The small team, with technical data expertise, worked out of HHS’ Office of the Assistant Secretary for Planning and Evaluation, or ASPE. Their dismissal mirrored others across HHS, which came without warning and left officials puzzled as to why they were “RIF’ed” — as in “reduction in force,” the bureaucratic language used to describe the firings.

“I suspect they RIF’ed offices that had the word ‘data’ or ‘statistics’ in them,” said one of the laid-off employees, a social scientist whom KFF Health News agreed not to name because the person feared further recrimination. “It was random, as far as we can tell.”

Among those fired was Kendall Swenson, who had led development of the poverty guidelines for many years and was considered the repository of knowledge on the issue, according to the social scientist and two academics who have worked with the HHS team.

The sacking of the office could lead to cuts in assistance to low-income families next year unless the Trump administration restores the positions or moves its duties elsewhere, said Robin Ghertner, the fired director of the Division of Data and Technical Analysis, which had overseen the guidelines.

The poverty guidelines are “needed by many people and programs,” said Timothy Smeeding, a professor emeritus of economics at the La Follette School of Public Affairs at the University of Wisconsin. “If you’re thinking of someone you fired who should be rehired, Swenson would be a no-brainer,” he added.

Under a 1981 appropriations bill, HHS is required annually to take Census Bureau poverty-line figures, adjust them for inflation, and create guidelines that agencies and states use to determine who is eligible for various types of help.

There’s a special sauce for creating the guidelines that includes adjustments and calculations, Ghertner said. Swenson and three other staff members would independently prepare the numbers and quality-check them together before they were issued each January.

Everyone in Ghertner’s office was told last week, without warning, that they were being put on administrative leave until June 1, when their employment would officially end, he said.

“There’s literally no one in the government who knows how to calculate the guidelines,” he said. “And because we’re all locked out of our computers, we can’t teach anyone how to calculate them.”

ASPE had about 140 staff members and now has about 40, according to a former staffer. The HHS shake-up merged the office with the Agency for Healthcare Research and Quality, or AHRQ, whose staff has shrunk from 275 to about 80, according to a former AHRQ official who spoke on the condition of anonymity.

HHS has said it laid off about 10,000 employees and that, combined with other moves, including a program to encourage early retirements, its workforce has been reduced by about 20,000. But the agency has not detailed where it made the cuts or identified specific employees it fired.

“These workers were told they couldn’t come into their offices so there’s no transfer of knowledge,” said Wendell Primus, who worked at ASPE during the Bill Clinton administration. “They had no time to train anyone, transfer data, etc.”

HHS defended the firings. The department merged AHRQ and ASPE “as part of Secretary Kennedy’s vision to streamline HHS to better serve Americans,”  spokesperson Emily Hilliard said. “Critical programs within ASPE will continue in this new office” and “HHS will continue to comply with statutory requirements,” she said in a written response to KFF Health News.

After this article published, HHS spokesperson Andrew Nixon called KFF Health News to say others at HHS could do the work of the RIF’ed data analysis team, which had nine members. “The idea that this will come to a halt is totally incorrect,” he said. “Eighty million people will not be affected.”

Secretary Robert F. Kennedy Jr. has so far declined to testify about the staff reductions before congressional committees that oversee much of his agency. On April 9, a delegation of 10 Democratic members of Congress waited fruitlessly for a meeting in the agency’s lobby.

The group was led by House Energy and Commerce health subcommittee ranking member Diana DeGette (D-Colo.), who told reporters afterward that Kennedy must appear before the committee “and tell us what his plan is for keeping America healthy and for stopping these devastating cuts.”

Matt VanHyfte, a spokesperson for the Republican committee leadership, said HHS officials would meet with bipartisan committee staff on April 11 to discuss the firings and other policy issues.

ASPE serves as a think tank for the HHS secretary, said Primus, who later was Rep. Nancy Pelosi’s senior health policy adviser for 18 years. In addition to the poverty guidelines, the office maps out how much Medicaid money goes to each state and reviews all regulations developed by HHS agencies.

“These HHS staffing cuts — 20,000 — obviously they are completely nuts,” Primus said. “These were not decisions made by Kennedy or staff at HHS. They are being made at the White House. There’s no rhyme or reasons to what they’re doing.”

HHS leaders may be unaware of their legal duty to issue the poverty guidelines, Ghertner said. If each state and federal government agency instead sets guidelines on its own, it could create inequities and lead to lawsuits, he said.

And sticking with the 2025 standard next year could put benefits for hundreds of thousands of Americans at risk, Ghertner said. The current poverty level is $15,650 for a single person and $32,150 for a family of four.

“If you make $30,000 and have three kids, say, and next year you make $31,000 but prices have gone up 7%, suddenly your $31,000 doesn’t buy you the same,” he said, “but if the guidelines haven’t increased, you might be no longer eligible for Medicaid.”

The 2025 poverty level for a family of five is $37,650.

As of October, about 79 million people were enrolled in Medicaid or the related Children’s Health Insurance Program, both of which are means-tested and thus depend on the poverty guidelines to determine eligibility.

Eligibility for premium subsidies for insurance plans sold in Affordable Care Act marketplaces is also tied to the official poverty level.

One in eight Americans rely on the Supplemental Nutrition Assistance Program, or food stamps, and 40% of newborns and their mothers receive food through the Women, Infants, and Children program, both of which also use the federal poverty level to determine eligibility.

Former employees in the office said they were not disloyal to the president. They knew their jobs required them to follow the administration’s objectives. “We were trying to support the MAHA agenda,” the social scientist said, referring to Kennedy’s “Make America Healthy Again” rubric. “Even if it didn’t align with our personal worldviews, we wanted to be useful.”

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

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

A week into the reorganization of the Department of Health and Human Services announced by Secretary Robert F. Kennedy Jr., the scope of the staff cuts and program cutbacks is starting to become clear. Among the biggest targets for reductions were the nation’s premier public health agencies: the Centers for Disease Control and Prevention, the National Institutes of Health, and the FDA.

Meanwhile, Kennedy did not show up as invited to testify before the Senate Health, Education, Labor and Pensions Committee, known as HELP, but he did visit families in Texas whose unvaccinated children died of measles in the current outbreak and called for an end to water fluoridation during a stop in Utah.

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

Panelists

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Amid a dearth of public information about federal health cutbacks, HHS employees currently on administrative leave report they were given no opportunity to hand off their responsibilities, suggesting important work will simply be discontinued. Critical staff members have been cut from the FDA offices funded by user fees, for instance — affecting the drugmakers that pay the fees in exchange for timely evaluation of their products, as well as the patients hoping for access to those drugs. Even if the cuts were reversed, the damage could linger, especially in areas where there will be gaps in data such as disease surveillance.
• Meanwhile, the temporary public communications freeze implemented in the Trump administration’s early days apparently has not ended. State officials, desperate for information from federal health officials about ongoing programs, are receiving no response as they seek guidance from offices in which most or all staffers were laid off.
• President Donald Trump issued an executive order this week that instructs federal department heads to summarily repeal any regulation they deem “unlawful.” The order threatens to effectively short-circuit the federal regulatory process, which involves public notices and opportunities to comment. Businesses rely on that process to make decisions, and Trump’s order could create further instability for health care and other industries.
• And Kennedy traveled West this week, using his public appearances to call for removing fluoride from the water supply and to discuss the measles outbreak. He issued his strongest endorsement of the measles vaccine yet, but he also praised doctors who have used alternative and unapproved remedies to treat measles patients. Senators had called him to testify before Congress this week about the ongoing upheaval at HHS, but the hearing was canceled.
• Legislators in a growing number of states are introducing abortion bans that would punish women seeking abortions as well as abortion providers, suggesting a long game for abortion opponents that goes well beyond overturning a nationwide right to the procedure.

Also this week, Rovner interviews Georgetown Law School professor Stephen Vladeck about the limits of presidential power.

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

Julie Rovner: The New York Times’ “Why the Right Still Embraces Ivermectin,” by Richard Fausset.  

Victoria Knight: Wired’s “Dr. Oz Pushed for AI Health Care in First Medicare Agency Town Hall,” by Leah Feiger and Steven Levy.  

Alice Miranda Ollstein: The Guardian’s “‘We Are Failing’: Doctors and Students in the US Look to Mexico for Basic Abortion Training,” by Carter Sherman.  

Sandhya Raman: CQ Roll Call’s “In Sweden, a Focus on Smokeless Tobacco,” by Sandhya Raman. 

Also mentioned in this week’s podcast:

• The New York Times’ “The Three States That Are Especially Stuck if Congress Cuts Medicaid,” by Sarah Kliff and Margot Sanger-Katz.
• The AP’s “Ex-Official Says He Was Forced out of FDA After Trying To Protect Vaccine Safety Data From RFK Jr.,” by Matthew Perrone.

Click to open the transcript

Transcript: The Dismantling of HHS

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

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

Alice Miranda Ollstein: Hello. 

Rovner: Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

Rovner: And Victoria Knight of Axios news. 

Victoria Knight: Hello, everyone. 

Rovner: Later in this episode we’ll have my interview with Georgetown University law professor Stephen Vladeck, who will talk about the limits of presidential power — if there are any left. But first, this week’s news. 

So the dust is starting to settle, sort of, in that ginormous reorganization of the Department of Health and Human Services launched by Secretary Robert F. Kennedy Jr. last week, which I am now calling “The Great Dismantling.” Here’s some of what we know about the casualties at the CDC [Centers for Disease Control and Prevention]. Offices that worked on sexually transmitted disease prevention, injury prevention, lead poisoning surveillance, and tobacco were basically gutted. At NIH [the National Institutes of Health], the chronic pain division was eliminated, as was the Office of Long Covid. And at the FDA [Food and Drug Administration], offices handling veterinary medicine, generic drugs, and food safety were dramatically reduced. Now that we’ve had a week to absorb what’s been done and, despite claims of the contrary from Secretary Kennedy, we are told there is no plan to hire back some of those workers who were apparently let go in error, what are you guys hearing about where we are? 

Ollstein: Yeah, there’s a lot of people who were put on administrative leave, which is going to run out in a few weeks. By and large, they are not expecting to be called back. They are holding out hope. They would love to be called back. They keep telling me that they would love to get back to the work they were doing. They’re really worried about it not continuing without them, but they’re mostly assuming that these cuts are permanent for now. And contrary to claims from HHS that work isn’t being eliminated, it’s just being consolidated or folded in or there’s different words they’re using, all of these different laid-off workers told me from different divisions that they were basically given no opportunity to hand over their ongoing projects to anyone else, to train anyone else, to make sure it keeps going. So as far as they know, a lot of this surveillance work, research work, coordination work is just not going to be happening going forward. 

Rovner: As far as I can tell, money that’s supposed to be going out the door from places like the NIH isn’t. 

Knight: Yeah, you hit some of the offices, programs that have been cut, but also I think at FDA, we did some reporting this week on the user drug fee program and how staff that do the evaluating drugs and things like that have been cut. And it’s interesting because pharmaceutical companies pay these fees hoping that they’ll get timely evaluations of their drugs, and also— 

Rovner: They pay these fees and are told they will get timely evaluation of these drugs in exchange. That’s the deal. 

Knight: Exactly. And I know pharmaceutical companies are definitely concerned about this, and it’s also concerning for patients who may be waiting for certain drugs to be approved and things like that. And I think it’s interesting, also, Republicans like to talk a lot about innovation and getting new drugs approved and things like that, and this would harm that process if the staff are not rehired. I haven’t really heard an update on that, so— 

Raman: I would also add that part of it is that we just don’t have a lot of information, right? We had Secretary Kennedy invited to come testify before the Senate HELP Committee this week and go through some of these things and explain the rationale and get into that, and that did not happen. 

Rovner: Yeah, we’ll get to that. 

Raman: Yes, and I think, at the same time, a lot of those cuts were also to the communications folks within those agencies that could be disseminating this information to external folks, to internal folks to provide more clarity about where things would be going. And we don’t have those there now, so it will take some time to kind of see where things are going, and even when there’s going to be a delay in some of that stuff, getting that information out is going to be difficult. 

Ollstein: Sandhya is absolutely right about the communications issue here, and I’m just hearing that on so many fronts. States are desperate to get in contact with someone in the federal government to understand what’s going on. Do they have to keep collecting data and sending it to the federal government even though there’s no one left to compile and process it? They’re reaching out asking: Are certain grants going to continue or not? What should we do? Are we going to be in legal trouble if we continue some of this work? And there’s just no one answering, sometimes because all the people that would’ve answered have been let go. But also the communications freeze that was supposed to be temporary at the very beginning of the administration, a lot of federal workers told me that never really ended. 

So there are these email accounts that they were ordered to stop checking and responding to. So one example is the entire team that worked on IVF [in vitro fertilization], evaluating which IVF clinics had the best pregnancy success rates, monitoring safety, all of that — they were all eliminated. And one consequence of that is that there was this email account that doctors, patients, anybody could reach out to for information and to ask questions, and no one’s checking it, no one’s responding. 

Rovner: I don’t know about you guys. I am starting to hear from health care stakeholders. The federal government is so intertwined in, basically it’s a fifth of the economy, what we spend on health care, and it’s creating so much uncertainty. As you were saying, people don’t know if they’re going to get in trouble for not doing things or for doing things. But we do know, as we said, we talked about last week, FDA missed a deadline to rule on a Novavax vaccine. This is going to have ramifications way beyond just the people who are losing their jobs in the federal government, right? 

Raman: There’s so many people that receive the services that we contract out, that we put grants through across the country. And I think that even in speaking to some of these employees that have lost their jobs, one of the top concerns is not even for their own job but that no one else can do the work that they did. Or in some cases, the only person that could have done that work has also already been let go. And just that those things are going to fall through the cracks for a lot of vulnerable communities. 

Ollstein: Some of the folks also told me that even if this is reversed in the future, the damage will just be there for a very long time, especially on things like surveillance and data collection. If you have a gap in there, that skews things. That messes things up for the future. It makes it harder to make comparisons. It makes it harder to know if things are getting better or worse on, like, asthma rates and levels of lead in people’s blood, all kinds of things, things that are not politically controversial or partisan. And so it’ll just be really difficult going forward to know which programs are working, which interventions are working or not working. 

Rovner: So things are happening almost too fast to keep track of. But in his latest round of executive orders on Wednesday, President [Donald] Trump signed one called Directing the Repeal of Unlawful Regulations, in which he basically instructs the heads of all departments to repeal rules they consider unlawful, without notice or comment, which is not how this is supposed to work. I’m not sure even, though, quite what to make of all this. And it seems to be going mostly unnoticed in all of the attention, deservedly, to the other news that’s happening, some of which we’ll get to. But repealing rules basically on a whim could be as important to how the federal government functions as firing all these people, right? 

Raman: Yeah, there’s a reason that the rulemaking process is the way it is, that it takes a certain amount of time. You allow stakeholders to weigh in, to meet, to revise, and that the things aren’t changing too drastically. And there are some rules that go back and forth between the administrations, but a lot of things last over time, and the process is the way it is to make sure that you get the best possible result for whatever you’re changing and— 

Rovner: That you get stability. 

Raman: Yes. 

Rovner: I think that’s the theme here, is that that’s what we’re lacking right now. Nobody can count on what the rules are. 

Knight: And I was going to say, from an industry perspective, industries make decisions based on these rules and knowing when they’re going to come out and when they might change. Think about the insurance industry, physicians, people within the health care industry. And so that could really impact those groups as well a lot. So, and exactly, going back to what you said about stability, so it’ll make it really hard to make business decisions. 

Rovner: Right. So this goes along with the stuff with the tariffs, is that we have no idea what the rules of the road are going to be going forward if rules can be sort of disappeared in a matter of days the way staff is being. Well, let’s move to Congress. Remember Congress? Late last Friday, or I guess it was technically early Saturday, the Senate passed what was supposed to be a compromise Republican budget resolution between the House and the Senate. For those who have forgotten, while the House passed a resolution that would lead to a single gigantic budget reconciliation bill, including tax cuts and likely big cuts to Medicaid, the Senate’s original budget resolution would only have led to a bill on immigration and energy, saving the tax and health fights for later in the year. 

Well, it seems like the compromise, which is kind of a vaguer version of the House blueprint, didn’t go over so well in the House, where Speaker Mike Johnson had hoped to push it through this week. A vote was scheduled for Wednesday, then it got delayed, then it got shelved, at least for the night. They’re apparently trying to regroup and do this this morning. Where are we in this? 

Knight: Yeah, so you gave a pretty good rundown. I was here late last night talking to Freedom Caucus members, the House Freedom Caucus, the hard-liners. Their concerns with, this is basically a Senate amendment to the House’s resolution. And so what the Senate passed was an amendment, and it technically really just gives instructions for the Senate. It didn’t touch the House’s resolution. So the House’s budget resolution they passed is the same thing, but House Freedom Caucus members had issue that the Senate ceilings for cuts is much lower than the House’s. And so they’re saying— 

Rovner: It’s in the billions instead of trillions. 

Knight: Exactly. Exactly. So coming out, they holed up with Speaker Johnson last night and House GOP leadership and were saying, We need more binding cuts on the Senate side, and were like: We need you guys to commit to this, otherwise we’re unhappy with this amount of cuts. This is going to increase spending. There’s been a lot of discussion on how to do the budget math for these things, but it’s pretty clear the Senate’s resolution would not cut spending as much as the House’s. So that was what they came out demanding last night. This morning, Speaker Johnson and Senate Majority Leader John Thune came out, did a press conference, and said: We’re going to proceed with this. We’ll see if that changes. But it was interesting to note that Thune said, he noted that there are Senate Republicans that do want cuts that may be up to the $1.5 trillion, but he did not commit to making cuts on his side. So we’ll see how this goes. That seems to be the state of play. It’s very in flux. That could change over time. So if anyone has anything to add, I think that’s a rundown. 

Rovner: Yeah, it feels like they’re kind of buying time to see if they can keep together what’s clearly a very fractious group here. 

Knight: Yeah, and jet fumes are always a good motivator, and also holidays. So there’s supposed to be a two-week recess right after this, and Passover starts this weekend and Easter next weekend, so we’ll see if that motivates people to vote for it. I will say, an argument that we’ve heard from a lot of the moderates that are concerned about the Medicaid cuts, when they voted for these, they’ve said: This is just an outline. It’s just a blueprint. It’s not committing us to anything. But hard-liners don’t seem to like that argument as much. So can they convince them that way? I don’t know. 

Rovner: Well, let’s talk about those Medicaid cuts for a minute, which, by the way, as you pointed out, Victoria, is not really what’s holding up the vote in the House. Our New York Times podcast pals Sarah Kliff and Margot Sanger-Katz had a really interesting story over the weekend about three red states that would really be stuck if Medicaid gets cut. Oklahoma, Missouri, and South Dakota all passed their Medicaid expansions by ballot measure, including it as part of their state constitutions. Now this is exactly the opposite of those states that would immediately cancel their expansions if Congress cuts the Medicaid match. These three states would be totally stuck, unless they could have another ballot measure that would then eliminate what they added. I guess that helps explain why very conservative Missouri Republican Sen. Josh Hawley says he is so opposed to reducing the Medicaid match. But he seems OK with Medicaid work requirements that would also cut people off the rolls, just not necessarily in a way that would cost the state so much money, right? 

Ollstein: Yeah, I think we’re going to see a lot of interesting semantic games going forward. I think we’re going to see a lot of different interpretations of what a cut is. We’re going to see a lot of claims made about who does and doesn’t deserve Medicaid coverage. We’ve been seeing this for a long time, but as these tough decisions have to be made on the Hill, I think a lot of that is going to come to a head. And so I think you see a lot of conservatives wrestling with believing very strongly in cutting government spending but also recognizing that a lot of their constituents could be harmed by these policies and they would be very angry with their members if that happened. 

And so trying to thread that needle, we’ll see how they do it, whether they can do it successfully without getting a lot of political blowback. Even though there has been a lot of turnover in Congress, you have a decent number of folks who were there last time Congress tried to take a big whack at Medicaid in the Affordable Care Act repeal fight. 

Rovner: In 2017. 

Ollstein: Exactly. Exactly. And the impact on Medicaid is one of the biggest things that garnered a backlash. And Capitol Hill was covered in folks with disabilities protesting, and it was a really bad look, and it contributed to that effort failing. 

Knight: And I think interesting talking about Hawley, but also the Republican Governors Association joined up with some other conservative groups this week to start an ad saying, Don’t cut Medicaid, basically. And so we’re starting to hear that from the states. States are really concerned how this could affect their budgets. They’ve already expanded the program. It would be really hard for them to have to make up in the state that amount of money if the federal government takes away money from the Medicaid program for them or caps it or whatever. It’s interesting to see people walk that line. And House GOP moderates, they are more likely to fold, I think, than hard-liners, but they keep telling me when I talk to them, We’re OK with work requirements, but anything past that might be really hard for us to vote for. But who knows? They could fold if they have enough pressure, but they’re trying to walk the line at this moment. 

Rovner: This is going to be a very different Medicaid fight than it was in 2017. Well, turning to this week in “Make America Healthy Again,” I think we mentioned last week that HHS Secretary RFK Jr. had been invited to testify before the Senate Health, Education, Labor, and Pensions Committee today. Well, as Sandhya pointed out, that did not happen. We’re not entirely sure why, but the secretary continues to do things, well, things he kind of promised senators that he wouldn’t, like saying that he’s going to order the CDC to stop recommending adding fluoride to public water supplies, which he did on a trip to Utah this week. Once more for those in the back, why do most public health professionals support water fluoridation? 

Raman: It really reduces dental decay, by like 25%. ADA [the American Dental Association] has been recommending fluoride for years. So it’s a big proponent of that. 

Rovner: And as someone pointed out, it’s against dentists’ interests to be recommending something that gives them less work and yet they’re still recommending it. 

Ollstein: And even though we have a very silly system in the U.S. where dental care is siloed off from the rest of health care, it does impact your overall health a lot. So it could lead to lung issues, heart issues, all kinds of things if you have dental issues. So it’s not just a cosmetic problem, it can be a very serious health problem. And I will say, too, people should keep in mind that there’s a lot of pointing at studies about negative health impacts from excessive consumption of fluoride, but those studies have a level that is much, much higher than what’s in the U.S. tap water right now. So anything in excess can be bad for you — even just plain water can kill you if you have too much of it. And so I think that people should keep that in mind and remain skeptical about claims being made. 

Rovner: Well, RFK Jr. also continues to make news in his handling of the measles outbreak in Texas, which is now the largest in the nation in the past 30 years, having sickened nearly 600 people, mostly unvaccinated children. Kennedy traveled to the heart of the outbreak last week and visited with the families of the two children that we know have died so far of the virus. He also praised the measles vaccine, but then just hours later posed with and praised two doctors who are using unapproved treatments for measles, including one who was disciplined by Texas medical regulators. Meanwhile, Peter Marks, the FDA vaccine official forced to resign last month, is speaking out, calling Kennedy’s actions thus far, quote, “very scary” in an interview with The Wall Street Journal and telling the AP [Associated Press] that he got fired for trying to keep Kennedy’s team from editing or possibly erasing the very sensitive Vaccine Adverse Event Reporting System kept by the FDA. Is there any way we didn’t see all of this coming? 

Knight: Well, going back to the congressional aspect. The HELP chair, [Sen.] Bill Cassidy, he had both the HELP hearing and the Senate Finance hearing where he questioned Kennedy repeatedly about his views on vaccines, his views on the link between vaccines and autism, I think also measles and autism. And he didn’t really ever get a super substantial answer from Kennedy. And yet the compromise was somewhat that Cassidy said, You’ll have to come quarterly before the HELP Committee and testify about what’s going on, what your views are. And we saw Cassidy try to do that last week. And Kennedy has, as far as I know, the latest is that he received the request but he hasn’t accepted it yet, and unclear if he will. 

So that congressional oversight was supposed to be the way to keep him in check, somewhat. And that’s not happening. It’s not really that enforceable. So I think it’s pretty predictable what’s happening. I think what will be interesting is if the White House gets unhappy with some of Kennedy’s things that he’s doing. There’s been some stories of how they’re having to take over his communications because there’s been no communications from HHS on it, and so they’re kind of unhappy with that. We’ll see if that reaches to a level where they could change leadership or something. But, not there yet, certainly, but something to watch. 

Rovner: Again, so much going on. I think this would normally rise to a higher level than it has given all of the other news that’s happening. Moving on to abortion. We talked last week, or maybe it was the week before, about the Overton window moving towards criminalizing women who have or even seek abortions. That’s apparently the point of a bill introduced in the Alabama Legislature. In North Carolina, a new bill could subject anyone convicted of performing or receiving an abortion to life in prison. We talked a few weeks ago about a similar bill in Georgia that got a legislative hearing. Even if none of these bills pass — and it seems that none of them will pass, at least this year — it certainly seems that claims by the anti-abortion movement that they don’t want to punish women are either not true or falling on deaf ears. 

Ollstein: So the anti-abortion movement, just like the pro-abortion-rights movement, is not a monolith. And just like the political parties, there are moderates and hard-liners. There are people who disagree on tactics. And so I think for so long the movement appeared united because their main goal was just overturning Roe v. Wade. And they were able to paper over other divisions by focusing pretty exclusively on that, or not exclusively but that being the overriding goal. And now that they’ve accomplished that and now that there are a lot more opportunities for them, you’re seeing these divisions. And we’ve seen that over the past few years. There were people who said, OK, a 15-week ban is better than nothing, and we can build on it. And there are people who say: No, that’s an unacceptable compromise, and it has to be a total ban or nothing. And if you do a 15-week ban, you’re endorsing the murder of most babies, because most abortions happen before 15 weeks of pregnancy. 

So I think this is a continuation of that. And it’s also a reflection that there is a lot of frustration in the anti-abortion movement that not only have abortions not ceased when states enact bans, in some cases they’ve gone up, nationally. And that’s a combination of people traveling, that’s a combination of people using telehealth and getting pills mailed to them. That’s become a huge thing that people rely on. And so looking at ways to crack down on those things, including this kind of criminalization of the pregnant patient that’s been sort of a third rail that is now more in the conversation. Of course, people have been proposing such things for a while now, but it’s getting more prominent attention than before. 

Rovner: Yeah. And that was my question, is it used to be a real outlier, and now we’ve seen legislation introduced in 10 states that would criminalize the woman in some way, shape, or form. Sandhya, you wanted to add something. 

Raman: I was going to say it’s also a long game. There are things that we’ve had proposed years ago that I think garnered attention then as being very outside the realm of something that people would consider. And then a few years later, when we first saw some of these personhood bills years ago, I think those got attention as being a little different than some of the other things that were being considered. And now that has become more mainstream. We see that in a lot of states now. And I think that something like this, even though it is very different than the messaging we’ve seen in the past, it doesn’t mean that, down the line, a greater portion of the movement pivots toward this. Because we’ve seen so much of this throw the spaghetti at the wall with seeing different things that they can see, what can pass, what doesn’t get litigated, that kind of thing. So a lot of this is kind of a long game. 

Ollstein: Yeah. And there is an imbalance between the two sides where the right is much more willing to throw spaghetti at the wall and see what sticks, much more willing to throw out things that could anger people, could generate controversy, could generate backlash, but they do believe will advance the goal. And you’re not really seeing the same willingness on the left. You’re not really seeing states propose, Let’s get rid of all abortion restrictions in total. And so you have this imbalance of what each side is willing to even consider, where the left has been, overall, not exclusively, but overall much more cautious and much more consensus-seeking. 

Rovner: Well, meanwhile, in Texas, where over the past few years we’ve had story after story about women with wanted pregnancies nearly dying from complications, the legislature finally has before it a compromise bill that would better define when doctors can end a doomed pregnancy without risking going to prison, except it’s turning out to be not as much of a compromise as its backers had hoped. Is there any way to actually find a compromise on what is a necessary abortion and what is saving the woman’s life? They write these things and they say: Well, look. Here are the exceptions, and they should work. But now they’re trying to spell out the exceptions and they can’t seem to agree on those, either. 

Ollstein: So it’s really a catch-22. And I was just in Texas. I was interviewing OB-GYNs, and they were explaining — and those in other states with bans have said the same thing — that, look, it’s really tough, because if a law is too broad and too vague, then doctors don’t feel comfortable doing even things they feel are absolutely medically necessary. But if a law is too prescriptive — if, for example, it tries to list every single possible condition that would necessitate an emergency abortion or an abortion to save someone’s life for health — you’re never going to be able to list everything. So many things can go wrong during a pregnancy, and so any attempt to be comprehensive will inevitably leave something out. And so if you go the route of listing specific conditions and someone comes in with a condition that’s not on the list, doctors won’t feel comfortable, because they’ll feel that, Oh, well, because the law lists these other conditions, that must mean that anything else is not allowed. 

But on the other hand, if it’s too vague, you have the opposite problem. And so really a lot of mainstream medical groups like ACOG, the American College of Obstetricians and Gynecologists, have really come down on, like: Just don’t legislate this at all. Just let us do our jobs. Because they are in this conundrum. I will say, there are divides within the medical community despite that, where some feel like, OK, well, if we can add a few more exceptions and that can even help a few more people, that’s at least something to consider, where others think, OK, no, if we endorse these quote-unquote “fixes,” that kind of in a way is endorsing the underlying ban, and we don’t want to do that. And so there’s some tension there as well. 

Rovner: Yeah, this is going to continue to be an issue going forward. All right, well, finally this week there is some other policy news. The Trump administration last week reversed a Biden administration decision to start covering those GLP-1 [glucagon-like peptide 1] drugs for people with obesity as well as those with diabetes. According to The New York Times, the administration didn’t attribute the decision to Secretary Kennedy’s known dislike of the drugs, which he has said are inferior to people just, you know, eating better, and that it may reconsider the decision in the future. But obviously cost is a huge issue here. These drugs are less expensive than they were, but they are still super expensive if they’re going to be taken by the millions of people who would qualify for an indefinite period of time. Is there any talk of finding a way to bring that cost down? That would obviously be popular and something that President Trump has said he wants to do in terms of drug prices overall. 

Raman: I have not heard of anything on bringing the cost down. I think that the only discussions that really come about are really tailoring who would qualify within that bucket, and to narrow that as a piece to bring the cost down rather than the cost of the specific drugs. And we’ve been — yeah. 

Rovner: I would say, I know that Ozempic is on the list of Medicare drugs to be negotiated this year, but I think that’s only for the diabetic indication. So on the one hand, that could bring down the cost for— 

Ollstein: And that wouldn’t help people for years and years. Yeah. 

Rovner: Exactly. So I mean we might — if you have diabetes, Medicare could start saving money on one of the GLP drugs, but I guess it’s going to be a while before we see the cost fall. And of course, we didn’t even talk about the potential tariffs on prescription drugs, because we’re not going to talk about that this week. 

That is this week’s news. Now we will play my interview with law professor Stephen Vladeck, then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Stephen Vladeck, professor at Georgetown University Law School and author of the invaluable Substack “One First,” which helps explain the workings of the Supreme Court to us lay folks. Steve Vladeck, welcome to “What the Health?” 

Stephen Vladeck: Thanks, Julie. Great to be with you. 

Rovner: So I’ve asked you to help us with the next in a series I’m calling “How Things Are Supposed to Work in Health Policy.” And I’m particularly interested in how much power the president has vis-à-vis Congress and the courts. Is there kind of a 30-second law school description of who has the power to do what? 

Vladeck: It’s a little longer than 30 seconds, but to make the long version shorter: Congress makes laws, the president carries those laws into effect, and the courts decide whether everyone’s playing by the rules and abiding by those laws. That’s how it’s supposed to go — and if only that were how it actually was. 

Rovner: Now, I’m not a lawyer, but I have been at this for a long time, and I always understood that executive orders from presidents were mostly for show. They were expressions of intent that needed to be carried out by someone else in the executive branch most of the time, usually using the formal regulatory process. But that is not at all what this administration is doing with its executive orders, right? 

Vladeck: So, Julie, I think part of the problem is that we really are at the apex of something that’s been building for a while, which is that as Congress has stopped doing its job, as Congress has stopped passing statutes to respond to our pressing issues of the day, presidents of both parties have been left to govern more and more aggressively based on increasingly, for lack of a better word, creative interpretations of old statutes and constitutional authorities. And so, yes, I think we’re seeing differences in both degree and kind from President Trump, but some of this has been building for a while where, we haven’t had meaningful immigration reform since 1986. We haven’t had meaningful financial systems reform in 25 years. And so in those spaces, presidents are going to do what they can to try to accomplish their policy goals, which means more and more executive orders where the presidents are at least purporting to interpret authorities that they’ve been given, either by statute or the Constitution, as we get further and further away from those authorities themselves. 

Rovner: So this is the unitary executive theory that we’ve, those of us who play to be lawyers sometimes, have heard about. But how abnormal is what Trump is doing now? Is this even legal, a lot of what he’s doing? 

Vladeck: So a lot of what he’s doing is not legal, but some of it is legal. And one of the complications is that the illegalities are at scales and in ways that we haven’t really seen before and that therefore our existing legal processes aren’t necessarily well set up to respond to. I would break Trump’s behavior into a couple of categories. So I think there’s the internal stuff, which is firing tons of people, hollowing out the bureaucracy, demanding political fealty from even those who are civil servants. And we’ve seen, Julie, I think, flash points of those before. What’s novel about what’s happening now is just the sheer scale on which it’s happening. I think the biggest area of real novel action is the effort by Trump really to sort of change how all federal money is spent, right? Money is supposed to be Congress’s, like, superpower. Not only is appropriations Congress’ most important function, but it’s actually the only thing that the Constitution specifically says only Congress can do. 

And yet we’re seeing really novel assertions by the president of the power to not spend money Congress has appropriated, of the power to stop paying for contracts where the work has already been performed, of the power to threaten Maine and other jurisdictions with the withholding of federal funds if they don’t just bend the knee to Trump. And that is really, I think, both shocking and dangerous because it basically means that the president’s trying to seize unilateral control over what has historically been Congress’ principal vehicle for doing policy. And at that point, you don’t really have much of a separation of powers anymore. You’ve just got a president. 

