could cut at least $880 billion over the next decade from a pool of funding that includes Medicaid. Some Republicans, however, are starting to question the political wisdom of making such large cuts to a program that provides health coverage to so many of their constituents.

Meanwhile, the Supreme Court heard arguments in a case challenging the requirement that most private insurance cover certain preventive services with no out-of-pocket cost for patients.

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

Panelists

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Tami Luhby
CNN

@Luhby

Read Tami's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• On the hunt for ways to pay for an extension of President Donald Trump’s tax cuts, many congressional Republicans are choosing their words carefully as they describe potential cuts to Medicaid — cuts that, considering heavy reliance on the program, especially in red states, could be politically unpopular.
• Amid the buzz over Medicaid cuts, another federal program that helps millions of Americans afford health care is also on the chopping block: the enhanced government subsidies introduced under the Biden administration that help pay premiums for Affordable Care Act plans. The subsidies expire at the end of this year, and Congress has yet to address extending them.
• One little-discussed option for achieving deep government spending cuts is Medicare Advantage, the private alternative to traditional Medicare that offers a variety of extra benefits for those over 65 — but that also costs the federal government a bundle. Even Mehmet Oz, the new head of the Centers for Medicare & Medicaid Services who once pushed Medicare Advantage plans as a TV personality, has cast sidelong glances at private insurers over how much they charge the government.
• And the Supreme Court heard oral arguments this week in a case that challenges the U.S. Preventive Services Task Force and could hold major implications for preventive care coverage nationwide. The justices’ questioning suggests the court could side with the government and preserve the task force’s authority — though that decision would also give more power over preventive care to Robert F. Kennedy Jr., the health and human services secretary.

Also this week, Rovner interviews KFF Health News’ Rae Ellen Bichell about her story on how care for transgender minors is changing in Colorado.

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

Julie Rovner: MedPage Today’s “Medical Journals Get Letters From DOJ,” by Kristina Fiore.

Sarah Karlin-Smith: The Tampa Bay Times’ “Countering DeSantis, $10M Hope Florida Donation Came From Medicaid, Draft Shows,” by Alexandra Glorioso and Lawrence Mower.

Tami Luhby: Stat’s “In Ireland, a Global Hub for the Pharma Industry, Trump Tariffs Are a Source of Deep Worry,” by Andrew Joseph.

Alice Miranda Ollstein: The New York Times’ “A Scientist Is Paid to Study Maple Syrup. He’s Also Paid to Promote It,” by Will Evans, Ellen Gabler, and Anjali Tsui.

Also mentioned in this week’s podcast:

• Stat’s “New England Journal of Medicine Gets Swept Up in U.S. Attorney Inquiry Into Alleged Bias,” by Anil Oza.
• KFF’s “KFF Tracking Poll on Health Information and Trust: The Public’s Views on Measles Outbreaks and Misinformation,” by Alex Montero, Grace Sparks, Julian Montalvo III, Ashley Kirzinger, and Liz Hamel.
• Bloomberg News’ “Food Industry Says There’s No Agreement With US Health Agency to Cut Dyes,” by Rachel Cohrs Zhang.
• Politico’s “RFK Jr. Eyes Reversing CDC’s Covid-19 Vaccine Recommendation for Children,” by Adam Cancryn.
• The New Yorker’s “The Cost of Defunding Harvard,” by Atul Gawande.
• The Wall Street Journal’s “Trump’s FDA Sends a Bullish Signal to Biotech,” by David Wainer

click to open the transcript

Transcript: Can Congress Reconcile Trump’s Wishes With Medicaid’s Needs?

[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, April 24, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: Tami Luhby of CNN. 

Tami Luhby: Hello. 

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

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with my KFF Health News colleague Rae Ellen Bichell about her story about how care options are changing for trans kids in Colorado. But first, this week’s news. 

We’re going to start this week with Congress, which is still out, by the way, on spring break but does return on Monday. When members get back, it will be full speed ahead on that, quote, “big, beautiful” reconciliation bill, as the president likes to call it. But there are already some big storm clouds on the horizon, particularly when it comes to cutting Medicaid by $880 billion over the next decade. We would appear to have both moderate and conservative Republicans voicing doubts about those big Medicaid cuts. Or are they hiding behind semantics? Some of them are saying, Well, we don’t want to cut Medicaid, but it would be OK to have work requirements, which, as we’ve talked about many times, would cut a lot of people off of Medicaid. Alice, I see you nodding. 

Ollstein: Yes. So, people really need to pay attention to the specifics and press members on exactly what they mean. What do they mean by “cut”? Because some people don’t consider certain things a cut. Some people consider them efficiency or savings, or there’s a lot of different words we hear thrown around. And also, who is impacted? Who are they OK being impacted? There’s a lot of rhetoric sort of pitting the people on the Medicaid expansion, who are not parents, not people with disabilities, against people on traditional Medicaid in ways that some advocates find offensive or misleading. And so, I think when members say, I am against Medicaid cuts, I will not vote for Medicaid cuts, we really need to ask: What do you consider a cut? And who are you OK allowing to be impacted? 

Luhby: Yeah. Speaker Mike Johnson had a very telling comment on Fox News’ “Sunday Morning Futures” earlier this month where he said, “The president has made absolutely clear many times, as we have as well, that we’re going to protect Medicare, Social Security, Medicaid for people who are legally beneficiaries of those programs.” But then he goes on to say: “At the same time, we have to root out fraud, waste, and abuse. We have to eliminate on, for example, [on] Medicaid, people who are not actually eligible to be there. Able-bodied workers, for example, young men who should never be on the program at all.” 

Of course, these folks are legal beneficiaries or legal enrollees of the program thanks to the Affordable Care Act’s Medicaid expansion, which has been expanded in 40 states. But yeah as Alice was saying, they are using language like “protecting the vulnerable” or people who “really need the program.” 

The new CMS [Centers for Medicare & Medicaid Services] administrator, Mehmet Oz, has also used the same language. So he seems to be in step with them. But yeah I think we’re really going to see work requirements and other methods, such as potentially cutting the FMAP [Federal Medical Assistance Percentage] for the federal matching money for the expansion population, which is set at 90%, which is far higher than it is for the traditional population, which a lot of folks don’t think is fair. But if the federal government, if Congress, does cut that match for the expansion population, we will see a lot of people lose their coverage. 

Rovner: And for the six people that haven’t heard me say this a thousand times, there are 12 states that automatically end their Medicaid expansion if that 90% match gets cut, because they legit can’t afford to make up the difference. I’ve seen numbers this week. It’s like $620 billion that states would have to make up if Congress just reduces that 90% match to whatever the match is, because each state gets a slightly different match. Poor states get more money from the federal government. 

For a bill where the repeal of the Affordable Care Act is supposedly not on the table, it is certainly on the menu. One item that I don’t think gets talked about enough is the expiration of the expanded subsidies for ACA coverage that were implemented during the pandemic. That’s effectively doubled ACA marketplace enrollment to 24 million people. And if those subsidies end, which they do at the end of the year in the absence of congressional action — this isn’t like the Medicaid match where Congress would have to actively go in and lower it. This was temporary, and it expires unless it is renewed. If that happens, a lot of people, including a lot of Republican voters in a lot of very red states, are going to get hit with huge increases starting in 2026. 

Is that starting to dawn on some Republican members of the House and Senate? And might it change the odds that those subsidies are allowed to expire, which I think we all just assumed when [Donald] Trump got elected last November? 

Ollstein: You are not hearing as much about it as you are about Medicaid, even from Democrats. So I’m curious, when Congress returns from its recess, if that dynamic is going to change, because even advocacy groups right now are really hammering the Medicaid cuts issue in ads, TV ads, billboards, press conferences. And so I’m not sure if that same messaging will sort of expand to include the people who would be hit by these cost increases, if these supports expire, or if there will be different messaging, or if it’ll get lost in the current fight about Medicaid. 

Luhby: I was saying it had been discussed quite a bit earlier this year, but then it has completely fallen off the radar. One thing that some folks are also trying to put it now as is saying that it’s also part of the waste, fraud, and abuse, because they’re arguing that a lot of folks, because part of the expansion was that people under 150% of poverty could get pretty much no-cost, no-premium subsidy plans. They could get no-premium plans. And there have been, even during the Biden administration also, there was a lot of accusations that people were fraudulently deflating their income so that they would qualify for this, or brokers were trying to do that for them. 

Rovner: Yeah. I think the other thing, though, that where the enrollment has gone up the most are in the 10 states that didn’t expand Medicaid, because those are people who are now eligible for, as Tami was saying, these extremely low-cost and, in some cases, free plans, and those would be the people who would be either kicked off or see their costs go way up. I’ll be interested to see what happens when this starts to kind of penetrate the psyches of members as they go through this exercise, which, as I say, is just going to get underway. The big effort launches next week, so we will watch this closely. 

I wanted to talk about a related subject, Medicare Advantage. Congress could find a lot of savings in Medicare Advantage without cutting Medicaid and without cutting Medicare benefits, or at least directly cutting Medicare benefits. Instead, Medicare Advantage plans are set to get big increases next year, which has boosted insurance stock prices even as the broader stock market has kind of tanked. Yes, as we saw at the confirmation hearing last month for Mehmet Oz to lead the Centers for Medicare & Medicaid Services, some Republicans are actually questioning whether the federal government should continue to overpay those Medicare Advantage plans. Is the tide starting to turn maybe a little bit on this former Republican-favored program? 

Luhby: We’ll see. Actually, surprisingly, Dr. Oz, who long touted Medicare Advantage plans on his show and in social media, actually also during his confirmation hearing kind of cast a little shade on the insurers. And much of the increase that was announced recently was probably done, obviously, before he took office. So we’ll see what happens next year or during the course of this year. But at this point, it looks like the increase for 2026 is a step back from the Biden administration’s efforts to rein in the costs. 

Rovner: Yeah but they could, I mean, if they wanted to they could — people keep talking about Energy and Commerce, House Energy and Commerce Committee, and all the money that it needs to save, presumably from Medicaid. Well, Energy and Commerce also has jurisdiction over Medicare Advantage, and if they wanted to save some of that $880 billion, they could take it out of Medicare Advantage too if they really wanted to. I don’t know that I’m going to bet that they will. I’m just suggesting that they could. 

All right, well, turning to the Supreme Court, the justices heard oral arguments this week in the case challenging the Affordable Care Act’s no-cost coverage of preventive care. Tami, remind us what this case is about. And what would happen if the court found for the plaintiffs? 

Luhby: Well, so this is a case that’s been — it’s not as much of a threat to the Affordable Care Act as previous cases have been. This case surrounds the preventive care mandate in the ACA, which basically says that insurers have to provide no-cost care for a host of different services that are recommended by three different groups. The court case at the Supreme Court was focusing on one set of recommendations, specifically from the U.S. Preventive Services Task Force. And the plaintiffs have said basically that the task force isn’t constitutional and therefore its recommendations can’t be enforced and they shouldn’t have to provide these services at no cost. 

So it would have actually a big effect on a lot of services. The lower-court ruling was kind of strange in saying that it limited the advances to just those since the enactment of the Affordable Care Act in March of 2010 when the ACA was passed, but it would still affect a host, things like statins, increased cancer screenings for certain groups, and screenings for pregnant women. So there are a lot of things that this would really affect people. 

And so I listened to the oral arguments, and it was very interesting. A lot of the discussion — it didn’t really talk about the preventive care and what that would mean for folks — but there was a lot of discussion about whether the HHS [Department of Health and Human Services] secretary has oversight over this task force or whether the members are independent. And that’s really at the crux of the argument here. And so there were several notable comments from conservative justices, and it seemed generally that folks we spoke to as well as media coverage seemed to say that the Supreme Court was leaning in the direction of the government. And Justice Brett Kavanaugh said that members of the task force are removable at will by the HHS secretary. Truly independent agencies, he noted, typically have legal protections that require a president to show cause before firing members of a board. The— 

Rovner: Like the head of the Federal Reserve, she inserts. 

Luhby: Justice Amy Coney Barrett said, who’s another conservative, said that she described the challenger’s position as very maximalist. So it seems that potentially — we don’t know, of course — but potentially the government may prevail here. 

But interestingly, if that does happen, that will actually give HHS Secretary Robert F. Kennedy Jr. more power over preventive services requirements. And as we know, he has a different view on certain public health measures. So we could really see him putting his stamp on the recommendations. Notably, this does not focus on vaccines. That’s a different group. That’s a different group that recommends vaccines, but that is still being discussed in the lower courts. So the vaccine issue isn’t over, but it’s not part of this case, per se. 

Rovner: This particular case, though, was really about PrEP [pre-exposure prophylaxis], right? It was about HIV preventives. 

Ollstein: Well, basically, the challengers, these conservative employers in Texas, in going after PrEP specifically, also are going after all preventive services. And the piece of the case that focused specifically on PrEP, where they said that requiring them to cover this HIV prevention drug would violate their religious rights, that piece did not go to the Supreme Court. So, lower courts have allowed these specific employers to opt out of covering PrEP, but because that ruling was not applied to anybody else in the country, the Biden Justice Department did not appeal it up to the Supreme Court. Probably, I’m just reading the tea leaves, not wanting to give this Supreme Court an opportunity to go after that. 

So that piece of it was not at issue, but the experts I talked to said that PrEP would still be really vulnerable if there was a broader ruling against preventive care, because PrEP is extremely expensive. And unlike other preventive services that insurers may see as really saving them money, they may see this as costing them and would drop that coverage, which could be really devastating to the U.S. effort to end the spread of HIV. 

Rovner: So I think one of the big surprises in this case was not that the Biden administration sued but that the Trump administration continued the position of the Biden administration. And one theory of why the Trump administration is defending the USPSTF [U.S. Preventive Services Task Force] is that it wants to exercise more power over not just that advisory panel but others, too, which brings us to a report in Politico that HHS Secretary Kennedy is considering unilaterally ordering the ACIP — that’s the advisory committee on immunizations — to drop its recommendation that children continue to receive the vaccine to protect against covid. 

Now, Sarah, isn’t this exactly what Kennedy promised Sen. Bill Cassidy that he wouldn’t do during his confirmation hearings? Personally meddle with scientific recommendations? 

Karlin-Smith: Kennedy did make a very explicit promise related to the vaccine schedule, I think, and I think we’ve seen multiple times already, and I’m sure Bill Cassidy is getting tired of reporters asking him, Are you going to do something about this? But I think Kennedy has already probably walked back, really not kept the thrust of a lot of his commitments to Cassidy. And a change to the vaccine schedule for the covid vaccine for children could essentially impact insurance coverage. It might make it no longer eligible for the Vaccines for Children Program, which ensures people with lower incomes or no insurance can afford vaccines for their children. And so I think this is a particularly concerning step for people. Even though it wouldn’t necessarily take the vaccine away, it could make it really inaccessible and unaffordable. 

I did want to quickly say about the idea in [Kennedy v.] Braidwood that the government wins, RFK gets more authority. I heard a really interesting comment yesterday about that thread, and the head of the American Public Health Association was trying to emphasize, like, it’s sort of status quo. If the Braidwood case goes the way of the government, anybody can technically misuse the authority, and the thing they’ll be watching for is to see what happens there or pushing for a legislative construct so that he can’t really misuse it, because, I think, in their minds, a lot of public health associations and leaders want a win here. So I think they’re sort of pushing back on the messaging about exactly what this means for Kennedy. 

Rovner: So there are also some indications that the public is starting to buy what RFK Jr. is selling, at least when it comes to vaccines, even as measles and now whooping cough cases continue to mount. A new poll from my colleagues here at KFF finds a growing share of adults who have heard the false claims, including that the measles vaccine causes autism or that the vaccine is more dangerous than getting measles, both of which are not true. 

Sarah, you were at the World Vaccine Congress here in Washington this week. What are the folks there feeling about all of this? 

Karlin-Smith: So I overheard someone in the hallway say yesterday that everybody here is shell-shocked, and I think that is probably a good characterization of the mood in the vaccine world. The environment they operate in has sort of been turned on its head very quickly, and there is concern about the future. 

I went to one panel where lawyers were sort of very optimistic that the way the country has sort of set up our vaccine system and authorities, a lot of authority rests in the hands of the states and state laws that may protect our ability to access and get vaccines, as well as they seem to feel that this Supreme Court as well, when it comes to vaccine issues and any attempts by the federal government to encroach more power, would lean in favor of the states and having the power in the states. There was a lot of hope there. I think that does rely on the rule of law sort of being followed by this administration, which doesn’t always happen. 

The other thing that I think will be interesting to watch moving forward is those assumptions that we have systems in place to protect our vaccine infrastructure and access do rely on the vaccines actually being approved. And to get to that point, particularly with new vaccines, you have to have the federal government approve them. And that the buck could kind of stop there. And we’ve already seen some signs that FDA [Food and Drug Administration] and HHS politicals are interfering in that process. So certainly, again, the vaccine community is nervous and feeling like they have to defend something that, as somebody said, change the world from one where you didn’t know if your children would live to go to school to one where you can just sort of assume that, and that’s a really dramatic difference in our health and our lives. 

Rovner: Well, that is a perfect segue into what I wanted to talk about next, which was the continuing impact of the cuts at HHS. This week, we’ve learned of the shutting down of some major longitudinal studies, including the landmark Women’s Health Initiative, which has tracked more than 160,000 women in clinical trials and even more outside of them since the 1990s and has led to major changes in how women are diagnosed and treated for a variety of health conditions. Also, apparently being defunded is a multistate diabetes study as well as the CDC’s longitudinal study of maternal health outcomes. 

Alice, you have a story this week on how clinics are starting to close due to the cutoff of Title X family planning funding. A lot of these things are going to be difficult or even impossible to restart even if the courts eventually do say that, No, administration, you didn’t have the authority to do this and you have to restore them, right? 

Ollstein: Yeah. So in the Title X context, I’ve been talking to providers around the country who had tens of millions in funding frozen. And it was frozen indefinitely. They don’t know when or whether they’ll get it. They’re being investigated for possible violations of executive orders. They submitted evidence trying to prove they aren’t in violation, and they just have no idea what’s going to happen, and they’re really struggling to keep the lights on. And they were explaining, yeah. once you lay off staff, once you lay off doctors and nurses, and once you close clinics, you can’t just flip a switch and reopen, and even if the funding comes through again later. 

And I think that’s true in the research context as well. Once you halt research, once you close down a lab, even if the funding is restored, either as a result of a court case on the sooner side or buy a future administration, you can’t just unplug the government and plug it back in again. 

Rovner: Atul Gawande has a story in The New Yorker this week that I will link to about what’s going on at Harvard, which is, obviously, gets huge headlines because it’s Harvard. But the thing that really jumped out at me was there’s an ongoing study of a potential, a really good, vaccine for TB, which scientists have been looking for for a hundred years, and they were literally just about to do sort of the TB challenge for the macaques who have been given this vaccine, and now everything is frozen. And it seems that it’s not just that it would ruin that, but you would have to start over. It’s a waste of money. That’s what I keep trying to say. This seems like — this does not seem like it is saving money. This seems like it is just trying to basically wreck the scientific establishment. Or is that just me? 