Rovner: Could Congress take back this authority if it wanted to? 

Vladeck: Sure. But just before letting folks get too optimistic, one of the problems is that taking back this authority probably means, at the very least, passing new statutes, and Trump’s not going to sign those statutes. So one of the things that has been a fear of separation-of-power scholars for a long time is that when Congress delegates authority to the president, or when Congress acquiesces in the drift of power to the president, it’s actually really hard for Congress to get that power back, because it’s usually going to require veto-proof supermajorities, and really hard to see in our current political climate a veto-proof supermajority agreeing even to the fact that today is Tuesday, let alone that we should take back power from the president. So Congress could do tons of things. The problem is that assuming Congress won’t, we really are left to these series of confrontations between the president and the courts, because the courts are all that’s left. 

Rovner: Which brings me to something that I think most people would think would be not really health-policy-related but really is, which are all these threats against these big law firms. How does that play into this whole thing? 

Vladeck: So I think it’s a big piece of the puzzle because what the threats, I think, are really intended to do is to cow law firms into submission, to try to increase the cost both economically and politically of bringing lawsuits challenging what the federal government’s doing. And Julie, I think that the long-term idea is to chill people from suing the federal government, to chill people from hiring folks who worked in administrations from the wrong party in ways that I think are really disruptive not just to the economics of law firms but to the courts. The courts depend upon a strong, robust, and independent bar that is able to actually move freely when it comes to challenging the government. Courts can’t go out and find cases. Lawyers bring the cases to them. And if the lawyers are for some reason disincentivized from bringing those cases, part of the separation of powers breaks down even further. 

Rovner: Or basically, in this case, I guess they’re promising not to bring cases that the administration doesn’t like. 

Vladeck: Exactly. We should be terrified. No matter what you think of lawyers, no matter what you think of the administration, we should want a world in which there’s no disincentive to challenge what the government’s doing in court. We should want a world, as James Madison put it, where ambition is counteracting ambition, where the branches are pushing up against each other, not where they are stunned into submission. 

Rovner: And finally, you’re an expert in the Supreme Court. Is there any chance that the Supreme Court’s going to rescue us here? 

Vladeck: No, but I think what I would say — to try to both be a little more optimistic and to try to put a little more depth into my one-word answer — it’s not the Supreme Court’s job to rescue us. It’s the Supreme Court’s job to protect the separation of powers. And as you and I are sitting here, we’ve seen a couple of early rulings from the court that have kind of sided with Trump in these sort of very, very fleeting technical emergency postures without actually saying anything about what he’s doing is legal. I have at least a modicum of faith, Julie, that when the courts get to the legality questions, they’re going to find that most of this stuff actually is illegal. 

I think the question is, what happens then? And this is why, although I’m as big a believer in a powerful and independent judiciary as anyone, the courts alone can’t save us, right? What we need is we need the courts backed by Congress, by the people, by our other institutions, universities, law firms. I mean it should be all of the institutions of our civil society, not opposing Trump to oppose Trump but standing up for the notion that our institutions matter and that the way that we can be confident that the government is working the way it’s supposed to is when the institutions are pushing up against each other with all their might and without the fear of what’s going to happen to them if they lose. 

Rovner: I feel like one of the bright spots out of this is that finally the nation is getting the lesson in civics that it’s needed for a while. 

Vladeck: I couldn’t agree more. I think we are seeing the very, very real costs of generations of insufficient civics education, but I also think this opens the door to real conversation about how to fix this. And in the short term, some of it is about stopping a lot of what Trump is doing, and that’s what a lot of these lawsuits are about. When we talk about, Julie, building back institutions, whether it’s in the public health space or more broadly, I hope that we keep having the civics lesson, and I hope that we don’t forget that it’s actually really important to have independent agencies, and it’s important to have a civil service, and it’s important to have institutions that are actually not just subject to the whims of whoever happens to be the current president. And the more that we can build off of that going forward, maybe the more that we can prevent what has happened already over the first 11 weeks of the second Trump administration from becoming a permanent feature of our constitutional system. 

Rovner: Well, we will keep at it. I hope you’ll come back and join us again. 

Vladeck: I’d love to. Thanks for having me. 

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’ll put the links in our show notes on your phone or other mobile device. Sandhya, why don’t you go first this week? 

Raman: So my piece for extra credit is from me, on Roll Call. It’s called “In Sweden, a Focus on Smokeless Tobacco,” and it’s the first in my series I’m doing through the Association of Health Care Journalists, where I went to Sweden to learn about smoking cessation and public health between Sweden and what we can learn in the U.S. And the story looks at the different political factions of the Parliament over there and how they found some common ground in areas to become hopefully the first country in Europe below 5% daily smokers, and just what lessons the U.S. can learn as they’re trying to reduce smoking here as well. 

Rovner: So jealous that you got to do this. Alice, why don’t you go next? 

Ollstein: I chose a piece from The Guardian by Carter Sherman [“‘We Are Failing’: Doctors and Students in the US Look to Mexico for Basic Abortion Training”] on an issue that has interested me for a long time, which is how U.S. residents are learning how to provide abortions when their training opportunities have been eliminated in so many states. I’ve been covering those who have been traveling to different U.S. states, but this piece is about a small but growing number who are traveling to Mexico for this training. Mexico, like many countries in Latin America and really around the world over the last few years, has moved in the direction of decriminalizing abortion as the U.S. has moved in the opposite direction and is very eager to help train more people. 

But the article stresses that this is not a solution for everyone in the U.S. who needs this training, because you have to be able to speak fluent Spanish in order to do it. You have to already have some abortion experience, which not every medical resident has. And it’s also expensive. There are fellowships, but the trip and the training and everything costs thousands of dollars. And so I think it’s a very interesting opportunity for some people. And the article also talks about folks who are doing some training in the U.K., as well. And so I wonder if these international opportunities will become more of a piece of the puzzle in the future. 

Rovner: Victoria. 

Knight: OK, my extra credit for this week is an article in Wired called “Dr. Oz Pushed for AI Health Care in First Medicare Agency Town Hall.” So basically this was Dr. [Mehmet] Oz’s first town hall talking to CMS [Centers for Medicare & Medicaid Services] staff, and he talked about a lot of his personal story and not as much of the goals of the agency, seemed to be the vibe of the meeting. But also, interestingly, he talked about using AI avatars instead of actual people. So that’s like people that do simple health diagnoses using AI instead to diagnose people, is kind of what it sounded like. And that’s in part because— 

Rovner: My comment to this story was: Not at all creepy. Sorry. 

Knight: Right. And— 

Rovner: I interrupted you, Victoria. 

Knight: No, no, that’s OK. But he was saying the benefit of this is that it could cost less because it could only cost maybe like $2 an hour versus a doctor could be a hundred dollars for a consult. And so people interviewed in the story were CMS employees that felt very concerned about that and also felt like it could come off a bit tone-deaf when there have been a bunch of CMS staff also just recently let go. And CMS was actually on the agencies that was hit with less workforce cuts. But even so, people are still upset about it. And so, it was like, Why are you replacing great people that worked here with AI? It was just an interesting look at his first week at the agency 

Rovner: Yeah. And it’s a big agency with a lot of money. All right, my extra credit this week is from The New York Times. It’s called “Why the Right Still Embraces Ivermectin,” by Richard Fausset. And it’s a pretty hair-raising story of medical malfeasance, foisted on people by those seeking political or financial gain or both. Quoting from the story: “Ivermectin has become a sort of enduring pharmacological MAGA hat: a symbol of resistance to what some of the movement described as an elitist and corrupt cabal of politicians, scientists and medical experts.” This is another in a long list of unproven remedies people take just to thumb their noses at treatments that have, you know, actual scientific evidence behind them. It’s a really interesting read. 

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 it if you left us a review. That helps other people find us, too. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. 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 folks these days? Alice, you’re the birthday girl. Where can we all wish you a happy birthday? 

Ollstein: Mainly on Bluesky, @alicemiranda, but still hanging on X, @AliceOllstein. 

Rovner: Sandhya. 

Raman: On X and Bluesky, @sandhyawrites. 

Rovner: Victoria. 

Knight: I’m just on X, @victoriaregisk. 

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

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Josephine, 16, has been diagnosed with tetrasomy 8p mosaicism, severe autism, severe obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder, among other conditions, which will require constant assistance and supervision for the rest of her life.

Ortiz, 25, is Josephine’s caregiver. A Venezuelan immigrant, Ortiz helps Josephine eat, bathe, and perform other daily tasks that the teen cannot do alone at her home in West Orange, New Jersey. Over the past 2½ years, Ortiz said, she has developed an instinct for spotting potential triggers before they escalate. She closes doors and peels barcode stickers off apples to ease Josephine’s anxiety.

But Ortiz’s ability to work in the U.S. has been thrown into doubt by the Trump administration, which ordered an end to the temporary protected status program for some Venezuelans on April 7. On March 31, a federal judge paused the order, giving the administration a week to appeal. If the termination goes through, Ortiz would have to leave the country or risk detention and deportation.

“Our family would be gutted beyond belief,” said Krysta Senek, Josephine’s mother, who has been trying to win a reprieve for Ortiz.

Americans depend on many such foreign-born workers to help care for family members who are older, injured, or disabled and cannot care for themselves. Nearly 6 million people receive personal care in a private home or a group home, and about 2 million people use these services in a nursing home or other long-term care institution, according to a Congressional Budget Office analysis.

Increasingly, the workers who provide that care are immigrants such as Ortiz. The foreign-born share of nursing home workers rose three percentage points from 2007 to 2021, to about 18%, according to an analysis of census data by the Baker Institute for Public Policy at Rice University in Houston.

And foreign-born workers make up a high share of other direct care providers. More than 40% of home health aides, 28% of personal care workers, and 21% of nursing assistants were foreign-born in 2022, compared with 18% of workers overall that year, according to Bureau of Labor Statistics data.

That workforce is in jeopardy amid an immigration crackdown President Donald Trump launched on his first day back in office. He signed executive orders that expanded the use of deportations without a court hearing, suspended refugee resettlements, and more recently ended humanitarian parole programs for nationals of Cuba, Haiti, Nicaragua, and Venezuela.

In invoking the Alien Enemies Act to deport Venezuelans and attempting to revoke legal permanent residency for others, the Trump administration has sparked fear that even those who have followed the nation’s immigration rules could be targeted.

“There's just a general anxiety about what this could all mean, even if somebody is here legally,” said Katie Smith Sloan, president of LeadingAge, a nonprofit representing more than 5,000 nursing homes, assisted living facilities, and other services for aging patients. “There's concern about unfair targeting, unfair activity that could just create trauma, even if they don't ultimately end up being deported, and that's disruptive to a health care environment.”

Shutting down pathways for immigrants to work in the United States, Smith Sloan said, also means many other foreign workers may go instead to countries where they are welcomed and needed.

“We are in competition for the same pool of workers,” she said.

Growing Demand as Labor Pool Likely To Shrink

Demand for caregivers is predicted to surge in the U.S. as the youngest baby boomers reach retirement age, with the need for home health and personal care aides projected to grow about 21% over a decade, according to the Bureau of Labor Statistics. Those 820,000 additional positions represent the most of any occupation. The need for nursing assistants and orderlies also is projected to grow, by about 65,000 positions.

Caregiving is often low-paying and physically demanding work that doesn’t attract enough native-born Americans. The median pay ranges from about $34,000 to $38,000 a year, according to the Bureau of Labor Statistics.

Nursing homes, assisted living facilities, and home health agencies have long struggled with high turnover rates and staffing shortages, Smith Sloan said, and they now fear that Trump’s immigration policies will choke off a key source of workers, leaving many older and disabled Americans without someone to help them eat, dress, and perform daily activities.

With the Trump administration reorganizing the Administration for Community Living, which runs programs supporting older adults and people with disabilities, and Congress considering deep cuts to Medicaid, the largest payer for long-term care in the nation, the president’s anti-immigration policies are creating “a perfect storm” for a sector that has not recovered from the covid-19 pandemic, said Leslie Frane, an executive vice president of the Service Employees International Union, which represents nursing facility workers and home health aides.

The relationships caregivers build with their clients can take years to develop, Frane said, and replacements are already hard to find.

In September, LeadingAge called for the federal government to help the industry meet staffing needs by raising caps on work-related immigration visas, expanding refugee status to more people, and allowing immigrants to test for professional licenses in their native language, among other recommendations.

But, Smith Sloan said, “There's not a lot of appetite for our message right now.”

The White House did not respond to questions about how the administration would address the need for workers in long-term care. Spokesperson Kush Desai said the president was given “a resounding mandate from the American people to enforce our immigration laws and put Americans first” while building on the “progress made during the first Trump presidency to bolster our healthcare workforce and increase healthcare affordability.”

Refugees Fill Nursing Home Jobs in Wisconsin

Until Trump suspended the refugee resettlement program, some nursing homes in Wisconsin had partnered with local churches and job placement programs to hire foreign-born workers, said Robin Wolzenburg, a senior vice president for LeadingAge Wisconsin.

Many work in food service and housekeeping, roles that free up nurses and nursing assistants to work directly with patients. Wolzenburg said many immigrants are interested in direct care roles but take on ancillary roles because they cannot speak English fluently or lack U.S. certification.

Through a partnership with the Wisconsin health department and local schools, Wolzenburg said, nursing homes have begun to offer training in English, Spanish, and Hmong for immigrant workers to become direct care professionals. Wolzenburg said the group planned to roll out training in Swahili soon for Congolese women in the state.

Over the past 2½ years, she said, the partnership helped Wisconsin nursing homes fill more than two dozen jobs. Because refugee admissions are suspended, Wolzenburg said, resettlement agencies aren’t taking on new candidates and have paused job placements to nursing homes.

Many older and disabled immigrants who are permanent residents rely on foreign-born caregivers who speak their native language and know their customs. Frane with the SEIU noted that many members of San Francisco’s large Chinese American community want their aging parents to be cared for at home, preferably by someone who can speak the language.

“In California alone, we have members who speak 12 different languages,” Frane said. “That skill translates into a kind of care and connection with consumers that will be very difficult to replicate if the supply of immigrant caregivers is diminished.”

The Ecosystem a Caregiver Supports

Caregiving is the kind of work that makes other work possible, Frane said. Without outside caregivers, the lives of the patient and their loved ones become more difficult logistically and economically.

“Think of it like pulling out a Jenga stick from a Jenga pile, and the thing starts to topple,” she said.

Thanks to the one-on-one care from Ortiz, Josephine has learned to communicate when she’s hungry or needs help. She now picks up her clothes and is learning to do her own hair. With her anxiety more under control, the violent meltdowns that once marked her weeks have become far less frequent, Ortiz said.

“We live in Josephine’s world,” Ortiz said in Spanish. “I try to help her find her voice and communicate her feelings.”

Ortiz moved to New Jersey from Venezuela in 2022 as part of an au pair program that connects foreign-born workers with people who are older or children with disabilities who need a caregiver at home. Fearing political unrest and crime in her home country, she got temporary protected status when her visa expired last year to keep her authorization to work in the United States and stay with Josephine.

Losing Ortiz would upend Josephine’s progress, Senek said. The teen would lose not only a caregiver, but also a sister and her best friend. The emotional impact would be devastating.

“You have no way to explain to her, ‘Oh, Alanys is being kicked out of the country, and she can't come back,’” she said.

It’s not just Josephine: Senek and her husband depend on Ortiz so they can work full-time jobs and take care of themselves and their marriage. “She's not just an au pair,” Senek said.

The family has called its congressional representatives for help. Even a relative who voted for Trump sent a letter to the president asking him to reconsider his decision.

In the March 31 court decision, U.S. District Judge Edward Chen wrote that canceling the protection could “inflict irreparable harm on hundreds of thousands of persons whose lives, families, and livelihoods will be severely disrupted.”

‘Doing the Work That Their Own People Don’t Want To Do’

News of immigration dragnets that sweep up lawfully present immigrants and mass deportations are causing a lot of stress, even for those who have followed the rules, said Nelly Prieto, 62, who cares for an 88-year-old man with Alzheimer’s disease and a man in his 30s with Down syndrome in Yakima County, Washington.

Born in Mexico, she immigrated to the United States at age 12 and became a U.S. citizen under a law authorized by President Ronald Reagan that made any immigrant who entered the country before 1982 eligible for amnesty. So, she’s not worried for herself. But, she said, some of her co-workers working under H-2B visas are very afraid.

“It kills me to see them when they talk to me about things like that, the fear in their faces,” she said. “They even have letters, notarized letters, ready in case something like that happens, saying where their kids can go.”

Foreign-born home health workers feel they are contributing a valuable service to American society by caring for its most vulnerable, Prieto said. But their efforts are overshadowed by rhetoric and policies that make immigrants feel as if they don’t belong.

“If they cannot appreciate our work, if they cannot appreciate us taking care of their own parents, their own grandparents, their own children, then what else do they want?” she said. “We’re only doing the work that their own people don’t want to do.”

In New Jersey, Ortiz said life has not been the same since she received the news that her TPS authorization was slated to end soon. When she walks outside, she fears that immigration agents will detain her just because she’s from Venezuela.

She’s become extra cautious, always carrying proof that she’s authorized to work and live in the U.S.

Ortiz worries that she’ll end up in a detention center. But even if the U.S. now feels less welcoming, she said, going back to Venezuela is not a safe option.

“I might not mean anything to someone who supports deportations,” Ortiz said. “I know I'm important to three people who need me."

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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

The Department of Health and Human Services underwent an unprecedented purge this week, as thousands of employees from the National Institutes of Health, the FDA, the Centers for Disease Control and Prevention, and other agencies across the department were fired, placed on administrative leave, or offered transfers to far-flung Indian Health Service facilities in such places as New Mexico, Montana, and Alaska. Altogether, the layoffs mean the federal government, in a single day, shed hundreds if not thousands of years of health and science expertise.

Meanwhile, the Supreme Court heard a case about whether states can bar Planned Parenthood from providing non-abortion-related services to Medicaid patients. But by the time the case is settled, it’s unclear how much of Medicaid or the Title X Family Planning Program will remain intact.

 This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.

Panelists

Rachel Cohrs Zhang
Bloomberg News

@rachelcohrs

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• As details trickle out about the major staffing purge underway at HHS, long-serving and high-ranking health officials are among those who have been shown the door: in particular, senior scientists at FDA, including the top vaccine regulator, and even the head veterinarian working on bird flu response.
• The Trump administration has also gutted entire offices, including the FDA’s tobacco division — even though the division’s elimination would not save taxpayer money because it’s not funded by taxpayers. Still, the tobacco industry stands to benefit from less regulatory oversight. Many health agencies have their own examples of federal jobs cut under the auspices of saving taxpayer money when the true effect will be undermining federal health work.
• Democratic Sen. Cory Booker of New Jersey set a record this week during a marathon, 25-hour-plus chamber floor speech railing against Trump administration actions, and he used much of his time discussing the risks posed to Americans’ health care. With Republicans considering deep cuts that could hit Medicaid hard, it’s possible that health changes could be the area that resonates most with Americans and garner key support for Democrats come midterm elections.
• And the tariffs unveiled by President Donald Trump this week reportedly touch at least some pharmaceuticals, leaving the drug industry scrambling to sort out the impact. It seems likely tariffs would raise the prices Americans pay for drugs, as tariffs are expected to do for other consumer products — leaving it unclear how Americans stand to benefit from the president’s decision to upend global trade.

Also this week, Rovner interviews KFF Health News’ Julie Appleby, whose latest “Bill of the Month” feature is about a short-term health plan and a very expensive colonoscopy. Do you have a baffling, confusing, or outrageous medical bill 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: Stat’s “Uber for Nursing Is Here — And It’s Not Good for Patients or Nurses,” by Katie J. Wells and Funda Ustek Spilda.

Sarah Karlin-Smith: MSNBC’s “Florida Considers Easing Child Labor Laws After Pushing Out Immigrants,” by Ja’han Jones.

Lauren Weber: The Atlantic’s “Miscarriage and Motherhood,” by Ashley Parker.

Rachel Cohrs Zhang: The Wall Street Journal’s “FDA Punts on Major Covid-19 Vaccine Decision After Ouster of Top Official,” by Liz Essley White.

Also mentioned in this week’s podcast:

• Stat’s “Laid-Off HHS Leaders Offered Transfers to Remote Indian Health Service Regions,” by Usha Lee McFarling.
• The Washington Post’s “Fired Health Workers Were Told To Contact an Employee. She’s Dead.” By Lauren Weber.
• Georgia Recorder’s “Bill That Criminalizes Abortion, Undermines IVF Access Gets Georgia House Panel Hearing,” by Jill Nolin.

Click to open the transcript

Transcript: American Health Gets a Pink Slip

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

Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, Julie. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello hello. 

Rovner: And we welcome back to the podcast Rachel Cohrs Zhang, now at Bloomberg News. 

Rachel Cohrs Zhang: Hi, everyone. 

Rovner: Later in this episode we’ll have my interview with my colleague Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month,” about yet another very expensive colonoscopy. But first, this week’s news. 

We’re going to start this week, as usual, with the latest changes to the Department of Health and Human Services from the Trump administration. But before we dive in, I want to exercise my host prerogative to make a personal observation for those who think that what’s happening here is, quote, “politics as usual.” I am now a month into my 40th year of covering health policy in Washington and HHS in particular. When I began, Ronald Reagan was still president. So I’ve been through Democratic and Republican administrations, and Democratic- and Republican-controlled Congresses, and all the changeovers that have resulted therefrom. 

And obviously the HHS I cover today is far different from the one I covered in 1986, but I can safely say I have never seen such a swift and sweeping dismantling of the structure that oversees the U.S. health system as we’ve witnessed these past 60 days. Agencies and programs that were the result of years of expert consultations and political compromises have been summarily eliminated, and health and science professionals with thousands of years of combined experience cut loose via middle-of-the-night form emails. To call the scope and speed of the changes breathtaking is an understatement, and while I won’t take any more personal time here, if you want to hear me expand further on just how different this all really is, I’m on this week’s episode of my friend Dan Gorenstein’s “Tradeoffs” podcast, which you should all be listening to anyway. 

All right. That said, now let’s dive in. I suppose it was inevitable that we would see the results of last week’s announced reorganization of HHS on April Fools’ Day. Let’s start with who was let go. While the announcement last week suggested it would mostly be redundancies and things like IT and HR and procurement, there were a bunch of longtime leaders included in this purge, right? 

Karlin-Smith: Yeah. At FDA [the Food and Drug Administration] there were some of the most senior scientists, like their Office of New Drugs directors, their chief medical officer, almost everybody who works on policy, legislative affairs, entire communications offices, external affairs. And even in the case where they are laying off people whose job titles might sound extraneous, or not as important to the health of people in the U.S., I think you can sort of debate that, but they did it in such a way that they laid off so many people in those departments that the people they said, We are protecting, because we do at least understand these jobs are important, cannot actually fully do their jobs. So scientists are not able to access the supplies they need. It’s not even clear how people at FDA are going to get paid and do their timesheets and track time given how many people they laid off. 

And it also just seems like there’s been a ton of, again, to the extent they were trying to protect certain positions that they deemed more critical to U.S. health and well-being, like medical reviewers or inspectors, they didn’t quite understand who actually is critical to doing that work, because it’s not just somebody who has, like, “inspector” in the title. Vanity Fair had a great piece about this man who really has saved people in the U.S. from going blind by helping inspectors catch sterility issues in eye drops, and they walk through very clearly how people like him do not have a title of inspector but are absolutely needed to ensure we have drugs that are safe for people in the U.S. So, probably not surprising to people who’ve tracked the administration so far, but it’s been a lot of the move-fast -break-things, and then realize on the back end that they maybe broke things they didn’t necessarily mean to, or don’t actually care as much about whether it’s broken. 

Rovner: Lauren. 

Weber: They got rid of the head veterinarian on the bird flu response. That would seem to be a thing that is surprising. I spoke to a congressman yesterday who said that seems very dumb. It’s not just that. They also eliminated entire swaths of the CDC [Centers for Disease Control and Prevention], small agencies that maybe a lot of people have no idea alphabetically what they do but are pivotal in preventing injury deaths, and in really the preventative and chronic disease care that RFK [Robert F. Kennedy Jr.] has said is really vital to getting America back on track. When we talk about dollars and cents saved in health care, a lot of that is in chronic disease and in preventative care. And to see some of these places get hit so broadly is quite shocking considering the end goal is allegedly to save money. 

Rovner: There are also a lot of things that seem sort of at odds with [President Donald] Trump’s own agenda. David Kessler, the former FDA commissioner, was on TV last night talking about how the people who answer the phones when a doctor wants to get an emergency use authorization for a drug that’s not yet approved. That’s something that’s been a very big deal for Donald Trump. The people who answer the phones got fired. So, when a doctor has a patient who, nothing else will work and they need an experimental drug, and they’re supposed to be able to call FDA. And I think there are rules about how fast FDA is supposed to respond. But now there’s nobody to actually answer the phone and take those requests. 

Karlin-Smith: Yeah, I think the list of things that don’t seem to align is very long. One thing I was talking to somebody about yesterday who said, well, pretty much everybody who deals with tracking pesticides in foods, and food safety at the FDA in regards to pesticides was let go. And making our food system healthier and safer, and concerns about pesticides, has actually been a big focus of RFK. Similarly, Martin Makary talked a lot in his opening speech to FDA employees yesterday about obesity, and they are basically gutting offices that work on pediatrics, minority health. They’ve laid off lots of people in their tobacco division at FDA, and FDA’s tobacco division actually is not funded at all by taxpayer funding. So, I have a hard time understanding how anybody besides the tobacco industry really benefits from this loss. As Lauren said, it’s like every health agency, you can kind of find examples of that. They say America is not healthy, but they’re cutting these top researchers that have found incredible advances in Parkinson’s and some of the chronic diseases he’s most cared about. 

Rovner: They also, I mean, there are some big names who were let go. We didn’t even — the Peter Marks firing at FDA happened last week after we taped, so we haven’t even talked about that. Somebody tell us who Peter Marks is and why everybody’s all freaked out about that. 

Cohrs Zhang: Well, Peter Marks was head of the division of biologics and the top regulator of vaccines, and complicated injectable medicines like insulin products, too, fell under his purview. And I think we saw markets react in a panic on Monday. The shares of vaccine makers like Moderna were falling. And we saw companies selling gene therapies that Peter Marks has been really involved in regulating and championing through some of those processes, they were kind of freaked out because it just creates uncertainty as to kind of what the new philosophy toward these medicines will be. And the Trump administration, we’ve seen, especially on the Marks being pushed out, I think they’ve tried to highlight some of his more controversial actions in the past. 

We saw a White House adviser, Calley Means, was personally attacking Marks for some conflicts he had with vaccine regulators during debate over the covid booster approvals, and just his decisions to overrule recommendations by FDA experts on some innovative medications that some people disagreed with. But the perspective from former officials has been that, like Peter Marks or not, the idea that scientific expertise is being purged in this way is concerning. And it wasn’t just Peter Marks. There’s another regulator at the Office of New Drugs, Peter Stein. who was pushed out. We have Anthony Fauci’s successor at NIH [the National Institutes of Health] was pushed out, Jeanne Marrazzo, as well as a couple other heads of scientific research institutes at NIH. 

Rovner: Anthony Fauci’s wife was pushed out— 

Cohrs Zhang: Yeah. Yeah. 

Rovner: —as the head of the office of bioethics at NIH. 

Cohrs Zhang: Truly, and I think we had heard that some of these more politically sensitive center leader positions would be at risk. We’ve heard this for a very long time, but it seems like they took advantage of the chaos to implement some of these high-level cuts to people that they may have disagreed with. But, like, people will be filling those positions. I don’t know that there’s a cost-saving argument there. But it certainly seems like they were trying to push out senior leaders with a lot of experience. 

Rovner: It also feels like, the way that people were let go seems, to put it bluntly, purposely cruel, like sending out RIF [reduction in force] notices at 5 a.m. and then having people find out they’ve been let go when they stand in long lines only to find out that their IDs no longer work, or CMS [Centers for Medicare & Medicaid Services] employees being directed to contact a person who died last year. Is there a strategy here? Lauren, you wanted to add something. 

Weber: I wrote a story on the CMS employees being told to contact someone who was dead. And I spoke to one of this woman Anita Pinder’s former colleagues who said she was just heartbroken. She said CMS employees who got that email had gone to this woman’s funeral, and what a gut punch. She said, Look — this person who was talking to me is a former CMS employee — said: Look, you know, there always is a way to reorganize. It’s not that there isn’t waste or ability to consolidate or streamline in the federal government. She’s like, That’s not my problem. My problem, this woman told me, was that it was done in such a way that you really can’t take that back. People getting a dead woman’s name as their point of contact to contest their firings is something that is difficult to take back. 

Rovner: I guess my question is: Is this just sloppy, or are they actually trying to be cruel in this? Because it certainly feels like they’re trying to be cruel. 

Karlin-Smith: I think it’s possible. It’s both, a combination, one or the other. Again, it seems like the people who are doing this are not expert, right? They didn’t actually take the time to assess HHS and all what the agency does to understand what people do for the government beyond just looking at their job titles. And so some of it may be intentional cruelty, and some of it just may be really just rushing and not understanding the process. I mean, there were other notices at FDA that were signed by somebody that no longer worked there. People’s performance scores were wrong. The sense is they didn’t follow the normal process of, like, when you do a RIF, you have to give — there’s certain people that get preferences and who stays and who goes and whether it’s veteran status, disability, all those things. 

And I think some of that will probably result in legal challenges down the line, including they got rid of certain offices, or everybody in them, that were mandated by Congress. So some of it’s probably sloppy, but some of it is — right? — they don’t really care how they treat people, because there is like a very clear message that comes from their rhetoric of kind of lack of respect for government bureaucracy. 

Rovner: And I know some of these senior leaders, they figured out that they can’t just summarily fire them. So a number of them were offered transfers to the Indian Health Service in places like Alaska and Montana, and they were given 36 hours to decide whether they would accept the transfer. And we are told that Secretary Kennedy is very concerned about Native populations and the Indian Health Service, which is short of workers in a lot of places. But this seemed to be insulting to both the people who were given these quote-unquote “transfers” and to the Indian Health Service, because it wasn’t sending the Indian Health Service what it actually needs, which are practitioners, doctors and nurses, and laboratory workers. It was sending research analysts and bench scientists and people whose qualifications do not match what the IHS needs. 

Karlin-Smith: Right. They wanted to send, I think, the FDA’s tobacco head to the IHS to do, I think, medical care. So it enraged people in the IHS. 

Rovner: Yeah, I don’t think the Native population was really thrilled about this, either. Lauren, you wanted to add something. 

Weber: Yeah, I would just say that this is a playbook the Trump administration has executed in other government agencies. Members of the FBI, top leaders of the FBI were reassigned to child sex trafficking crimes or faraway distant lands in the hopes of getting them to resign. So, I think we are seeing that play out at HHS, but it certainly is a tactic they’ve used in other federal agencies to, quote-unquote, “drain the swamp.” 

Rovner: Right. And in the first Trump administration, they did move some offices out of Washington to the middle of the country, if you will, and most people obviously didn’t go. And now there’s a lot of expertise that, again, that we lost. I think that really can’t be overstated, is how much expertise is being pushed out the door right now, in terms of things that, as I said, this administration says that it wants to do or get accomplished. Meanwhile, Secretary Kennedy has been invited — or should I say summoned — to come testify next week before the Senate health committee at the behest of Republican Chairman Bill Cassidy, Democratic ranking member Bernie Sanders. So far Congress has mostly just been kind of sitting back and watching all of this happen. Is there any indication that that’s about to change? 

Karlin-Smith: I think Democrats are pushing a little bit harder, but I’m not sure they have enough power or have enough, again, momentum yet to actually do what they can with their power. I’m interested to see how Cassidy handles this hearing going forward because his statement the day of the big reduction in force seemed to suggest that the media was maybe unfairly reporting on it and that Kennedy may have another side to the story to share to justify it. And it didn’t sound like somebody that was necessarily going to go particularly hard at RFK. It seemed like somebody who wanted to give him a chance to justify his moves. But we’ll see what happens. I think Cassidy has been, despite RFK walking back a lot of his promises he made to Cassidy around vaccines and so forth, Cassidy has not been that willing to go hard on him so far. 

Rovner: Yeah, the other thing we’ve seen is that most of the big health groups that you would expect to be out on the front lines, hair on fire, have actually been keeping their heads down through most of these huge changes. But that seems to be maybe changing a little bit, too. This is a pretty dramatic change to get not a huge response from. I’ve seen way lesser changes get way bigger responses. 

Cohrs Zhang: Yeah, I think I spend a lot of time thinking about what is going to be the last straw for some of these organizations. And I think we saw some more effective organizing from the, like, medical device industry when actual medical device reviewers were laid off, and I think they went public pretty quickly, and those people were rehired. But I think it’s important to remember that some of these larger trade organizations in these companies are looking at a broader picture here. And there are all these different pieces of the puzzle. And certainly I think we’ve seen some trade groups that represent, like, pharmaceutical companies criticize some of the cutbacks at HHS, but also for now they were spared in a tariff announcement this week. 

And so I think they are trying to walk this tightrope where they have to figure out how to get the wins that they think they need and take losses in other place, and hope it kind of all evens out for them. So, I think they’re in a tough situation, and I think there’s much more concern behind the scenes than we’re seeing spill out into the public. But I think at some point maybe the line will be crossed, and I just don’t think we’ve seen that quite yet. 