Karlin-Smith: No, I think there’s plenty of examples of that where, again, they’ve wrapped a lot of this in the idea that they’re going after government efficiency and waste. And when you look at what is actually falling to the cutting-room floor, there’s a lot of evidence that shows it’s not waste of you think of these long-term studies like the diabetes study or the Woman’s Health Initiative they’ve been running for so many years, to then have to lose those people involved in that and to replicate it would cost, I saw one report was saying, maybe a million dollars just to kind of get it back up and running on the ground again. 

And it also conflicts with other Kennedy and health administration priorities that they’ve called for, which is to improve chronic disease treatment and management in the U.S. So there’s a lot of misalignment, it seems like, between the rhetoric and what they’re saying and what’s actually happening on the ground. 

Rovner: Well, Secretary Kennedy does continue to make news himself after last week announcing that he planned to reveal the cause of autism by this September. This week, the secretary says, as part of that NIH [National Institutes of Health]-ordered study, the department will create a registry of people with autism. The idea is to bring together such diverse databases as pharmacy, medication records, private insurance claims, lab tests, and other data from the VA [Department of Veterans Affairs] and the Indian Health Service, even data from smartwatches and fitness trackers. What could possibly go wrong here? 

Ollstein: There’s a lot of anxiety in the autism community and just among people who are concerned about privacy and concerned about this administration in particular having access to all of these records. There’s concern about people being included or excluded in such a registry in error, since we’ve seen, I think, a lot of what the administration has been doing has been relying on artificial intelligence to make decisions and comb through records. And there have been some very notable errors on that front so far. So, yes, a lot of skepticism, and I think there will be some interesting pushback on this. 

Rovner: Yeah. I just, I think anytime somebody talks about making registries of people, it does set off alarm bells in a lot of communities. 

Well, meanwhile, the secretary held a press conference Tuesday to announce that he’s reached an agreement with food-makers to phase out petroleum-based food dyes by next year. Except our podcast pal Rachel Cohrs Zhang over at Bloomberg reports that no agreement has actually been reached, and The Wall Street Journal is reporting that biotech is warming up to the new leadership at the FDA that’s promising to streamline approval in a number of ways. So, Sarah, which is it? Is this HHS cracking down on manufacturers or cozying up to them? 

Karlin-Smith: I think it’s a complicated story. I think the food dye announcement is interesting because, again, they sort of suggested they had this big accomplishment, and then you look at the details, and they’re really just asking industry to do something, which I find ironic because Kennedy’s criticism of the FDA and the food industry’s relationship and the fact that we have these ingredients in our food in the first place has been that FDA has been too reliant on the food industry to self-police itself, and they really aren’t starting the regulatory process that would actually ban the products. 

And again, I think there’s sort of mixed research on how much, if any, harm comes from these products to begin with, so that picture isn’t really great. But there’s, again, these incredible ironies of the reports also coming out this week that they’re not inspecting milk the way they should and other parts of our food system and them touting this as this big health achievement. But at the same time, it does seem like the food industry is somewhat willing to work with them. 

I think on the biotech side, I maybe take slight disagreement with The Wall Street Journal. I think there are some positive signs for companies in that space from Commissioner [Martin] Makary in terms of his thinking about how to maybe make some products in the rare disease space go through the approval of process faster. I would just caution that Makary was very vague in how he described it, and it’s not even clear if he’s really thinking about something that would be new or what he would implement. 

And at the same time, again, you have to count all of that with the other elements coming out of the administration, including for Makary, that are kind of concerning about how they view vaccines. Makary also made some comments at the food dye event that are very reminiscent of RFK’s remarks, where he was very critical about the pharmaceutical industry and our use of drugs for treating obesity, depression, and other things that just repeats this sort of thread that kind of undermines the value of pharmaceuticals. So I think people are very hopeful in the industry about Makary and that he’d be a kind of counterbalance to Kennedy, but I think it’s too soon to really say whether he’s going to be a positive for that industry. 

Rovner: In other words, watch what they say and what they do. All right. Well, finally this week, I’m going to do my extra credit early because I want to let you guys comment on it, too. The story’s from MedPage Today. It’s by Kristina Fiore, and it’s called “Medical Journals Get Letters From DOJ,” and the story is a lot more dramatic than that. 

It seems that the interim U.S. attorney here in Washington, D.C., is writing to medical journals — yes, medical journals — accusing them of partisanship and failing to take into account, quote, “competing viewpoints.” And breaking just this morning, the prestigious New England Journal of Medicine has apparently gotten one of these letters, too. Now, none of these are so-called pay-to-play journals, which have their own issues. Rather, these are journals whose articles are peer-reviewed and based on scientific evidence. 

This strikes me as more than a little bit chilling and not at all in keeping with the radical transparency that this administration has promised. I honestly don’t know what to make of this. I’m curious as to what your guys’ take is. Is this one rogue U.S. attorney or the tip of the spear of an administration that really does want to go after the entire scientific establishment? 

Ollstein: I think we can see a pattern of the administration going after many entities and institutions that they perceive as providing a check on their power and rhetoric. So we’re seeing that with universities. We’re seeing that with news organizations. We are seeing that with quasi-independent government agencies and nonprofits. Now we’re seeing it with these medical journals. 

I’m not sure what their jurisdiction is here. These are not federally run or supported entities. These are private entities that theoretically have the right to set their own criteria for publication. But this may be intimidating and, like you said, chilling to some. So we’ll have to see what the response is. 

Rovner: Sarah, what are you hearing? 

Karlin-Smith: I think that it is interesting to me that they’re going after medical journals, because I’ve noticed a lot of the parts of the health industry are not willing to speak out and go after [President] Trump, even though probably privately behind the scenes a lot of people are very nervous about some of the activities. And the medical journals have been one place where I think you’ve seen a bit more freedom and seen the editorials and the viewpoints that have been harsher. 

So I wouldn’t be surprised if these are the entities that are willing to sort of cave to this kind of pressure, but I do think we’re in a very difficult environment. Again, being at this vaccine conference and talking to people about what you are doing to try and preserve your products that are so valuable to society, people don’t know what to do. They don’t know when pushing back will end up with them being in a worse situation. They don’t know when doing nothing will end up with them being in the worse situation. And it’s a really difficult place for all different kinds of groups, whether it’s a medical journal or a university or a drug company, to navigate. 

Rovner: We’ll add this to the list of stories that we are watching. All right, that is this week’s news. Now, we’ll play my interview with KFF Health News’ Rae Ellen Bichell. Then we will come back and do our extra credits. 

I am so pleased to welcome back to the podcast my KFF Health News colleague Rae Ellen Bichell, who’s here to talk to us about a story she did on how services are changing for transgender youth and their families in Colorado. Hi, Rae. 

Rae Ellen Bichell: Hi. Thanks for having me. 

Rovner: So, Colorado has long been considered a haven for gender-affirming care, but even there, health care for transgender youth temporarily flickered as hospitals responded to executive orders from the Trump administration trying to limit what kinds of care can be provided to minors. Let’s start with, what kind of health care are we talking about? 

Bichell: There’s a lot of different things that count as gender-affirming care. It can really be anything from talk therapy or a haircut all the way to medications and surgery. 

For medical interventions, on that side of things, the process for getting those is long and thorough. To give you an idea, the guidelines for this typically come from the World Professional Association for Transgender Health, and the latest document is 260 pages long. So this was very thorough. 

With medications, there’s puberty blockers that pause puberty and are reversible, and then the ones that are less reversible are testosterone and estrogen. So patients who need and want them will get puberty blockers first as puberty is setting in — so the timing matters, just to put everything on the ice — and then would start hormones later on. It is important to note, lots of trans kids don’t get these medications. Researchers found that transgender youth are not likely to get them, and politicians like to talk about surgery, of course, but it’s really rare for teens to get surgery. So for every 100,000 trans minors, fewer than three undergo surgery. 

Rovner: So when we talk about transgender care, as you said, particularly the Trump administration presents this as go to school one gender and come home another. That’s not what this is. 

Bichell: It is not an easy or fast process by any measure. 

Rovner: So, remind us what the president’s executive order said. 

Bichell: There were two of them. So one, right out of the gate on his first day in office, said it is a, quote, “false claim that males can identify as and thus become women and vice versa.” And then a second one called puberty blockers and hormones, for anyone under age 19, a form of chemical, quote, “mutilation” and a, quote, “a stain on our Nation’s history.” And that one directed agencies to take steps to ensure that recipients of federal research or education grants stop providing that care. 

Rovner: And that’s where the hospitals got involved in this, right? 

Bichell: Right. That’s where we started to see changes in Colorado and in other states as well. Here, there were three major health care organizations — so that’s Children’s Hospital Colorado, Denver Health, and UCHealth — and they all announced changes to the gender-affirming care that they provide to patients under 19. So this is in direct response to the executive order. 

Those changes were effective immediately and included no new hormone or puberty blocker prescriptions for patients who hadn’t had them before, limited or no renewals for those who had had such prescriptions before, and no surgeries. Some of that care has since resumed, and that happened after Colorado joined a U.S. District Court lawsuit in Washington state. And the situation there is there’s a preliminary injunction that’s blocking the orders from taking effect but only applies to the four states that are involved in the lawsuit. 

But even though the care has been restored, even though Colorado joined that Washington lawsuit, it was still enough to shake people’s confidence in this state. 

Here’s Louise. We’re using her middle name. She’s the mom of a trans teenager. 

Louise: I mean, Colorado, as a state, was supposed to be a safe haven, right? We have a law that makes it a right for trans people to have health care, and yet our health care systems are taking that away and not making sure that our trans people can have health care, especially our trans kids. 

Rovner: So what kind of impact did that have on patients, even if it was just temporary? 

Bichell: Pretty profound. One family I spoke to with a 14-year-old, they predicted this might happen. They started stockpiling testosterone, the mom said, as soon as the election happened. And what that means is kind of just saving anything that was left over in the vial after the teen took his dose so they could stretch it for as long as possible. 

That teen also had a kind of surprise moment where even his birth control came into question. And that’s because his birth control suppresses his period, which is considered part of his gender-affirming care. So his doctor had to have this special meeting just to make sure that he could keep getting that prescription, too. 

And then one part of this health care that has not turned back on is surgery. And so, even though it’s rare, for the patients who want and need it, that’s a significant gap. 

Rovner: And what does that mean for patients? 

Bichell: So, Louise’s son, David — that’s his middle name, too. He’s 18 years old. And I visited him in his dorm room in Gunnison. That’s a mountain town here. He told me that testosterone has helped him a lot. 

David: I don’t know if you noticed, but there are no mirrors in here. 

Bichell: I did not notice that. 

David: Yeah. 

Bichell: You’re right. 

David: My sister and best friend will come up and stay the weekend or something like that. And every time they come up, they complain that I don’t have a mirror. And I’m like, I don’t want to look at myself, because, I don’t know, for the longest time I just had so much body dysphoria and dysmorphia that it can be kind of hard to look in the mirror. But when I do, most of the time I see something that I really like. 

Bichell: So his confidence and mental health has really improved with the testosterone, but he also would really like to get a mastectomy and thought that he could do it this summer so that he’d have enough recovery time before the new school year started in the fall. But he’s not aware of anyone now in Colorado who will do this surgery for 18-year-old patients, so he has to wait until he turns 19. He has taken a significant mental health hit because of having to wait. 

The irony here is that he could easily get surgery to enhance his breasts but can’t reduce or remove them. And the other irony here is that cisgender men and boys can still get gender-affirming breast reduction surgeries and do. In fact, they’re more likely to get that kind of surgery than transgender men and boys. 

Rovner: So what do things look like going forward in Colorado? 

Bichell: There is a bill making its way through the state capitol right now. It’s about protecting access to gender-affirming care. So let’s see where that lands. But in the meantime, the families that I’ve been speaking with, a moment that really stood out to them was, in early April, the Trump administration came out with a proclamation that said, quote, “One of the most prevalent forms of child abuse facing our country today is the sinister threat of gender ideology,” end quote. So they’re still feeling pretty apprehensive about the future. 

Rovner: Well, we’ll watch this as it goes forward. Rae Ellen Bichell, thank you so much. 

Bichell: Thanks again. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. I’ve already done mine. Alice, you’ve got a lighter story this week. Why don’t you go next? 

Ollstein: A sweeter story, you might say. So I have a piece from The New York Times that is about — it’s a great exposé of a researcher who is in the pocket of Big Maple Syrup, according to this reporting. The article is “A Scientist Is Paid to Study Maple Syrup. He’s Also Paid to Promote It.” This is a great piece of how he exaggerated the health benefits of maple syrup. He cherry-picked findings that appeared to make this a health-promotion food more than the findings really showed. 

But it all really, on a serious note, made me think about the current federal cuts to research and how, in the absence of that taxpayer public support, more and more scientists may need to turn to industry support for their work. And that brings all of these ethical problems that you really see in this article. Pressure to come to certain findings. Pressure to not release certain findings if they don’t fit with the agenda, etc. So I think this is a little bit silly but also serious. 

Rovner: I was personally disappointed to read this story because maple is my favorite sweetener. 

Ollstein: Well— 

Rovner: And I was really happy when I started seeing the research that said it’s really good for you. It will still be my favorite sweetener. Sarah. 

Karlin-Smith: I took a look at a story from Alexandra Glorioso and Lawrence Mower of the Miami Herald/[Tampa Bay] Times [“Countering DeSantis, $10M Hope Florida Donation Came From Medicaid, Draft Shows”] that documents how it appears that Gov. [Ron] DeSantis in Florida steered about $10 million that the state got back through a settlement with one of their Medicaid contractors to a nonprofit run by his wife, and then seeming to having to kept steering the money to political committees that are supporting Republicans. 

And as Julie mentioned, this is probably one of those things that would’ve gotten tons of attention, much slower news time, but it’s a fascinating story and just very interesting to watch just how they were able to figure out and document how all this money was being transferred. And that even the, in some of the stories you see, even the Republican lawmakers and Congress and their state legislature are pretty frustrated about it. 

Rovner: Local journalism still matters. Tami. 

Luhby: I looked at a story out of Stat News by Andrew Joseph titled “In Ireland, a Global Hub for the Pharma Industry, Trump Tariffs Are a Source of Deep Worry.” So, many of us, including me, have been writing about the potential for tariffs on pharmaceutical imports since Trump, unlike his first term, has been promising to impose them on the drug industry. 

Well what I liked about this story was that it focused on drug manufacturing in Ireland, with Joseph reporting from Dublin and County Cork. I’d like to get that assignment myself. But he shows how America pharma companies, how important they are to the Irish economy. Ireland has lured them with low taxes and concerted efforts to build its manufacturing workforce. And interestingly, the country started to move foreign investment in the 1950s. It mentions, interestingly, that President Trump had specifically called out pharma operations in Ireland, criticizing the U.S. trade balance while meeting with the Irish prime minister for St. Patrick’s Day. 

But there were a lot of good details in the piece. Of the 72.6 billion euros’ worth of exports that Ireland sent to the U.S. last year, 58.3 billion were classified as chemical and related products, the bulk of them pharmaceutical goods. The biopharma industry now employs 50,000 people in Ireland. 

And, another little tidbit that I liked, the National Institute for Bioprocessing Research and Training in Dublin actually has a mock plant where thousands of workers have been trained for careers in the industry. And it talks about, even getting down to the county and local levels, how Ireland is concerned that tariffs could prompt American drugmakers to invest less in the country in the future, which will hurt Ireland’s export business, its corporate tax base, the jobs, and the economy overall. 

Rovner: Yeah, globalization’s a real thing, and you can’t just turn it off by turning a switch. It was a really interesting story. 

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

Karlin-Smith: I feel like I’m trying to be everywhere on social media. So you can find me, @SarahKarlin or @sarahkarlin-smith on Bluesky, LinkedIn, all those fun places. 

Rovner: Alice? 

Ollstein: Mainly on Bluesky, @alicemiranda. Still on X, @AliceOllstein. 

Rovner: Tami. 

Luhby: Mostly at CNN at cnn.com. 

Rovner: There you go. We’ll be back in your feed next week. Until then, be healthy. 

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

USE OUR CONTENT

This story can be republished for free (details).

Aproximadamente dos tercios de los padres con inclinaciones republicanas desconocen el aumento en los casos de sarampión este año, mientras que cerca de dos tercios de los demócratas sabían sobre el tema, según una encuesta de KFF publicada el miércoles 23 de abril.

Los republicanos son mucho más escépticos con respecto a las vacunas y tienen el doble de probabilidades (1 de cada 5) que los demócratas (1 de cada 10) de creer que la vacuna contra el sarampión es peor que la enfermedad, según la encuesta realizada a 1.380 adultos estadounidenses.

Alrededor del 35% de los republicanos que respondieron a la encuesta, realizada del 8 al 15 de abril por internet y por teléfono, aseguraron que la teoría desacreditada que vincula la vacuna contra el sarampión, las paperas y la rubéola con el autismo era definitiva o probablemente cierta, en comparación con solo el 10% de los demócratas.

Las tendencias son prácticamente las mismas que las reportadas por KFF en una encuesta de junio de 2023.

Sin embargo, en la nueva encuesta, 3 de cada 10 padres creían erróneamente que la vitamina A puede prevenir las infecciones por el virus del sarampión, una teoría que Robert F. Kennedy Jr., el secretario de Salud y Servicios Humanos, ha diseminado desde que asumió el cargo, en medio del brote de sarampión.

Se han reportado alrededor de 900 casos en 27 estados, la mayoría en un brote centrado en el oeste de Texas.

“Lo más alarmante de la encuesta es que estamos observando un aumento en la proporción de personas que han escuchado estas afirmaciones”, afirmó la coautora Ashley Kirzinger, directora asociada del Programa de Investigación de Encuestas y Opinión Pública de KFF. (KFF es una organización sin fines de lucro dedicada a la información sobre salud que incluye a KFF Health News).

“No es que más gente crea en la teoría del autismo, sino que cada vez más gente escucha sobre ella”, afirmó Kirzinger. Debido a que las dudas sobre la seguridad de las vacunas es factor directo de la decision de los padres reducer la vacunación de sus hijos, “esto demuestra la importancia de que la información veraz forme parte del panorama mediático”, añadió.

“Esto es lo que cabría esperar cuando la gente está confundida por mensajes contradictorios provenientes de personas en posiciones de autoridad”, afirmó Kelly Moore, presidenta y directora ejecutiva de Immunize.org, un grupo de defensa de la vacunación.

Numerosos estudios científicos no han establecido ningún vínculo entre cualquier vacuna y el autismo. Sin embargo, Kennedy ha ordenado al Departamento de Salud y Servicios Humanos (HHS) que realice una investigación sobre los posibles factores ambientales que contribuyen al autismo, prometiendo tener “algunas de las respuestas” sobre el aumento en la incidencia de la afección para septiembre.

La profundización del escepticismo republicano hacia las vacunas dificulta la difusión de información precisa en muchas partes del país, afirmó Rekha Lakshmanan, directora de estrategia de The Immunization Partnership, en Houston.