Karlin-Smith: Yeah, I think the dam is definitely starting to break a bit, though. I was shocked — I guess, what day was it, Tuesday, when all this happened? — when finally late in the day, pharma sent a statement, and it was more scathing than you might even expect. And I think it was the first time they’ve actually responded to anything I’ve asked them to respond to that the administration does. And they said that it’s going to raise crucial questions about the FDA’s ability to fulfill its role. And so I think that is a big sign because, as Rachel mentioned, the medical device community was willing to stick their neck out there when they felt they were really harmed. Smaller trade associations have been starting to push back, but the silence has really been notable, and notable I think by people outside who were hoping that these powerful industries that have sort of more connections to the Republican Party would use that leverage, and they sort of felt abandoned by them. So, I think that is a significant crack to follow. 

Rovner: I feel like everybody’s waiting for somebody else to stand up and see if they get their head chopped off. I agree. I mean, I’m hearing, quietly, I’m hearing the concern, too, but publicly not so much. Well, moving to Capitol Hill, Congress is in this week. Well, they were in. We’ll get to the House in a minute. But first in the Senate, New Jersey’s Cory Booker set a new record for holding the floor, which is saying something for a place where being long-winded is basically a prerequisite. Twenty-five hours and five minutes, besting by almost an hour the 1957 filibuster against the Civil Rights Act by Strom Thurmond of South Carolina. Much of what Booker talked about during his more than a day on the Senate floor was health care. Is this still the issue that Democrats are hoping to ride to their political return? 

Weber: I was going to say, if the massive Medicaid cuts that are forecast come through, I do think that will be the midterm political return of Democrats. I think the writing is on the wall politically for Republicans if those do go through, which is why I think you’re seeing a lot of Republican leaders start to say: Oh, no. No, no, no. We don’t want some of these Medicaid cuts like this. But to be determined how that actually plays out. 

Rovner: Rachel. 

Cohrs Zhang: I was just going to say that Democrats are just trying to figure out something that will break through to people. They’re just trying to throw spaghetti at the wall and see if there’s some strategy they can find to get through to people. And I think this, just given the viewership of Sen. Booker’s speech, seemed to break through in a way and felt like even though Democrats do have really limited levers of power in Washington right now, that at least somebody was doing something, you know. And that’s kind of the takeaway that I had from that speech. 

But I will say I think Congressman Jake Auchincloss appeared after White House adviser Calley Means criticized the scientific establishment and HHS and was defending these cuts, and Congressman Auchincloss, I think, did have a more forceful tone in pushing back and just arguing for the scientific advances that have happened and had some really camera-ready little tidbits about the new administration being run by like conspiracy theorists and podcast bros. And I think they’re trying to figure out how to push back and how to get through to people and what approaches are going to work. And I think that was just a new tactic that we saw break through. 

Rovner: Well, if the Democrats did want to make a statement about Medicaid, they could make a stand against President Trump’s nominee to head the Medicaid program, as well as Medicare and the ACA [Affordable Care Act], Dr. Mehmet Oz. That vote is scheduled in the Senate for today after we finish taping. But we’re not really seeing that much pushback. Are we, Lauren? 

Weber: Not so far. I guess we’ll see. We’re taping before this happens. But Mehmet Oz really waltzed through his confirmation hearing process. It’s rare that you see someone who will lead such a massive agency on health care mention the multiple Daytime Emmys he’s won, but I think that helped in his charming of legislators. His daytime bona fides were on high display. He was able to dodge multiple questions about what he would do about cuts to Medicaid, and even Democratic senators were inviting him to come to church. I would be surprised if we see some sort of big stand today. 

Rovner: He was super well prepped, which we said — we did a special after the hearing — which is of all of the Trump nominees, I think he was the best prepped of anybody I’ve seen. He was ready with tidbits from every single member of the committee. But I will say that, going back years, and as I said, you know, 40 years, this is a position that one party or the other has frequently blocked, not for reasons that the nominee was not qualified but because they wanted to make a point about something that was going on at the agency. And it kind of surprises me that we haven’t seen that sort of thing. There were years where we did not have a Senate-approved head of Medicare and Medicaid. Sarah, as you pointed out, there were years when we didn’t have a Senate-approved head of the FDA for the same reason. Had nothing to do with the nominee. Had everything to do with the party that was out of power trying to use that as leverage to make a point. And we’re just not even seeing the Democrats try that. 

Weber: I guess we’ll see this afternoon. You could be forecasting what’s going to happen, Julie. But I think on top of him being well prepped, Oz does have a history in health care, is a very accomplished surgeon. But what is fascinating to me is that he’s coming back to the Senate after a 2014 grilling by the Senate on his pushing of supplements and other things for, quote, “fat blasting” and, quote, “weight loss” products. And it’s just the turnaround of daytime TV star to failed Senate candidate to potential administrator for CMS, which runs hundreds of millions Americans’ health insurance, potentially at a very consequential period in which there are massive cuts to them, is really going to be something. 

Rovner: Yes. Yet another eye-opening thing out of this administration. Well, over in the House, things are a little more confusing. On Tuesday, the usually unified Republicans rejected a rule, normally a party-line , because Speaker Mike Johnson was using it to avoid a vote on a bill that would allow new parents to vote by proxy, basically granting them parental leave. I did not have this fight on my bingo card for this year. It’s actually less a partisan fight than one between younger — read, childbearing age — members of Congress and older ones from both parties. I’m kind of surprised that this of all things is what stopped the House from doing business this week. 

Cohrs Zhang: Yeah, I think that it is an interesting contrast here because House Republicans have had this very pro-family rhetoric in the campaign, but they also have been so against remote work in any fashion, and members of Congress travel really far. There’s a time in pregnancy when you can no longer fly on a plane. And so I think given Republicans’ really, really slim majority in the House, it puts them in kind of a pickle where they need these votes to keep the majority, but it kind of sits at the intersection of all these different forces at play. So, I think, yeah, just a really weird political pickle that House Republicans have found themselves in this week. 

Rovner: Yeah, and of course this was a member of the House Freedom Caucus, a Republican member of the House Freedom Caucus, who was pushing this, who got a majority of the House to sign her discharge petition, which is supposed to bring this bill to the floor. So, we will see how that one plays out. Obviously, with everything else that’s going on, it’s not the biggest story, but it sure is interesting. 

Well, the big non-health news of the week are the tariffs that President Trump announced in the Rose Garden Wednesday afternoon. There is a health care angle to this story. The tariffs reportedly include at least some drugs and drug ingredients that are manufactured overseas. This, again, feels like it’s going to do exactly the opposite of what the president says he wants to do in terms of reducing drug prices, right? 

Weber: I mean, yes, yes. That would seem to be exactly how that is likely to go. Even look at drugs we get from Canada. They’re going to have tariffs on them. I think we have to wait and see exactly what happens. Trump has had a history of proposing these and then taking them back. Obviously these are much more sweeping than the ones we’ve seen so far. So, I think it, the jury is out on how exactly this will play out over the next couple weeks. 

Rovner: Right. And I said there’s also the exception process, right? 

Karlin-Smith: So, yeah, there’s been I think a lot of confusion and lack of clarity around exactly what happened yesterday here. It seems like the drug industry did get some key exemptions, but people are trying to kind of clarify some of those, including, like: Do you just apply to finished product? Do ingredients that they need lower down in the supply chain get impacted? So, I think it seems like pharma at least got some amount of a win here and got some of the typical exemptions for medicines, but people are not confident in all of that and how it’s going to play out. And I’ve seen sort of mixed reactions from analysts in the space. But yeah, it’s just like other parts of the economy that people have talked about with tariffs. It’s not entirely clear how the average American consumer would actually benefit from these tariffs versus having to just pay more money for goods. 

Rovner: We are apparently going to tariff penguins from islands off the coast of Australia. That much we seem clear on this morning. Turning to abortion, this week, as we mentioned last week, the Supreme Court heard a case out of South Carolina testing whether a state can kick Planned Parenthood not just out of the federal Family Planning Program, Title X, but whether Planned Parenthood can be disallowed from providing Medicaid services as well. Now, Planned Parenthood gets way more money from Medicaid than it does from Title X, and neither program allows the use of federal funds to pay for abortion. I will say that again: Neither program allows the use of federal funds to pay for abortion. Interestingly, it seems the high court might actually be leaning towards Planned Parenthood in this case, not because the conservative justices have any sympathy towards Planned Parenthood but because the court has fairly recently made it clear that the provision of Medicaid law that says patients can choose any qualified provider actually means what it says: The patient can choose any qualified provider. 

At the same time, though, the Trump administration this week declined to distribute a big swath of that Title X funding. And you have to wonder whether, even if Planned Parenthood wins this South Carolina case, what’s going to be left of either Title X or the Medicaid program. Possibly a Pyrrhic victory coming here? It seems that this administration is just whacking things, and even if the court ultimately says you can’t kick them out, there’s going to be nothing for them to stay in. 

Karlin-Smith: Well, the any-willing-provider debate struck me as sort of most interesting here because that type of clause seems to be something you typically see conservatives want to put into a government health program. They don’t feel comfortable kind of restricting people and choices in that way around who they see. So that was one of the elements of this case. The other thing that I think is being watched is this argument that the state is making around, like, how you enforce disagreements, I guess, around how the Medicaid program is being operated. And that seems like it could have a lot of long-lasting impacts as well if people, depending on if the court weighs in on that and so forth, just what rights people have to contest problematic decisions made in state Medicaid programs. 

Rovner: Yeah, for the first hour of the debate, the word “abortion” wasn’t mentioned. The word “Planned Parenthood” wasn’t mentioned. This was really about whether patients actually have a right to sue over not being able to get the kind of care that they want, which has been a long-standing fight in Medicaid, back to, I think, pretty much the beginning of Medicaid. So, we’ll see how this one comes out. Well, turning to the states and another case we have talked about, Texas wants to prosecute a New York doctor who was acting legally under New York law from prescribing abortion pills via telemedicine to a Texas patient. The latest is that the court clerk in Ulster County, New York, has refused to file a judgment for the $100,000 fine that Texas says the New York doctor owes. 

At the other end of the spectrum, in Georgia, meanwhile, lawmakers held a hearing on a bill that would — and I’m quoting from a Georgia state news service here — “ban abortions in Georgia from the moment of fertilization and codify it as a felony homicide crime unless a pregnant woman was threatened with violence to have the procedure.” Now, under this bill, both the woman and the doctor could be charged with murder. This bill is unlikely to be enacted this year, but I feel like the Overton window on this continues to move towards maybe punishing women with poor pregnancy outcomes. 

Karlin-Smith: Well, and punishing women who have trouble getting pregnant, as some of the opponents of this bill are arguing. It’s not clear whether it will really be possible to do IVF procedures if the bill was enacted how it was written. And even it seems like some of the reason why some pretty anti-abortion groups are concerned about this law, because they feel uncomfortable that it’s penalizing or going after the woman rather than other people involved in the abortion system. 

Rovner: I feel like we’ve been creeping this direction for a while, though. Obviously, this bill’s probably not going to move this cycle, but it got a hearing. We’ve seen a lot of things like this introduced. We’ve rarely seen it progress to the hearing stage. Another thing that bears watching. So, last week in the segment that I’m now calling “MAHA [Make America Healthy Again] in the States,” we talked about West Virginia banning food dyes and additives. Well, hold my beer — um, make that water, says Utah. Utah has now become the first state to ban fluoride in public water systems, something takes effect next month. Lauren, I feel like states are rushing to match RFK Jr. Is that what we’re seeing? 

Weber: There is some interest at the state level, but I also think it speaks to RFK’s limitations. I think everybody always thinks the game is always in D.C., but there’s a lot the states can do. And so I think it’ll be fascinating to kind of see how this continues to play out. 

Rovner: Yeah, well, we will keep watching it. All right, that is this week’s health news. Now we will play my interview with KFF Health News’ Julie Appleby. Then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast KFF Health News’ other Julie, Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month.” Julie, welcome back. 

Julie Appleby: Thanks for having me. 

Rovner: So, this month’s patient is yet another with a gigantic colonoscopy bill, but there’s a twist with this one. Tell us who he is and, important for this story, what kind of health insurance he has. 

Appleby: Yes, absolutely. His name is Tim Winard, and he lives in Addison, Illinois. He bought his own health insurance after he left his management job to launch his own business. So he shopped around a little bit. This is the first time he’s bought insurance. And he chose a short-term policy, which is good for six months in his state. And the first six months went pretty well. And he was still working on starting his business, so he signed up for another short-term policy with a different insurer. And this one cost about $500 a month. 

Rovner: So, remind us again. What is short-term health insurance? And how is it different from most employer and Affordable Care Act coverage? 

Appleby: Right. These types of policies have been sold for years. They’re generally intended for people who are, like, between jobs or maybe just getting out of school. They’re a temporary bridge to more comprehensive insurance, and as such they are not considered Affordable Care Act-qualified plans. So they don’t have to meet the rules that are set under the Affordable Care Act. So, for example, they might look like comprehensive major medical policies, but they all have sort of significant caveats. And some of these might surprise people who are accustomed to work-based or ACA plans. So, for example, like in Tim Winard’s plan, some set specific dollar caps on certain types of medical care, and sometimes those are, like, per day or per visit or something like that, and they can be sometimes far below what it actually costs. 

And all of them — this is a key difference with ACA plans — all of these types of short-term plans screen applicants for health conditions, and they can reject people because of health problems or exclude those conditions from coverage. Many also do not cover drugs or maternity care. So people really have to read their policies carefully to see what they cover and what they don’t cover. 

Rovner: So this is sort of like pre-ACA. It’s cheap because it doesn’t cover that much. 

Appleby: Exactly. That’s why they can offer them lower premiums. Now, again, some people with a subsidized ACA plan, these are not necessarily cheaper, but for others these are less expensive. 

Rovner: So back to our patient this month. He does what we always advise and calls his insurance company before he goes for this, because it is obviously scheduled care, not an emergency. What did they tell him? 

Appleby: Well, I think he only asked where he could go. He was concerned that he would go to a facility that was in-network, and they told him he could pretty much go anywhere. He did not ask about cost in that phone call. 

Rovner: Yeah, so he gets his colonoscopy. Everything turns out OK medically. And then, as we say, the bill comes. How big was it? 

Appleby: He was left owing $7,226 after his plan paid about $817 towards the bill. They got a little bit of a discount for being insured, but then he was still left owing more than $7,000. 

Rovner: And what was the explanation for him owing that much? Just a reminder that this should have been fully covered if he’d had an ACA plan, right? 

Appleby: That’s correct. Under the ACA, screening colonoscopies and other types of cancer screenings are covered without a copay for the patient. But he didn’t have an ACA plan here. So, what was the explanation? Well, this time he did email his insurance company, which is Companion Life Insurance of Columbia, South Carolina, and they wrote him back, and they told him his policy classified the procedure and all of its costs, including the anesthesia, under his policy’s outpatient surgery facility benefit. What is that? you might ask. Well, in his policy, that benefit caps insurance payments within that facility to a maximum of a thousand dollars per day. So, the most they were going to pay towards this was a thousand dollars, because they classified the whole thing as an outpatient procedure with that cap. And this surprised Winard because he thought the cancer screening was covered and he would only owe 20% of the bill, not almost the entire thing, basically. 

Rovner: So how did this eventually work out? 

Appleby: Well, we reached out and tried to reach Companion Life, and we also talked to Scott Wood, who works as a program manager and is a co-founder of a marketing company that markets Companion Life and other insurance plans. And he thought there was some room for interpretation in the billing and in the policy language. So he asked Companion Life to take another look. And shortly after that, Winard said he was contacted by his insurer, and a representative told him that upon reconsideration the bill had been adjusted. And he wasn’t really given a reason why that happened, but as it turns out his new bill showed he owed only $770. 

Rovner: Which is, I assume, about what he expected when he went into this, right? 

Appleby: That’s, yes, correct. He didn’t think he was going to have to pay as much as it was initially billed at. 

Rovner: So, what’s the takeaway here other than to come to us if you have a bill that you can’t deal with? 

Appleby: Right. Well, I think experts say to be very cautious and read the plans very carefully if you’re shopping for a short-term plan. And realize they have some of these limits and they may not cover everything. They may not cover preexisting conditions. And this could become more widespread in the coming years as — short-term plans have been somewhat of a political football. So, out of concern that people would choose them over more comprehensive coverage, President Barack Obama’s administration limited them to terms of three months. Those rules were lifted during the first Trump administration, and he allowed the plans to again be sold as 364-day policies, just one day short of a year, and then you could try to get another one. Or in some cases the insurer could opt to renew them. 

And then Joe Biden came in, and President Biden called them “junk insurance,” and he restricted the policies to four months. So, it’s been bouncing back and forth, back and forth. Everybody really expects the Trump administration to do what it did the last time and make them available for longer periods. So I think if we’re going to hear more about short-term plans. They may become more common. And again, it’s just a matter of trying to understand what you’re buying, and why they might be less expensive in your mind than an ACA plan, but they might not turn out to be. 

Rovner: And you can always ask for an estimate, right? 

Appleby: And always ask for an estimate. That’s a given. Experts always say, before any kind of scheduled procedure, call your insurer, call the provider, ask for an estimate on how much this might cost you out-of-pocket. 

Rovner: Good. And if all else fails, then you can write to us. 

Appleby: There you go. 

Rovner: Julie Appleby, thank you very much. 

Appleby: Thanks for having me. 

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

Cohrs Zhang: All right. My extra credit is a piece in The Wall Street Journal, and the headline is “FDA Punts on Major COVID-19 Vaccine Decision After Ouster of Top Official,” by Liz Essley White. It’s a great story, and I think, as we talked about earlier, I’m thinking about: What are the breaking points for companies, for industries, as they look at how the HHS is changing? And I think one of those metrics is if the FDA starts missing deadlines to approve products. I think this one is a little bit of a special case because it is a covid-19 vaccine, which is, like, the most highly politicized medical product right now. But I think there could be other cases, and I think industry is watching this so closely to see if some of these changes at FDA really do bleed into approvals, whether the approval process will be politicized, whether they’re going to start missing deadlines. And given just the amount of financial support that industry provides to fund routine activities, I think this was kind of a really good marker in this process as we learn what the impacts are. 

Rovner: Yeah, agree. Lauren. 

Weber: I read “Miscarriage and Motherhood” by Ashley Parker, now at The Atlantic. And I’ve got to be honest — if you read it, be in a place where you can cry. It’s an incredibly moving piece about tragedies of miscarriage, and frankly about women’s health care, and how little support and understanding there is in general about what surrounds that entire field. And some of the fascinating parts in it is when Ashley details going in for a D&C [dilation and curettage] and being told that is an abortion. And it’s kind of an interesting interplay between how what words mean, what people understand what words mean, and what exactly parenthood entails in modern America today. 

Rovner: And how extremely common miscarriage is. I think people just don’t realize, because it’s something that’s just not talked about very much. It’s a really beautiful story. Sarah. 

Karlin-Smith: I looked at an MSNBC piece [“Florida Considers Easing Child Labor Laws After Pushing Out Immigrants”] by Ja’han Jones, about Florida considering easing their child labor laws after pushing out immigrants. And, yeah, the state is considering bills that would allow very young teenagers to work overnight, to maybe work at the kinds of jobs that would normally be seen as too unsafe for such young people. And, yeah, it just seems like an interesting sort of consequence of pushing out immigrant workers. But also it comes after some really moving reports over the past few years, too, about just how dangerous some of this work is, and how even under current law that is supposed to prevent this, particularly immigrants and the most vulnerable workers have ended up with young people in this job, and they’ve really — these types of jobs — and they’ve been harmed by it. 

Rovner: Who could have possibly seen this coming? Sorry. My extra credit this week is from Stat, and it’s called “Uber for Nursing is Here — and It’s Not Good for Patients or Nurses,” by Katie J. Wells and Funda Ustek Spilda. And it’s yet another case of something that sounds really good, using an app to help nurses who want to find extra work and set their own schedules get it, and helping facilities that need extra help find workers. But like so many of these things, it’s not as rosy as it appears unless you’re the one that’s collecting the fees from the app. Workers are basically all temps. They may not be familiar with the facilities they’ve been assigned to, much less the patients, which doesn’t always result in optimal care. And they bid against each other for who will do the job for the lowest rate, creating a race to the bottom for wages. It’s another one of those quote-unquote “advances” that’s a lot less than meets the eye. 

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 producer, Francis Ying, and our editor, Emmarie Huetteman. 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 these days? Rachel, you’re still on LinkedIn, right? 

Cohrs Zhang: Still on LinkedIn. Still on X. I do have a Bluesky account, too. But any and all the places. 

Rovner: Excellent. Sarah. 

Karlin-Smith: Yeah, I’m at Bluesky, some X, some LinkedIn, @SarahKarlin or @sarahkarlin-smith. 

Rovner: Lauren. 

Weber: I’m still on X, and I am on Bluesky, @LaurenWeberHP. And as a member of — a congressional staffer asked me: Does the “HP” really stand for “health policy”? And yes, it does. So, still there. 

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

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

As had been rumored for weeks, Health and Human Services Secretary Robert F. Kennedy Jr. unveiled a plan to reorganize the department. It involves the downsizing of its workforce, which formerly was roughly 80,000 people, by a quarter and consolidating dozens of agencies that were created and authorized by Congress.

Meanwhile, in just the past week, HHS abruptly cut off billions in funding to state and local public health departments, and canceled all research studies into covid-19, as well as diseases that could develop into the next pandemic.

This week’s panelists are Julie Rovner of KFF Health News, Maya Goldman of Axios News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Maya Goldman
Axios

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Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• As federal health officials reveal the targets of a significant workforce purge and reorganization, the GOP-controlled Congress has been notably quiet about the Trump administration’s intrusions on its constitutional powers. Many of the administration’s attempts to revoke and reorganize federally funded work are underway despite Congress’ previous approval of that funding. And while changes might be warranted, reviewing how the federal government works (or doesn’t) — in the public forums of congressional hearings and floor debate — is part of Congress’ responsibilities.
• The news of a major reorganization at HHS also comes before the Senate finishes confirming its leadership team. New leaders of the National Institutes of Health and the FDA were confirmed just this week; Mehmet Oz, the nominated director of the Centers for Medicare & Medicaid Services, had not yet been confirmed when HHS made its announcement; and President Donald Trump only recently named a replacement nominee to lead the Centers for Disease Control and Prevention, after withdrawing his first pick.
• While changes early in Trump’s second term have targeted the federal government and workforce, the impacts continue to be felt far outside the nation’s capital. Indeed, cuts to jobs and funding touch every congressional district in the nation. They’re also being felt in research areas that the Trump administration claims as priorities, such as chronic disease: The administration said this week it will shutter the office devoted to studying long covid, a chronic disease that continues to undermine millions of Americans’ health.
• Meanwhile, in the states, doctors in Texas report a rise in cases of children with liver damage due to ingesting too much vitamin A — a supplement pushed by Kennedy in response to the measles outbreak. The governor of West Virginia signed a sweeping ban on food dyes and additives. And a woman in Georgia who experienced a miscarriage was arrested in connection with the improper disposal of fetal remains.

Also this week, Rovner interviews KFF senior vice president Larry Levitt about the 15th anniversary of the signing of the Affordable Care Act and the threats the health law continues to face.

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

Julie Rovner: CNN’s “State Lawmakers Are Looking To Ban Non-Existent ‘Chemtrails.’ It Could Have Real-Life Side Effects,” by Ramishah Maruf and Brandon Miller. 

Alice Miranda Ollstein: The New York Times Wirecutter’s “23andMe Just Filed for Bankruptcy. You Should Delete Your Data Now,” by Max Eddy. 

Maya Goldman: KFF Health News’ “‘I Am Going Through Hell’: Job Loss, Mental Health, and the Fate of Federal Workers,” by Rachana Pradhan and Aneri Pattani. 

Joanne Kenen: The Atlantic’s “America Is Done Pretending About Meat,” by Yasmin Tayag. 

Also mentioned in this week’s podcast:

• The New York Times’ “West Virginia Bans 7 Artificial Food Dyes, Citing Health Concerns,” by Alice Callahan.
• The Washington Post’s “Why I Left My Job Leading Public Health Messaging for the CDC,” by Kevin Griffis.
• Politico’s “The Limits of RFK Jr.’s Power,” by Joanne Kenen.

Click to open the transcript

Transcript: The Ax Falls at HHS

[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, March 27, at 10 a.m. As always, news happens fast — really fast this week — and things might well 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: Maya Goldman of Axios News. 

Maya Goldman: Great to be here. 

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

Joanne Kenen: Hi everybody. 

Rovner: Later in this episode we’ll have my interview with KFF Senior Vice President Larry Levitt, who will riff on the 15th anniversary of the signing of the Affordable Care Act and what its immediate future might hold. But first, this week’s news. 

So for this second week in a row, we have news breaking literally as we sit down to tape, this time in the form of an announcement from the Department of Health and Human Services with the headline “HHS Announces Transformation to Make America Healthy Again.” The plan calls for 10,000 full-time employees to lose their jobs at HHS, and when combined with early retirement and other reductions, it will reduce the department’s workforce by roughly 25%, from about 82,000 to about 62,000. It calls for creation of a new “Administration for a Healthy America” that will combine a number of existing HHS agencies, including the Health Resources and Services Administration, the Agency for Toxic Substances and Disease Registry, and the National Institute for Occupational Safety and Health under one umbrella. 

Reading through the announcement, a lot of it actually seems to make some sense, as many HHS programs do overlap. But the big overriding question is: Can they really do this? Isn’t this kind of reorganization Congress’ job? 

Ollstein: Congress has not stood up for itself in its power-of-the-purse role so far in the Trump administration. They have stood by, largely, the Republican majorities in the House and Senate, or they’ve offered sort of mild concerns. But they have not said, Hey guys, this is our job, all of these cuts that are happening. There’s talk of a legislative package that would codify the DOGE [Department of Government Efficiency] cuts that are already happening, rubber-stamping it after the fact. But Congress has not made moves to claw back its authority in terms of saying, Hey, we approved this funding, and you can’t just go back and take it. There’s lawsuits to that effect, but not from the members — from outside groups, from labor unions, from impacted folks, but not our dear legislative branch. 

Rovner: You know, Joanne, you were there for a lot of this. We covered the creation of a lot of these agencies. Agency for Healthcare Research and Quality, I covered the creation of its predecessor agency, which there were huge compromises that went into this, lots of policymaking. It just seems that RFK [Robert F. Kennedy] Jr. going to say: We don’t actually care all these things you did. We’re just going to redo the whole thing. 

Kenen: As many of the listeners know, many laws that Congress passes have to be reauthorized every five years or every 10 years. Five is the most typical, and they often don’t get around to it and they extend and blah, blah, blah, blah, blah. But basically the idea is that things do change and things do need to be reevaluated. So, normally when you do reauthorization — we all just got this press release announcing all these mergers of departments and so forth at HHS. None of us are experts in procurement and IT. Maybe those two departments do need to be merged. I mean, I don’t know. That’s the kind of thing that, reauthorization, Congress looks at and Congress thinks about. Well, and agencies and legislation do get updated. Maybe the NIH [National Institutes of Health] doesn’t need 28 institutes and they should have 15 or whatever. But it’s just sort of this, somebody coming in and waving a magic DOGE wand, and Congress is not involved. And there’s not as much public input and expert input as you’d have because Congress holds hearings and listens to people who do have expertise. 

So it’s not just Congress not exercising power to make decisions. It’s also Congress not deliberating and learning. I mean all of us learned health policy partly by listening to experts at congressional panels. We listen to people at Finance, and Energy and Commerce, and so forth. So it’s not just Congress’ voice being silenced. It’s this whole review and fact-based — and experts don’t always agree and Congress makes the final call. But that’s just been short-circuited. And I mean we all know there’s duplication in government, but this isn’t the process we have historically used to address it. 

Rovner: You know, one other thing, I think they’re merging agencies that are in different locations, which on the one hand might make sense. But if you have one central IT or one central procurement agency in Washington or around Washington, you’ve got a lot of these organizations that are outside of Washington. And they’re outside of Washington because members of Congress put them there. A lot of them are in particular places because they were parochial decisions made by Congress. That may or may not make sense, but that’s where they are. It might or might not make sense. Maya, sorry I interrupted you. 

Goldman: No, I was just going to add to Joanne’s point. Julie, I think before we started recording you mentioned that the administration is saying: We’ve thought this all out. These are well-researched decisions. But they’ve been in office for two months. How much research can you really do in that time and how intentional can those decisions really be in that time frame? 

Ollstein: Especially because all of the leaders aren’t even in place yet. Some people were just confirmed, which we’re going to talk about. Some people are on their way to confirmation but not there yet. They haven’t had the chance to talk to career staff, figure out what the redundancies are, figure out what work is currently happening that would be disrupted by various closures and mergers and stuff. So Maya’s exactly right on that. 

Goldman: You know there’s — the administration chose a lead for HRSA and other offices. And so what happens to those positions now? Do they just get demoted effectively because they’re no longer heads of offices? I would be pretty— 

Rovner: But we have a secretary of education whose job is to close the department down, so—. 

Goldman: Good point. 

Rovner: That’s apparently not unprecedented in this administration. Well, as Alice was saying, into this maelstrom of change comes those that President [Donald] Trump has selected to lead these key federal health agencies. The Senate Tuesday night confirmed policy researcher Jay Bhattacharya to head the NIH and Johns Hopkins surgeon and policy analyst Marty Makary to head the Food and Drug Administration. Bhattacharya was approved on a straight party-line vote, while Makary, who I think it’s fair to say was probably the least controversial of the top HHS nominees, won the votes of three Democrats: Minority Whip Dick Durbin of Illinois and New Hampshire’s Democrats, [Sens.] Maggie Hassan and Jeanne Shaheen, along with all of the Republicans. What are any of you watching as these two people take up their new positions? 

Kenen: Well, I mean, the NIH, Bhattacharya — who I hope I’ve learned to pronounce correctly and I apologize if I have not yet mastered it — he’s really always talked about major reorganization, reprioritization. And as I said, maybe it’s time to look at some overlap, and science has changed so much in the last decade or so. I mean are the 28 — I think the number’s 28 — are the 28 current institutes the right— 

Rovner: I think it’s 27. 

Kenen: Twenty-seven. I mean, are there some things that need to be merged or need to be reorganized? Probably. You could make a case for that. But that’s just one thing. The amount of cuts that the administration announced before he got there, and there is a question in some things he’s hinted at, is he going to go for that? His background is in academia, and he does have some understanding of what this money is used for. We’ve talked before, when you talk to a layperson, when you hear the word “overhead,” “indirect costs,” what that conjures up to people as waste, when in fact it’s like paying for the electricity, paying for the staff to comply with the government regulations about ethical research on human beings. It’s not parties. It’s security. It’s cleaning the animal cages. It’s all this stuff. So is he going to cut as deeply as universities have been told to expect? We don’t know yet. And that’s something that every research institution in America is looking at. 

The FDA, he’s a contrarian on certain things but not across the board. I mean, as you just said, Julie, he’s a little less controversial than the others. He is a pancreatic surgeon. He does have a record as a physician. He has never been a regulator, and we don’t know exactly where his contrarian views will be unconventional and where — there’s a lot of agreement with certain things Secretary Kennedy wants to do, not everything. But there is some broad agreement on, some of his food issues do make sense. And the FDA will have a role in that. 

Rovner: I will say that under this reorganization plan the FDA is going to lose 3,500 people, which is a big chunk of its workforce. 

Kenen: Well things like moving SAMHSA [the Substance Abuse and Mental Health Services Administration], which is the agency that works on drug abuse within and drug addiction within HHS, that’s being folded into something else. And that’s been a national priority. The money was voted to help with addiction on a bipartisan basis several times in recent years. The grants to states, that’s all being cut back. The subagency with HHS is being folded into something else. And we don’t know. We know 20,000 jobs are being cut. The 10 announced today and the 10 we already knew about. We don’t know where they’re all coming from and what happens to the expertise and experience addressing something like the addiction crisis and the drug abuse crisis in America, which is not partisan. 

Rovner: All right. Well we’ll get to the cuts in a second. Also on Tuesday, the Senate Finance Committee voted, also along party lines, to advance to the Senate floor the nomination of Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services. And while he would seem likely to get confirmed by the full Senate, I did not have on my bingo card Dr. Oz’s nomination being more in doubt due to Republicans than Democrats. Did anybody else? 

Ollstein: Based on our reporting, it’s not really in doubt. [Sen.] Josh Hawley has raised concerns about Dr. Oz being too squishy on abortion and trans health care, but it does not seem that other Republicans are really jumping on board with that crusade. It sort of reminds me of concerns that were raised about RFK Jr.’s background on abortion that pretty much just fizzled and Republicans overwhelmingly fell in line. And that seems to be what’s going to happen now. Although you never know. 

Rovner: At least it hasn’t been, as you point out, it hasn’t failed anybody else. Well, the one nominee who did not make it through HHS was former Congressman Dave Weldon to head the CDC [Centers for Disease Control and Prevention]. So now we have a new nominee. It’s actually the acting director, Susan Monarez, who by the way has a long history in federal health programs but no history at the CDC. Who can tell us anything about her? 

Goldman: She seems like a very interesting and in some ways unconventional pick, especially for this administration. She was a career civil servant, and she worked under the Obama administration. And it’s interesting to see them be OK with that, I think. And she also has a lot of health care background but not in CDC. She’s done a lot of work on AI in health care and disaster preparedness, I think. And clearly she’s been leading the CDC for the last couple months. So she knows to that extent. But it will be very interesting when she gets around to confirmation hearings to hear what her priorities are, because we really have no idea. 

Rovner: Yeah, she’s not one of those good-on-Fox News people that we’ve seen so many of in this administration. So while Monarez’s nomination seems fairly noncontroversial, at least so far, the nominee to be the new HHS inspector general is definitely not. Remember that President Trump fired HHS IG Christi Grimm just days after he took office, along with the IGs of several other departments. Grimm is still suing to get her job back, since that firing violated the terms of the 1978 Inspector General Act. But now the administration wants to replace her with Thomas Bell, who’s had a number of partisan Republican jobs for what’s traditionally been a very nonpartisan position and who was fired by the state of Virginia in 1997 for apparently mishandling state taxpayer funds. That feels like it might raise some eyebrows as somebody who’s supposed to be in charge of waste, fraud, and abuse. Or am I being naive? 