El 23 de abril, Lakshmanan iba a presentar un documento sobre cómo contrarrestar el activismo antivacunas ante el Congreso Mundial de Vacunas en Washington. El documento se basaba en una encuesta que reveló que, en las asambleas estatales de Texas, Louisiana, Arkansas y Oklahoma, los legisladores con profesiones médicas se encontraban entre los menos propensos a apoyar las medidas de salud pública.

“Hay un componente político que influye en estos legisladores”, afirmó. Por ejemplo, cuando los legisladores invitan a quienes se oponen a las vacunas a testificar en las audiencias legislativas, se alimenta una avalancha de desinformación difícil de refutar, agregó.

Eric Ball, pediatra de Ladera Ranch, California, área afectada por un brote de sarampión en 2014-2015 que comenzó en Disneyland, afirmó que el miedo al sarampión y las restricciones más estrictas del estado de California sobre las exenciones de vacunas evitaron nuevas infecciones en su comunidad del condado de Orange.

“La mayor desventaja de las vacunas contra el sarampión es que funcionan muy bien. Todos se vacunan, nadie contrae sarampión, todos se olvidan del sarampión”, concluyó. “Pero cuando regresa la enfermedad, se dan cuenta de que hay niños que se están enfermando de gravedad, y potencialmente muriendo en la propia comunidad, y todos dicen: ‘¡Caramba! ¡Mejor que vacunemos!’”.

En 2015, Ball trató a tres niños muy enfermos de sarampión. Después, su consultorio dejó de atender a pacientes no vacunados. “Tuvimos bebés expuestos en nuestra sala de espera”, dijo. “Tuvimos una propagación de la enfermedad en nuestra oficina, lo cual fue muy desagradable”.

Aunque dos niñas que eran sanas murieron de sarampión durante el brote de Texas, “la gente todavía no le teme a la enfermedad”, dijo Paul Offit, director del Centro de Educación sobre Vacunas del Hospital Infantil de Philadelphia, que ha atendido algunos casos.

Pero las muertes “han generado más angustia, según la cantidad de llamadas que recibo de padres que intentan vacunar a sus bebés de 4 y 6 meses”, contó Offit. Los niños generalmente reciben su primera vacuna contra el sarampión al año de edad, porque tiende a no producir inmunidad completa si se administra antes.

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

USE OUR CONTENT

This story can be republished for free (details).

A KFF Health News analysis underscores that the terminations are sparing no part of the country, politically or geographically. About 40% of organizations whose grants the NIH cut in its first month of slashing, which started Feb. 28, are in states Trump won in November.

The Trump administration has singled out Ivy League universities including Columbia and Harvard for broad federal funding cuts. But the spending reductions at the NIH, the nation’s foremost source of funding for biomedical research, go much further: Of about 220 organizations that had grants terminated, at least 94 were public universities, including flagship state schools in places such as Florida, Georgia, Ohio, Nebraska, and Texas.

The Trump administration has canceled hundreds of grants supporting research on topics such as vaccination; diversity, equity, and inclusion; and the health of LGBTQ+ populations. Some of the terminations are a result of Trump’s executive orders to abandon federal work on diversity and equity issues. Others followed the Senate confirmation of anti-vaccine activist Robert F. Kennedy Jr. to lead the Department of Health and Human Services, which oversees the NIH. Many mirror the ambitions laid out in Project 2025’s “Mandate for Leadership,” the conservative playbook for Trump’s second term.

Affected researchers say Trump administration officials are taking a cudgel to efforts to improve the lives of people who often experience worse health outcomes — ignoring a scientific reality that diseases and other conditions do not affect all Americans equally.

KFF Health News found that the NIH terminated about 780 grants or parts of grants between Feb. 28 and March 28, based on documents published by the Department of Health and Human Services and a list maintained by academic researchers. Some grants were canceled in full, while in other cases, only supplements — extra funding related to the main grant, usually for a shorter-term, related project — were terminated.

Among U.S. recipients, 96 of the institutions that lost grants in the first month are in politically conservative states including Florida, Ohio, and Indiana, where Republicans control the state government or voters reliably support the GOP in presidential campaigns, or in purple states such as North Carolina, Michigan, and Pennsylvania that were presidential battleground states. An additional 124 institutions are in blue states.

Sybil Hosek, a research professor at the University of Illinois-Chicago, helps run a network that focuses on improving care for people 13 to 24 years old who are living with or at risk for HIV. The NIH awarded Florida State University $73 million to lead the HIV project.

“We never thought they would destroy an entire network dedicated to young Americans,” said Hosek, one of the principal investigators of the Adolescent Medicine Trials Network for HIV/AIDS Interventions. The termination “doesn’t make sense to us.”

NIH official Michelle Bulls is director of the Office of Policy for Extramural Research Administration, which oversees grants policy and compliance across NIH institutes. In terminating the grant March 21, Bulls wrote that research “based primarily on artificial and nonscientific categories, including amorphous equity objectives, are antithetical to the scientific inquiry, do nothing to expand our knowledge of living systems, provide low returns on investment, and ultimately do not enhance health, lengthen life, or reduce illness.”

Adolescents and young adults ages 13 to 24 accounted for 1 in 5 new HIV infections in the U.S. in 2022, according to the Centers for Disease Control and Prevention.

“It’s science in its highest form,” said Lisa Hightow-Weidman, a professor at Florida State University who co-leads the network. “I don’t think we can make America healthy again if we leave youth behind.”

HHS spokesperson Emily Hilliard said in an emailed statement that “NIH is taking action to terminate research funding that is not aligned with NIH and HHS priorities.” The NIH and the White House didn’t respond to requests for comment.

“As we begin to Make America Healthy Again, it's important to prioritize research that directly affects the health of Americans. We will leave no stone unturned in identifying the root causes of the chronic disease epidemic as part of our mission to Make America Healthy Again,” Hilliard said.

Harm to HIV, Vaccine Studies

The NIH, with its nearly $48 billion annual budget, is the largest public funder of biomedical research in the world, awarding nearly 59,000 grants in the 2023 fiscal year. The Trump administration has upended funding for projects that were already underway, stymied money for new applications, and sought to reduce how much recipients can spend on overhead expenses.

Those changes — plus the firing of 1,200 agency employees as part of mass layoffs across the government — are alarming scientists and NIH workers, who warn that they will undermine progress in combating diseases and other threats to the nation’s public health. On April 2, the American Public Health Association, Ibis Reproductive Health, and affected researchers, among others, filed a lawsuit in federal court against the NIH and HHS to halt the grant cancellations.

Two National Cancer Institute employees, who were granted anonymity because they were not authorized to speak to the press and feared retaliation, said its staff receives batches of grants to terminate almost daily. On Feb. 27, the cancer institute had more than 10,800 active projects, the highest share of the NIH’s roughly two dozen institutes and centers, according to the NIH’s website. At least 47 grants that NCI awarded were terminated in the first month.

Kennedy has said the NIH should take a years-long pause from funding infectious disease research. In November 2023, he told an anti-vaccine group, “I’m gonna say to NIH scientists, ‘God bless you all. Thank you for public service. We’re going to give infectious disease a break for about eight years,’” according to NBC News.

For years, Kennedy has peddled falsehoods about vaccines — including that “no vaccine” is “safe and effective,” and that “there are other studies out there” showing a connection between vaccines and autism, a link that has repeatedly been debunked — and claimed falsely that HIV is not the only cause of AIDS.

KFF Health News found that grants in blue states were disproportionately affected, making up roughly two-thirds of terminated grants, many of them at Columbia University. The university had more grants terminated than all organizations in politically red states combined. On April 4, Democratic attorneys general in 16 states sued HHS and the NIH to block the agency from canceling funds.

Researchers whose funding was stripped said they stopped clinical trials and other work on improving care for people with HIV, reducing vaping and smoking rates among LGBTQ+ teens and young adults, and increasing vaccination rates for young children. NIH grants routinely span several years.

For example, Hosek said that when the youth HIV/AIDS network’s funding was terminated, she and her colleagues were preparing to launch a clinical trial examining whether a particular antibiotic that is effective for men to prevent sexually transmitted infections would also work for women.

“This is a critically important health initiative focused on young women in the United States,” she said. “Without that study, women don’t have access to something that men have.”

Other scientists said they were testing how to improve health outcomes among newborns in rural areas with genetic abnormalities, or researching how to improve flu vaccination rates among Black children, who are more likely to be hospitalized and die from the virus than non-Hispanic white children.

“It's important for people to know that — if, you know, they are wondering if this is just a waste of time and money. No, no. It was a beautiful and rare thing that we did,” said Joshua Williams, a pediatric primary care doctor at Denver Health in Colorado who was researching whether sharing stories about harm experienced due to vaccine-preventable diseases — from missed birthdays to hospitalizations and job loss — might inspire caregivers to get their children vaccinated against the flu.

He and his colleagues had recruited 200 families, assembled a community advisory board to understand which vaccinations were top priorities, created short videos with people who had experienced vaccine-preventable illness, and texted those videos to half of the caregivers participating in the study.

They were just about to crack open the medical records and see if it had worked: Were the group who received the videos more likely to follow through on vaccinations for their children? That’s when he got the notice from the NIH.

“It is the policy of NIH not to prioritize research activities that focuses gaining scientific knowledge on why individuals are hesitant to be vaccinated and/or explore ways to improve vaccine interest and commitment,” the notice read.

Williams said the work was already having an impact as other institutions were using the idea to start projects related to cancer and dialysis.

A Hit to Rural Health

Congress previously tried to ensure that NIH grants also went to states that historically have had less success obtaining biomedical research funding from the government. Now those places aren’t immune to the NIH’s terminations.