Goldman: My eyebrows were definitely raised when I saw that news. I, to be honest, don’t know very much about him but will be very interested to see how things go, especially given that fraud, waste, and abuse and rooting out fraud, waste, and abuse are high priorities for this administration, but also things that are very up to interpretation in a certain way. 

Ollstein: Yes, although it’s clearly been very mixed on that front because the administration is also dismantling entire agencies that go after fraud and abuse— 

Goldman: Exactly. 

Ollstein: —like the Consumer Financial Protection Bureau. So there is some mixed messaging on that front for sure. 

Rovner: Well, as Joanne mentioned, the DOGE cuts continue at the NIH. In just the last week, billions of dollars in grants have been terminated that were being used to study AIDS and HIV, covid and other potential pandemic viruses, and climate change, among other things. The NIH also closed its office studying long covid. Thank you, Alice, for writing that story. This is, I repeat, not normal. NIH only generally cancels grants that have been peer reviewed and approved for reasons of fraud or scientific misconduct, yet one termination letter obtained by Science Magazine simply stated, quote, “The end of the pandemic provides cause to terminate COVID-related grant funds.” Why aren’t we hearing more about this, particularly for members of Congress whose universities are the ones that are being cut? 

Kenen: I mean, the one Republican we heard at the very beginning was [Sen.] Katie Britt because the University of Alabama is a big, excellent, and well-respected national medical and science center, and they were targeted for a lot of cuts. She’s the only Republican, really, and she got quiet. I mean, she raised her voice very loud and clear. We may go into a situation — and everybody sort of knows this is how Washington sometimes works — where individual universities will end up negotiating with NIH over their funds and that— 

Rovner: Columbia. Cough, cough. 

Kenen: Right. And Alabama may come out great and Columbia might not, or many other leading research institutions. But these job cuts affect people in every congressional district across the country. And the funding cuts affect every congressional district across the country. So it’s not just their constitutional responsibilities. It’s also, like, their constituents are affected, and we’re not hearing it. 

Rovner: And as I point out for the millionth time, it’s not a coincidence that these things are located in every congressional district. Members of Congress, if not the ones who are currently in office then their predecessors, lobbied and worked to get these funds to their states and to their district. And yet the silence is deafening. 

Ollstein: To state the obvious, one, covid is not over. People are still contracting it. People are still dying from it. But not only that, a lot of this research was about preparing for the inevitable next pandemic that we know is coming at some point and to not be caught as unawares as we were this past time, to be more prepared, to have better tools so that there don’t have to be widespread lockdowns, things can remain open because we have more effective prevention and treatment efforts. And that’s what’s being defunded here. 

Kenen: The other thing is that long covid is in fact a chronic disease and even though it’s caused by an infectious disease, a virus. But people have long covid but it is a chronic disease, and HHS says that’s their priority, chronic disease, but they’re not including long covid. And there’s also more and more. When we think of long covid, we think of brain fog and being short of breath and tired and unable to function. There’s increasing evidence or conversation in the medical world about other problems people have long-term that probably stem from covid infections or multiple covid infections. So this is affecting millions of Americans as a chronic disease that is not well understood, and we’ve just basically said, That one doesn’t count, or: We’re not going to pay attention to that one. We’re going to, you know, we’re looking at diabetes. Yeah, we need to look at diabetes. That’s one of the things that Kennedy has bipartisan support. This country does not eat well. I wrote about this about a week ago. But what he can and can’t do, because he can’t wave a magic wand and have us all eating well. But it’s very selective in how we’re defining both the causes of diseases and what diseases we’re prioritizing. We basically just shrunk addiction. 

Goldman: In the press release announcing the reorganization this morning, there was a line talking about how the HHS is going to create this new Administration for a Healthy America to investigate chronic disease and to make sure that we have, I think it was, wholesome food, clean water, and no environmental toxins, in order to prevent chronic disease. And those are the only three things that it mentions that lead to chronic disease. 

Rovner: And none of which are under HHS’ purview. 

Goldman: Right, right. Yeah. 

Rovner: With the exception of— 

Goldman: There are things that HHS does in that space. But yeah, we’re being very selective about what constitutes a chronic disease and what causes a chronic disease. If you’re trying to actually solve a problem, maybe you should be more expansive. 

Kenen: So HHS has some authority over food, not significant authority of it, but it is shared with the USDA [U.S. Department of Agriculture]. Like school lunches are USDA, the nutritional guidelines are shared between USDA and HHS, things like that. So yeah, it has some control about, over food but not entirely control over food. 

And then EPA [Environmental Protection Agency], which has also been completely reoriented to be a pro-fossil-fuel agency, is in charge of clean water and the environmental contaminants. That’s not an HHS bailiwick. And Kennedy is not aligned with other elements of the administration on environmental issues. And also genetics, right? Genetics is also, you know, who knows? That’s NIH? But who knows what’s going to happen to the National Cancer Institute and other genetic research at NIH? We don’t know. 

Rovner: Yes. Clearly much to be determined. Well, speaking of members of Congress whose states and districts are losing federal funds, federal aid is also being cut by the CDC. In a story first reported by NBC News, CDC is reportedly clawing back more than $11 billion in covid-related grants. Among other things, that’s impacting funding that was being used in Texas to fight the ongoing measles outbreak. How exactly does clawing back this money from state and local public health agencies make America healthy again? 

Goldman: That’s a great question, and I’m curious to see how it plays out. I don’t have the answer. 

Rovner: And it’s not just domestic spending. The fate of PEPFAR [the President’s Emergency Plan for AIDS Relief], the international AIDS/HIV program that’s credited with saving more than 20 million lives, remains in question. And The New York Times has gotten hold of a spreadsheet including more global health cuts, including those for projects to fight malaria and to pull the U.S. out of Gavi. That’s the global vaccine alliance that’s helped vaccinate more than 1.1 billion children in 78 countries. Wasn’t there a court order stopping all of these cuts? 

Ollstein: So there was for some USAID [U.S. Agency for International Development] work, but not all of these things fall under that umbrella. And that is still an ongoing saga that has flipped back and forth depending on various rulings. But I think it’s worth pointing out, as always, that infectious diseases don’t respect international borders, and any pullback on efforts to fight various things abroad inevitably will impact Americans as well. 

Rovner: Yeah. I mean, we’ve seen these measles cases obviously in Texas, but now we’re getting measles cases in other parts of the country, and many of them are people coming from other countries. We had somebody come through Washington, D.C.’s Union Station with measles, and we’ve had all of these alerts. I mean, this is what happens when you don’t try and work with infectious diseases where they are, then they spread. That’s kind of the nature of infectious disease. 

Well, at the same time, HHS Secretary RFK Jr. is putting his Make America Healthy Again agenda into practice in smaller ways as well. First up, remember that study that Kennedy promised again to look into any links between childhood vaccines and autism? It will reportedly be led by a vaccine skeptic who was disciplined by the Maryland Board of Physicians for practicing medicine without a license and who has pushed the repeatedly debunked assertion that autism can be caused by the preservative thimerosal, which used to be used in childhood vaccines but has long since been discontinued. One autism group referred to the person who’s going to be running this study as, quote, “a known conspiracy theorist and quack.” Sen. [Bill] Cassidy seemed to promise us that this wasn’t going to happen. 

Kenen: Well, we think that Sen. Cassidy was promised it wouldn’t happen, and it’s all happening. And in fact, when a recent hearing, he was very outspoken that there’s no need to research the autism link, because it’s been researched over and over and over and over and over again and there’s a lot of reputable scientific evidence establishing that vaccination does not cause autism. We don’t know what causes autism, so— 

Rovner: But we know it’s not thimerosal. 

Kenen: Right, which has been removed from many vaccines, in fact, and autism rates went up. So Cassidy has not come out and said, Yeah, I’m the guy who pulled the plug on Weldon. But it’s sort of obvious that he had, at least was, a role in. It is widely understood in Washington that he and a few other Republicans, [Sens. Lisa] Murkowski and [Susan] Collins, I believe — I think Murkowski said it in public — said that the CDC could not go down that route. 

Rovner: Well, I would like to be inadvertently invited to the Signal chat between Secretary Kennedy and Sen. Cassidy. I would very much wish to see that conversation. 

Meanwhile, in Texas, where HHS just confiscated public health funding, as we said, a hospital in Lubbock says it’s now treating children with liver damage from too much vitamin A, which Secretary Kennedy recommended as a way to prevent and or treat measles. Which it doesn’t, by the way. But that points to, that some of these — I hesitate of how to describe these people who are “making America healthy again.” But some of the things that they point to can be actively dangerous, not just not helpful. 

Goldman: Yeah. And I think it also shows how much messaging from the top matters, right? People are listening to what Secretary Kennedy says, which makes sense because he’s the secretary of health and human services. But if he’s pedaling misinformation or disinformation, that can have real harmful effects on people. 

Kenen: And his messages are being amplified even if some people are not, their parents, who aren’t maybe directly tuned in to what Kennedy personally is saying, but they follow various influencers on health who are then echoing what Kennedy’s saying about vitamin A. Yeah, we all need vitamin A in our diet. It’s something, part of healthy nutrition. But this supplement’s unnecessary, or excess supplements, vitamin A or cod liver oil or other things that can make them sick, including liver damage. And that’s what we’re seeing now. Vitamin A does have a place in measles under very specific circumstances, under medical supervision in individual cases. But no, people should not be going to the drugstore and pouring huge numbers of tablets of vitamin C down their children’s throat. It’s dangerous. 

Rovner: And actually the head of communications at the CDC not only quit his job this week but wrote a rather impassioned op-ed in The Washington Post, which I will post in our show notes, talking about he feels like he cannot work for an agency that is not giving advice that is based in science and that that’s what he feels right now. Again, that’s before we get a new head of the CDC. Well, MAHA is apparently spreading to the states as well. West Virginia Republican Gov. Patrick Morrisey this week signed a bill to ban most artificial food coloring and two preservatives in all foods sold in the state starting in 2028. Nearly half the rest of the states are considering similar types of bans. But unless most of those other states follow, companies aren’t going to remake their products just for West Virginia, right? 

Kenen: West Virginia is not big enough, but they sometimes do remake their products for California, which is big. The whole food additive issue is, traditionally the food manufacturers have had a lot of control over deciding what’s safe. It’s the industry that has decided. Kennedy has some support across the board and saying that’s too loose and we should look at some of these additives that have not been examined. There are others, including some preservatives, that have been studied and that are safe. Some preservatives have not been studied and should be studied. There are others that have been studied and are safe and they keep food from going rotten or they can prevent foodborne disease outbreaks. Something that does make our food healthy, we probably want to keep them in there. So, and are there some that— 

Rovner: I think people get mixed up between the dyes and the preservatives. Dyes are just to make things look more attractive. The preservatives were put there for a reason. 

Kenen: Right. And there’s some healthy ways of making dyes, too, if you need your food to be red. There’s berry abstracts instead of chemical extracts. So things get overly simplified in a way that does not end up necessarily promoting health across the board. 

Rovner: Well, not all of the news is coming from the Trump administration. The Supreme Court next week will hear a case out of South Carolina about whether Medicaid recipients can sue to enforce their right to get care from any qualified health care providers. But this is really another case about Planned Parenthood, right, Alice? 

Ollstein: Yep. If South Carolina gets the green light to kick Planned Parenthood out of its Medicaid program, which is really what is at the heart of this case, even though it’s sort of about whether beneficiaries can sue if their rights are denied. A right isn’t a right if you can’t enforce it, so it’s expected that a ruling in that direction would cause a stampede of other conservative states to do the same, to exclude Planned Parenthood from their Medicaid programs. Many have tried already, and that’s gone around and around in the courts for a while, and so this is really the big showdown at the high court to really decide this. 

And as I’ve been writing about, this is just one of many prongs of the right’s bigger strategy to defund Planned Parenthood. So there are efforts at the federal level. There are efforts at the state level. There are efforts in the courts. They are pushing executive actions on that front. We can talk. There was some news on Title X this week. 

Rovner: That was my next question. Go ahead. 

Ollstein: Some potential news. 

Rovner: What’s happening with Title X? 

Ollstein: Yeah. So HHS told us when we inquired that nothing’s final yet, but they’re reviewing tens of millions of Title X federal family planning grants that currently go to some Planned Parenthood affiliates to provide subsidized contraception, STI [sexually transmitted infection] screenings, various non-abortion services. And so they are reviewing those grants now. They are supposed to be going out next week, so we’ll have to see what happens there. There was some sort of back-and-forth in the reporting about whether they’re going to be cut or not. 

Rovner: What surprises me about the Title X grant, and there has been, there have been efforts, as you point out, going back to the 1980s to kick Planned Parenthood out of the Title X program. That’s separate from kicking Planned Parenthood out of Medicaid, which is where Planned Parenthood gets a lot more money. 

But the first Trump administration did kick Planned Parenthood out of Title X, and they went through the regulatory process to do it. And then the Biden administration went through the regulatory process to rescind the Trump administration regulations that kicked them out. Now it looks like the Trump administration thinks that it can just stop it without going through the regulatory process, right? 

Ollstein: That’s right. So not only are they going around Congress, which approves Title X funding every year, they are also going around their own rulemaking and just going for it. Although, again, it has not been finally announced whether or not there will be cuts. They’re just reviewing these grants. 

Rovner: But I repeat for those in the back, this is not normal. It’s not how these things are supposed to work it. 

Kenen: It’s normal now, Julie. 

Rovner: Yeah, clearly it’s becoming normal. Well, finally this week, another case of a woman arrested for a poor pregnancy outcome. This happened in Georgia where the woman suffered a natural miscarriage, not an abortion, which was confirmed by the medical examiner, but has been arrested on charges of improperly disposing of the fetal remains. Alice, this is turning into a trend, right? 

Ollstein: Yes. And it’s important for people to remember that this was happening before Dobbs. This was happening when Roe v. Wade was still in place. This has happened since then in states where abortion is legal. Some prosecutors are finding other ways to charge people. Whether it’s related to, yeah, the disposal of the fetus, whether it’s related to substance abuse, substance use during pregnancy, even sometimes the use of substances that are actually legal, but people have been charged, arrested for using them during pregnancy. So yes, it’s important to remember that even if there’s not a quote-unquote “abortion ban” on the books, there are still efforts underway in many places to criminalize pregnancy loss however it happens, naturally or via some abortifacient method. 

Rovner: Well, something else we’ll be keeping an eye on. All right, that’s as much news as we have time for this week. Now, we will play my interview with KFF’s Larry Levitt. Then we’ll come back and do our extra credits. 

So, last Sunday was the 15th anniversary of President Barack Obama’s signing of the original Affordable Care Act. And before you ask, yes, I was there in the White House East Room that day. Anyway, to discuss what the law has meant to the U.S. health system over the last decade and a half and what its future might be, I am so pleased to welcome back to the podcast my KFF colleague Larry Levitt, executive vice president for health policy. 

Larry, thanks for joining us again. 

Larry Levitt: Oh, thanks for having me. 

Rovner: So, [then-House Speaker] Nancy Pelosi was mercilessly derided when she said that once the American people learned exactly what was in the ACA, they would come to like it. But that’s exactly what’s happened, right? 

Levitt: It is. Yes. I think people took her comments so out of context, but the ACA was incredibly controversial and divisive when it was being debated. Frankly, after a pass, the ACA became pretty unpopular. If you go back to 2014, just before the main provisions of the ACA were being implemented, there was all this controversy over the individual mandate, over people’s plans being canceled because they didn’t comply with the ACA’s rules. And then, of course, healthcare.gov, the website, didn’t work. So the ACA was very underwater in public opinion. And even after it first went into effect and people started getting coverage, that didn’t necessarily turn around immediately, there was still a lot of divisiveness over the law. 

What changed is, No. 1, over time, more and more people got covered, people with preexisting conditions, people who couldn’t afford health insurance, people who turned 26 or could stay on their parents’ plans until 26 and then could enroll in the ACA or Medicaid after turning 26. All these people got coverage and started to see the benefits of the law. The other thing that happened was in 2017, Republicans tried unsuccessfully to repeal and replace the ACA, and people really realized what they could be missing if the law went away. 

Rovner: So what’s turned out to be the biggest change to the health care system as a result of the ACA? And is it what you originally thought it would be? 

Levitt: Well, yeah, in this case it was not a surprise, I think. The biggest change was the number of people getting covered and a big decrease in the number of people uninsured. We have been at the lowest rate of uninsurance ever recently due to the ACA and some of the enhancements, which we’ll probably talk about. And that was what the law was intended to do, was to get more people covered. And I think you’d have to call that a success, in retrospect. 

Rovner: I will say I was surprised by how much Medicaid dominated the increased coverage. I know now it’s sort of balanced out because of reductions in premiums for private coverage, I think in large part. But I think during the 2017 fight to undo the ACA, that was the first time since I’ve been covering Medicaid that I think people really realized how big and how important Medicaid is to the health care system. 

Levitt: No, that’s right. I mean the ACA marketplace, healthcare.gov, the individual mandate, preexisting condition protections, I mean, those are the things that got a lot of the public attention. But in fact, yeah, in the early years of the ACA, I mean really up until just the last couple years, the Medicaid expansion in the ACA was really the engine of coverage. And that’s not what a lot of people expected. In fact, Congressional Budget Office in their original projections kind of got that wrong, too. 

Rovner: So what was the biggest disappointment about something the ACA was supposed to do but didn’t do or didn’t do very well? 

Levitt: Yeah, I mean, I would have to point to health care costs as the biggest disappointment. The ACA really wasn’t intended to address health care costs head-on. And that was both a policy judgment but also a political decision. If you go back to the debate over the Clinton health plan in the early ’90s, which failed spectacularly — you and I were both there — it addressed health care costs aggressively, took on every segment of the health care industry, and died under that political weight. The political judgment of Obama and Democrats in Congress with the ACA was to not take on those vested health care interests and not really address health care costs head-on. That’s what enabled it to get passed. But it sort of lacked teeth in that regard. There were some things in the ACA like expansion of ACOs, accountable care organizations, which maybe had some promise but frankly have not done a whole lot. 

Rovner: And of course, Congress undoing what teeth there were in the ensuing years probably didn’t help very much, either. 

Levitt: No. I mean there was this provision in the ACA called the Cadillac plan tax, right? The idea was to tax so-called Cadillac health plans, very generous health plans. That probably would’ve had an effect. I’m not sure it would’ve done what people intended for it to do. I mean, I think it would’ve actually shifted costs to workers and caused deductibles to rise even higher. But no one but economists liked that Cadillac plan tax, and it was repealed. 

Rovner: So, as you mentioned, you and I are both also veterans of the 1993, 1994 failed effort by President Bill Clinton to overhaul the nation’s health care system, which, like the fight over the ACA, featured large-scale, deliberate mis- and disinformation by opponents about what a major piece of health legislation could do. In fact, and I have done lots of stories on this, scare tactics about the possible impact of providing universal health insurance coverage date back to the early 1900s and have been a feature of every single major health care debate since then. What did we learn from the ACA debate about combating this kind of deliberate misinformation? 

Levitt: Yeah, you’re so right about the disinformation, and I was actually looking yesterday — we have a timeline of health policy over the decades in our KFF headquarters in San Francisco, and we have an ad up there from the debate over the Truman health plan. You and I were not there for that debate. 

Rovner: Thank you. 

Levitt: And the AMA [American Medical Association] opposed that as socialized medicine and ran these ads featuring robots who were going to be your doctor if the Truman plan passed. So this is certainly nothing new. And we saw it in the ACA with death panels, right? I mean, which just spread like wildfire through the media and over social media. I would kind of hope we learned some lessons from the ACA. I’m not sure we have. And I kind of worry that with declining trust in institutions, particularly government institutions, I just wonder whether we’ll get back to a place where, yeah, we’ll disagree about policy. There will be spin, there will be scare tactics, but at least there’s some trusted source of facts and data that we can rely on, and I’m not so hopeful there. 

Rovner: Somebody asked former [HHS] Secretary Kathleen Sebelius at a 15th-anniversary event what she regretted most about not having in the ACA, and she said, With all the talk of our actually taking over the health care system, we should have just taken over the health care system, since that’s what everybody was accusing it of. It might’ve worked better. 

Levitt: Yeah, there is — we could have a whole other session on “Medicare for All” and single payer and the pros and cons of that. But one thing I think we did learn from the ACA, that complexity is just a huge problem. Even what’s supposed to be the simplest part of our health care system now, Medicare, has become incredibly complex with Part A and Part B and Part C and Part D. Seniors kind of scratch their heads trying to figure out what to do, and the ACA even more so. 

And I think back to your original question, part of what made the ACA so hard for people to grasp is there was not one single, Oh, I’m going to sign up for the ACA. There were so many pieces of it. And over time, I’m not even sure people identify those pieces with the ACA anymore. 

Rovner: Yeah. Oh, no, I am surprised at how many younger people have no idea of what the insurance market was like before the ACA and how many people were simply redlined out of getting coverage. 

Levitt: Right. No. I mean, once you fix those problems, then people don’t see them anymore. 

Rovner: So let’s look forward quickly. It seemed at least for a while after the Republicans failed in 2017 to repeal and replace the law that efforts to undo it were finally over. But while this administration isn’t saying directly that they want to end it, they do have some big targets for undoing big pieces of it. What are some of those and what are the likelihood of them happening? 

Levitt: Yeah, in some ways we have an ACA repeal-and-replace debate going on right now, just not in name. And there are really kind of two big pieces on the table. One, of course, is potential cuts to Medicaid. The House has passed a budget resolution calling for $880 billion in cuts, by the Energy and Commerce Committee, which has jurisdiction over Medicaid. The vast majority of those cuts would have to be in Medicaid. The math is simply inescapable. And a big target on the table is that expansion of Medicaid that was in the ACA. 

And interestingly, you’re even hearing Republicans on the Hill talking about repealing the enhanced federal matching payments for the ACA Medicaid expansion and saying: Well, that’s not Medicaid cuts. That’s Obamacare. That’s not Medicaid. But 20 million people are covered under that Medicaid expansion. So it would lead to the biggest increase in the number of people uninsured we’ve ever had, if that gets repealed. 

The other issue really has not gotten a lot of attention yet this year, which is the extra premium assistance that was passed under [President Joe] Biden and by Democrats in Congress. And that’s led to a dramatic increase in ACA marketplace enrollment. ACA enrollment has more than doubled to 24 million since 2020. Those subsidies expire at the end of this year. So if Congress does nothing, people would be faced with very big out-of-pocket premium increases. And I suspect it’s going to get more attention as we get closer to the end of the year, but so far there hasn’t been a big debate over it yet. 

Rovner: Well, we’ll continue to talk about it. Larry Levitt, thank you so much. 

Levitt: Oh, thanks. Great conversation. 

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. Joanne, why don’t you go first this week? 

Kenen: There’s a piece in The Atlantic this week called “America Is Done Pretending About Meat,” by Yasmin Tayag, and it’s basically saying that half of the people who said they were vegan or vegetarian were lying and that meat is very much back in fashion. That the new pejorative term — some of us may remember from 20 years or so ago, the “quiche eaters” —now it’s the “soy boy.” And that one of the new “in” foods, and I think this is the first for the podcast to use the phrase, raw beef testicles. So when we’re talking about political red meat, it’s not just political red meat. America is, we’re eating a lot more meat than we said we did, and we’re no longer saying that we’re not eating it. 

Rovner: Real red meat for the masses. 

Ollstein: For what it’s worth, “soy boy” has been a slur since the Obama administration. 

Kenen: Well, it’s just new to me. Thank you. I welcome the— 

Ollstein: I unfortunately have been in the online fever swamps where people say things like that. 

Kenen: Thank you, Alice. Now I know. 

Rovner: Maya, why don’t you go next? 

Goldman: My extra credit is a KFF Health News article by Rachana Pradhan and Aneri Pattani called “‘I Am Going Through Hell’: Job Loss, Mental Health, and the Fate of Federal Workers.” And I think it’s just worth remembering that there are real consequences, real mental health consequences to mass upheaval at the scale of what’s going on in the federal government right now with so many people losing their jobs and just not sure if their jobs are stable, especially in light of this morning’s news about HHS reorganizations. But also I think this article does a really good job of highlighting how this chaos and instability is only going to exacerbate already ongoing mental health crises that some of these workers that have been laid off were trying to help solve. And so it’s just this cycle that keeps running through. It’s worth remembering. 

Rovner: The chaos is the point. Alice. 

Ollstein: So, I have a piece from the New York Times Wirecutter section called “23andMe Just Filed for Bankruptcy. You Should Delete Your Data Now.” And it’s what it says. The company that millions and millions of people have sent samples of their DNA to over the years to find out what percent European they are and all this stuff and their propensity for various inherited diseases, that company is going bankrupt, and there is the expectation that it will be sold off for parts, including people’s very sensitive DNA. And the article points out that because they are not a health care provider, they are not subject to HIPAA [Health Insurance Portability and Accountability Act]. And so many elected officials and privacy advocates are recommending that people, very quickly, if they have given their DNA to this company, go and delete their information now before it gets sold off to who knows who. 

Rovner: And for who knows what reason. My extra credit this week is something I really did think at first was from The Onion. It’s actually from CNN, and it’s called “State Lawmakers Are Looking to Ban Non-Existent ‘Chemtrails.’ It Could Have Real-Life Side Effects,” by Ramishah Maruf and Brandon Miller, who’s a CNN meteorologist. It seems that several states are moving to ban those white lines the jets leave behind them, on the theory that they are full of toxic chemicals and/or intended to manipulate the weather. In fact, they’re mostly just water vapor. They’re called contrails because the con is for condensation. But these laws could outlaw some new types of technologies that are aimed at addressing things like climate change. Clearly we need to teach more science along with more civics. 

OK, 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 producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you could 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 folks hanging these days? Maya? 

Goldman: I am on X and Bluesky. If you search Maya Goldman, you’ll find me. And also increasingly on LinkedIn. Find me there. 

Rovner: Hearing that a lot. Alice. 

Ollstein: I am on X, @AliceOllstein, and Bluesky, @alicemiranda. 

Rovner: Joanne. 

Kenen: I’m mostly at Bluesky, and I’m also using LinkedIn a lot. @joannekenen at Bluesky. LinkedIn is reverberating more. 

Rovner: All right, we’ll be back in your feed next week with still more breaking news. Until then, be healthy. 

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

Two months into the new administration, federal workers and contractors remain off-balance as the Trump administration ramps up its efforts to cancel jobs and programs — even as federal judges declare many of those efforts illegal and/or unconstitutional.

As it eliminates programs deemed duplicative or unnecessary, however, President Donald Trump’s Department of Government Efficiency is also cutting programs and workers aligned with Health and Human Services Secretary Robert F. Kennedy Jr.’s “Make America Healthy Again” agenda.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Rachel Roubein of The Washington Post.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories.

Among the takeaways from this week’s episode:

• Kennedy’s comments this week about allowing bird flu to spread unchecked through farms provided another example of the new secretary of health and human services making claims that lack scientific support and could instead undermine public health.
• The Trump administration is experiencing more pushback from the federal courts over its efforts to reduce and dismantle federal agencies, and federal workers who have been rehired under court orders report returning to uncertainty and instability within government agencies.
• The second Trump administration is signaling it plans to dismantle HIV prevention programs in the United States, including efforts that the first Trump administration started. A Texas midwife is accused of performing illegal abortions. And a Trump appointee resigns after being targeted by a Republican senator.

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

Julie Rovner: The Washington Post’s “The Free-Living Bureaucrat,” by Michael Lewis.

Rachel Roubein: The Washington Post’s “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” by Carolyn Y. Johnson.

Sarah Karlin-Smith: KFF Health News’ “Scientists Say NIH Officials Told Them To Scrub mRNA References on Grants,” by Arthur Allen.

Jessie Hellmann: Stat’s “NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease,” by Elaine Chen.

Also mentioned in this week’s podcast:

• The Wall Street Journal’s “Trump Administration Weighing Major Cuts to Funding for Domestic HIV Prevention,” by Liz Essley White, Dominique Mosbergen, and Jonathan D. Rockoff.
• The Washington Post’s “Disabled Americans Fear Losing Protections if States’ Lawsuit Succeeds,” by Amanda Morris.

click to open the transcript

Transcript: Federal Health Work in Flux

[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, March 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi. 

Rovner: Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hello. 

Rovner: No interview today, but, as usual, way more news than we can get to, so let us jump right in. In case you missed it, there’s a bonus podcast episode in your feed. After last week’s Senate Finance Committee confirmation hearing for Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services, my KFF Health News colleagues Stephanie Armour and Rachana Pradhan and I summarized the hearing and caught up on all the HHS [Department of Health and Human Services] nomination actions. It will be the episode in your feed right before this one. 

So even without Senate-confirmed heads at — checks notes — all of the major agencies at HHS, the department does continue to make news. First, Robert F. Kennedy Jr., the new HHS secretary, speaks. Last week it was measles. This week it was bird flu, which he says should be allowed to spread unchecked in chicken flocks to see which birds are resistant or immune. This feels kind of like what some people recommended during covid. Sarah, is there any science to suggest this might be a good idea? 

Karlin-Smith: No, it seems like the science actually suggests the opposite, because doctors and veterinary specialists are saying basically every time you let the infection continue to infect birds, you’re giving the virus more and more chances to mutate, which can lead to more problems down the road. The other thing is they were talking about the way we raise animals, and for food these days, there isn’t going to be a lot of genetic variation for the chickens, so it’s not like you’re going to be able to find a huge subset of them that are going to survive bird flu. 

And then the other thing I thought is really interesting is just it doesn’t seem economically to make the most sense either as well, both for the individual farmers but then for U.S. industry as a whole, because it seems like other countries will be particularly unhappy with us and even maybe put prohibitions on trading with us or those products due to the spread of bird flu. 

Rovner: Yeah, it was eyebrow-raising, let us say. Well, HHS this week also announced its first big policy effort, called Operation Stork Speed. It will press infant formula makers for more complete lists of ingredients, increase testing for heavy metals in formula, make it easier to import formula from other countries, and order more research into the health outcomes of feeding infant formula. This feels like maybe one of those things that’s not totally controversial, except for the part that the FDA [Food and Drug Administration] workers who have been monitoring the infant formula shortage were part of the big DOGE [Department of Government Efficiency] layoffs. 

Roubein: I talked to some experts about this idea, and, like you said, they thought it kind of sounded good, but they basically needed more details. Like, what does it mean? Who’s going to review these ingredients? To your point, some people did say that the agency would need to staff up, and there was a neonatologist who is heading up infant formula that was hired after the 2022 shortage who was part of the probationary worker terminations. However, when the FDA rescinded the terminations of some workers, so, that doctor has been hired back. So I think that’s worth noting. 

Rovner: Yes. This is also, I guess, where we get to note that Calley Means, one of RFK Jr.’s, I guess, brain trusts in the MAHA movement, has been hired as, I guess, in an Elon Musk-like position in the White House as an adviser. But this is certainly an area where he would expect to weigh in. 

Hellmann: Yeah, I saw he’s really excited about this on Twitter, or X. There’s just been concerns in the MAHA movement, “Make America Healthy Again,” about the ingredients that are in baby formula. And the only thing is I saw that he also retweeted somebody who said that “breast is best,” and I’m just hoping that we’re not going back down that road again, because I feel like public health did a lot of work in pushing the message that formula and breast milk is good for the child, and so that’s just another angle that I’ve been thinking about on this. 

Rovner: Yes, I think this is one of those things that everybody agrees we should look at and has the potential to get really controversial at some point. While we are on the subject of the federal workforce and layoffs, federal judges and DOGE continue to play cat-and-mouse, with lots of real people’s lives and careers at stake. Various judges have ordered the reinstatement, as you mentioned, Rachel, of probationary and other workers. Although in many cases workers have been reinstated to an administrative leave status, meaning they get put back on the payroll and they get their benefits back, but they still can’t do their jobs. At least one judge has said that does not satisfy his order, and this is all changing so fast it’s basically impossible to keep up. But is it fair to say that it’s not a very stable time to be a federal worker? 

Karlin-Smith: That’s probably the nicest possible way to put it. When you talk to federal workers, everybody seems stressed and just unsure of their status. And if they do have a job, it’s often from their perspective tougher to do their job lately, and then they’re just not sure how stable it is. And many people are considering what options they have outside the federal government at this point. 

Rovner: So for those lucky federal workers who do still have jobs, the Trump administration has also ordered everyone back to offices, even if those offices aren’t equipped to accommodate them. FDA headquarters here in Maryland’s kind of been the poster child for this this week. 

Karlin-Smith: Yeah, FDA is an interesting one because well before covid normalized working from home and transitioned a lot of people to working from home, FDA’s headquarters couldn’t accommodate a lot of the new growth in the agency over the years, like the tobacco part of the FDA. So it was typical that people at least worked part of their workweek at home, and FDA really found once covid gave them additional work-from-home flexibilities, they were able to recruit staff they really, really needed with specialized degrees and training who don’t live near here, and it actually turned out to be quite a benefit from them. 

And now they’re saying everybody needs to be in an office five days a week, and you have people basically cramped into conference rooms. There’s not enough parking. People are trying to review technical scientific data, and you kind of can’t hear yourself think. Or you’re a lawyer — I heard of a situation where people are basically being told, Well, if you need to do a private phone call because of the confidentiality around what you’re doing, go take the call in your car. So I think in addition to all of the concerns people have around the stability of their jobs, there’s now this element of, on a personal level, I think for many of them it’s just made their lives more challenging. And then they just feel like they’re not actually able to do, have the same level of efficiency at their work as they normally would. 

Rovner: And for those who don’t know, the FDA campus is on a former military installation in the Maryland suburbs. It’s not really near any public transportation. So you pretty much have to drive to get there. And I think that the parking lots are not that big, because, as you pointed out, Sarah, the workforce is now bigger than the headquarters was created to accommodate it. And we’re seeing this across the government. This week it happened to be FDA. You have to ask the question: Is this really just an effort to make the government not work, to make federal workers, if they can’t fire them, to make them quit? 

Hellmann: I definitely think that’s part of the underlying goal. If you see some of the stuff that Elon Musk says about the federal workforce, it’s very dismissive. He doesn’t seem to have a lot of respect for the civil servants. And they’ve been running into a lot of pushback from federal judges over many lawsuits targeting these terminations. And so I think just making conditions as frustrating as possible for some of these workers until they quit is definitely part of the strategy. 

Roubein: And I think this is overlaid with the additional buyout offers, the additional early retirement offers. There’s also the reduction-in-force plans that federal workers have been unnerved about, bracing for future layoffs. So it’s very clear that they want to shrink the size of the federal workforce. 

Rovner: Yeah, we’ve seen a lot of these people, I’ve seen interviews with them, who are being reinstated, but they’re still worried that now they’re going to be RIF-ed. They’re back on the payroll, they’re off the payroll. I mean there’s nothing — this does not feel like a very efficient way to run the federal government. 

Karlin-Smith: Right. I think that’s what a lot of people are talking about is, again, going back to offices, for many of these people, is not leading to productivity. I talked to one person who said: I’m just leaving my laptop at the office now. I’m not going to take it home and do the extra hours of work that they might’ve normally gotten from me. And that includes losing time to commute. FDA is paying for parking-garage spaces in downtown Silver Spring [Maryland] near the Metro so that they can then shuttle people to the FDA headquarters. I’ve taken buses from that Metro to FDA headquarters. In traffic, that’s a 30-minute drive. They’re spending money on things that, again, I think are not going to in the long run create any government efficiency. 

And in fact, I’ve been talking to people who are worried it’s going to do the opposite, that drug review, device review, medical product review times and things like that are going to slow. We talked about food safety. I think The New York Times had a really good story this week about concerns about losing the people. We need to make sure that baby formula is actually safe. So there’s a lot of contradictions in the messaging of what they’re trying to accomplish and how the actions actually are playing out. 

Rovner: Well, and finally, I’m going to lay one more layer on this. There’s the question of whether you can even put the toothpaste back in the tube if you wanted to. After weeks of back-and-forth, the federal judge ruled on Tuesday that the dissolution of USAID [the U.S. Agency for International Development] was illegal and probably unconstitutional, and ordered email and computer access restored for the remaining workers while blocking further cuts. But with nearly everybody fired, called back from overseas, and contracts canceled, USAID couldn’t possibly come close to doing what it did before DOGE basically took it apart, right?. 

Karlin-Smith: You hear stories of if someone already takes a new job, they’re lucky enough to find a new job, why are they going to come back? Again, even if you’re brought back, my expectation is a lot of people who have been brought back are probably looking for new jobs regardless because you don’t have that stability. And I think the USAID thing is interesting, too, because again, you have people that were working in all corners of the world and you have partnerships with other countries and contractors that have to be able to trust you moving forward. And the question is, do those countries and those organizations want to continue working with the U.S. if they can’t have that sort of trust? And as people said, the U.S. government was known as, they could pay contractors less because they always paid you. And when you take that away, that creates a lot of problems for negotiating deals to work with them moving forward. 

Rovner: And I think that’s true for federal workers, too. There’s always been the idea that you probably could earn more in the private sector than you can working for the federal government, but it’s always been a pretty stable job. And I think right now it’s anything but, so comes the question of: Are we deterring people from wanting to work for the federal government? Eventually one would assume there’s still going to be a federal government to work for, and there may not be anybody who wants to do it. 

Roubein: Yeah, you saw various hiring authorities given to try and recruit scientists and other researchers who make a lot, lot more in the public health sector, and some of those were a part of the probationary workforce because they had been hired recently under those authorities. 

Rovner: Yeah, and now this is all sort of coming apart. Well, meanwhile, the cuts are continuing even faster than federal judges can rule against them. Last week, the administration said it would reduce the number of HHS regional offices from 10 to four. Considering these are where the department’s major fraud-fighting efforts take place, that doesn’t seem a very effective way of going after fraud and abuse in programs like Medicare and Medicaid. Those regional offices are also where lots of beneficiary protections come from, like inspections of nursing homes and Head Start facilities. How does this serve RFK Jr.’s Make America Healthy Again agenda? 

Karlin-Smith: I think it’s not clear that it does, right? You’re talking about, again, the Department of Government Efficiency has focused on efficiency, cost savings, and Medicare and Medicaid does a pretty good job of fighting fraud and making HHS OIG [Office of Inspector General], all those organizations, they collect a lot of money back. So when you lose people— 

Rovner: And of course the inspector general has also been laid off in all of this. 

Karlin-Smith: Right. It’s not clear to me, I think one of the things with that whole reorganization of their chief counsel is people are suggesting, again, this is sort of a power move of HHS wanting to get a little bit more control of the legal operations at the lower agencies, whether it’s NIH [the National Institutes of Health] or FDA and so forth. But, right, it’s reducing head count without really thinking about what people’s roles actually were and what you lose when you let them go. 

Rovner: Well, the Trump administration is also continuing to cut grants and contracts that seem like they’d be the kind of things that directly relate to Make America Healthy Again. Jessie, you’ve chosen one of those as your extra credit this week. Tell us about it. 

Hellmann: Yeah. So my story is from Stat [“NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease”], and it’s about a nationwide study that tracks patients with prediabetes and diabetes. And it was housed at Columbia University, which as we know has been the subject of some criticism from the Trump administration. They had lost about $400 million in grants because the administration didn’t like Columbia’s response to some of the protests that were on campus last year. But that has an effect on some research that really doesn’t have much to do with that, including a study that looked at diabetes over a really long period of time. 

So it was able to over decades result in 200 publications about prediabetes and diabetes, and led to some of the knowledge that we have now about the interventions for that. And the latest stage was going to focus on dementia and cognitive impairment, since some of the people that they’ve been following for years are now in their older ages. And now they have to put a stop to that. They don’t even have funding to analyze blood samples that they’ve done and the brain scans that they’ve collected. So it’s just another example of how what’s being done at the administration level is contradicting some of the goals that they say that they have. 

Rovner: Yeah, and it’s important to remember that Columbia’s funding is being cut not because they deemed this particular project to be not helpful but because they are, as you said, angry at Columbia for not cracking down more on pro-Palestinian protesters after Oct. 7. 

Well, meanwhile, people are bracing for still more cuts. The Wall Street Journal is reporting the administration plans to cut domestic AIDS-HIV programming on top of the cuts to the international PEPFAR [President’s Emergency Plan for AIDS Relief] program that was hammered as part of the USAID cancellation. Is fighting AIDS and HIV just way too George W. Bush for this administration? 

Hellmann: It’s interesting because President [Donald] Trump unveiled the Ending the HIV Epidemic initiative in his first term, and the goal was to end the epidemic in the United States. And so if they were talking about reducing some of that funding, or I know there were reports that maybe they would move the funding from CDC [the Centers for Disease Control and Prevention] to HRSA [the Health Resources and Services Administration], it’s very unclear at this point. Then it raises questions about whether it would undermine that effort. And there’s already actions that the Trump administration has done to undermine the initiative, like the attacks on trans people. They’ve canceled grants to researchers studying HIV. They have done a whole host of things. They canceled funding to HIV services organizations because they have “trans” in their programming or on their websites. So it’s already caused a lot of anxiety in this community. And yeah, it’s just a total turnaround from the first administration. 

Rovner: I know the Whitman-Walker clinic here in Washington, which has long been one of the premier AIDS-HIV clinics, had just huge layoffs. This is already happening, and as you point out, this was something that President Trump in his first term vowed to end AIDS-HIV in the U.S. So this is not one would think how one would go about that. 

Well, it’s not just the administration that’s working to constrict rights and services. A group of 17 states, led by Texas, of course, are suing to have Biden-era regulations concerning discrimination against trans people struck down, except as part of that suit, the states are asking that the entirety of Section 504 of the Rehabilitation Act be declared unconstitutional. Now, you may never have heard of Section 504, but it is a very big deal. It was the forerunner of the Americans With Disabilities Act, and it prevents discrimination on the basis of disability in all federally funded activities. It is literally a lifeline for millions of disabled people that enables them to live in the community rather than in institutions. Are we looking at an actual attempt to roll back basically all civil rights as part of this war on “woke” and DEI [diversity, equity, and inclusion] and trans people? 

Hellmann: The story is interesting, because it seems like some of the attorneys general are saying, That’s not our intent. But if you look at the court filings, it definitely seems like it is. And yeah, like you said, this is something that would just have a tremendous impact. And Medicaid coverage of home- and community-based services is one of those things that states are constantly struggling to pay for. You’re just continuing to see more and more people need these services. Some states have waiting lists, so— 

Rovner: I think most states have waiting lists. 

Hellmann: Yeah. It’s something, you have to really question what the intent is here. Even if people are saying, This isn’t our intent, it’s pretty black-and-white on paper in the court records, so— 

Rovner: Yeah, just to be clear, this was a Biden administration regulation, updating the rules for Section 504, that included reference to trans people. But in the process of trying to get that struck down, the court filings do, as you say, call for the entirety of Section 504 to be declared unconstitutional. This is obviously one of those court cases that’s still before the district court, so it’s a long way to go. But the entire disability community, certainly it has their attention. 

Well, we haven’t had any big abortion news the past couple of weeks, but that is changing. In Texas, a midwife and her associate have become the first people arrested under the state’s 2022 abortion ban. The details of the case are still pretty fuzzy, but if convicted, the midwife who reportedly worked as an OB-GYN doctor in her native Peru and served a mostly Spanish-speaking clientele, could be sentenced to up to 20 years in prison. So, obviously, be watching that one. Meanwhile, here in Washington, Hilary Perkins, a career lawyer chosen by FDA commissioner nominee Marty Makary to serve as the agency’s general counsel, resigned less than two days into her new position after complaints from Missouri Sen. Josh Hawley that she defended the Biden administration’s position on the abortion pill mifepristone. 

Now, Hilary Perkins is no liberal trying to hide out in the bureaucracy. She’s a self-described pro-life Christian conservative hired in the first Trump administration, but she was apparently forced out for the high crime of doing her job as a career lawyer. Is this administration really going to try to evict anyone who ever supported a Biden position? Will that leave anybody left? 

Roubein: I think what’s notable is Sen. Josh Hawley here, who expressed concerns and I had heard expressed concerns to the White House, and the post on X from the FDA came an hour before the hearing. There were concerns that he was not going to make it out of committee and— 

Rovner: Before the Marty Makary hearing. 

Roubein: Yes, sorry, before the vote in the HELP [Health, Education, Labor and Pensions] Committee on Marty Makary. And Hawley said because of that, he would vote to support him. What was interesting is two Democrats actually ended up supporting him, so he could have passed without Hawley’s vote. But I think in general it poses a test for Marty Makary when he’s an FDA commissioner, and how and whether he’s going to get his people in and how he’ll respond to different pressure points in Congress and with HHS and with the White House. 

Rovner: And of course, Hawley’s not a disinterested bystander here, right? 

Karlin-Smith: So his wife was one of the key attorneys in the recent big Supreme Court case that was pushed down to the lower courts for a lack of standing, but she was trying to essentially get tighter controls on the abortion pill mifepristone. But it seems like almost maybe Hawley jumped too soon before doing all of his research or fully understanding the role of people at Justice. Because even before this whole controversy erupted, I had talked to people the day before about this and asked them, “Should we read into this, her being involved in this?” And everybody I talked to, including, I think, a lot of people that have different views than Perkins does on the case, that they were saying she was in a role as a career attorney. You do what your boss, what the administration, wants. 

If you really, really had a big moral problem with that, you can quit your job. But it’s perfectly normal for an attorney in that kind of position to defend a client’s interest and then have another client and maybe have to defend them wrongly. So it seems like if they had just maybe even picked up the phone and had a conversation with her, the whole crisis could have been averted. And she was on CNN yesterday trying to plead her case and, again, emphasize her positions because perhaps she’s worried about her future career prospects, I guess, over this debacle. 

Rovner: Yeah, now she’s going to be blackballed by both sides for having done her job, basically. Anyway, all right, well, one big Biden initiative that looks like it will continue is the Medicare Drug Price Negotiation program. And we think we know this because CMS announced last week that the makers of all of the 15 drugs selected for the second round of negotiations have agreed to, well, negotiate. Sarah, this is news, right? Because we were wondering whether this was really going to go forward. 

Karlin-Smith: Yeah, they’ve made some other signals since taking over that they were going to keep going with this, including last week at his confirmation hearing, Dr. Oz, for CMS, also indicated he seemed like he would uphold that law and they were looking for ways to lower drug costs. So I think what people are going to be watching for is whether they yield around the edges in terms of tweaks the industry wants to the law, or is there something about the prices they actually negotiate that signal they’re not really trying to get them as low as they can go? But this seems to be one populist issue for Trump that he wants to keep leaning into and keep the same consistency, I think, from his first administration, where he always took a pretty hard line on the drug industry and drug pricing. 

Rovner: And I know Ozempic is on that list of 15 drugs, but the administration hasn’t said yet. I assume that’s Ozempic for its original purpose in treating diabetes. This administration hasn’t said yet whether they’ll continue the Biden declaration that these drugs could be available for people for weight loss, right? 

Karlin-Smith: Correct. And I think that’s going to be more complicated because that’s so costly. So negotiating the price of drugs saves money. So yes, basically because Ozempic and Wegovy are the same drug, that price should be available regardless of the indication. But I’m more skeptical that they continue that policy, because of the cost and also just because, again, HHS Secretary Robert F. Kennedy seems to be particularly skeptical of the drugs, or at least using that as a first line of defense, widespread use, reliance on that. He tends to, in general, I think, support other ways of medical, I guess, treatment or health treatments before turning to pharmaceuticals. 

Rovner: Eating better and exercising. 

Karlin-Smith: Correct, right. So I think that’s going to be a hard sell for them because it’s just so costly. 

Rovner: We will see. All right, that is as much news as we have time for this week. Now, it is 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. Jessie, you’ve done yours already this week. Rachel, why don’t you go next? 

Roubein: My extra credit, the headline is “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” In The Washington Post by my colleague Carolyn Y. Johnson. And I thought the story was particularly interesting because it really dove into the personal level. You hear about all these cuts from a high level, but you don’t always really know what it means and how it came about. So the backstory is the National Institutes of Health terminated dozens of research grants that focused on why some people are hesitant to accept vaccines. 

And Carolyn profiled one researcher, Nisha Acharya, but there was a twist, and the twist was she doesn’t actually study how to combat vaccine hesitancy or ways to increase vaccine uptake. Instead, she studies how well the shingles vaccine works to prevent the infection, with a focus on whether the shot also prevents the virus from affecting people’s eyes. But in the summary of her project, she had used the word “hesitancy” once and used the word “uptake” once. And so this highlights the sweeping approach to halting some of these vaccine hesitancy research grants. 

Rovner: Yeah that was like the DOD [Department of Defense] getting rid of the picture of the Enola Gay, the plane that dropped the atomic bomb, because it had the word “Gay” in it. This is the downside, I guess, of using AI for these sorts of things. Sarah. 

Karlin-Smith: I took a look at a KFF story by Arthur Allen, “Scientists Say NIH Officials Told Them to Scrub mRNA References on Grants,” and it’s about NIH officials urging people to remove any reference to mRNA vaccine technology from their grants. And the story indicates it’s not yet clear if that is going to translate to defunding of such research, but the implications are quite vast. I think most people probably remember the mRNA vaccine technology is really what helped many of us survive the covid pandemic and is credited with saving millions of lives, but the technology promise seems vast even beyond infectious diseases, and there’s a lot of hope for it in cancer. 

And so this has a lot of people worried. It’s not particularly surprising, I guess, because again, the anti-vaccine movement, which Kennedy has been a leader of, has been particularly skeptical of the mRNA technology. But it is problematic, I think, for research. And we spent a lot of time on this call talking about the decimation of the federal workforce that may happen here, and I think this story and some of the other things we talked about today also show how we may just decimate our entire scientific research infrastructure and workforce in the U.S. outside of just the federal government, because so much of it is funded by NIH, and the decisions they’re making are going to make it impossible for a lot of scientists to do their job. 

Rovner: Yeah, we’re also seeing scientists going to other countries, but that’s for another time. Well, my extra credit this week, probably along the same lines, also from The Washington Post. It’s part of a series called “Who Is Government?” This particular piece [“The Free-Living Bureaucrat”] is by bestselling author Michael Lewis, and it’s a sprawling — and I mean sprawling — story of how a mid-level FDA employee who wanted to help find new treatments for rare diseases ended up not only figuring out a cure for a child who was dying of a rare brain amoeba but managed to obtain the drug for the family in time to save her. It’s a really good piece, and it’s a really excellent series that tells the stories of mostly faceless bureaucrats who actually are working to try to make the country a better place. 

OK, that’s 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. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. 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 these days? Sarah? 

Karlin-Smith: A little bit everywhere. X, Bluesky, LinkedIn — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Jessie. 

Hellmann: I’m @jessiehellmann on X and Bluesky, and I’m also on LinkedIn more these days. 

Rovner: Great. Rachel. 

Roubein: @rachelroubein at Bluesky, @rachel_roubein on X, and also on LinkedIn. 

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

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La administración Biden ha ampliado las protecciones financieras para los pacientes, incluyendo una propuesta histórica de la Oficina de Protección Financiera del Consumidor (CFPB) para eliminar la deuda médica de los informes de crédito de los consumidores.

En 2022, el presidente Joe Biden también firmó la Ley de Reducción de la Inflación, que limita cuánto deben pagar los afiliados de Medicare por medicamentos recetados, incluyendo un tope de $35 al mes para la insulina. Y en legislaturas de todo el país, demócratas y republicanos han trabajado juntos de manera discreta para promulgar leyes que frenen a los cobradores de deudas.

Sin embargo, defensores dicen que el gobierno federal podría hacer más para abordar un problema que afecta a 100 millones de estadounidenses, obligando a muchos a trabajar más, perder sus hogares y reducir el gasto en alimentos y otros artículos esenciales.

“Biden y Harris han hecho más para abordar la crisis de deuda médica en este país que cualquier otra administración”, dijo Mona Shah, directora senior de política y estrategia en Community Catalyst, una organización sin fines de lucro que ha liderado los esfuerzos nacionales para fortalecer las protecciones contra la deuda médica. “Pero hay más por hacer y debe ser una prioridad para el próximo Congreso y administración”.

Al mismo tiempo, los defensores de los pacientes temen que si el ex presidente Donald Trump gana un segundo mandato, debilitará las protecciones de los seguros permitiendo que los estados recorten sus programas de Medicaid o reduciendo la ayuda federal para que los estadounidenses compren cobertura médica. Eso pondría a millones de personas en mayor riesgo de endeudarse si enferman.

En su primer mandato, Trump y los republicanos del Congreso intentaron en 2017 derogar la Ley de Cuidado de Salud a Bajo Precio (ACA), un movimiento que, según analistas independientes, habría despojado de cobertura médica a millones de estadounidenses y habría aumentado los costos para las personas con afecciones preexistentes, como diabetes y cáncer.

Trump y sus aliados del Partido Republicano continúan atacando a ACA, y el ex presidente ha dicho que quiere revertir la Ley de Reducción de la Inflación, que también incluye ayuda para que los estadounidenses de bajos y medianos ingresos compren seguros de salud.

“Las personas enfrentarán una ola de deuda médica por pagar primas y precios de medicamentos recetados”, dijo Anthony Wright, director ejecutivo de Families USA, un grupo de consumidores que ha apoyado las protecciones federales de salud. “Los pacientes y el público deberían estar preocupados”.

La campaña de Trump no respondió a consultas sobre su agenda de salud. Y el ex presidente no suele hablar de atención médica o deuda médica en la campaña, aunque dijo en el debate del mes pasado que tenía “conceptos de un plan” para mejorar la ACA. Trump no ha ofrecido detalles.

Harris ha prometido repetidamente proteger ACA y renovar los subsidios ampliados para las primas mensuales del seguro creados por la Ley de Reducción de la Inflación. Esa ayuda está programada para expirar el próximo año.

La vicepresidenta también ha expresado su apoyo a un mayor gasto gubernamental para comprar y cancelar deudas médicas antiguas de los pacientes. En los últimos años, varios estados y ciudades han comprado deuda médica en nombre de sus residentes.

Estos esfuerzos han aliviado la deuda de cientos de miles de personas, aunque muchos defensores dicen que cancelar deudas antiguas es, en el mejor de los casos, una solución a corto plazo, ya que los pacientes seguirán acumulando facturas que no pueden pagar sin una acción más sustantiva.

“Es un bote con un agujero”, dijo Katie Berge, una cabildera de la Sociedad de Leucemia y Linfoma. Este grupo de pacientes fue una de más de 50 organizaciones que el año pasado enviaron cartas a la administración Biden instando a las agencias federales a tomar medidas más agresivas para proteger a los estadounidenses de la deuda médica.

“La deuda médica ya no es un problema de nicho”, dijo Kirsten Sloan, quien trabaja en política federal para la Red de Acción contra el Cáncer de la Sociedad Americana de Cáncer. “Es clave para el bienestar económico de millones de estadounidenses”.

La Oficina de Protección Financiera del Consumidor está desarrollando regulaciones que prohibirían que las facturas médicas aparezcan en los informes de crédito de los consumidores, lo que mejoraría los puntajes crediticios y facilitaría que millones de estadounidenses alquilen una vivienda, consigan un trabajo o consigan un préstamo para un automóvil.

Harris, quien ha calificado la deuda médica como “crítica para la salud financiera y el bienestar de millones de estadounidenses”, apoyó con entusiasmo la propuesta de regulación. “No se debería privar a nadie del acceso a oportunidades económicas simplemente porque experimentó una emergencia médica”, dijo en junio.

El compañero de fórmula de Harris, el gobernador de Minnesota, Tim Walz, quien ha dicho que su propia familia luchó con la deuda médica cuando era joven, firmó en junio una ley estatal que reprime el cobro de deudas.

Los funcionarios de la CFPB dijeron que las regulaciones se finalizarán a principios del próximo año. Trump no ha indicado si seguiría adelante con las protecciones contra la deuda médica. En su primer mandato, la CFPB hizo poco para abordarla, y los republicanos en el Congreso han criticado durante mucho tiempo a la agencia reguladora.

Si Harris gana, muchos grupos de consumidores quieren que la CFPB refuerce aún más las medidas, incluyendo una mayor supervisión de las tarjetas de crédito médicas y otros productos financieros que los hospitales y otros proveedores médicos han comenzado a ofrecer a los pacientes. Por estos préstamos, las personas están obligadas a pagar intereses adicionales sobre su deuda médica.

“Estamos viendo una variedad de nuevos productos financieros médicos”, dijo April Kuehnhoff, abogada senior del Centro Nacional de Derecho del Consumidor. “Estos pueden generar nuevas preocupaciones sobre las protecciones al consumidor, y es fundamental que la CFPB y otros reguladores supervisen a estas empresas”.

Algunos defensores quieren que otras agencias federales también se involucren.

Esto incluye al enorme Departamento de Salud y Servicios Humanos (HHS), que controla cientos de miles de millones de dólares a través de los programas de Medicare y Medicaid. Ese dinero otorga al gobierno federal una enorme influencia sobre los hospitales y otros proveedores médicos.

Hasta ahora, la administración Biden no ha utilizado esa influencia para abordar la deuda médica.

Pero en un posible anticipo de futuras acciones, los líderes estatales en Carolina del Norte recientemente obtuvieron la aprobación federal para una iniciativa de deuda médica que obligará a los hospitales a tomar medidas para aliviar las deudas de los pacientes a cambio de ayuda gubernamental. Harris elogió la iniciativa.

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

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

When it comes to health care, this year’s presidential campaign is increasingly a matter of which candidate voters choose to believe. Democrats, led by Vice President Kamala Harris, say Republicans want to further restrict reproductive rights and repeal the Affordable Care Act, pointing to their previous actions and claims. Meanwhile, Republicans, led by former President Donald Trump, insist they have no such plans.

Meanwhile, with open enrollment approaching for Medicare, the Biden administration dodges a political bullet, avoiding a sharp spike next year in Medicare prescription drug plan premiums.

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

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• This week, Sen. JD Vance of Ohio muddled his ticket’s stances on health policy during the vice presidential debate, including by downplaying the possibility of a national abortion ban. And Melania Trump, the former president’s wife, spoke out in support of abortion rights. Their comments seem designed to soothe voter concerns that former President Donald Trump could take actions to further block abortion access.
• Vance raised eyebrows with his debate-night claim that Trump “salvaged” the Affordable Care Act — when, in fact, the former president vowed to repeal the law and championed the GOP’s efforts to deliver on that promise. Meanwhile, Trump deflected questions from AARP about his plans for Medicare, replying, “What we have to do is make our country successful again.”
• On the Democratic side, Vice President Kamala Harris is campaigning on health, in particular by pushing out new ads highlighting the benefits of the ACA and Trump’s efforts to restrict abortion. Polls show health is a winning issue for Democrats and that the ACA is popular, especially its protections for those with preexisting conditions.
• Also in the news, the Centers for Medicare & Medicaid Services reported a slight dip in average Medicare drug plan premiums for next year. Coming in an annual report — out shortly before Election Day — it looks as though government subsidies cushioned changes to the system, sparing seniors from potentially paying in premiums what they may save under the new $2,000 annual out-of-pocket drug cost cap, for instance.
• And in abortion news, a judge struck down Georgia’s six-week abortion ban — but many providers have already left the state. And a new California law protects coverage for in vitro fertilization, including for LGBTQ+ couples.

Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month,” about a teen athlete whose needed surgery lacked a billing code. Do you have a confusing or outrageous medical bill you want to share? Tell us about it.

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

Julie Rovner: KFF Health News’ “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” by Ronnie Cohen.

Anna Edney: Bloomberg News’ “A Free Drug Experiment Bypasses the US Health System’s Secret Fees,” by John Tozzi.

Alice Miranda Ollstein: The Wall Street Journal’s “Hospitals Hit With IV Fluid Shortage After Hurricane Helene,” by Joseph Walker and Peter Loftus.

Sandhya Raman: The Asheville Citizen Times’ “Without Water After Helene, Residents at Asheville Public Housing Complex Fear for Their Health,” by Jacob Biba.

Also mentioned on this week’s podcast:

• SisterSong v. State of Georgia: Superior Court of Fulton County decision.

Click to open the transcript

Transcript: The Health of the Campaign

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, October 4th, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Rovner: Today we are joined via teleconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Sandhya Raman of CQ Roll Call. 

Raman: Hello, everyone. 

Rovner: And Anna Edney of Bloomberg News. 

Anna Edney: Hi there. 

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 is a high school athlete whose problem got fixed, but his bill did not. But first, the news. 

We’re going to start this week with the campaign. It is October. I don’t know how that happened. On Tuesday, vice-presidential candidates Senator JD Vance of Ohio and Governor Tim Walz of Minnesota held their first and only debate. It felt very Midwestern nice, with Walz playing his usual Aw shucks self and Vance trying very hard to seem, for want of a better word, likable. Did we learn anything new from either candidate? 

Edney: I don’t think I heard anything new, no — not that I can remember. 

Rovner: I know, obviously, they exchanged some views on abortion. Vance tried very hard to distance himself from his own hard-line views on the subject, including denying that he’d ever supported a national abortion ban, which he did, by the way. Meanwhile, during the debate, former President [Donald] Trump announced on social media that he would veto a national abortion ban, something he’d not said in those exact words before. Alice, you’ve got a pretty provocative story out this week suggesting that this all might actually be working on a skeptical public. Is it? 

Ollstein: Yes. This has been a theme I’ve been tracking for a little bit. It was part of the reporting I was doing in Michigan a couple weeks ago. One, what I thought was interesting about that night was Trump and Vance have been talking past each other on abortion and contradicting each other, and now … 

Rovner: Oh, yeah. 

Ollstein: … it finally seems that they are on the same page, in terms of trying to convince the public: Nothing to see here. We won’t do a national ban. Don’t worry about it. Democrats and abortion rights groups are running around screaming: They’re lying. Look at their record. Look at what their allies have proposed in things like Project 2025. But the Republican message on this front does seem to be working. Polls show that even people who care about abortion rights and support abortion rights in some of these key battleground states still plan to vote for Trump. It’s a continuation of a pattern we’ve seen over the past few years where a decent chunk of people vote for these state ballot initiatives to protect abortion but then also vote for anti-abortion politicians. 

Voters contain multitudes. We don’t know exactly if it’s because they are not worried that Trump and Vance will pursue national restrictions. We don’t know if it’s because just other issues are more important to them. But I think it’s really worth keeping an eye on in terms of a pattern. And KFF has done some really interesting polling showing that people in states where the ballot initiatives have already passed sort of view it as, Oh, we took care of that, it’s settled, and they don’t see the urgency and the threat of a national ban in the way that Democrats and abortion rights groups want them to. 

Rovner: Which we’ll talk about separately in a minute. In late breaking news, Melania Trump this week came out and said that she supports abortion rights. Is this part of the continuing muddle where everybody can see what it is that they want to see, or is this going to have any impact at all? 

Ollstein: Can I say one more thing about the debate first? 

Rovner: Sure. 

Ollstein: OK. So what really struck me about what Vance said about abortion at the debate is he really portrayed two arguments that I’ve seen sort of trickle up from the grass roots of the anti-abortion movement. So one, there were some semantics quibbles around what is a ban. There’s really been an effort in the anti-abortion movement to say that only a total ban throughout pregnancy with no exceptions, only that they call a ban. Everything else, they don’t consider it a ban. 

Rovner: It’s a national standard. 

Ollstein: Yeah, minimum standard, federal standard. There’s a lot of different words they use — “limit,” “restriction.” But what they’re describing is what others call a ban. It’s not a different policy, and so we saw that on full display on the debate stage. We also saw this argument sort of that these government programs and funding and support are the answer to abortion, so, basically, promoting the idea that with enough child care supports and health care supports, fewer people would have abortions — which the data is mixed on that, I will say, from the U.S. and from other countries. But financial hardship is just one of many reasons people have abortions, so that would impact some people and not others. It also goes against a lot of the sort of traditional small-government, cut-government-spending Republican ethos, and so it is this really interesting sort of pro-natalist direction that some of the party wants to go in and some of the activist movement wants to go in. But there’s definitely some tension around that. And, of course, we’ve seen Republicans vote against those programs and funding at the state and federal level. 

Rovner: Things like paid family leave have been a Democratic priority much, much longer than it’s been a Republican priority, if it ever was and if it is now. 

Ollstein: But it’s interesting that he was promoting that to sort of show a kinder, gentler face to the anti-abortion movement, which has been a trend we’ve been seeing. 

Rovner: Yes. Yes, not just from JD Vance but from lots of Republicans on the anti-abortion side. And Melania— 

Ollstein: Sorry, back to Melania. 

Rovner: Is there any impact from this? 

Edney: Oh, it’s certainly worked for the Trump campaign to muddy the waters on any subject. If you think about immigration, certainly that worked before, and I think you can see where they’re realizing that. And they are coming together, like Alice mentioned, with JD Vance and Trump talking on the same page now a bit better but using sort of a, I don’t want to say “underling,” but like a second … 

Rovner: A surrogate. 

Edney: Yeah, a surrogate, a secondary character to say, I support abortion rights. And she has Trump’s ear, and that could really be a solid salve to a lot of people. 

Rovner: I was fascinated because she’s been pretty much invisible all year. I think this is the first time we have actually heard her voice, the first time I have heard her voice in 2024. 

Raman: I would add that it’s not unprecedented for a first lady on the Republican side to come out in favor of abortion rights. I think what makes it so interesting is, A, how close we are to the election and that we are actively in a campaign. When we look at the remarks that Laura Bush made several years ago, it was after [former President George W.] Bush had left office for a few years. And so this, I think, is just what really makes it, if the book is going to come out about a month or so before the election that … 

Rovner: Melania’s book. 

Raman: Yeah, Melania’s book, yes. 

Rovner: So yes, we will see. All right. Well, abortion was not the only health issue that came up during the debate. So did the Affordable Care Act. JD Vance went as far to claim that Donald Trump is actually the one that saved the Affordable Care Act. That’s not exactly how I remember things happening. You’re shaking your head. 

Raman: I think this was one of the most striking parts of the debate for me, just because he made several comments about how this was a bipartisan process and Trump was trying to salvage the ACA. And for those of us that were reporting in 2017, he was kind of ringleading the effort to repeal and replace the Affordable Care Act. And I guess there were just numerous claims within the few statements he made that were just all incorrect. He was talking about how Trump had divided risk pools, and that was not something that happened. I think that we assume that he was referring to the reinsurance waivers, but those were also created under the Obama administration, so it wasn’t like a Trump invention. We just had some approved under Trump. And he’d mentioned that enrollment was reaching record heights. Health enrollment grew more under the Biden administration than it did under Trump. 

Rovner: Yeah, I went back and actually looked up those numbers because I was so, like, “What are you talking about?” Actually, it was the moderator question: Didn’t enrollment go up during the Trump administration? No, it went down every year. 

Ollstein: The number of uninsured went up, in fact, during the Trump administration. 

Rovner: That’s right. 

Ollstein: But, I mean, this is, again, part of a long pattern. Trump has routinely taken credit for things that were the decisions of other administrations, both before and after him. 

Rovner: And things that he tried to do and failed to do. 

Ollstein: Right. 

Rovner: Like lowering drug prices. 

Ollstein: Right. Right, right, right. Exactly. Exactly. Like Anna said, there was very little new that was revealed in this exchange. 

Rovner: Well, elsewhere on the campaign trail, the Harris campaign is working hard to elevate health care as an issue, including rolling out not just a 60-second ad warning of what repealing the Affordable Care Act could mean, but also issuing a 43-page white paper theorizing what Trump and Vance are likely to have in mind with their, quote, “concepts” of a health care plan based on what they’ve said and done in the past. They must be seeing something in the polls suggesting this could have some legs, don’t you think? I’m a little surprised, because everybody keeps saying: Not a health care election. This is not a health care election. But I don’t know. The Harris campaign sure keeps behaving like it might be. 