Sophia Newcomer, an associate professor of public health at the University of Montana, said she had 18 months of work left on a study examining undervaccination among infants, which means they were late in receiving recommended childhood vaccines or didn’t receive the vaccines at all. Newcomer had been analyzing 10 years of CDC data about children’s vaccinations and had already found that most U.S. infants from 0 to 19 months old were not adequately vaccinated.

Her grant was terminated March 10, with the NIH letter stating the project “no longer effectuates agency priorities,” a phrase replicated in other termination letters KFF Health News has reviewed.

“States like Montana don’t get a lot of funding for health research, and health researchers in rural areas of the country are working on solutions to improve rural health care,” Newcomer said. “And so cuts like this really have an impact on the work we’re able to do.”

Montana is one of 23 states, along with Puerto Rico, that are eligible for the NIH’s Institutional Development Award program, meant to bolster NIH funding in states that historically have received less investment. Congress established the program in 1993.

The NIH’s grant terminations hit institutions in 15 of those states, more than half that qualify, plus Puerto Rico.

Researchers Can’t ‘Just Do It Again Later’

The NIH’s research funds are deeply entrenched in the U.S. health care system and academia. Rarely does an awarded grant stay within the four walls of a university that received it. One grant’s money is divvied up among other universities, hospitals, community nonprofits, and other government agencies, researchers said.

Erin Kahle, an infectious disease epidemiologist at the University of Michigan, said she was working with Emory University in Georgia and the CDC as part of her study. She was researching the impact of intimate partner violence on HIV treatment among men living with the virus. “They are relying on our funds, too,” she said.

Kahle said her top priority was to ethically and safely wind down her nationwide study, which included 418 people, half of whom were still participating when her grant was terminated in late March. Kahle said that includes providing resources to participants for whom sharing experiences of intimate partner violence may cause trauma or mental health distress.

Rachel Hess, the co-director of the Clinical & Translational Science Institute at the University of Utah, said the University of Nevada-Reno and Intermountain Health, one of the largest hospital systems in the West, had received funds from a $38 million grant that was awarded to the University of Utah and was terminated March 12.

The institute, which aims to make scientific research more efficient to speed up the availability of treatments for patients, supported over 5,000 projects last year, including 550 clinical trials with 7,000 participants. Hess said that, for example, the institute was helping design a multisite study involving people who have had heart attacks to figure out the ideal mix of medications “to keep them alive” before they get to the hospital, a challenge that’s more acute in rural communities.

After pushback from the university — the institute’s projects included work to reduce health care disparities between rural and urban areas — the NIH restored its grant March 29.

Among the people the Utah center thanked in its announcement about the reversal were the state’s congressional delegation, which consists entirely of Republican lawmakers. “We are grateful to University of Utah leadership, the University of Utah Board of Trustees, our legislative delegation, and the Utah community for their support,” it said.

Hilliard, of HHS, said that “some grants have been reinstated following the appeals process, and the agency will continue to carry out the remaining appeals as planned to determine their alignment.” She declined to say how many had been reinstated, or why the University of Utah grant was among them.

Other researchers haven’t had the same luck. Kahle, in Michigan, said projects like hers can take a dozen years from start to finish — applying for and receiving NIH funds, conducting the research, and completing follow-up work.

“Even if there are changes in the next administration, we’re looking at at least a decade of setting back the research,” Kahle said. “It’s not as easy as like, ‘OK, we’ll just do it again later.’ It doesn’t really work that way.”

Methodology

KFF Health News analyzed National Institutes of Health grant data to determine the states and organizations most affected by the Trump administration’s cuts.

We tallied the number of terminated NIH grants using two sources: a Department of Health and Human Services list of terminated grants published April 4; and a crowdsourced list maintained by Noam Ross of rOpenSci and Scott Delaney of the Harvard T.H. Chan School of Public Health, as of April 8. We focused on the first month of terminations: from Feb. 28 to March 28. We found that 780 awards were terminated in total, with 770 of them going to recipients based in U.S. states and two to recipients in Puerto Rico.

The analysis does not account for potential grant reinstatements, which we know happened in at least one instance.

Additional information on the recipients, such as location and business type, came from the USAspending.gov Award Data Archive.

There were 222 U.S. recipients in total. At least 94 of them were public higher education institutions. Forty-one percent of organizations that had NIH grants cut in the first month were in states that President Donald Trump won in the 2024 election.

Some recipients, including the University of Texas MD Anderson Cancer Center and Vanderbilt University Medical Center, are medical facilities associated with higher education institutions. We classified these as hospitals/medical centers.

We also wanted to see whether the grant cuts affected states across the political spectrum. We generally classified states as blue if Democrats control the state government or Democratic candidates won them in the last three presidential elections, and red if they followed this pattern but for Republicans. Purple states are generally presidential battleground states or those where voters regularly split their support between the two parties: Arizona, Michigan, Nevada, New Hampshire, North Carolina, Pennsylvania, Virginia, and Wisconsin. The result was 25 red states, 17 blue states, and eight purple states. The District of Columbia was also blue.

We found that, of affected U.S. institutions, 96 were in red or purple states and 124 were in blue states.

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

USE OUR CONTENT

This story can be republished for free (details).

Si te adentras demasiado en la oscuridad, le decían, un gigantesco y monstruoso mono que vive en las sombras podría atraparte.

Ahora, cuando García-Ramírez mira por encima del hombro, no son los monos monstruosos a los que teme. Son los agentes del Servicio de Inmigración y Control de Aduanas de Estados Unidos (ICE).

“Hay un miedo constante de que vayas caminando por la calle y se te cruce un vehículo”, dijo García-Ramírez, de 57 años. “Te dicen: ‘Somos de ICE; estás arrestado’, o ‘Muéstrame tus papeles’”.

Silverthorne, una pequeña ciudad entre las mecas del esquí de Breckenridge y Vail, ha sido el hogar de García-Ramírez durante los últimos dos años. Trabaja como cajero en un supermercado y comparte un apartamento de dos habitaciones con cuatro compañeros.

La ciudad de casi 5.000 habitantes ha sido un refugio acogedor para el exiliado político, quien fue liberado de prisión en 2023 después que el gobierno autoritario de Nicaragua negociara un acuerdo con el gobierno estadounidense para transferir a más de 200 presos políticos a Estados Unidos.

A los exiliados se les ofreció residencia temporal en Estados Unidos bajo un programa de libertad condicional humanitaria (conocido como parole humanitario) de la administración Biden.

Este permiso humanitario de dos años de García-Ramírez expiró en febrero, apenas unas semanas después que el presidente Donald Trump emitiera una orden ejecutiva para poner fin al programa que había permitido la residencia legal temporal en Estados Unidos a cientos de miles de cubanos, haitianos, nicaragüenses y venezolanos. Esto lo que lo ponía en riesgo de deportación.

A García-Ramírez se le retiró la ciudadanía nicaragüense al llegar a Estados Unidos. Hace poco más de un año, solicitó asilo político. Sigue esperando una entrevista.

“No puedo decir con seguridad que estoy tranquilo o que estoy bien en este momento”, dijo García-Ramírez. “Uno se siente inseguro, pero también incapaz de hacer algo para mejorar la situación”.

Vail y Breckenridge son mundialmente famosos por sus pistas de esquí, que atraen a millones de personas cada año. Pero la vida para la fuerza laboral del sector turístico que atiende a los centros turísticos de montaña de Colorado es menos glamorosa.

Los residentes de los pueblos montañosos de Colorado experimentan altas tasas de suicidio y adicciones, impulsadas en parte por las fluctuaciones estacionales de los ingresos, que pueden causar estrés a muchos trabajadores locales.

Las comunidades latinas, que constituyen una proporción significativa de la población residente permanente en estos pueblos de montaña, son particularmente vulnerables.

Una encuesta reciente reveló que más de 4 de cada 5 latinos encuestados en la región de la Ladera Occidental, donde se encuentran muchas de las comunidades rurales de estaciones de esquí del estado, expresaron una preocupación “extrema o muy grave” por el consumo de sustancias.

Esta cifra es significativamente mayor que en el condado rural de Morgan, en el este de Colorado, que también cuenta con una considerable población latina, y en Denver y Colorado Springs.

A nivel estatal, la preocupación por la salud mental ha resurgido entre los latinos en los últimos años, pasando de menos de la mitad que la consideraba un problema extremada o muy grave en 2020 a más de tres cuartas partes en 2023.

Tanto profesionales de salud como investigadores y miembros de la comunidad afirman que factores como las diferencias lingüísticas, el estigma cultural y las barreras socioeconómicas pueden exacerbar los problemas de salud mental y limitar el acceso a la atención médica.

“No recibes atención médica regular. Trabajas muchas horas, lo que probablemente significa que no puedes cuidar de tu propia salud”, dijo Asad L. Asad, profesor adjunto de sociología de la Universidad de Stanford. “Todos estos factores agravan el estrés que todos podríamos experimentar en la vida diaria”.

Si a esto le sumamos los altísimos costos de vida y la escasez de centros de salud mental en los destinos turísticos rurales de Colorado, el problema se agrava.

Ahora, las amenazas de la administración Trump de redadas migratorias y la inminente deportación de cualquier persona sin residencia legal en el país han disparado los niveles de estrés.

Según estiman defensores, en las comunidades cercanas a Vail, la gran mayoría de los residentes latinos no tienen papeles. Las comunidades cercanas a Vail y Breckenridge no han sufrido redadas migratorias, pero en el vecino condado de Routt, donde se encuentra Steamboat Springs, al menos tres personas con antecedentes penales han sido detenidas por el ICE, según informes de prensa.

Las publicaciones en redes sociales que afirman falsamente haber visto a oficiales del ICE merodeando cerca de sus hogares han alimentado aún más la preocupación.