Raman: Hammering in on the preexisting conditions and protecting those, just because that is such a popular part of the ACA across the board, is probably a good strategy for them, just because that is something that is not the most wonky with that and that people can understand in a campaign ad and kind of distill down. 

Edney: Yeah, that was what I was thinking as well, is it’s a popular issue for, certainly, to be talking about, but also just the idea that he’s talking about it in a way that people think, Oh, we don’t have to worry. And Alice has made this point on abortion before. There’s a lot that he can do through executive order and things like that, and did do like taking away money for the navigators and things to help people enroll. So even if they don’t think it’s maybe going to be about health care fully, it makes sense to try to counter some of that. And you can’t do that on a debate stage most of the time, not in an effective way, but certainly putting out this paper, I mean, it did get some press and things like that, and if you really wanted to go read it, you could. 

Rovner: Even I didn’t want to read all 43 pages. 

Edney: Yeah. 

Rovner: Well, as Anna previewed, the AARP released what’s normally a pretty routine interview with both candidates about issues important to Americans over age 50, things like Medicare, Social Security, and caregiving. But I think it’s fair to say that, at least, former President Trump’s answers were anything but routine. Asked how he would protect Medicare from cuts and improve the program, he said, and I quote: “What we have to do is make our country successful again. This has to do with Medicare and Social Security and other things. We have to let our country become successful, make our country successful again, and we’ll be able to do that.” How do you even respond to things like that? Or is this campaign now so completely divorced from the issues that literally nothing matters? 

Edney: Well, I kind of noticed a trend in between that answer and one JD Vance gave when he was talking about abortion, and he said: We just need to make women trust us. They need to trust us again. We need to make them trust us. I was like, I don’t understand how that even connects. But also, how are you going to do that? And I think that this is the same thing. You’re just saying these words over and over again in relation. So in somebody’s mind, Medicare and success is Trump’s word, and trust and abortion as JD Vance’s thing, and you’re connecting these in their minds. And I was seeing this as a trend. It just felt familiar to me after listening to the vice-presidential debate. They’re not going to talk about any policy or anything, but repeating these words over and over again like you were listening to morning affirmations or something was going to really get that through in a voter’s mind is maybe what they’re going for. 

Rovner: And I have to say, I mean, when candidates start to talk about actual policy ideas, it gets really wonky really fast. Sort of going back to the debate, JD Vance was talking about visas and immigration, and I think it’s an app that he was talking about. I know this stuff pretty well. I had no idea what he was talking about. I mean, maybe it does work better when Trump says, I’m not going to cut Medicare or Social Security, and leave it at that. 

Ollstein: Well, right, because when you talk specific policies, that opens it up to critique. And when you just talk total platitudes, then it’s harder to pick apart and criticize, even though it’s clearly not an answer to the questions they’re asking. And it was even a little bit funny to me for the AARP interview, because I believe they sent in written responses, and so they had the ability— 

Rovner: I think they also talked on the phone. 

Ollstein: Oh, OK. 

Rovner: So I think it was a little bit of both. 

Ollstein: Right. Right, right, right. It wasn’t the sort of live televised interview. They could have looked up — it was an open-book test. 

Rovner: It was. 

Ollstein: And yet all of the responses from Trump were just like, We’re going to do something and it’s going to be great and awesome and it’ll fix everything, and it was completely devoid of policy specifics, which again may be smarter politically than actually saying what you plan to do, which as we’ve seen in Project 2025, generates a lot of backlash. But it is also a little bit dangerous to go into the election not knowing the specifics of what someone wants to do on health care. 

Rovner: Yeah, I know. I find when I listen to some of these focus groups with undecided voters, we want to know what exactly they’re going to do, except they don’t really want to know what exactly they’re going to do. They think they do, but it appears that that is not necessarily the case. One thing that we know does matter, at least to people on Medicare, is the premiums they pay for their coverage. And unfortunately, for every administration, that announcement comes just weeks before Election Day every year. So this year, the Biden administration was worried about big jumps in premiums for Medicare Part D drug coverage, mostly thanks to the new caps on spending that will save consumers money but will cost insurers more. That didn’t happen, though. And in fact, average premiums will actually fall slightly next year. 

Now, I’m not sure I understand exactly what the administration did to avoid this, but they used existing demonstration authority to boost payments to insurers. And, not surprisingly, Republicans are pretty furious. On the other hand, Republicans used pretty much this same authority to avoid Medicare premium spikes in the past. Anna, is this just political manipulation or good governing, or a little bit of both? 

Edney: Yeah, it is certainly very timely and probably necessary also because the IRA, the Inflation Reduction Act, kept the seniors’ out-of-pocket pay at $2,000 a year. And so that was going to skyrocket premiums, and they did not want to face that, particularly in an election year. And as you mentioned, this all happens around that time. And so they did this demonstration, and I have read a few things trying to figure out exactly what it does, and I can’t. 

Rovner: So it’s not just me. It’s complicated. 

Edney: It’s not just you. It’s really complicated, and it has to do with payments that usually come at the end that insurers are now going to get upfront. And that’s the best I can tell you. But they’ll be getting some subsidies upfront, and it’s to try to spread these premium increases to help mitigate those so that seniors don’t have to then pay on that end instead of for their drugs out-of-pocket. So I think that they need to do something. I mean, already, the premiums were able to go up. I think it’s $35 a month, and some plans did elect to do that and others have them staying even. And you even have some with them going down a little bit. So I guess the moral of the story is for consumers to shop around this year, certainly. 

Rovner: That’s right, and we will talk more about Medicare open enrollment, which opens in a couple of weeks, because it’s October, and all of these things happen at once. Moving back to abortion, a judge in Georgia struck down, at least for now, the state’s six-week abortion ban, quoting from “The Handmaid’s Tale” about how the law requires women to serve as human incubators. And I’ll put a link to the decision, because that’s quite the decision. But Alice, this is far from the last word on this, right? 

Ollstein: Yes. It’s just so fascinating what a slow burn these lawsuits are. I mean, this, the one in North Dakota recently that restored access, these just sort of simmer under the radar for months or even years, and then a decision can have a major impact. And so access has been restored in some of these states. Some interesting things that came to mind were, one, it could be reversed again and pingpong back and forth, and all of that is very challenging for doctors and patients to manage. 

But also — and I’m thinking more of North Dakota, because Georgia is sort of a medical powerhouse with a lot of providers and hospitals and facilities and stuff — but in North Dakota, the state’s only abortion clinic moved out of state, and they do not plan to move back as a result of this decision. This isn’t a switch you can flip back and forth. And so when access is restored on paper in the law, that doesn’t mean it’s going to be restored in practice. You need doctors willing to work in these states and provide the procedure. And even with the court rulings, they may not feel comfortable doing so, or the logistics are just too daunting to move back. So I would urge people to keep that in mind. 

Rovner: Yeah, and the state’s already said that it’s going to appeal to the next-higher court. So we will see this continue, but I think it was definitely worth mentioning. We’ve talked a lot this year about women experiencing pregnancy complications not being able to get care in states with abortion bans and restrictions. Well, it’s happening in states where abortion is supposed to be widely available, too. 

In California, the state’s attorney general filed suit this week against a Catholic hospital in the rural northern part of the state that refused to terminate the doomed pregnancy of a woman carrying twins after her water broke at 15 weeks, because they said one of the twins still had a heartbeat. She eventually was driven to the only other hospital within a hundred miles of the labor and delivery unit, where she did get the care that she needed, although she was hemorrhaging, but not until after a nurse at the Catholic hospital gave her a bucket of towels, quote, “in case something happens in the car.” Meanwhile, the labor and delivery unit at the hospital she was taken to is itself scheduled to close. Are women starting to get the idea that this is about more than just selective abortions and that no matter where they live, that being pregnant could be more dangerous than it has been in the past? 

Raman: I was going to say this is something that abortion rights advocates have been saying for years now, that it’s not just abortion, that they point to things like the whole ordeal that we’ve been having with IVF [in vitro fertilization] and birth control and so many other things. Even in the last couple years, people trying to get other medications that have nothing to do with pregnancy and not being able to get those because they might have an effect or cause miscarriage or things like that. So I think in one way, yes. But at the same time, when you look at something like what we saw happen with the two deaths in Georgia, right? The messaging from the anti-abortion crowd has been that this was not because of the abortion ban but because of the regulations that allowed these people to get a medication abortion and that’s what’s driving the death. 

So we think that, in some ways, there’s certain camps that are just going to be focused on a different side of how the emergency might not be related to abortion at all, or the branding is that this is not an abortion in certain cases versus an abortion, it’s just semantics. So I don’t know how many minds it’s changing at this point. 

Ollstein: Like Sandhya said, the awareness that this is not just for so-called elective abortions. Obviously, that term is disputed and there’s gray area of what that means. I think the overwhelming focus in messaging — from Democrats, anyway — has been about these wanted pregnancies that suffer medical complications and people can’t get care, and so the spillover effect on miscarriage care. But I think the piece that’s new that this could emphasize is that it’s not a strict red-state-blue-state divide, that Catholic hospitals and other facilities in states with protections, like California — it could happen there, too. So I think that’s what this case may be contributing in a new way to people’s understanding. 

Rovner: And, of course, this was happening long before Dobbs — I mean, with Catholic hospitals, particularly Catholic hospitals in areas where there are not a lot of hospitals, denying care according to Catholic teachings and women having basically no place, at least nearby, to go. So I think people are seeing it in a new light now that it seems to be happening in many, many places at the same time. Well, while we are visiting California, Governor Gavin Newsom this week signed legislation requiring large group health insurance plans to cover IVF and other fertility treatments starting next year. California is far from the first state to do this. I think it’s now up to over a dozen. But it’s by far the most populous state to do this. Do we expect to see more of this, particularly given, as you were saying, Sandhya, the attention that IVF is suddenly getting? 

Raman: I think we could. We’ve had a lot of states do different variations of those so far, and they haven’t necessarily been blue versus red. I think one thing that was interesting about the California law in particular was that it included LGBTQ people within the infertility definition, which we’ve been having IVF laws for over 20 years at this point and I don’t know that that has been necessarily there in other ones. So I would be watching for more things like that and seeing how widespread that would be in some of the bills coming up in the next legislative cycle. 

Rovner: Yes, and another issue that I suspect will continue to simmer beyond this election. Well, finally this week, two big business-of-health-related stories: Over the summer, we talked about how the CEO of Steward Health Care, which is a chain of hospitals bought out by private equity and basically run into bankruptcy, refused to show up to testify before the Senate Health, Education, Labor and Pensions Committee. Well, in the last two weeks, the committee, followed by the full Senate, voted to hold CEO Ralph de la Torre in criminal contempt. And as of last week, he is now ex-CEO Ralph de la Torre, and now he is suing the Senate over that contempt vote. If nothing else, I guess this raises the stakes in Congress to continue to look at the impact of private equity in health care? 

Edney: Yeah, I think it’s interesting, because when you look at [Sen.] Bernie Sanders calling in pharmaceutical CEOs, they typically show up and they take their hits and they go home. And in this case, it probably kind of heightens that idea that private equity is the evil person. And I’m not saying everyone thinks pharma is not, but they do understand Washington. And there’s a chance that a lot of New York–focused, Wall Street–focused private equity folks may not get that quite in the same way or just may not view it as important. But now, that may be changing. 

Rovner: I was surprised by how bipartisan this was. 

Edney: Yeah. 

Rovner: I mean, beating up on pharma tends to be a Democratic thing, but this was bipartisan in the committee and bipartisan in the Senate. I mean, it’s also important to remember that Steward Health Care is a chain of hospitals in a whole bunch of states, so there are a lot of senators who are seeing hospitals in, now, dire straits through this whole private equity thing, who I imagine are not very happy about it. And their constituents are not very happy about it. But I think the bipartisanship of it is what sort of stuck out to me. 

Raman: I was just going to say hospitals are such a big employer for so many districts that I think that, but I would say this was the first time in 50 years they’ve sent a contemptor to the DOJ [Department of Justice]. And especially doing that in a unanimous fashion is just very striking to me, and I’m curious if DOJ kind of goes forth and does, takes penalty and action with it. 

Rovner: Yeah, this is a real under-the-radar story that I think could explode in a big way at some point. Well, the other big, evolving business story this week involves Medicare Advantage, the private sector alternative that gives enrollees extra benefits and makes insurance shareholders rich, mostly at taxpayer expense. Well, the party is, if not ending, then at least slowly closing down. Humana’s stock price dropped dramatically this week after the company reported the new way Medicare officials are calculating quality scores from Medicare Advantage. They get stars. The more stars, the better. The new way that Humana appears to be getting its stars could effectively deprive it of its entire operating profit. 

In separate news, UnitedHealthcare is suing Medicare over its Medicare Advantage payments in one of those single-judge conservative districts in Texas, of course. Democrats have been working to at least somewhat rein in these excess payments to Medicare Advantage for the past, I don’t know, two decades or so, but I assume this will all likely be reversed if Trump wins. And Medicare Advantage has been a troublesome issue because it’s really popular with beneficiaries, but it’s really expensive, because it’s really popular, because they get extra money, and some of that extra money goes to give extra benefits. Talk about things that are hard to explain to people. It’s great that you get all these extra benefits, but it’s costing the government more than it should. 

Edney: Yeah. 

Raman: I guess I do wonder if people, how much attention they’re paying. Are they going to switch plans if it’s dropping that many stars? If you’re on a Humana plan and a huge number of them got demoted to a lower rating, the next time you’re looking for a plan, are you going to switch to something else? And how often people are doing that and just if that would move the needle, because it’s just a longer process than overnight. 

Rovner: Although, I think it isn’t just that people have to switch. If people stay in those plans with fewer stars, the company gets less money. 

Raman: Yeah. 

Rovner: Because they get bonuses when people are in the, quote-unquote, “higher quality” plan. So even if their four-star plan is now a three-star plan and they stay in it, the company’s going to lose money, which I think is why the stock price took such a quick and dramatic bath. 

Edney: Yeah, I was surprised. It’s such a seemingly wonky issue, but it did really hit Humana very hard in the stock price. Technically, I think — correct me if I’m wrong — the stars aren’t even out yet. This is people doing searches to see if they can find some of them that have been changed at all, and so they’re coming out soon, but Humana particularly is very Medicare-focused out of all of the insurers. They rely on that for a large part of their revenue, so it is a big deal for them. I don’t know how much, but certainly Wall Street was. And as you mentioned with Trump, the Republicans typically really have supported Medicare Advantage because it is private insurers offering this instead of being just government-run Medicare. So that could have an effect. 

It’s hard to tell why their stars went down currently. With UnitedHealth, you at least get a little insight. They’re suing because, last year, their star rating went down for some plans, they said, because of one bad customer service phone call. So someone from Medicare calls and does a test thing, and UnitedHealth says they didn’t ask the right question, so the person never got a chance to answer it correctly, and then their star ratings went down. So, it does feel like it could happen at any point for any reason, so I don’t know how conducive that is, how much that actually plays into people who might have a Humana plan that think, “Oh, I haven’t had any issues, so why would I change?” 

Rovner: Yeah. All these under-the-hood things, as you point out, we have all looked at and don’t quite understand is worth billions and billions and billions of dollars. It’s one of the reasons why health care is so expensive and such a big part of the economy. All right. Well, we will continue to watch that space, too. That is the news for the week. Now we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back with our extra credits. 

I am pleased to welcome to the podcast my KFF Health News colleague Lauren Sausser, who reported and wrote the latest KFF Health News “Bill of the Month.” Lauren, thanks for joining us. 

Lauren Sausser: Thanks for having me. 

Rovner: So tell us about this month’s patient, who he is, and what kind of medical care he needed. 

Sausser: This month’s patient is a young man named Preston Nafz. He’s 17. He’s a senior in high school. He lives in Hoover, Alabama, which is right outside of Birmingham. And he played youth sports his whole life and recently is focused on lacrosse, but like many kids in this country, he has sort of cycled through a bunch of different sports, and ended up injured last year. 

Rovner: And what happened? 

Sausser: He had really debilitating pain in his hip, and the pain was progressive. And, obviously, they tried some treatments on one end of the spectrum, but it kept growing worse and worse. And at one point last year, he ended up limping off of the lacrosse field. He couldn’t do really simple things like turning over in bed or getting in and out of a car. These things were really painful for him. So he ended up as a patient at a sports medicine clinic, and providers at that clinic recommended surgery. 

Rovner: And to cut to the chase, the story, at least medically, has a happy ending, right? The surgery worked? He’s better? 

Sausser: Yes, the surgery worked. He ended up getting something late last year, a procedure called a sports hernia repair, which is a little bit of a misnomer because he didn’t actually have a hernia. But it’s kind of a catchall phrase that orthopedic surgeons use to talk about a procedure to relieve this type of pain that he was having in his pelvis, groin area. And the recovery was longer than he was anticipating, but yes, it medically does have a happy ending. He was able to play lacrosse again, although the last time I spoke to him, he had another sports-related injury. But the sports hernia repair did do what it was supposed to do, so that’s the good news. 

Rovner: So it sounded like it should have been routine. Kid growing up, gets hurt playing sports, family has health insurance, goes to sports medicine, doctor fixes problem. Except for the bill, right? 

Sausser: Yeah. So the interesting thing about this story, and this is really why we pursued it, is because there is no CPT [Current Procedural Terminology] code for a sports hernia repair. CPT codes, your listeners are probably familiar with, but they’re the medical codes that providers and insurers use to figure out how things get paid for. And it can become more complicated when there’s no code for a procedure, which was the case here. So Preston’s dad was told before the surgery that he was going to have to pay upfront because his insurance company, which was Blue Cross Blue Shield of Alabama, likely wasn’t going to pay for it. 

Rovner: And how much was it upfront? 

Sausser: It was just over $7,000. So the surgery itself was $6,000. There was, I think, almost $500 for anesthesia, a little over $600 for the facility fee. And Preston’s dad paid for it on a few different credit cards. 

Rovner: So kid has the surgery, is in rehab, and Dad is now trying to recoup this money that he has paid for upfront. And what happened then? 

Sausser: Yeah. Before the surgery even happened, Preston’s dad tried to call his insurance company and say: Can I get this covered? My son’s doctor says this is medically necessary. And initially, he got good news. His insurer said: It sounds like this is something that should be covered. If this is something that’s medically necessary, your insurance plan generally covers those things. As the date of the surgery grew closer and closer, he found that the people he was talking to at the insurance company weren’t being as definitive with their answers. And so before the surgery, he got a no. He said he got a no from his insurer saying that they were not going to cover this. Now, on the back end of the surgery, after he’d paid the bill with those credit cards, he tried to appeal that decision by filing a lot of paperwork. And he did end up getting a few hundred dollars reimbursed, but when the insurer sent him that check, it was unclear exactly what they were covering. And, obviously, that didn’t come close to the $7,000-plus that they had paid for it. 

Rovner: So that’s what eventually happened with the bill, right? He ended up getting stuck with almost all of it? 

Sausser: Yeah. 

Rovner: Is there anything he could have done differently that might’ve helped this get reimbursed? 

Sausser: That’s the tricky thing about this story, because they did do almost everything right. But it’s almost a cautionary tale for people who are faced with this prospect in the future. So if your provider is recommending something that doesn’t have a CPT code, it is going to be harder to get reimbursed from your insurer. You should assume that. That’s not to say it’s impossible, but it’s going to take more work on your end. It’s going to take more paperwork, it may take more work on your doctor’s end, and you should be prepared to get some pushback, if that makes sense. 

Rovner: And has he just sort of written this off? 

Sausser: I mean, he paid off the surgery using the credit cards. And the last I spoke to this family, they were still getting some confusing communication from their insurer. I don’t know that they’ve gotten the final, final no yet. I think that he still is invested in getting reimbursed if he can. But at this point, we’re approaching almost the one-year anniversary of the surgery, so it’s looking less likely. 

Rovner: Well, we will keep following it. Lauren Sausser, thank you so much. 

Sausser: Thanks for having me. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read too. Don’t worry if you miss the details. We’ll include links to all these stories in our show notes on your phone or other mobile device. We have two hurricane-related extra credits this week. Sandhya, why don’t you go first? 

Raman: My extra credit this week is called “Without Water After Helene: Residents at Asheville Public Housing Complex Fear for Their Health,” and it is from the Asheville [North Carolina] Citizen Times, by Jacob Biba. And the story just looks at the residents of a specific complex in Asheville that have been hit really hard by the hurricane. And, when this was written, they’d been without water for two days and it might not come back for weeks, and just some of the public health impacts they were facing. One person couldn’t clean their nebulizer or their tracheostomy tube. Others were worrying about sanitation from not being able to flush toilets. I think it’s a good one to check out. 

Rovner: Yeah. We think about so many things with hurricanes. We think about being without power. We don’t tend to think about being without water. Alice, you have a related story. 

Ollstein: Yeah, and this is more of a supply chain story but really shows that these hurricanes and natural disasters can have really widespread impacts outside the region that they’re in. And so this is from The Wall Street Journal. It’s called “Hospitals Hit With IV Fluid Shortage After Hurricane Helene.” It’s by Joseph Walker and Peter Loftus, and it’s about a facility in North Carolina that produces, like I said, IV bag fluids that hospitals around the country depend on. And yeah, we’ve talked before about just how vulnerable our medical supply chains are and we don’t spread the risk around maybe as much as we need to in this age of climate instability. And so, yeah, hospitals, they’re not rationing the fluids, but they are taking steps to conserve. And so they’re thinking, OK, certain patients can take fluids orally instead of intravenously in order to conserve. And so that’s happening now. Hopefully, it doesn’t become rationing down the road. But, yeah, with the long recovery the region is expecting, it’s a bit scary. 

Rovner: Anna. 

Edney: I did one from a colleague of mine at Bloomberg, John Tozzi. It’s “A Free Drug Experiment Bypasses the US Health System’s Secret Fees.” So he looked at this Blue Shield of California plan that is deciding to just bypass the pharmacy benefit managers and go directly to a drugmaker to get a biosimilar of Humira, the rheumatoid arthritis and many other ailments drug. And they’re going to be getting it for $525 a month for this drug that a lot of the PBMs are offering for more than a thousand dollars. And so the PBMs mentioned to him, We give rebates, and it’s less than a thousand dollars. But they didn’t say if it was as low as $525. And Blue Shield of California seems to think that this is a really good deal and that they’re basically going to give it for free just to show that it can reach Americans affordably. And so I thought it was a good look at this plan and at maybe a trend, I don’t know, that plans might start going outside of the PBM network. 

Rovner: We shall see. Well, I chose a story from KFF Health News this week from Ronnie Cohen, and it’s called “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” and it’s a really thoughtful piece about how to best protest things you disagree with. In this case, some doctors want medical groups to move professional conferences out of states with abortion bans, in order to exert financial pressure and to make a point. But there are those who worry that that amounts to punishing the victims and that it won’t do much anyway, frankly, unless you’re the Super Bowl or the baseball All-Star Game. It’s not like your conference is going to make or break some city’s annual budget. But it’s a microcosm of a bigger debate that’s going on in medicine that I’ve been covering. How do doctors balance their duty to serve patients with their duty to themselves and their own families? There are obviously pregnant medical professionals who do not wish to travel to states with abortion bans lest something bad happens. It’s a struggle that is obviously going to continue. It’s a really interesting story. 

OK. That is our show. Before we go this week, it is October and we want your scariest Halloween haikus. The winner will get their haiku illustrated by our award-winning in-house artists, and I will read it on the podcast that we tape on Halloween. We will have a link to the entry page in our show notes. 

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 technical guru, Francis Ying, and our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, or you can still find me at X. I’m @jrovner. Sandhya? 

Raman: @SandhyaWrites. 

Rovner: Anna? 

Edney: @annaedney. 

Rovner: Alice. 

Ollstein: @AliceOllstein. 

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

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

The Republican National Convention highlighted a number of policy issues this week, but health care was not among them. That was not much of a surprise, as it is not a top priority for former President Donald Trump or most GOP voters. The nomination of Sen. J.D. Vance of Ohio adds an outspoken abortion opponent to the Republican ticket, though he brings no particular background or expertise in health care.

Meanwhile, abortion opponents are busy trying to block state ballot questions from reaching voters in November. Legal battles over potential proposals continue in several states, including Florida, Arkansas, and Arizona.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine.

Panelists

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Among the takeaways from this week’s episode:

• Sen. J.D. Vance of Ohio has cast few votes on health policy since joining Congress last year. He has taken a doctrinaire approach to abortion restrictions, though, including expressing support for prohibiting abortion-related interstate travel and invoking the Comstock Act to block use of the mail for abortion medications. He also speaks openly about his mother’s struggles with addiction, framing it as a health rather than criminal issue in a way that resonates with many Americans.
• Although Republicans have largely abandoned calls to repeal and replace the Affordable Care Act, it would be easy for former President Donald Trump to undermine the program in a second term; expanded subsidies for coverage are due to expire next year, and there’s always the option to cut spending on marketing the program, as Trump did during his first term.
• Trump’s recent comments to Robert F. Kennedy Jr. about childhood vaccinations echoed tropes linked to the anti-vaccination movement — particularly the false claim that while one vaccine may be safe, it is perhaps dangerous to receive several at once. The federal vaccination schedule has been rigorously evaluated and found to be safe and effective.
• Covid is surging once again, with President Joe Biden among those testing positive this week. The virus is proving a year-round concern and has peaked regularly in summertime; covid spreads best indoors, and lately millions of Americans have taken refuge inside from extremely high temperatures. Meanwhile, the virology community is concerned that the nation isn’t testing enough animals or humans to understand the risk posed by bird flu.

Also this week, Rovner interviews KFF Health News’ Renuka Rayasam, who wrote the June installment of KFF Health News-NPR’s “Bill of the Month,” about a patient who walked into what he thought was an urgent care center and walked out with an emergency room bill. If you have an exorbitant or baffling medical bill, you can send it to us here.

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

Julie Rovner: Time magazine’s “‘We’re Living in a Nightmare:’ Inside the Health Crisis of a Texas Bitcoin Town,” by Andrew R Chow.

Joanne Kenen: The Washington Post’s “A Mom Struggles To Feed Her Kids After GOP States Reject Federal Funds,” by Annie Gowen.

Alice Miranda Ollstein: ProPublica’s “Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant To Help Needy Families, but No One Knows if It Works,” by Cassandra Jaramillo, Jeremy Kohler, and Sophie Chou, ProPublica, and Jessica Kegu, CBS News.

Sarah Karlin-Smith: The New York Times’ “Promised Cures, Tainted Cells: How Cord Blood Banks Mislead Patients,” by Sarah Kliff and Azeen Ghorayshi.

Also mentioned on this week’s podcast:

The Wall Street Journal’s “Mail-Order Drugs Were Supposed To Keep Costs Down. It’s Doing the Opposite,” by Jared S. Hopkins.

Click to open the transcript

Transcript: At GOP Convention, Health Policy Is Mostly MIA

KFF Health News’ ‘What the Health?’Episode Title: ‘At GOP Convention, Health Policy Is Mostly MIA’Episode Number: 356Published: July 18, 2024

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 18, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go.

We are joined today via video conference by Alice Miranda Ollstein, of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Sarah Karlin-Smith at the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: And Joanne Kenen of the Johns Hopkins Schools of public health and nursing, and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Renuka Rayasam, about the latest “Bill of the Month.” This month’s patient went to a facility with urgent care in its name but then got charged emergency room prices. But first, this week’s news.

So as of this morning, we are most of the way through the Republican National Convention, which obviously has a somewhat different tone than was expected, following last weekend’s assassination attempt on former President Donald Trump. The big news of the week is Trump’s selection of Ohio Republican Sen. JD Vance as his running mate. Vance has only been in the Senate since 2023, had not served previously in public office, and he doesn’t have much of a record on much of anything in health care. So, what do we know about what he thinks?

Ollstein: Well, I have been most focused on his abortion record, which is somewhat more extensive than his record on other health policy. Obviously, Congress has not done very much on abortion, but he’s been loud and proud about his anti-abortion views, including calling for national restrictions. He calls it a national minimum standard, but the idea is that he does not want people in conservative states where abortion is banned to be able to travel to progressive states where it is allowed. He has given interviews to that effect. He has signed letters to that effect. He has called for enforcement of the Comstock Act, which, as we’ve talked about before, is this long dormant statute that prohibits the mailing of abortion drugs or medical instruments that could be used to terminate a pregnancy. And so this is a very interesting moment to pick Vance.

The Republican Party is attempting to reach out to more moderate voters and convince them that they are hoping to leave this issue to the states. Vance’s record somewhat says otherwise. He also opposed efforts in his own state of Ohio to hold a referendum that ended up striking down that state’s abortion ban. So, definitely a lot for Democrats to go after in his record and they are not wasting any time; they are already doing it.

Rovner: Yeah, I’m kind of surprised because Vance, very much like Trump, has been kind of everywhere, or at least he has said that he’s kind of everywhere on abortion. But as you mentioned, Alice, you don’t have to look very hard to see that he’s pretty doctrinaire on the issue. Do you think people are going to buy this newer, softer Republicanism on abortion?

Ollstein: Well, abortion rights groups that I’ve spoken to are worried that people are buying it. They’re worried as they campaign around the country that the Republican Party’s attempt to walk away from their past calls for national restrictions on abortion are breaking through to people. And so they are trying really hard to counter that message and to stress that Republicans can and would pursue national restrictions, if elected.

I think both Democratic candidates and abortion rights groups are working to say even the leave-it-to-states position is too extreme and is harming people. And so they’re lifting up the stories of people in Texas and other states with bans who have experienced severe medical harm as a result of being denied an abortion. And so they’re lifting up those stories to say, “Hey, even saying let’s leave it to the states, let’s not do a national ban — even that is unacceptable in the eyes of the left.”

Kenen: The other issue obviously with his life story is opioids. His mother was addicted. Originally it began with being prescribed a legal painkiller. It’s a familiar story: became addicted, he was raised by his grandmother. His mother, who he showed on TV last night and she was either in tears or really close to tears, she’s 10 years sober now. He had a tough life and opioids was part of the reason he had a tough life. And whatever you think of his politics, that particular element of his life story resonates with people because it may explain some of his political views. But that experience is not a partisan experience and he was a kid. So I think he clearly does see opioids as a medical problem, not just, oh, let’s throw them in jail. I mean, the country and the Republican Party, that has been a change. It’s not a change that’s completed, but that shift is across party lines as well. That’s part of him that — it’s something you listen to when he tells that story.

I mean also, he told a story about his grandmother late in life, the grandmother who raised him, having, when she died, they found 19 handguns in the house all over the place. And he told sort of a funny story that she was old and frail and she always wanted to have one within reach. And all I could think of is, all these unlocked handguns with kids in the house! I mean, which is not a regulatory issue, but there’s a gun safety issue there. I’m just thinking, oh my God, 19 guns in drawers all over the house. But he’s obviously a very, the Republican Party is … I mean, after the assassination attempt, you have not heard Donald Trump say, “Maybe I need to rethink my position on gun control.” I mean, that’s not part of the dialogue right now.

I think having someone with that experience, talking about it the way he does, is a positive thing, really. Saying, “Here’s what we went through. Here’s why. Here’s how awful it was. Here’s how difficult it was to get out of it. And this is what these families need.” I mean, that is …

Rovner: Although it’s a little bit ironic because he’s very anti-social programs, in general.

Karlin-Smith: And he’s had a bad track record of trying to address the opioid crisis. He had a charity he started that he ended I guess about when he was running for Senate that really was deemed nonsuccessful. It also had questionable ties to Purdue Pharma, that’s sort of responsible for the opioid crisis. And the other thing that you sometimes hear in both him and Trump’s rhetoric is the blaming of immigrants and the drug cartels and all of that stuff for the opioid crisis. So, there’s a little bit of use of the topic, I think, to drop anti-immigrant sentiment and not really think about how to address the actual health struggles.

Kenen: When he talks about his family, he’s not saying China sent my mother fentanyl. I think it is good for people to hear stories from the perspective of a family who had this, as it is a health problem, reminding people that this is not thugs on the street shooting heroin. It’s a substance abuse disorder, it’s a disease. And so I think the country has come a long way, but it isn’t where it needs to be in terms of understanding that it’s a behavioral health problem. So I think in that sense he will probably be a reminder of that. But he doesn’t have a health record. I mean, he wasn’t there during the Obamacare wars. We don’t really know what he thinks about. I’m not aware of anything he’s really said about entitlements and Medicare. He does come from the state … I mean, Trump is saying he won’t touch it. But I mean if he said Medicare stuff, I missed it. I mean, if one of you knows, correct …

Karlin-Smith: Well, he has actually said that he supports Medicare drug price negotiation at times, which is interesting and unique for a Republican. And I mean Trump, as well, has been a bit different from the traditional Republican, I think, when it comes to the pharma industry and stuff, but I think that maybe is even a bridge too far in some ways.

Rovner: Yeah, he’s generally pretty anti-social program, so it’ll be interesting to see how he walks that line.

Well, this is all good segue into my next question, which is, health in general has been mostly MIA during this convention, including any update on Trump’s ear injury from the attempted assassination. Are we finally post-repeal-and-replace in the Republican Party? Or is this just one of those things that they don’t want to talk about but might yet take up if they get into office?

Kenen: We don’t know what the balance of power is in the Senate and the House, right? I mean, that’s probably going to be part of it. I mean, if they have huge … if they capture both chambers with huge majorities, it’s a new ballgame. Whether they actually try to repeal it, versus there’s all sorts of ways they can undermine it. Trump did not succeed in repealing it. Trump and the House Republicans did not, the Republicans in general did not succeed in repealing it, despite a lot of effort. But they did undermine it in all sorts of ways and coverage actually fell during the Trump administration. ACA [Affordable Care Act] coverage did drop; it didn’t vanish completely, but it dropped. And under Biden it continued to grow. Now, the Republicans get their health care through the ACA, so it’s become much more normalized, but we don’t know what they will do. Trump is not a predictable politician, right? I mean, he often made a big deal about trying to lower drug prices early in his term, and then nothing. And then he even released huge, long list of things …

I remember one of our reporters — Sarah and I were both … Sarah, Alice, and I were all at Politico — and I think it was David who counted the number of question marks in that report. And at the end of the day, nothing much happened. I don’t think the ACA is untouchable; it may or may not be unrepealable in its entirety, but it’s certainly not untouchable.

Rovner: Well, he also changes positions on a whim, as we’ve seen. Most politicians you can at least count on to, when they take a position, to keep it at least for a matter of days or weeks, and Trump sometimes in the same interview can sort of contradict himself, as we know. But I mean, obviously a quick way to undermine the ACA, as you say, would just be to let the extended subsidies expire because they would need to be re-upped if that’s going to continue and there are many millions of people that are now …

Kenen: And they expire next year.

Rovner: … Yes, that are …

Kenen: And there are also two other things. You cut the navigating budget. You cut advertising. You don’t try to sell it. I don’t mean literally sell it, but you don’t try to go out and urge … I mean, that was their playbook last time, and that’s why — it’s one reason enrollment dropped. And that was, the subsidies were under Biden, the extended subsidies. So that’s one year away.

Ollstein: But it’s no surprise that this hasn’t been a big topic of discussion at the RNC [Republican National Convention]. I mean, polling shows that voters trust Democrats more on health care; it’s one of their best issues. It’s not a good issue for Republicans. And so it was fully expected that they would stick to things that are more favorable to them: crime, inflation, whatnot. So, I do expect to hear a lot about health care at the DNC [Democratic National Convention] in a few weeks. But beyond that, we do not know what’s going to happen at the DNC.

Rovner: Yeah.

Karlin-Smith: I was going to say, the one health issue we haven’t really touched on, which the Republicans have been hammering on, is transgender health care and pushing limits on it, especially for people transitioning, children, and adolescents. And I think that’s clearly been a strategic move, particularly as they’ve gotten into more political trouble with abortion and women in the party. They clearly seem to think that the transgender issue, in general, appeals more to their base and it’s less risky for them.

Rovner: Their culture warrior base, as you will. Yeah, and we have in fact seen a fair bit of that. Well, before we leave the convention, one more item: It seems that Trump and RFK Jr. [independent presidential candidate Robert F. Kennedy Jr.] had a phone conversation, which of course leaked to the public, during which they talked about vaccine resistance. Now we know that RFK Jr. is a longtime anti-vaxxer. What, if anything, does the recounting of this conversation suggest about former President Trump’s vaccine views? And we’ve talked about this a little bit before, he’s been very antimandate for the covid vaccine, but it’s been a little bit of a blank on basic childhood vaccines.

Karlin-Smith: And I mean, his remarks are, they’re almost a little bit difficult to parse, they don’t quite make sense, but they seem to be essentially repeating anti-vax tropes around, well, maybe one vaccine on their own isn’t dangerous, but we give kids too many vaccines at a time or too close together. And all of that stuff has been debunked over the years as incorrect. The vaccine schedule has been rigorously evaluated for safety and efficacy and so forth.

That said, Trump obviously was in office when we spearheaded the development of covid vaccines, which ended up being wildly successful, and he didn’t really undermine that process, I guess, for the most part when he was in office. So it’s hard to know. Again, there’s a lot of difficulty in predicting what Trump will actually do and it may depend a lot who he surrounds himself with and who he appoints to key positions in his health department and what their views are. Because he seems like he can be easily persuaded and right now he may just be in, again, campaign mode, very much trying to appeal to a certain population. And you could easily see him — because he doesn’t seem to care about switching positions — just pivoting and being slightly less anti-vax. But it’s certainly concerning to people who have been even more about the U.S. anti-vax sentiments since covid and decreases in vaccination rates.

Rovner: It did feel like he was trying to say what he thought RFK Jr. wanted to hear, so as to win his endorsement, which we know that Trump is very good at doing. He channels what he says depending on who he’s talking to, which is what a lot of politicians do. He just tends to do it more obviously than many others.

Kenen: Julie, we heard this at the tail end of the 2016 campaign. He made a few comments, exactly, very, very similar to this, the size of a horse vaccine and you see the changes — there’s too many, too many vaccines, too large doses. We heard this briefly in the late 2016, and we heard it at the very — I no longer remember whether it was during transition in 2016 or whether it was early in 2017 when he was in the White House — but we heard a little bit of this then, too. And he had a meeting with RFK then. And RFK said that Trump was talking about maybe setting up a commission and RFK at one point said that Trump had asked him to head the commission. We don’t think that was necessarily the case.

First of all, there was no commission. The White House never confirmed that they had asked RFK to lead it. Who knows who said what in a closed room, or who heard what or what they wanted to hear; we don’t know. But we heard this whole episode, including Trump and RFK, at approximately the beginning of 2017, and it did go away. Covid didn’t happen right away; covid was later. There was no anti-vax commission. There was no vax commission. There was no change in vaccination policy in those early years prepandemic. And as Sarah just pointed out, Trump was incredibly pro-vaccine during the pandemic. I mean, the Operation Warp Speed was hailed by even people who didn’t like anything else about Trump. When public health liked Operation Warp Speed, he got vaccines into arms fast, faster than many of us thought, right?

The difference — there were anti-vaxxers then; there have been since smallpox — but it is much more politicized and much more prominent, and in some ways it has almost replaced the ACA as your identifying health issue. If you talk to somebody about the ACA, you know what party they are, you even know where within the party they are, what wing. And that’s not 100% true of anti-vaxxers. There are anti-vaxxers on both sides, but the politicization has been on the Republican-medical-libertarian side, that you-can’t-tell-me-what-to-do-it’s-my-body side. It is much more part of his base and a more intense, visible, and vocal part of his base. So, it’s the same comments, or very similar comments, to the same person in a different political context.

Rovner: Well, I think it’s safe to say that abortion does remain the most potent political health issue of the year, and there was lots of state-based abortion election news this week. As we’ve been discussing all year, as many as a dozen states will have abortion questions on the ballot for voters this November, but not without a fight. Florida has just added an addendum to its ballot measures, suggesting that if passed, it could cost the state money. And in Arkansas and Montana, there are now legal fights over which signatures should or shouldn’t be counted in getting some of those questions to the ballot.

Alice, in every state that’s voted on abortion since Dobbs [v. Jackson Women’s Health Organization], the abortion-right side has prevailed. Is the strategy here to try to prevent people from voting in the first place?

Ollstein: Oh, yes. I wrote a story about this in January. It’s been true for a while, and it’s been true in the states that already had their votes, too. There were efforts in Ohio to make a vote harder or to block it entirely. There were efforts in Michigan to do so. And even the same tactics are being repeated. And so the fight over the cost estimate in Florida, which is usually just a very boring, bureaucratic, routine thing, has become this political fight. And that also happened in Missouri. So, we’re seeing these trends and patterns and basically any aspect of this process that can be mobilized to become a fight between conservative state officials and these groups that are attempting to get these measures on the ballot, it has been. And so Arizona is also having a fight over the language that is going to go in the voter guide that goes out to everybody. So there’s a fight going on there that’s going to go to court next week about whether it says fetus or unborn child. So, all of these little aspects of it, there’s going to be more lawsuits over signature, validation, and so it’s going to be a knockdown, drag-out fight to the end.

It’s been really interesting to see that conservative efforts to mount these so-called decline-to-sign campaigns, where they go out and try to just convince people not to sign the petition — those have completely failed, even in states that haven’t gotten the kind of national support and funding that Florida and Nevada and some of these states have. Even those places have met their signature goals and so they’re now moving to this next phase of the fight, which is these legal and bureaucratic challenges.

Rovner: This is going to play out, I suspect, right, almost until the last minute, in terms of getting some of these on the ballot.

Meanwhile, here on Capitol Hill, there’s an effort underway by some abortion rights backers to repeal the 1873 Comstock Act, which some anti-abortion activists say could be used to establish a national abortion ban. On the one hand, repealing the law would take away that possibility. On the other hand, suggesting that it needs to be repealed undercuts the Biden administration’s contention that the law is currently unenforceable. This seemed to be a pretty risky proposition for abortion rights forces no matter which way they go, right?

Ollstein: Well, for a while, the theory on the abortion rights side was, oh, we shouldn’t draw attention to Comstock because we don’t want to give the right the idea of using it to make a backdoor abortion ban. But that doesn’t really hold water anymore because they clearly know about it and they clearly have the idea already and are open about their desire to use it in documents like Project 2025, in letters from lawmakers urging enforcement of the Comstock Act. And so the whole …

Rovner: In concurring opinions in Supreme Court cases.

Ollstein: … Exactly, exactly. In legal filings in Supreme Court cases from the plaintiffs. So clearly, the whole “don’t give the right the idea thing” is not really the strategy anymore; the right already has the idea. And so now I think it’s more like you said, about undercutting the legal argument that it is not enforceable anyway. But those who do advocate for its repeal say, “Why wouldn’t we take this tool out of contention?” But this is sort of a philosophical fight because they don’t have the votes to repeal it anyway.

Rovner: Yeah, though I think the idea is if you bring it up you put Republicans on the record, as …

Ollstein: Sure, but they’ve been doing that on so many things. I mean, they’ve been doing that on IVF [in vitro fertilization], they’ve been doing that on contraception, they’ve been doing that on abortion, they’ve been doing it on the right to travel for an abortion. They’ve been doing it over and over and over and I don’t see a lot of evidence that it’s making a big impact in the election. I could be wrong, but I think that’s the current state of things.

Rovner: Yeah, I’m with you on that one.

All right, well, while we are all busy living our lives and talking about politics, covid is making its now annual summer comeback. President Biden is currently quarantining at his beach house in Rehoboth after testing positive. HHS [Department of Health and Human Services] Secretary Xavier Becerra was diagnosed earlier this week. And wastewater testing shows covid levels are “very high” in seven states, including big ones like Florida, Texas, and California. Sarah, do we just not care anymore? Is this just not news?

Karlin-Smith: Probably, it depends on who you ask, right? But I think obviously with Biden getting covid, it’s going to get more attention again. I think that a lot of health officials, including in the Biden administration, spent a lot of time trying to maybe optimistically hope that covid was going to become a seasonal struggle, much like flu, where we really sort of know a more defined risk period in the winter and that helps us manage it a bit. And always sort of seemed a little bit more optimistic than reality. And I think recently I’ve listened to some CDC [Centers for Disease Control and Prevention] meetings and stuff where — it’s not really, it’s a little bit subtle — but I think they’re finally kind of coming around to, oh wait, actually this is something where we probably are going to have these two peaks every year. They’re sort of year-round risk. But there hasn’t been a ton done to actually think through, OK, what does that mean for how we handle it?

In this country, every year they have been approving a second vaccine for the people most at risk, although uptake of that is incredibly low. So it does seem like it’s become a little bit of a neglected public health crisis. And certainly in the news sometimes when something kind of stays at this sort of constant level of problem, but nothing changes, it can sometimes, I think, be harder for news outlets to figure out how to draw attention to it.

Rovner: It does seem like, I mean, most of the prominent people who have been getting it have been getting mild cases. I imagine that that sort of has something to do … We’re not seeing … even Biden, who’s as we all know, 81, is quarantining at his beach house, so.

Karlin-Smith: Right, I mean, if you kind of stay up to date, as the terminology is, on your vaccinations, you don’t have a lot of high-risk conditions, if you are in certain at-risk groups you get Paxlovid. For the most part a lot of people are doing well. But that said, I think, I’m afraid to say the numbers, but if you look up the amount of deaths per week and so forth, it’s still quite high. We’re still losing — again, more people are still dying from covid every year, quite a few more than from the flu. I mean, one thing I think people have also pointed out is when new babies are born, you can’t get vaccinated until you’re 6 months. The under-6-month population has been impacted quite a bit again. So, it is that tension. And we saw it with the flu before covid, which is every year flu is actually a very big issue in the U.S. and the public health world for hospitals and stuff but the U.S. never quite put enough maybe attention or pressure to figure out how to actually change that dynamic and get better flu vaccine uptake and so forth.

Kenen: And the intense heat makes it, I mean — covid is much, much, much, much more transmissible inside than outside. And the intense heat — we’re not sitting around enjoying warm weather, we’re inside hiding from sweltering weather. We’re all in Washington or the Washington area, and it’s been hot with a capital H for weeks here, weeks. So people are inside. They can’t even be outside in the evening, it’s still hot. So we think of winter as being the indoors time in most of the country, and summer sort of the indoors time in only certain states. But right now we are in more transmissible environments for covid and …

Rovner: Meanwhile, while we’re all trying to ignore covid, we have bird flu that seems to be getting more and more serious, although people seem to just not want to think about it. We’re looking at obviously in many states bird flu spreading to dairy cows and therefore spreading to dairy workers. Sarah, we don’t really even know how big this problem is, right? Because we’re not really looking for it?

Karlin-Smith: That seems to be one of the biggest concerns of people in the public health-virology community who are criticizing the current response right now, is just we’re not testing enough, both in terms of animal populations that could be impacted and then the people that work or live closely by these animal populations, to figure out how this virus is spreading, how many people are actually impacted. Is the genetics of the virus changing? And the problem of course then is, if you don’t do this tracking, there’s a sense that we can get ourselves in a situation where it’s too late. By the time we realize something is wrong, it’s going to already be a very dangerous situation.

Rovner: Yeah, I mean, before covid, the big concern about a pandemic was bird flu. And was bird flu jumping from birds to other animals to humans, which is exactly what we’re seeing even though we’re not seeing a ton of it yet.

Kenen: We’re not seeing a ton of it, and in its current form, to the best of our knowledge, it’s not that dangerous. The fear is the more species it’s in and the more people it’s in, the more opportunities it has to become more dangerous. So, just because people have not become seriously ill, which is great, but it doesn’t mean it stays great, we just don’t — Sarah knows more about this than I do, but the flu virus mutates very easily. It combines with other flu viruses. That’s why you hear about Type A and Type B and all that. I mean, it’s not a stable virus and that is not, I’m not sure if stable is the right …

Rovner: It’s why we need a different flu shot every year.

Kenen: Right, and the flu shots we have, bird flu is different.

Rovner: Well, we will continue to watch that.

Kenen: Sarah can correct anything I just got wrong. But I think the gist was right, right?

Rovner: Sarah is nodding.

All right, well finally, one follow up from last week in the wake of the report from the Federal Trade Commission on self-dealing by pharmacy benefits managers: We get a piece from The Wall Street Journal this week [“Mail-Order Drugs Were Supposed To Keep Costs Down. It’s Doing the Opposite.”] documenting how much more mail-order pharmacies, particularly mail-order pharmacies owned by said PBMs [pharmacy benefit managers] are charging. Quoting from the story, “Branded drugs filled by mail were marked up on average three to six times higher than the cost of medicines dispensed by chain and grocery-store pharmacies, and roughly 35 times higher than those filled by independent pharmacies.” That’s according to the study commissioned by the Washington State Pharmacy Association. It’s not been a great month for the PBM industry. Sarah, I’m going to ask you what I asked the panel last week: Is Congress finally ready to do something?

Karlin-Smith: It seemed like Congress has finally been ready to do something for a while. Certainly, both sides have passed legislation and committees and so forth, and it’s been pretty bipartisan. So we’ll see. I think some of it costs — I forget if some of it costs a little money — but some of it does save. And that’s always an issue. And we know that Congress is just not very good at passing stand-alone bills on particular topics, so I think the key times will be to look at when we get to any big end-of-year funding deals and that sort of thing, depending on all the dynamics with the election and the lame duck, but …

Rovner: I mean, this has been so bipartisan. I mean, there’s bipartisan irritation in both houses, in both parties.

Karlin-Smith: Right, and I think the antitrust sort of element of this with PBMs kind of appeals to the Republican side of the aisle quite a bit. And that’s why there’s always been a bit of bipartisan interest. And the question becomes: PBMs sort of fill the role that in other countries government price negotiators fill. And that’s not particularly popular in the U.S., particularly on the Republican side of the aisle. And so most of the legislation that is pending, I think, will maybe hopefully get us to some transparency solutions, tweak some things around the edges, but it’s not really going to solve the crisis. It’s going to be, I mean, a very [Washington,] D.C. health policy move, which is kind of, take some incremental steps that might eventually move us down to later reforms, but it’s going to be slow-moving, whatever happens. So, PBMs are going to be in the spotlight for probably a while longer.

Rovner: Yes, which popular issue moves slower: drug prices or gun control?

All right, well finally this week the health policy community has lost another giant. Gail Wilensky, who ran Medicare and Medicaid under the first President Bush, and the advisory group MedPAC for many years after that, died of cancer last week at age 81. Gail managed to be both polite and outspoken at the same time. A Republican economist who worked with and disagreed with both Democrats and Republicans, and who, I think it’s fair to say, was respected by just about everyone who ever dealt with her. She taught me, and lots of others, a large chunk of what I know about health policy. She will be very much missed. Joanne, I guess you worked with her probably as long as I did.

Kenen: Yeah, I’m the one who told you she had died, right?

Rovner: That’s true.

Kenen: I think that when I heard her speak in a professional setting in the last few years, she talked to her about herself not as a Republican health economist, but as a free market health economist. She was very well respected and very well liked, but she also ended up being a person without a party. But she was a fixture and she was a nice person.

Rovner: And she wasn’t afraid to say when she was the head of MedPAC she made a lot of people angry. She made a lot of Republicans angry in some of those sort of positions that she took. She basically called it as she saw it and let the chips fall.

Kenen: And Julie, she went to Michigan, right?

Rovner: Yes, and she went to Michigan. That’s true. A fellow Michigan Wolverine. All right, well, that is the news for this week. Now we will play my interview with Renuka Rayasam, and then we will come back and do our extra credits.

I am pleased to welcome to the podcast my KFF Health News colleague Renuka Rayasam, who reported and wrote the latest KFF Health News-NPR “Bill of the Month.” It’s about what should have been a simple visit to an urgent care center but of course turned out to be anything but. Renu, thanks for joining us.

Renuka Rayasam: Thanks for having me.

Rovner: So, tell us about this month’s patient, who he is, and what kind of medical problem he had.

Rayasam: Sure, let me tell you about the patient in this month’s “Bill of the Month.” His name is Tim Chong. He’s a Dallas man, and last December he felt severe stomach pain and he didn’t know what it was from. And he thought at first maybe he’d had some food poisoning. But the pain didn’t subside and he thought, OK, I don’t want to have to pay an ER bill, so let me go to an urgent care. And he opted to visit Parkland Health’s Urgent Care Emergency Center, where he learned he had a kidney stone and was told to go home and that it would pass on its own.

Rovner: Now, we’re told all the time exactly what he was told, that if we have a health problem that needs immediate attention but probably not a hospital-level emergency, we should go to an urgent care center rather than a hospital emergency room. And most insurers encourage you to do this; they give you a big incentive by charging a far smaller copay for urgent care. So, that’s what he tried to do, right?

Rayasam: That’s what he tried to do, at least that’s what he thought he was doing. Like I said, this is a facility, it’s called Urgent Care Emergency Center. He told me that he walked in, he thought he was at an urgent care, he got checked out, was told it was a kidney stone. He actually went back five days later because his stomach pain worsened and didn’t get better. And it wasn’t until he got the bills the following month that he realized he was actually at an emergency center and not an urgent care center. His bill was $500 for each visit, not $50 for each visit as he had anticipated.

Rovner: And no one told him when he went there?

Rayasam: He said no one told him. And we reached out to Parkland Health and they said, “Well, we have notices all over the place. We label it very clearly: This is an emergency care center, you may be charged emergency care fees,” but they also sent me a picture of some of those notices and those are notices that are buried among a lot of different notices on walls. Plus, this is a person who is suffering from severe stomach pain. He was really not in a position to read those disclosures. He went by what the front desk staff did or didn’t tell him and what the name of the facility was.

Rovner: I was going to say, there was a sign that said “Urgent Care,” right?

Rayasam: Right, absolutely. Urgent Care Emergency Center, right? And so when we reached out to Parkland, they said, “Hey, we are clearly labeled as an emergency center. We’re an extension of the main emergency room.” And that’s the other thing you have to remember about this case, which is that this is the person who knew Parkland’s facility. He knew they had a separate emergency room center and he said, “I didn’t go into that building. I didn’t go into the building that’s labeled emergency room. I run into this building labeled Urgent Care Emergency Center.” Parkland says, hey, this is an extension of their main emergency room. This is where they send lower-level emergency cases, but obviously it’s a really confusing name and a really confusing setup.

Rovner: Yeah, absolutely. So, how did this all turn out? Medically, he was OK eventually, right?

Rayasam: Medically he was OK eventually. Eventually the stone did pass. And it wasn’t until he got these bills that he kind of knew what happened. When he first got the bills, he thought, well, obviously there’s some mistake. He talked to his insurer. His insurer, BlueCross and BlueShield of Texas, told him that Parkland had billed these visits using emergency room codes and he thought, wait a second, why are they using emergency room codes? I didn’t go into the emergency room. And that’s when Parkland told him, “Hey, you actually did go into an emergency room. Sorry for your confusion. You still owe us $1,000 total.” He paid part of the bills. He was trying to challenge the bills and he reached out to us at “Bill of the Month,” but eventually his bill got sent to collection and Parkland’s sort of standing by their decision to charge him $500 for each visit.

Rovner: So he basically still owes $1,000?

Rayasam: Yes, that’s right.

Rovner: So what’s the takeaway here? This feels like the ultimate bait and switch. How do you possibly make sure that a facility that says urgent care on the door isn’t actually a hospital emergency room?

Rayasam: That’s a great question. When it comes to the American medical system, unfortunately patients still have to do a lot of self-triage. One expert I’ve talked to said it’s still up to the patients to walk through the right door. Regulators have done a little bit, in Texas in particular, of making sure these facilities, these freestanding emergency room centers, as they’re called — and this one is hospital-owned, so the name is confusin, but it’s technically a freestanding emergency center, so it did have the name emergency in the name of the facility, and I think that that’s required in Texas — but I’ve talked to others who’ve said, you should ban the term urgent care from a facility that’s not urgent care. Because this is a concept that’s very familiar to most Americans. Urgent care has been around for decades; you have an idea of what an urgent care is.

And when you look at this place on its website, it’s called Urgent Care Emergency Center, it’s sort of advertised as a separate clinic within Parkland structure. It’s closed on nights, it’s closed on Sundays. The list of things they say they treat very much resembles an urgent care. So, this patient’s confusion I think is very, very understandable and he’s certainly not the only one that’s had that confusion at this facility. Regulators could ban the term urgent care for facilities that bill like emergency rooms. But until that happens it’s up to the patients to call, to check, and to ask about billing when they show up, which isn’t always easy to do when you’re suffering from severe stomach pain.

Rovner: Another thing for patients to watch out for.

Rayasam: Yes, absolutely, and worry about.

Rovner: Yes, Renuka Rayasam, thank you so much for joining.

Rayasam: Thank you, Julie.

Rovner: OK, we are back. It’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device.

Sarah, why don’t you go first this week?

Karlin-Smith: Sure, I looked at a New York Times piece called “Promised Cures, Tainted Cells: How Cord Blood Banks Mislead Patients.” And it’s about the often very aggressive sort of tactics of these banks to convince women to save some of the cord blood after they give birth with the promise that it may be able to help treat your child’s illness down the road. And the investigation into this found that there’s a number of problems. One is that, for the most part, the science has progressed in a way that some of what people used to maybe use some of these cells for, they now use adult stem cells. The other is these banks are just not actually storing the products properly and much of it gets contaminated so it couldn’t even be used. Or sometimes you just don’t even collect enough, I guess, of the tissue to even be able to use it.

In one instance, they documented a family that — the bank knew that the cells were contaminated and were still charging them for quite a long time. And the other thing that I actually personally found fascinated by this — because my OB-GYN actually did kind of, I feel like, push one of these companies — was that they can pay the OB-GYNs quite a hefty fee for what seems like a very small amount of work. And it’s not subject to the same sort of kickback type of regulation that there may be for other pharmaceutical/medical device interactions between doctors and parts of the biotech industry. So I found that quite fascinating as well, what the economic incentives are to push this on people.

Rovner: Yeah. One more example of capitalism and health care being uncomfortable bedfellows, Chapter 1 Million. Joanne?

Kenen: There was a fantastic piece in The Washington Post by Annie Gowan: “A Mom Struggles To Feed Her Kids After GOP States Reject Federal Funds,” which was a long headline, but it was also a long story. But it was one of those wonderful narrative stories that really put a human face on a policy decision.

The federal government has created some extra funds for childhood nutrition, childhood food, and some of the Republican governors, including in this particular family’s case, the Republican Gov. Kevin Stitt in Oklahoma, have turned down these funds. And families … So this is a single, full-time working mom. She is employed. She’s got three teenagers. They’re all athletic and active and hungry and she doesn’t have enough food for them. And particularly in the summer when they don’t get meals in school, the struggle to get enough food, she goes without meals. Her kids — one of the kids actually works in the food pantry where they get their food from. The amount of time and energy this mom spends just making sure her children get fed when there is a source of revenue that her state chose not to us: It’s a really, really good story. It’s long, but I read it all even before Julie sent it to me. I said, “I already read that one.” It’s really very good and it’s very human. And, why?

Rovner: Policy affects real people.

Kenen: This is hungry teenagers.

Rovner: It’s one of things that journalism is for.

Kenen: Right, right, and they’re also not eating real healthy food because they’re not living on grapefruits and vegetables. They’re living on starchy stuff.

Rovner: Alice?

Ollstein: I chose a good piece from ProPublica called “Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant To Help Needy Families, but No One Knows if It Works.” And it is about just how little oversight there is of the budgets of taxpayer dollars that are going to these anti-abortion centers that in many cases use the majority of funding not for providing services. A lot of it goes to overhead. And so there’s a lot of fascinating details in there. These centers can bill the state a lot of money just for handing out pamphlets, for handing out supplies that were donated that they got for free. They get to charge the state for handing those out. And there’s just not a lot of evaluation of, is this serving people? Is this improving health outcomes? And I think it’s a good critical look at this as other states are moving towards adopting similar programs to what’s going on in Texas.

Rovner: Yeah, we’re seeing a lot of states put a lot of money towards some of these centers.

Well, my extra credit this week is from Time magazine. It’s called, “‘We’re Living in a Nightmare:’ Inside the Health Crisis of a Texas Bitcoin Town,” by Andrew Chow. And in case we didn’t already have enough to worry about, it seems that the noise that comes from the giant server farms used to mine bitcoin can cause all manner of health problems for those in the surrounding areasm from headaches to nausea and vomiting to hypertension. At a local meeting, one resident reported that “her 8-year-old daughter was losing her hearing and fluids were leaking from her ears.”

The company that operates the bitcoin plant says it’s in the process of moving to a quieter cooling system. That’s what makes all the noise. But as cryptocurrency mining continues to grow and spread, it’s likely that other communities will be affected in the way the people of Granbury, Texas, have been.

All right. That is our show for this week. 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. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, I’m @jrovner. Sarah, where are you these days?

Karlin-Smith: I’m mostly on X @SarahKarlin or on some other platforms like Bluesky, at @sarahkarlin-smith.

Rovner: Alice?

Ollstein: I’m on X @AliceOllstein and on Bluesky @alicemiranda.

Rovner: Joanne?

Kenen: A little bit on X @JoanneKenen and a little bit on Threads @joannekenen1.

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

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

In what will certainly be remembered as a landmark decision, the Supreme Court’s conservative majority this week overruled a 40-year-old legal precedent that required judges in most cases to yield to the expertise of federal agencies. It is unclear how the elimination of what’s known as the “Chevron deference” will affect the day-to-day business of the federal government, but the decision is already sending shockwaves through the policymaking community. Administrative experts say it will dramatically change the way key health agencies, such as the FDA and the Centers for Medicare & Medicaid Services, do business.

The Supreme Court also this week decided not to decide a case out of Idaho that centered on whether a federal health law that requires hospitals to provide emergency care overrides the state’s near-total ban on abortion.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico Magazine, Victoria Knight of Axios, and Alice Miranda Ollstein of Politico.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's articles.

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• In 1984, the Supreme Court ruled broadly that courts should defer to the decision-making of federal agencies when an ambiguous law is challenged. On Friday, the Supreme Court ruled that the courts, not federal agencies, should have the final say. The ruling will make it more difficult to implement federal laws — and draws attention to the fact that Congress, frequently and pointedly, leaves federal agencies much of the job of turning written laws into reality.
• That was hardly the only Supreme Court decision with major health implications this week: On Thursday, the court temporarily restored access to emergency abortions in Idaho. But as with its abortion-pill decision, it ruled on a technicality, with other, similar cases in the wings — like one challenging Texas’ abortion ban.
• In separate rulings, the court struck down a major opioid settlement agreement, and it effectively allowed the federal government to petition social media companies to remove falsehoods. Plus, the court agreed to hear a case next term on transgender health care for minors.
• The first general-election debate of the 2024 presidential cycle left abortion activists frustrated with their standard-bearers — on both sides of the aisle. Opponents didn’t like that former President Donald Trump doubled down on his stance that abortion should be left to the states. And abortion rights supporters felt President Joe Biden failed to forcefully rebut Trump’s outlandish falsehoods about abortion — and also failed to take a strong enough position on abortion rights himself.

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

Julie Rovner: The Washington Post’s “Masks Are Going From Mandated to Criminalized in Some States,” by Fenit Nirappil.  

Victoria Knight: The New York Times’ “The Opaque Industry Secretly Inflating Prices for Prescription Drugs,” by Rebecca Robbins and Reed Abelson. 

Joanne Kenen: The Washington Post’s “Social Security To Drop Obsolete Jobs Used To Deny Disability Benefits,” by Lisa Rein.  

Alice Miranda Ollstein: Politico’s “Opioid Deaths Rose 50 Percent During the Pandemic. in These Places, They Fell,” by Ruth Reader.  

Also mentioned in this week’s podcast:

• Politico’s “Inside the $100 Million Plan To Restore Abortion Rights in America,” by Alice Miranda Ollstein.
• JAMA Network Open’s “Use of Oral and Emergency Contraceptives After the US Supreme Court’s Dobbs Decision,” by Dima M. Qato, Rebecca Myerson, Andrew Shooshtari, et al.
• JAMA Health Forum’s “Changes in Permanent Contraception Procedures Among Young Adults Following the Dobbs Decision,” by Jacqueline E. Ellison, Brittany L. Brown-Podgorski, and Jake R. Morgan.
• JAMA Pediatrics’ “Infant Deaths After Texas’ 2021 Ban on Abortion in Early Pregnancy,” by Alison Gemmill, Claire E. Margerison, Elizabeth A. Stuart, et al.

click to open the transcript

SCOTUS Ruling Strips Power From Federal Health Agencies

KFF Health News’ ‘What the Health?’Episode Title: ‘SCOTUS Ruling Strips Power From Federal Health Agencies’Episode Number: 353Published: June 28, 2024

[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.] 

Mila Atmos: The future of America is in your hands. This is not a movie trailer, and it’s not a political ad, but it is a call to action. I’m Mila Atmos and I’m passionate about unlocking the power of everyday citizens. On our podcast, “Future Hindsight,” we take big ideas about civic life and democracy and turn them into action items for you and me. Every Thursday, we talk to bold activists and civic innovators to help you understand your power and your power to change the status quo. Find us at futurehindsight.com or wherever you listen to podcasts.

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, June 28, at 10:30 a.m. As always, news happens fast and things might’ve changed by the time you hear this, so here we go.

We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Victoria Knight of Axios News.

Victoria Knight: Hello, everyone.

Rovner: And Joanne Kenen of the Johns Hopkins Schools of Nursing and Public Health and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: I hope you enjoyed last week’s episode from Aspen Ideas: Health. This week we’re back in Washington with tons of breaking news, so let’s get right to it. We’re going to start at the Supreme Court, which is nearing, but not actually at, the end of its term, which we now know will stretch into next week. We have breaking news, literally breaking as in just the last few minutes: The court has indeed overruled the Chevron Doctrine. That’s a 1984 ruling that basically allowed experts at federal agencies to, you know, expert. Now it says that the court will get to decide what Congress meant when it wrote a law. We’re obviously going to hear a lot more about this ruling in the hours and days to come, but does somebody have a really quick impression of what this could mean?

Ollstein: So this could prevent or make it harder for health agencies, and all the federal agencies that touch on health care, to both create new policies based on laws that Congress pass and update old ones. Things need to be updated; new drugs are invented. There’s been all these updates to what Obamacare does and doesn’t have to cover. That could be a lot harder going forward based on this decision. It really takes away a lot of the leeway federal agencies had to interpret the laws that Congress passed and implement them.

I think kicking things back to courts and Congress could really slow things down a lot, and a lot of conservatives see that as a good thing. They think that federal agencies have been too untouchable and not have the same accountability mechanisms because they’re career civil servants who are not elected. But this has health policy experts … Honestly, we interviewed members of previous Republican administrations and Democratic administrations and they’re both worried about this.

Rovner: Yeah, going forward, if Donald Trump gets back into the presidency, this could also hinder the ability of his Department of Health and Human Services to make changes administratively.

Knight: These agencies are stacked with experts. This is what they work on. This is what they really are primed to do. And Congress does not have that same type of staffing. Congress is very different. It’s very young. There’s a lot of turnover. There are experienced staffers, but usually when they’re writing these laws, they leave so much up to interpretation of the agency because they are experts.

So I think pushing things back on Congress would really have to change how Congress works right now. When I talked to experts, we would need staffers who are way more experienced. We would need them to write laws that are way more specific. And Congress is already so slow doing anything. This would slow things down even more. So that’s a really important congressional aspect I think to note.