Yirka Díaz Platt, trabajadora social bilingüe de Silverthorne, originaria de Perú, afirmó que el temor generalizado a la deportación ha llevado a muchos trabajadores y residentes latinos a refugiarse en las sombras.

Según trabajadores de salud y defensores locales, las personas han comenzado a cancelar reuniones presenciales y a evitar solicitar servicios gubernamentales que requieren el envío de datos personales. A principios de febrero, algunos residentes locales no se presentaron a trabajar como parte de una huelga nacional convocada por el “día sin inmigrantes”. Los empleadores se preguntan si perderán empleados valiosos por las deportaciones.

Algunos inmigrantes han dejado de conducir por temor a ser detenidos por la policía. Paige Baker-Braxton, directora de salud conductual ambulatoria del sistema de salud de Vail, comentó que ha observado una disminución en las visitas de pacientes hispanohablantes en los últimos meses.

“Intentan mantenerse en casa. No socializan mucho. Si vas al supermercado, ya no ves a mucha gente de nuestra comunidad”, dijo Platt. “Existe ese miedo de: ‘No, ahora mismo no confío en nadie'”.

Juana Amaya no es ajena a la resistencia para sobrevivir. Amaya emigró a la zona de Vail desde Honduras en 1983 como madre soltera de un niño de 3 años y otro de 6 meses. Lleva más de 40 años trabajando como limpiadora de casas en condominios y residencias de lujo en los alrededores de Vail, a veces trabajando hasta 16 horas al día. Con apenas tiempo para terminar el trabajo y cuidar de una familia en casa, comentó, a menudo les cuesta a los latinos de su comunidad admitir que el estrés ya es demasiado.

“No nos gusta hablar de cómo nos sentimos”, dijo, “así que no nos damos cuenta de que estamos lidiando con un problema de salud mental”.

El clima político actual solo ha empeorado las cosas.

“Ha tenido un gran impacto”, dijo. “Hay personas que tienen niños pequeños y se preguntan qué harán si están en la escuela y se los llevan a algún lugar, pero los niños se quedan. ¿Qué hacen?”.

Asad ha estudiado el impacto de la retórica de la deportación en la salud mental de las comunidades latinas. Fue coautor de un estudio, publicado el año pasado en la revista Proceedings of the National Academy of Sciences, que concluyó que el aumento de esta retórica puede causar mayores niveles de angustia psicológica en los no ciudadanos latinos e incluso en los ciudadanos latinos.

Asad descubrió que ambos grupos pueden experimentar mayores niveles de estrés, y las investigaciones han confirmado las consecuencias negativas de la falta de documentación de los padres en la salud y el rendimiento educativo de sus hijos.

“Las desigualdades o las dificultades que imponemos hoy a sus padres son las dificultades o desigualdades que sus hijos heredarán mañana”, afirmó Asad.

A pesar de los altos niveles de miedo y ansiedad, los latinos que viven y trabajan cerca de Vail aún encuentran maneras de apoyarse mutuamente y buscar ayuda.

Grupos de apoyo en el condado de Summit, donde se encuentra Breckenridge y a menos de una hora en coche de Vail, han ofrecido talleres de salud mental para nuevos inmigrantes y mujeres latinas. Building Hope, en el condado de Summit y Olivia’s Fund en el condado de Eagle, donde se encuentra Vail, ayudan a quienes no tienen seguro médico a pagar un número determinado de sesiones de terapia.

Vail Health planea abrir un centro psiquiátrico regional para pacientes hospitalizados en mayo, y la Alianza de Recursos Interculturales Móviles ofrece servicios integrales, incluyendo recursos de salud conductual, directamente a las comunidades cercanas a Vail.

De vuelta en Silverthorne, García-Ramírez, el exiliado nicaragüense, vive el día a día.

“Si me deportan de aquí, iría directamente a Nicaragua”, dijo García-Ramírez, quien contó haber recibido una amenaza de muerte verbal de las autoridades de su país natal. “Sinceramente, no creo que aguante ni un día”.

Mientras tanto, continúa su rutinario viaje a casa desde su trabajo de cajero, a veces sorteando nieve resbaladiza y calles oscuras después de las 9 pm. Cuando surgen pensamientos de pesadilla sobre su propio destino en Estados Unidos, García-Ramírez se concentra en el suelo bajo sus pies.

“Llueva, truene o nieve”, dijo, “yo camino”.

Este artículo se publicó con el apoyo de Journalism & Women Symposium (JAWS) Health Journalism Fellowship, asistida por subvenciones de The Commonwealth Fund.

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

USE OUR CONTENT

This story can be republished for free (details).

Adults, he recollects, would scare the kids with tales of the “Mona Bruja,” or “Monkey Witch.” Step too far into the dark, they told him, and you might just get snatched up by the giant monstrous monkey who lives in the shadows.

Now, when García-Ramírez looks over his shoulder, it’s not monster monkeys he is afraid of. It’s U.S. Immigration and Customs Enforcement officers.

“There’s this constant fear that you’ll be walking down the street and a vehicle rolls up,” García-Ramírez, 57, said in Spanish. “They tell you, ‘We’re from ICE; you’re arrested,’ or, ‘Show me your papers.’”

Silverthorne, a commuter town between the ski meccas of Breckenridge and Vail, has been García-Ramírez’s home for the past two years. He works as a cashier at the grocery and shares a two-bedroom apartment with four roommates.

The town of nearly 5,000 has proved a welcome haven for the political exile, who was released from prison in 2023 after Nicaragua’s authoritarian government brokered a deal with the U.S. government to transfer more than 200 political prisoners to the U.S. The exiles were offered temporary residency in the U.S. under a Biden administration humanitarian parole program.

García-Ramírez’s two-year humanitarian parole expired in February, just a few weeks after President Donald Trump issued an executive order to end the program that had permitted temporary legal residency in the U.S. for hundreds of thousands of Cubans, Haitians, Nicaraguans, and Venezuelans, putting him at risk of deportation. García-Ramírez was stripped of his Nicaraguan citizenship when he came to the U.S. Just over a year ago, he applied for political asylum. He is still waiting for an interview.

“I can’t safely say I’m calm, or I’m OK, right now,” García-Ramírez said. “You feel unsafe, but you also feel incapable of doing anything to make it better.”

Vail and Breckenridge are world famous for their ski slopes, which attract millions of people a year. But life for the tourism labor force that serves Colorado’s mountain resorts is less glamorous. Residents of Colorado’s mountain towns experience high rates of suicide and substance use disorders, fueled in part by seasonal fluctuations in income that can cause stress for many in the local workforce.

The Latino communities who make up significant proportions of year-round populations in Colorado’s mountain towns are particularly vulnerable. A recent poll found more than 4 in 5 Latino respondents in the Western Slope region, home to many of the state’s rural ski resort communities, expressed “extremely or very serious” concern about substance use. That’s significantly higher than in rural eastern Colorado’s Morgan County, which also has a sizable Latino population, and in Denver and Colorado Springs.

Statewide, concerns about mental health have surged among Latinos in recent years, rising from fewer than half calling it an extremely or very serious problem in 2020 to more than three-quarters in 2023. Health care workers, researchers, and community members all say factors such as language differences, cultural stigma, and socioeconomic barriers may exacerbate mental health issues and limit the ability to access care.

“You’re not getting regular medical care. You’re working long hours, which probably means that you can’t take care of your own health,” said Asad Asad, a Stanford University assistant professor of sociology. “All of these factors compound the stresses that we all might experience in daily life.”

Add sky-high costs of living and an inadequate supply of mental health facilities across Colorado’s rural tourist destinations, and the problem becomes acute.

Now, the Trump administration’s threats of immigration raids and imminent deportation of anyone without legal U.S. residency have caused stress levels to soar. In communities around Vail, advocates estimate, a vast majority of Latino residents do not have legal status. Communities near Vail and Breckenridge have not experienced immigration raids, but in neighboring Routt County, home to Steamboat Springs, at least three people with criminal records have been detained by ICE, according to news reports. Social media posts falsely claiming local ICE sightings have further fueled concerns.

Yirka Díaz Platt, a bilingual social worker in Silverthorne originally from Peru, said a pervasive fear of deportation has caused many Latino workers and residents to retreat into the shadows. People have begun to cancel in-person meetings and avoid applying for government services that require submitting personal data, according to local health workers and advocates. In early February, some locals didn’t show up to work as part of a nationwide “day without immigrants” strike. Employers wonder whether they will lose valuable employees to deportation.

Some immigrants have stopped driving out of fear they will be pulled over by police. Paige Baker-Braxton, director of outpatient behavioral health at the Vail Health system, said she has seen a decline in visits from Spanish-speaking patients over the last few months.

“They’re really trying to keep to themselves. They are not really socializing much. If you go to the grocery stores, you don’t see much of our community out there anymore,” Platt said. “There’s that fear of, ‘No, I’m not trusting anyone right now.’”

Juana Amaya is no stranger to digging in her heels to survive. Amaya immigrated to the Vail area from Honduras in 1983 as a single mother of a 3-year-old and a 6-month-old. She has spent more than 40 years working as a house cleaner in luxury condos and homes around Vail, sometimes working up to 16 hours a day. With barely enough time to finish work and care for a family at home, she said, it is often hard for Latinos in her community to admit when the stress has become too much.

“We don’t like to talk about how we’re feeling,” she said in Spanish, “so we don’t realize that we’re dealing with a mental health problem.”

The current political climate has only made things worse.

“It’s had a big impact,” she said. “There are people who have small children and wonder what they’ll do if they’re in school and they are taken away somewhere, but the children stay. What do you do?”