Rovner: I think when we look back at this term, this is probably going to be the biggest decision. Joanne, you want to add something before we move on?

Kenen: We’re recording. We don’t know if immunity just dropped, which is all still going to be, not a health care decision but an important decision of the country. I’ve got SCOTUSblog on my other screen. Here’s a quote from [Justice Elena] Kagan’s dissent. She says, because it’s very unfocused for what we do on this podcast, “Chevron has become part of the warp and woof of modern government, supporting regulatory efforts of all kinds, to name a few, keeping air and water clean, food and drugs safe and financial markets honest.” So two of the three of us. Financial markets affect the health industry as well.

Rovner: Oh, yeah.

Kenen: But I think that what the public doesn’t always understand is how much regulatory stuff there is in Washington. Congress can write a 1,000-page law like the ACA [Affordable Care Act]. I’ve never counted how many pages of regulation because I don’t think I can count that high. It’s probably tens of thousands.

Rovner: At least hundreds of thousands.

Kenen: Right. And that every one of those, there’s a lobbying fight and often a legal fight. It’s like the coloring book when we were kids. Congress drew the outline and then we all tried to scribble within the lines. And when you go out of the lines, you have a legal case. So the amount of stuff, regulatory activity is something that the public doesn’t really see. None of us have read every reg pertaining to health care. You can’t possibly do it in a lifetime. Methuselah couldn’t have done it. And Congress cannot hire all the expert staff and all the federal agencies and put them in; they won’t fit in the Capitol. That’s not going to happen. So how do they come to grips with how specific are they going to have to be? What kind of legal language can they delegate some of this to agency experts. We’re in really uncharted territory.

Rovner: I think you can tell from the tones of all of our voices that this is a very big deal, with a whole lot of blanks to be filled in. But for the moment …

Kenen: Maybe they’ll just let AI do it.

Rovner: Yeah, for the moment, let’s move on because, until just now, the biggest story of the week for us was on Thursday. We finally got a decision in that case about whether Idaho’s near-total ban on abortion can override a federal law called EMTALA, the Emergency Medical Treatment and Active Labor Act, which requires doctors in emergency rooms to protect a pregnant woman’s health, not just her life. And much like the decision earlier this month to send the abortion pill case back to the lower courts because the plaintiffs lacked legal standing, the court once again didn’t reach the merits here. So Alice, what did they do?

Ollstein: So like you said, both on abortion pills and on EMTALA, the court punted on procedural issues. So it was standing on the one and it was ripeness on the other one. This one was a lot more surprising. I think based on the oral arguments in the mifepristone case, we could see the standing-based decision coming. That was a big focus of the arguments. This was more of a surprise. This was a majority of justices saying, “Whoops, we shouldn’t have taken this case in the first place. We shouldn’t have swooped in before the 9th Circuit even had a chance to hear it. And not only take the case, but allow Idaho to fully enforce its law even in ways that people feel violate EMTALA in the meantime.” And so what this does temporarily is restore emergency abortion access in Idaho. It restores a lower-court order that made that the case, but it’s not over.

Rovner: Right. It had stayed Idaho’s ban to the extent that it conflicted with EMTALA.

Ollstein: So this goes back to lower courts and it’s almost certain to come back to the Supreme Court as early as next year, if not at another time. Because this isn’t even the only major federal EMTALA case that’s in the works right now. There’s also a case on Texas’ abortion ban and its enforcement in emergency situations like this. And so I think the main reaction from the abortion rights movement was temporary relief, but a lot of fear for the future.

Rovner: And I saw a lot of people reminding everybody that this Texas ruling in Idaho, now the federal law is taking precedence, but there’s a stay of the federal law in the 5th Circuit. So in Texas, the Texas ban does overrule the federal law that requires abortions in emergency circumstances to protect a woman’s health. That’s what the dispute is basically about. And of course, you see a lot of legal experts saying, “This is a constitutional law 101 case that federal law overrides state law,” and yet we could tell by some of the add-on discussion in this case, as they’re sending it back to the lower court, that some of the conservatives are ready to say, “We don’t think so. Maybe the federal law will have to yield to some of these state bans.” So you can kind of see the writing on the wall here?

Ollstein: It’s really hard to say. I think that you have some justices who are clearly ready to say that states can fully enforce their abortion bans regardless of what the federal government’s federal protections are for patients. I think they put that out there. I think the case is almost certain to come back to them, and there was clearly not a majority ready to fully side with the Biden administration on this one.

Rovner: And clearly not a majority ready to fully side with Idaho on this one. I think everything that I saw suggested that they were split 3-3-3. And with no majority, the path of least resistance was to say, “Our bad. You take this back lower court. We’ll see when it comes back.”

Ollstein: It was a very unusual move, but some of the justification made sense to me in that they cited that Idaho state officials’ position on what their abortion ban did and didn’t do has wavered over time and changed. And what they initially said when they petitioned to the court is not necessarily exactly what they said in oral arguments, and it’s not exactly what they have said since. And so at the heart here is you have some people saying there’s a clear conflict between the patient protections under EMTALA — which says you have to stabilize anyone that comes to you at a hospital that takes Medicare — and these abortion bans, which only allow an abortion when there’s imminent life-threatening situation. And so you have people, including the attorney general of Idaho, saying, “There is no conflict. Our law does allow these emergency abortions and the doctors are just wrong and it’s just propaganda trying to smear us. And they just want to turn hospitals into free-for-all abortion facilities.” This is what they’re arguing. And then you have people say …

Rovner: [inaudible 00:11:12] … in the meanwhile, we know that women are being airlifted out of Idaho when they need emergency abortions because doctors are worried about actually performing abortions …

Ollstein: Correct.

Rovner: And possibly being charged with criminal charges for violating Idaho’s abortion ban.

Ollstein: Sure, but I’m saying even amongst conservatives, there are those who are saying, “There’s no conflict between these two policies. The doctors are just wrong either intentionally or unintentionally.” And then there’s those who say there is a conflict between EMTALA and state bans, and it should be fine for the state to violate EMTALA.

Rovner: No. Obviously this one will continue as the abortion pill case is likely to continue. Well, also in this end-of-term Supreme Court decision dump, an oddly split court with liberals and conservatives on both sides, struck down the bankruptcy deal reached with Purdue Pharma that would’ve paid states and families of opioid overdose victims around $6 billion, but would also have shielded the company’s owners, the Sackler family, from further legal liability. What are we to make of this? This was clearly a difficult issue. There were a lot of people even who were involved in this settlement who said the idea of letting the Sackler family, which has hidden billions of dollars from the bankruptcy settlement anyway, and clearly acted very badly, basically giving them immunity in exchange for actually getting money. This could not have been an easy… obviously was not an easy decision even for the Supreme Court.

Kenen: No, it wasn’t theoretical. The ones who opposed blowing up the agreement were very much, “This is going to add delay any kind of justice for the families and the plaintiffs.” It was not at all abstract. It was like there are a lot of people who aren’t going to get help. At least the help will be delayed if this money doesn’t start flowing. So I was struck by how practical, relating to the families who have lost people because of the actions of Purdue. But the other side was, also that was much more a clear-cut legal issue, that people didn’t give up their right to sue. It was cutting off the right to sue was imposed on potential plaintiffs by the settlement. So that was a much more legalistic argument versus, it was a little bit more real world, but they need the help now. And including some of the conservatives. This is an interesting thing to read. This was painstaking. This is a huge settlement. It took so long. It had many, many moving parts. And I don’t know how you go back and put it together again.

Rovner: But that’s where we are.

Kenen: Yes.

Rovner: They have to basically start from scratch?

Kenen: I don’t know if they have to start entirely from scratch. You’d have to be nuts to get the Sacklers to say, “OK, we’ll be sued,” which they’re obviously you’re not going to. Is somebody going to come up with a “Split the difference, let’s get this moving and we won’t sue anymore?” I don’t know. But I don’t know that you have to start 100% from scratch, but you’re surely not anywhere near a finish line anymore.

Rovner: That’s big Supreme Court case No. 3 for this week. Now let’s get to big Supreme Court case No. 4. Earlier this week, the court turned back a challenge that the government had wrongly interfered with free speech by urging social media organizations to take down covid misinformation. But again, as with the abortion pill case, the court did not get to the merits. But instead, they ruled that the states and individuals who sued did not have standing. So we still don’t know what the court thinks of the role of government in trying to ensure that health information is correct. Right?

Knight: Right. And I thought it was interesting. Basically the White House was like, “Well, we talked to the tech companies, but it was their decision to do this. So we weren’t really mandating them do this.” I think they’re just being like, “OK, we’ve left it up to the tech companies. We haven’t really interfered. We’re just trying to say these things are harmful.” So I guess we’ll have to see. Like you said, they didn’t take it up on standing, but overall, conservatives that were saying, “This was infringing on free speech.” It was particularly some scientists, I think, that promoted the herd immunity theory, things like that.

So I think they’re obviously going to be upset in some way because their posts were depromoted on social media. But I think it just leaves things the way they are, the same way. But it would be interesting, I guess, if Trump does go to the White House, how that might play out differently?

Rovner: This court has been a lot of the court deciding not to decide cases, or not to decide issues. Sorry, Alice, go ahead.

Ollstein: Yeah, so I think it is pretty similar to the abortion pill case in one key way, which is that it’s the court saying, “Look, the connection between the harm you think you suffered and the entity you are accusing of causing that suffering, that connection is way too tenuous. You can’t prove that the Biden administration voicing concerns to these social media companies directly led to you getting shadow-banned or actual banned,” or whatever it is. And the same in the abortion pill case, the connection between the FDA [Food and Drug Administration] approving the drug and regulating the drug and these individual doctors’ experiences is way too tenuous. And so that’s something to keep in mind for future cases that, we’re seeing a pattern here.

Rovner: Yes, and I’m not suggesting that the court is directly trying to duck these issues. These are legitimate standing cases and important legal precedents for who can sue in what circumstance. That is the requirement of constitutional review that first you have to make sure that there’s both standing in a live controversy and there’s all kinds of things that the court has to go through before they get to the merits. So more often than not, they don’t get there.

Well, meanwhile, we have our first hot-button, Supreme Court case slotted in for next term. On Monday, the court granted “certiorari” [writ by which a higher court reviews a decision of a lower court] to a case out of Tennessee where the Biden administration is challenging the state’s ban on transgender care for minors. It was inevitable that one of these cases was going to get to the high court sooner or later, right?

Kenen: Yeah, I think it’s not a surprise, the politics of it and the techniques or tools used by the forces that are against the treatment for minors. It’s very similar to the politics and patterns of the abortion case, of turning something into an argument that it’s to protect somebody. A lot of the abortion requirements and fights were about to protect the woman. Ostensibly, that was the political argument. And now we’re seeing we have to protect the children so that it’s the courts, as opposed to families and doctors, who are, “protecting the children.”

There’s a lot of misunderstanding about what these treatments do and who gets them and at what age;  that they’re often described as mutilation and irreversible. For the younger kids, for preteen, middle school age-ish, early teens, nothing is irreversible. It’s drugs that if you stop them, the impact goes away. But it has become this enormous lightning rod for the intersection of health and politics. And I think we all have a pretty good guess as to where the Supreme Court’s going to end up on this. But you’re sometimes surprised. And also, there could be some …

Rovner: Maybe they don’t have standing.

Kenen: There could be some kind of moderation, too. It could be a certain … they don’t have to say all … it depends on how clinical they want to get. Maybe they’ll rule on certain treatments that are more less-reversible than a puberty blocker, which is very reversible, and some kind of safeguards. We don’t know the details. We’re not surprised that it ended up … and we know going in, you could have a gut feeling of where it’s likely to turn out without knowing the full parameters and caveats and details. They haven’t even argued it yet.

Rovner: This is a decision that we’ll be waiting for next June.

Kenen: Right. Well, could not. Maybe it’s so clear-cut, it’ll be May. Who knows, right?

Rovner: Yeah, exactly. All right, well, moving on. There was a presidential debate last night. I think it was fair to say that it didn’t go very well for either candidate, nor for anybody interested in what President Biden or former President Trump thinks about health issues. What did we learn, if anything?

Ollstein: Well, I was mainly listening for a discussion of abortion and, boy was it all over the place. What I thought was interesting was that both candidates pissed off their activist supporters with what they said. I was texting with a lot of folks on both sides and conservatives were upset that Trump doubled down on his position that this should be entirely left to states, and they disagree. They want him to push for federal restrictions if elected.

And on the left, there was a lot of consternation about Biden’s weird, meandering answer about Roe v. Wade. He was asked about abortions later in pregnancy. One, neither he nor the moderators pushed back on what Trump’s very inflammatory claims about babies being murdered and stuff. There was no fact-checking of that whatsoever. But then Biden gave a confusing answer, basically saying he supports going to the Roe standard but not further, which is what I took out of it. And that upset a lot of progressives who say Roe was never good enough. For a lot of people, when Roe v. Wade was still in place, abortion was a right in name only. It was not actually accessible. States could impose lots of restrictions that kept it out of reach for a lot of people. And in this moment, why should we go back to a standard that was never good enough? We should go further. So just a lot of anxiety on both sides of this.

Rovner: Yeah. Meanwhile, Trump seemed to say that he would leave the abortion pill alone, which jumped out at me.

Kenen: But that was a completely … CNN made a decision not to push back. They were going to have online fact-checking. Everybody else had online fact. … And they didn’t challenge. And I guess they assumed that the candidates would challenge each other, and Biden had a different kind of challenging night. Trump actually said that the previous Supreme Court had upheld the use of the abortion drug and that it’s over, it’s done. That was not a true statement. The Supreme Court rejected that case, as Alice just explained, on standing. It’s going to be back. It may be back in multiple forms, multiple times. It is not decided. It is not over, which is what Trump said, “Oh, don’t worry about the abortion drug. The Supreme Court OK’d it.” That’s not what the Supreme Court did, and Biden didn’t counter that in any way.

And then Biden, in addition to the political aspect that Alice just talked about, he also didn’t describe Roe, the framework of Roe, particularly accurately. And, as Alice just pointed out, the things that Trump said were over-the-top even for Trump, and that they went unchallenged by either the moderators or President Biden.

Rovner: I was a little bit surprised that there wasn’t anything else on health care or there wasn’t much else.

Knight: Biden tried to hit his health care talking points and did a very terrible job. Alice had a really good tweet getting the right. … He initially said wrong numbers for the insulin cap, for the cap on out-of-pocket for Medicare beneficiaries, how much they can spend on prescription drugs. He got both of those wrong. I think he got insulin right later in the night. And then the very notably, “We will beat Medicare.” That was just unclear what he even meant by that. Maybe it was about drug price negotiations, I’m sure. So he was trying, but just could not get the facts right and I don’t think it came across effective in any way. And health care does do really well for Democrats. Abortion does really well for Democrats. So he was not effective in putting those messages.

I also noticed the moderators asked a question about opioids, addressing the opioid epidemic. Trump did not answer at all, pivoted to I think border or something like that. I don’t think Biden really answered either, honestly. So that was an opportunity for them to also talk about addressing that, which I think is something they could both probably talk about in a winning way for both. But I thought it was mentioned more than I expected a little bit. I thought they may want to talk about it at all. So it was still not much substantive policy discussion on health care.

Kenen: Biden tried to get across some of the Democratic policies on drug prices and polls have shown that the public doesn’t really understand that is actually the law in going forward. So if any attempt to message that in front of a very large audience was completely muddled. Nobody listening to that debate would’ve come out — unless they knew going in — they would’ve not have come out knowing what was in the law about Medicare price negotiations. They would’ve gotten four different answers of what happened with insulin, although they probably figured something good, helpful happened. And a big opportunity to push a Democratic achievement that has some bipartisan popularity was completely evaporated.

Rovner: I think Biden did the classic over-prepare and stuff too many talking points into his head and then couldn’t sort them all out in the moment. That seemed pretty clear. He was trying to retrieve the talking point and they got a little bit jumbled in his attempt to bring them out. Well, back to abortion: Alice, you got a cool scoop this week about abortion rights groups banding together with a $100 million campaign to overturn the overturn of Roe. Tell us about that?

Ollstein: Yeah, so it’s notable because there’s been so much focus on the state level battles and fighting this out state by state, and the ballot initiatives that have passed at the state level and restored or protected access have been this glimmer of hope for the abortion rights movement. But I think there was a real crystallization of the understanding that that strategy alone would leave tens of millions of people out in the cold because a lot of states don’t have the ability to do a ballot initiative. And also, if there were to be some sort of federal restrictions imposed under a Trump presidency or whatever, those state level protections wouldn’t necessarily hold. So I think this effort of groups coming together to really spend big and say that they want to restore federal protections is really notable.

I also think it’s notable that they are not committing to a specific bill or plan or law they want to see. They are keeping on the, “This is our vision, this is our broad goal.” But they’re not saying, “We want to restore Roe specifically, we want to go further,” et cetera. And that’s creating some consternation within the movement. I’ve also, since publishing the story, heard a lot of anxiety about the level of spending going to this when people feel that that should be going to direct support for people who are suffering on the ground and struggling to access abortion. Right now you have abortion funds screaming that they’re being stretched to the breaking point and cannot help everyone who needs to travel out of state right now. So, of course, infighting on the left is a perennial, but I think it’s particularly interesting in this case.

Rovner: Well, meanwhile, we have a trio this week of examples of what I think it’s safe to call unintended consequences of the Supreme Court’s overturn of Roe. First, a study in the medical journal JAMA Pediatrics this week, found that in the first year abortion was dramatically restricted in Texas — remember, that was before the overturn of Roe — infant deaths rose fairly dramatically. In particular, deaths from congenital problems rose, suggesting that women carrying doomed fetuses gave birth instead of having abortions. What’s the takeaway from seeing this big spike in infant mortality?

Ollstein: So I’ve seen a lot of anti-abortion groups trying to spin this and push back really hard on it. Specifically picking up on what you just said, which is that a lot of these are fatal fetal anomalies. And so they were saying, “Were abortion still legal, those pregnancies could have been terminated before birth.” And so they’re saying, “There’s no difference really, because we consider that an infant death already. So now it’s an infant death after birth. Nothing to see here.”

Rovner: When everybody has suffered more, basically.

Ollstein: Yeah, that is the response I’m seeing on the right. On the left, I am seeing arguments that anyone who labels themselves pro-life should think twice about the impact of these policies that are playing out. And like you said, we’re only just beginning to get glimmers of this data. In part because Texas was out in front of everybody else, and so I think there’s a lot more to come.

The other pushback I’ve seen from anti-abortion groups is that infant mortality also rose in states where abortion remains legal. So I think that’s worth exploring, too. Obviously, correlation is not always causation, but I think it’s hard when you’re getting the data in little dribs and drabs instead of a full complete picture that we can really analyze.

Rovner: Well, in another JAMA study, this one in JAMA Network Open, they found that the use of Plan B, the morning-after birth control pill, fell by 60% in states that implemented abortion bans after the Dobbs [v. Jackson Women’s Health Organization] decision. Now, for the millionth time, Plan B is not the same as the abortion pill. It’s a high-dose contraceptive. But apparently, a combination of the closure of family planning clinics in states that impose bans, which are an important source of pills for people with low incomes who can’t afford over-the-counter versions, and misinformation about the continuing legality of the morning-after pill, which continues to be legal, contributed to the decline. At least that’s what the authors theorize. This is one of many ironies in the wake of Dobbs; that states with abortion bans may well be ending up with more unintended pregnancies rather than fewer.

Ollstein: Well, one trends that could be feeding this is that some of the clinics where people used to go to to access contraception, also provided abortion and have not been able to keep their doors open in a post-Roe environment. We’ve seen clinics shutting down across the South. I went to Alabama last year to cover this, and there are clinics there that used to get most of their revenue from abortion, and they’re trying to hang on and provide nonabortion gynecological services, including contraception, and the math just ain’t mathing, and they’re really struggling to survive.

And so this goes back to the finger-pointing within the movement about where money should be going right now. And I know that red state clinics that are trying to survive feel very left behind and feel that this erosion of access is a result of that.

Kenen: Julie, and also to put in, even before Dobbs, it was not easy in many parts of the country for low-income women to get free contraception. There are states in which clinics were few and far between. Federal spending on Title X has not risen in many years.

Rovner: Title X is a federal [indecipherable].

Kenen: Right. Alice knows this, and maybe I’ve said on the podcast, I once just pretty randomly with me and my cursor plunked my cursor down on a map of Texas and said, “OK, if I live here, how far is the nearest clinic?” And I looked at the map of the clinics and it was far, it was something like 95 miles, the nearest one. So we had abortion deserts. We’ve also had family planning deserts, and that has only gotten worse, but it wasn’t good in the first place.

Rovner: Well, finally, and for those who really want to make sure they don’t have unintended pregnancies, according to a study in a third AMA journal, JAMA Health Forum, the number of young women aged 18 to 30 who were getting sterilized doubled in the 15 months after Roe was overturned. Men are part of this trend, too. Vasectomies tripled over that same period. Are we looking at a generation that’s so scared, they’re going to end up just not having kids at all?

Kenen: Well, there are a lot of kids in this generation who are saying they don’t want to have kids for a variety of reasons: economic, climate, all sorts of things. I think that I was a little surprised to see that study because there are safe long-acting contraceptives. You can get an IUD that lasts seven to nine years, I think it is. I was a little surprised that people were choosing something irreversible because.. I do know young people who… You’re young, you go through lots of changes in life, and there is an alternative that’s multiyear. So I was a little surprised by that. But that’s apparently what’s happening. And it’s for… This generation is not as… What are they, Gen[eration] Z? They’re not as baby-oriented as their older brothers and sisters even.

Knight: Well, that age range is millennial and Gen Z. But I don’t know. I’m a millennial. I think a lot of my friends were not baby-oriented. So I think that’s probably a fair statement to say. But it is interesting that they wouldn’t choose an IUD or something like that instead. But I do think people are scared. We’ve seen the stories of people moving out of states that have really strict abortion bans because they are so concerned on what kind of medical care they could have, even if they think they want to get pregnant. And sometimes you don’t have a healthy pregnancy and then need to get an abortion. So I’m sure it has something to do with that but…

Rovner: Yeah, it’s one of those trends to keep an eye out for. Well, moving on, U.S. Surgeon General Vivek Murthy has been busy these past couple of weeks. First, he published an op-ed in The New York Times calling for a warning label for social media that’s similar to the one that’s already on tobacco products, warning that social media has not been proven safe for children and teenagers. Of course, he doesn’t have his own authority to do that. Congress would have to pass a law. Any chance of that? I know Congress is definitely into the “What are we going to do about social media” realm.

Kenen: But talking about it and doing something or thinking, it’s a long way. Is this as, compared to his other topic of the week, which was gun safety? He’s got a lot more bipartisan …

Rovner: We’re getting to that.

Kenen: … He’s got a lot more bipartisan support for the concern about health of young people and what social media is. What is social media? Social media is mixed. There are good things and bad things, and what is that balance? There is a bipartisan concern. I don’t know that that means you get to the labeling point. But the labeling point is one thing. That the larger concept of concern about it, and recognition about it, and what do we do about it, is bipartisan up to a point. How do you even label? What do you label? Your phone? Your computer? I’m not sure where the label goes. Your eyelids? [inaudible 00:33:07]

Knight: Right. Well, tech bills in Congress in general are like… Even though TikTok was surprisingly able to get done in the House. But TikTok lobby was big. But there would be a big social media lobby, I’m sure, against that. I guess there is bipartisan support. I don’t know. It’s not something I’ve asked members about, but I think that would be pretty far off from a reality actually happening.

Rovner: Well, also this week, as Joanne mentioned, the surgeon general issued a Surgeon General’s Advisory, declaring gun violence a public health crisis, calling for more research funding on gun injuries and deaths, universal background checks for gun buyers, and bans on assault weapons and high-capacity ammunition magazines. I feel like the NRA [National Rifle Association] has lost some of its legendary clout on Capitol Hill over the past few years, thanks to a series of scandals, but maybe not enough for some of these things. I feel like I’ve heard these suggestions before, like over the last 25 or 30 years.

Kenen: I think one of the interesting things about Vivek Murthy is he came to public prominence on gun safety and guns in public health before people were really talking about guns in public health. I forgot what year it was — 2016, 2017, whenever Obama first nominated him. Because remember, this is his second run as surgeon general. It was an issue that he had spoken about and had made a signature issue, and as he became a more public figure before the nomination. And then he went silent on it. He had trouble getting confirmed. He didn’t do anything about it. We never really heard … as far as I can recollect, we never even heard him talk about it once. Maybe there was a phrase or two here or there. He certainly didn’t push it or make it a signature issue.

Right now, he’s at the end of the last year with the Biden administration. Some kind of arc is being completed. He’s a young man, there’ll be other arcs. But this arc is winding down and the president cares about gun violence. Congress actually did, not the full agenda, but they did something on it, which was unusual. And I think that this is his chance to use his bully pulpit while he still has it in this particular perch to remind people that we do have tools. We don’t have all the solutions to gun violence. We do not understand everything about it. We do not understand why some people go and shoot a movie theater or a school or a supermarket or whatever, and there are multiple reasons. There are different kinds of mass killers. But we do know that there are some public health tools that do work. That red flag laws do seem to help. That safe gun storage … There are things that are less controversial than a spectrum of things one can do.

Some of them have broader support, and I think he is using this time — not that he expects any of these things to become law in the final year of the Biden administration — but I think he’s using it. This is bully pulpit. This is saying, “Moving forward, let’s think about what we can come to agreement on and do what we can on certain evidence-based things.” Because there’s been a lot of work in the last decade or so on the public health, not just the criminal… Obviously, it’s a legal and criminal justice issue. It’s also a public health issue, and what are the public health tools? What can we do? How do we treat this as basically an epidemic? And how can we stop it?

Rovner: Finally this week, since we didn’t really do news last week, there have been a couple of notable stories we really ought to mention. One is a court case, Braidwood v. Becerra. This is the case where a group of Christian businesses are claiming that the Affordable Care Act’s preventive services provisions that require them to provide no cost-sharing access to products, including HIV preventive medication, violates their freedom of religion because it makes them complicit in homosexual behavior. Judge Reed O’Connor, district court judge — if that name is familiar, it’s because he’s the Texas judge who tried to strike down the entire ACA back in 2018. Judge O’Connor not only found for the plaintiffs, he tried to slap a nationwide injunction on all of the ACA’s preventive services, which even the very conservative 5th Circuit appeals court struck down. But meanwhile, the appeals court has come up with its ruling. Where does that leave us on the ACA preventive services?

Ollstein: It leaves us right where we were when the 5th Circuit took the case because they said that, “We’re going to allow the lower court ruling to be enforced just for the plaintiffs in the meantime, but we’re not going to allow the entire country’s preventive care coverage to be disrupted while this case moves forward.” And so that basically continues to be the case. Some of the arguments are getting sent back down to the lower court for further consideration. And we still don’t know whether either side will appeal the 5th Circuit’s ruling to the Supreme Court.

Rovner: But notably, the appeals court said that U.S. Preventive Services Task Force, which is appointed by the Department of Health and Human Services, is basically illegally constituted because it should be nominated by the president, approved by the Senate, which it is not. That could in the long run be kind of a big deal. This is a group of experts that supposedly shielded from politics.

Kenen: Yeah, I don’t think this story is over either. It is for now. Right now we’re at the status quo, except for this handful of people who brought recommendations on all sorts of health measures, including vaccination and cancer screenings and everything else. They stand. They’re not being contested at this moment. How that will evolve under the next administration and this court remains to be seen.

Rovner: Finally, finally, finally, to end on a bit of a frustrating note, the National Academies of Sciences, Engineering, and Medicine, has found that two decades after it first called out some of the most egregious inequities in U.S. health care, not that much has changed. Joanne, this has been a very high-profile issue. What went wrong?

Kenen: Well, I think this report got very little attention probably because it’s like, oh, reports aren’t necessarily news stories. And it was like nothing changed, so why do we report it? But I think when I read the report — and I did not get through all 375 pages yet, but I did read a significant amount of it and I listened to a webinar on it — I think what really struck me is how we’re not any better than we really were 20 years ago. And what really was jarring is the report said, “And we actually know how to fix this and we’re not doing it. And we have the scientific and public health and sociological knowledge. We know if we wanted to fix it, we could, and we haven’t. Some of that is needing money and some of it is needing will.” So I thought the bottom line of it was really quite grim. If we didn’t know how bad it was, if the general public didn’t know how bad it was, the pandemic really should have taught them that because of the enormous disparities, and we’re back on this glide path toward nothing.

Rovner: I do think at very least, it is more talked about. It’s a little higher profile than it was, but obviously you’re right.

Kenen: They didn’t say no gains in any… I mean, the ACA helped. There are people who have coverage, including minorities, who didn’t have it before. That was one of the bright spots. But there’s still 10 states where it hasn’t been fully implemented. It was a pretty discouraging report.

Rovner: All right, well, that is this week’s news. Now it is time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?

Knight: Sure. So I was reading a story in The New York Times about PBMs [pharmacy benefit managers]. It was called “The Opaque Industry Secretly Inflating Prices for Prescription Drugs.” It’s by Rebecca Robbins and Reed Abelson. And so it kind of is basically an investigation into PBM practices. It was interesting for me because I cover health care in Congress, and so it’s always the different industries are fighting each other. And right now, one of the biggest fights is about PBMs. And for those that don’t know, PBMs negotiate with drug companies, they’re supposed to pay pharmacies, they help patients get their medications. And so they’re this middleman in between everyone. And so people don’t really know they exist, but they’re a big monopoly. There’s only three of them, really big ones in the U.S. that make up 80% of the market. And so they have a lot of control over things.

Pharma blames them for high drug prices and the PBMs blame pharma. So that’s always a fun thing to watch. There actually is quite a bit of traction in Congress right now for cracking down on PBM practices. Basically, The Times reporters interviewed a bunch of people and they came away with saying that PBMs …

Rovner: They interviewed like 300 people, right?

Knight: Yes, it said 300.

Rovner: A large bunch.

Knight: Yeah, and they came away with a conclusion that PBMs are causing higher drug prices and they’re pushing patients towards higher drugs. They’re charging employers of government more money than they should be. But it was interesting for me to watch this play out on Twitter because the PBM lobby was, of course, very upset by the story. They were slamming it and they put out a whole press release saying that it’s anecdotal and they don’t have actual data. So it was interesting, but I think it’s another piece in the policy puzzle of how do we reduce drug prices? And Congress thinks at least cracking on PBMs is one way to do it, and it has bipartisan support.

Rovner: And apparently this story is the first in a series, so there’s more to come.

Knight: Yes, I saw that. Yeah, more to come, so it’ll be fun. I also just noticed as I was just pulling it up on my phone and they had closed the comment section. It was causing some robust debate.

Rovner: Yes, indeed. Joanne?

Kenen: I should just say that after I read that story in The Times that same day, I think I got a phone call from a relative, a copay that had been something like $60 for 30 days is now $1,000. And this relative walked away without getting the drug because that’s not OK. So anyway, my extra credit [“Social Security To Drop Obsolete Jobs Used To Deny Disability Benefits,”] is from The Washington Post. Lisa Rein posted an investigation a couple of years ago, and this was the coda of the Social Security Administration finally followed through on what that investigation revealed. And Lisa wrote about the move, how it’s being addressed. That to get disability benefits, you have to be unemployable basically. And the Social Security Administration had a list of … it’s called the Dictionary of Occupational Titles. It had not been updated in 47 years. So disabled people were being denied Social Security disability benefits because they were being told, well, they could do jobs like being a nut sorter or a pneumatic tube operator or a microfilm something or other. And these jobs stopped existing decades ago.

So the Social Security Administration got rid of these obsolete jobs. You’re no longer being told, literally, to go store nuts. If you are, in fact, legitimately disabled, you’ll now be able to get the Social Security disability benefits that you are, in fact, qualified for. So thousands of people will be affected.

Rovner: No one can see this, but I’m wearing my America Needs Journalists T-shirt today. Alice?

Ollstein: I chose a piece [“Opioid Deaths Rose 50 Percent During the Pandemic. in These Places, They Fell”] by my colleague Ruth Reader, about a county in Ohio that, with some federal funds, implemented all of these policies to reduce opioid overdoses and deaths, and they had a lot of success. Overdoses went down 20% there, even as they went up by a lot in most of the country. But bureaucracy and expiring funding means that those programs may not continue, even though they’re really successful. The federal funding has run out. It is not getting renewed, and the state may not pick up the slack.

So it’s just a really good example. We see this so often in public health where we invest in something, it works, it makes a difference, it helps people, and then we say, “Well, all right, we did it. We’re done.” And then the problems come roaring back. So hopefully that does not happen here.

Rovner: Alas. Well, my extra credit this week is from The Washington Post. It’s called “Masks Are Going From Mandated to Criminalized in Some States.” It’s by Fenit Nirappil. I hope I’m pronouncing that right. In some ways, it’s a response to criminals who have obviously long used masks, and also to protesters, particularly those protesting the war in Gaza. But it’s also a mark of just how intolerant we’ve become as a society that people who are immunocompromised or just worried about their own health can’t go out masked in public without getting harassed. The irony, of course, is that this is all coming just as covid is having what appears to be now its annual summer surge, and the big fight of the moment is in North Carolina where the Democratic governor has vetoed a mask ban bill, that’s likely to be overridden by the Republican legislature. Even after covid is no longer front and center in our everyday lives, apparently a lot of the nastiness remains.

All right, that is our 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. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comment or questions. We’re at whatthehealth@kff.org, or you can still find me at Twitter, which the Supreme Court has now decided it’s going to call Twitter. I’m @jrovner. Alice?

Ollstein: I’m @AliceOllstein on X.

Rovner: Victoria?

Knight: I’m @victoriaregisk.

Rovner: Joanne?

Kenen: I’m at Twitter, @JoanneKenen. And I’m on Threads @joannekenen1, and I occasionally decided I just have better things to do.

Rovner: It’s all good. We will be back in your feed next week. Until then, be healthy.

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