Asad has studied the mental health impacts of deportation rhetoric on Latino communities. He co-authored a study, published last year in the journal Proceedings of the National Academy of Sciences, that found escalated deportation rhetoric may cause heightened levels of psychological distress in Latino noncitizens and even in Latino citizens.

Asad found that both groups may experience increased stress levels, and research has borne out the negative consequences of a parent’s lack of documentation on the health and educational attainment of their children.

“The inequalities or the hardships we impose on their parents today are the hardships or inequalities their children inherit tomorrow,” Asad said.

Despite heightened levels of fear and anxiety, Latinos living and working near Vail still find ways to support one another and seek help. Support groups in Summit County, home to Breckenridge and less than an hour’s drive from Vail, have offered mental health workshops for new immigrants and Latina women. Building Hope Summit County and Olivia’s Fund in Eagle County, home to Vail, help those without insurance pay for a set number of therapy sessions.

Vail Health plans to open a regional inpatient psychiatric facility in May, and the Mobile Intercultural Resource Alliance provides wraparound services, including behavioral health resources, directly to communities near Vail.

Back in Silverthorne, García-Ramírez, the Nicaraguan exile, takes things one day at a time.

“If they deport me from here, I’d go directly to Nicaragua,” said García-Ramírez, who said he had received a verbal death threat from authorities in his native country. “Honestly, I don’t think I would last even a day.”

In the meantime, he continues to make the routine trek home from his cashier job, sometimes navigating slick snow and dark streets past 9 p.m. When nightmarish thoughts about his own fate in America surface, García-Ramírez focuses on the ground beneath his feet.

“Come rain, shine, or snow,” he said, “I walk.”

This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.

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

USE OUR CONTENT

This story can be republished for free (details).

Colorado families say their state was a haven for those health services for a long time, but following executive orders from the Trump administration, even hospitals in Colorado limited the care they offer for trans patients under age 19. KFF Health News Colorado correspondent Rae Ellen Bichell spoke with youth and their families.

GRAND JUNCTION, Colo. — On a Friday after school, 6-year-old Esa Rodrigues had unraveled a ball of yarn, spooked the pet cat, polled family members about their favorite colors, and tattled on a sibling for calling her a “butt-face mole rat.”

Next, she was laser-focused on prying open cherry-crisp-flavored lip gloss with her teeth.

“Yes!” she cried, twisting open the cap. Esa applied the gloopy, shimmery stuff in her bedroom, where a large transgender pride flag hung on the wall.

Esa said the flag makes her feel “important” and “happy.” She’d like to take it down from the wall and wear it as a cape.

Her parents questioned her identity at first, but not anymore. Before, their anxious child dreaded going to school, bawled at the barbershop when she got a boy’s haircut, and curled into a fetal position on the bathroom floor when she learned she would never get a period.

Now, that child is happily bounding up a hill, humming to herself, wondering aloud if fairies live in the little ceramic house she found perched on a stone.

Her mom, Brittni Packard Rodrigues, wants this joy and acceptance to stay. Depending on a combination of Esa’s desire, her doctors’ recommendations, and when puberty sets in, that might require puberty blockers, followed by estrogen, so that Esa can grow into the body that matches her being.

“In the long run, blockers help prevent all of those surgeries and procedures that could potentially become her reality if we don’t get that care,” Packard Rodrigues said.

The medications known as puberty blockers are widely used for conditions that include prostate cancer, endometriosis, infertility, and puberty that sets in too early. Now, the Trump administration is seeking to limit their use specifically for transgender youth.

Esa’s home state of Colorado has long been known as a haven for gender-affirming care, which the state considers legally protected and an essential health insurance benefit. Medical exiles have moved to Colorado for such treatment in the past few years. As early as the 1970s, the town of Trinidad became known as “the sex-change capital of the world” when a cowboy-hat-wearing former Army surgeon, Stanley Biber, made his mark performing gender-affirming surgeries for adults.

On his first day in office, President Donald Trump signed an executive order refuting the existence of transgender people by saying it is a “false claim that males can identify as and thus become women and vice versa.” The following week, he issued another order calling puberty blockers and hormones for anyone under age 19 a form of chemical “mutilation” and “a stain on our Nation’s history.” It directed agencies to take steps to ensure that recipients of federal research or education grants stop providing it.

Subsequently, health care organizations in Colorado; California; Washington, D.C.; and elsewhere announced they would preemptively comply. In Colorado, that included three major health care organizations: Children’s Hospital Colorado, Denver Health, and UCHealth. At the end of January and in early February, the three systems announced changes to the gender-affirming care they provide to patients under 19, effective immediately: no new hormone or puberty blocker prescriptions for patients who hadn’t had them before, limited or no prescription renewals for those who had, and no surgeries, though Children’s Hospital had never offered it, and such surgery is rare among teens: For every 100,000 trans minors, fewer than three undergo surgery.

Children’s Hospital and Denver Health resumed offering puberty blockers and hormones on Feb. 24 and Feb. 19, respectively, after Colorado joined a U.S. District Court lawsuit in Washington state. The court concluded that Trump’s orders relating to gender “discriminate on the basis of transgender status and sex.” It granted a preliminary injunction blocking them from taking effect in the four states involved in the lawsuit.

Surgeries, however, have not resumed. Denver Health said it will “continue its pause on gender-affirming surgeries for patients under 19 due to patient safety and given the uncertainty of the legal and regulatory landscape.”

UCHealth has resumed neither medication nor surgery for those under 19. “Our providers are awaiting a more permanent decision from federal courts that may resolve the uncertainty around providing this care,” spokesperson Kelli Christensen wrote.

Trans youth and their families said the court ruling and the two Colorado health systems’ decisions to resume treatments haven’t resolved matters. It has bought them time to stockpile prescriptions, to try to find private practice physicians with the right training to monitor blood work and adjust prescriptions accordingly, and, for some, to work out the logistics of moving to another state or country.

The Trump administration has continued to press health providers beyond the initial executive orders by threatening to withhold or cancel federal money awarded to them. In early March, the Health Resources and Services Administration said it would review funding for graduate medical education at children’s hospitals.

KFF Health News requested comment from White House deputy press secretary Kush Desai but did not receive a response. HHS deputy press secretary Emily Hilliard responded with links to two prior press releases.

Medical interventions are just one type of gender-affirming care, and the process to get treatment is long and thorough. Researchers have found that, even among those with private insurance, transgender youth aren’t likely to receive puberty blockers and hormones. Interestingly, most gender-affirming breast reduction surgeries performed on men and boys are done on cisgender — not transgender — patients.

Kai, 14, wishes he could have gone on puberty blockers. He lives in Centennial, a Denver suburb. KFF Health News is not using his full name because his family is worried about him being harassed or targeted.

Kai got his period when he was 8 years old. By the time he realized he was transgender, in middle school, it was too late to start puberty blockers.

His doctors prescribed birth control to suppress his periods, so he wouldn’t be reminded each month of his gender dysphoria. Then, once he turned 14, he started taking testosterone.

Kai said if he didn’t have hormone therapy now, he would be a danger to himself.

“Being able to say that I’m happy in my body, and I get to be happy out in public without thinking everyone’s staring at me, looking at me weird, is such a huge difference,” he said.

His mom, Sherry, said she is happy to see Kai relax into the person he is.

Sherry, who asked to use her middle name to prevent her family from being identified, said she started stockpiling testosterone the moment Trump got elected but hadn’t thought about what impact there would be on the availability of birth control. Yet after the executive orders, that prescription, too, became tenuous. Sherry said Kai’s doctor at UCHealth had to set up a special meeting to confirm the doctor could keep prescribing it.

So, for now, Kai has what he needs. But to Sherry, that is cold comfort.

“I don’t think that we are very safe,” she said. “These are just extensions.”

The family is coming up with a plan to leave the country. If Sherry and her husband can get jobs in New Zealand, they’ll move there. Sherry said such mobility is a privilege that many others don’t have.

For example, David, an 18-year-old student at Western Colorado University in the Rocky Mountain town of Gunnison. He asked to be identified only by his middle name because he worries he could be targeted in this conservative, rural town.

David doesn’t have a passport, but even if he did, he doesn’t want to leave Gunnison, he said. He is studying geology, is learning to play the bass, and has a good group of friends. He has plans to become a paleontologist.

His dorm room shelves are scattered with his essentials: fossils, Old Spice deodorant, microwave macaroni and cheese. But there are no mirrors. David said he got in the habit of avoiding them.

“For the longest time, I just had so much body dysphoria and dysmorphia that it can be kind of hard to look in the mirror,” David said. “But when I do, most of the time, I see something that I really like.”

He’s been taking testosterone for three years, and the hormone helped him grow a beard. In January, his doctor at Denver Health was told to stop prescribing it. His mom drove hours from her home to Gunnison to deliver the news in person.

That prescription is back on track now, but the mastectomy he’d planned for this summer isn’t. He’d hoped to have adequate recovery time before sophomore year. But he doesn’t know anyone in Colorado who would perform it until he is 19. He could easily get surgery to enhance his breasts, but he must seek surgical options in other states to reduce or remove them.

“Colorado as a state was supposed to be a safe haven,” said his mother, Louise, who asked to be identified by her middle name. “We have a law that makes it a right for trans people to have health care, and yet our health care systems are taking that away.”

It has taken eight years and about 10 medical providers and therapists to get David this close to the finish line. That’s a big deal after living through so many years of dysphoria and dysmorphia.

“I’m still going, and I’m going to keep going, and there’s almost nothing they can do to stop me — because this is who I am,” David said. “There have always been trans people, and there always will be trans people.”

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

USE OUR CONTENT

This story can be republished for free (details).